Welcome to Triple-S Salud, Inc. Our priority is to serve ......All, but $1,316 All, but $329 a day...

TSS-PROD-0349-2016-B

Welcome to Triple-S Salud, Inc.

Our priority is to serve you in every stage of your life

For more than 55 years, we had taken care of your health and from thousands of puertorricans offering quality

and excellence services. Our priority has always been to serve you in every stage of your life. That is why we

are constantly striving to develop initiatives to help us comply with this commitment.

Triple-S Salud offers you a wide variety of integral health services to help improve your health and quality of

life. Furthermore, provide more and better services with extended operating hours in our Services Centers,

including Plaza Las Américas and Plaza Carolina Service Centers, also, 24 hours services everyday through

Teleconsulta, Telexpreso and the web page www.ssspr.com.

This Summary of the Medigap Coverage Policy will help you to know the benefits and programs that Triple-S

Salud put in your and your family disposition under Medicare supplementary policy.

We encourage you to read the document and keep it for future reference.

We wish that you continue to be a part of our family of insureds and let us take care of your most precious

possession, your health.

________________________________

Madeline Hernández Urquiza, CPA

President Triple-S Salud, Inc.

San Juan, Puerto Rico Independent Licensee of the Blue Cross and Blue Shield Association

Summary of the 2017 Medicare Supplementary Coverage – Benefit Chart of Medicare Supplement Plans Sold for

Effective Dates on or After June 1, 2010

This chart shows the benefits included in each model of the standard Medicare supplements plans. Every company must

make available Plan “A”. Plans E, H, I, and J are no longer available for sale. Some plans may not be available in Puerto Rico.

http://www.ssspr.com/

Medigap Model FMG 08/92 (Rev. 11/2016)

BASIC BENEFITS: Included in all the Plans. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare Program benefits end. Medical

Expenses: Part B coinsurance (generally 20% of Medicare approved expenses) or copayments for hospital outpatient services. Blood: Covers the first three pints of

blood each year. Hospice: Part A coinsurance.

A B C D F** G K L M N

Basic

Benefits

including

100% Part B

coinsurance

Basic

Benefits

including

100% Part B

coinsurance

Basic

Benefits

including

100% Part B

coinsurance

Basic Benefits

including 100%

Part B

coinsurance

Basic Benefits

including 100%

Part B

coinsurance

Basic Benefits

including 100%

Part B

coinsurance

Hospitalization and

preventive care

paid at 100%; other

basic benefits paid

at 50%

Hospitalization and

preventive care

paid at 100%; other

basic benefits paid

at 75%

Basic,

including

100% Part B

coinsurance

Basic, including 100%

Part B coinsurance,

except up to $20

copayment for office

visit, and up to $50

copayment for ER

Skilled

Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

Skilled Nursing

Facility

Coinsurance

50% Skilled

Nursing Facility

Coinsurance

75% Skilled

Nursing Facility

Coinsurance

Skilled

Nursing

Facility

Coinsurance

Skilled Nursing

Facility Coinsurance

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

Part A

Deductible

50% Part A

Deductible

75% Part A

Deductible

50% Part A

Deductible

Part A Deductible

Part B

Deductible

Part B

Deductible

Part B Excess

(100%)

Part B Excess

(100%)

Foreign

Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign

Travel

Emergency

Foreign Travel

Emergency

Out-of-pocket limit

$5,120; paid at

100% after limit

reached

Out-of-pocket limit

$2,560; paid at

100% after limit

reached

NOTE: Triple-S Salud will only offer Models A, B and C

** Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year ($2,200) deductible.

Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid

by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.


Triple-S Salud, Inc. San Juan, Puerto Rico Independent Licensee of the Blue Cross and Blue Shield Association SUMMARY OF THE MEDIGAP COVERAGE POLICY

2017

PREMIUM INFORMATION

Triple-S Salud can only raise your premium if we raise the premium for all policies like yours in Puerto Rico.

IT IS IMPORTANT THAT YOU READ YOUR POLICY AND THE RIDER CAREFULLY

This is an outline describing your policy’s most important features. The policy is your insurance contract. You

must read the policy and any rider, to understand all the rights and obligations of both, Triple-S Salud and you. Use this summary to compare the benefits and premiums among the Medigap policy models.

RIGHT TO RETURN THE POLICY

If you find that you are not satisfied with your policy, you may return it to PO Box 363628, San Juan, P.R. 00936-

3628. If you send the policy back to us within thirty (30) days after you received it, we will treat your policy as if it

had never been issued and return all of your payments.

POLICY REPLACEMENT

If you are replacing another health insurance policy, DO NOT cancel it until you have actually received your

new policy and are sure you want to keep it.

NOTICE

This policy may not fully cover all your medical costs. Neither Triple-S Salud, its authorized representatives,

producers nor its agents are related with Medicare. This Outline of Coverage does not give all the details of

Medicare coverage. Contact your Social Security Office or consult the Medicare and You Handbook for more

details.

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application form for the new policy, be sure to answer truthfully and completely all the

questions about your medical and health history. Triple-S Salud may cancel your policy and refuse to pay any

claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

The following Table describes the differences in benefits among Medigap policies (Models A, B and C) offered by

Triple-S Salud.


COMPARATIVE TABLE

MEDIGAP POLICIES MODELS A, B and C

BENEFITS MEDICARE PAYS MEDIPAG

PAYS:

MODEL A

(C-6)

MEDIPAG

PAYS:

MODEL B

(C-7)

MEDIPAG

PAYS:

MODEL C

(C-8)

Medicare Program Part A

Hospitalization insurance

Deductible per illness period $0 $0 $1,316 $1,316

First 60 days 100% $0 $0 $0

Coinsurance days 61 to 90 All except $329 daily $329 daily $329 daily $329 daily

Coinsurance days 91 to 150 All except $658 daily $658 daily $658 daily $658 daily

Additional period up to a maximum

of 365 per lifetime

$0

100% 100% 100%

Care Skilled Nursing Facility

First 20 days 100% $0 $0 $0

Coinsurance days 21 to 100 All, except $164.50 daily $0 $0 $164.50

daily

Medicare Program Part B

Coverage

Annual deductible $0 $0 $0 $183

Coinsurance 80% 20% 20% 20%

Deductible for the first 3 pints of

blood (combination of Parts A and B)

$0 100% 100% 100%

Additional Benefits:

Emergency outside Puerto Rico and

the United States of America

Some services when the

nearest facility is within the

borders of Mexico or

Canada.

$0 $0 80% up to a

lifetime

maximum of

$50,000,

subject to

an annual

deductible

of $250.00


MODEL A DESCRIPTION

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

SERVICES MEDICARE PAYS MODEL-A PAYS YOU PAY

HOSPITALIZATION*

Semiprivate room and board,

general nursing and

miscellaneous services and

supplies

First 60 days

61st. thru 90th day

91st. day and after :

-While using 60 lifetime reserve

days

-Once lifetime reserve days are

used:

-365 additional days

-Beyond the additional 365 days

All, but $1,316

All, but $329 a day

All, but $658 a day

$0

$0

$0

$329 a day

$658 a day

100% of Medicare

eligible expenses

$0

$1,316 (Part A Deductible)

$0

$0

$0**

All costs

SKILLED NURSING FACILITY*

You must meet Medicare’s

requirements, including having

been in a hospital for at least 3

days and entered a Medicare-

approved facility within 30 days

after leaving the hospital:

First 20 days

21st thru 100th day

101st day and after

All approved amounts

All, but $164.50 a day

$0

$0

$0

$0

$0

Up to $164.50 a day

All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE

Available as long as your doctor

certifies you are terminally ill

and you elect to receive these

services.

All but very limited

coinsurance for outpatient

drugs and inpatient respite

care.

Medicare

copayment or

coinsurance

$0

*A benefit period begins on the first day you receive as an inpatient in a hospital and ends after you have been out of the

hospital and have not received skilled care in any other facility for 60 days in a row.

**When your Medicare Part A hospital benefits are exhausted, Triple-S Salud stands in the place of Medicare and will pay

whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits”.

During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges

and the amount Medicare would have paid.


MODEL A DESCRIPTION (CONTINUATION)

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

***Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk),

your Part B deductible will have been met for the calendar year.

SERVICES MEDICARE

PAYS

MEDICARE

MODEL–A PAYS

YOU PAY

MEDICAL EXPENSES

In or out of the hospital and outpatient hospital

treatment, such as physician’s services, inpatient

and outpatient medical and surgical services and

supplies, physical and speech therapy, diagnostic

test, durable medical equipment.

First $183 of Medicare Approved Amounts***

Remainder of Medicare Approved Amounts

$0

Generally 80%

$0

Generally 20%

$183 (Part B

Deductible)

$0

Part B Excess Charges (Above Medicare approved

amounts )

$0

$0

All costs

BLOOD

First 3 pints

Next $183 of Medicare Approved Amounts***


$0

$0

80%

All costs

$0

20%

$0

$183 (Part B

Deductible)

$0

CLINICAL LABORATORY SERVICES

Blood test for diagnostic services

100%

$0

$0

PARTS A & B

HOME HEALTH CARE Medicare approved

services:

Medically necessary Skilled care services and

medical supplies.

Durable medical equipment

First $183 of Medicare Approved amounts ***

Remainder of Medicare Approved amounts

100%

$0

80%

$0

$0

20%

$0

$183 (Part B

Deductible)

$0


MODEL B DESCRIPTION

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

SERVICES MEDICARE PAYS MEDICARE MODEL–B

PAYS

YOU PAY

HOSPITALIZATION*


general nursing and miscellaneous

services and supplies:

First 60 days

61st. thru 90th day

91st. day and after:

- While using 60 lifetime reserve

days

- Once lifetime reserve days are

used:

- Additional 365 days

- Beyond the additional 365 days

All, except $1,316

All, except $329 per day

All, except $658 per day

$0

$0


$329 per day

$658 per day

100% of Medicare eligible

expenses

$0

$0

$0

$0

$0**

All costs

SKILLED NURSING FACILITY

CARE*

You must meet Medicare

requirements, including having in a

hospital for at least 3 days and

entered a Medicare-approved

facility within 30 days after leaving

the hospital.

First 20 days

21st up to the 100th day

101st day and the days that follow



$0

$0

$0

$0

$0


All costs

BLOOD

First 3 pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

HOSPICE CARE


certifies you are terminally ill and

you elect to receive these services.

All, but very limited

coinsurance for

outpatient drugs and

inpatient respite care.

Medicare copayment or

coinsurance

$0

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of

the hospital and have not received skilled care in any other facility for 60 days in a row.






MODEL B DESCRIPTION (CONTINUATION)


SERVICES MEDICARE

PAYS

MODEL-B

PAYS

YOU PAY

MEDICAL EXPENSES


treatment, such as physician’s services, inpatient and

outpatient medical and surgical services and supplies,

physical and speech therapy, diagnostic test, durable

medical equipment:



$0

Generally 80%

$0

Generally 20%

$183 (Part B

Deductible)

$0


amounts)

$0

$0

All costs

BLOOD

First 3 pints

Next $183 of Amounts Approved by Medicare***

Remainder of the Amounts Approved by Medicare

$0

$0

80%

All costs

$0

20%

$0

$183 (Part B

Deductible)

$0


Blood Test for diagnostic Services

100%

$0

$0

PARTS A & B

HOME HEALTH CARE Medicare approved services:

Medically necessary skilled care services and medical

supplies.


First $183 of amounts Approved by Medicare***

Remainder of Amounts Approved by Medicare

100%

$0

80%

$0

$0

20%

$0

$183 (Part B

Deductible)

$0

***Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an

asterisk), your Part B deductible will have been met for the calendar year.


MODEL C DESCRIPTION

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT SERVICES

SERVICES MEDICARE PAYS MODEL-C PAYS YOU PAY

HOSPITALIZATION*


general nursing and miscellaneous

services and supplies.

First 60 days

61st. thru the 90th day

91st. day and after:

- While using 60 lifetime reserve

days

- Once lifetime reserve days are

used:

- Additional 365 days

- Beyond the additional 365 days

All, but $1,316

All, but $329 a day

All, but $658 a day

$0

$0


$329 a day

$658 a day

100% of Medicare eligible

expenses

$0

$0

$0

$0

$0**

All costs

SKILLED NURSING FACILITY

CARE*

You must meet Medicare’s

requirements, including having

been in a hospital for at least 3

days entered a Medicare-approved

facility within 30 days after leaving

the hospital.

First 20 days

21st thru 100th day

101st day and after



$0

$0

Up to $164.50 a day

$0

$0

$0

All costs

BLOOD

First 3 pints

Additional pints

$0

100%

All costs

$0

$0

$0

HOSPICE CARE


certifies you are terminally ill and

you elect to receive these services.

All, but very limited

coinsurance for

outpatient and inpatient

respite care.

Medicare copayment or

coinsurance

$0

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of

the hospital and have not received skilled care in any other facility for 60 days in a row.






MODEL C DESCRIPTION (CONTINUATION)


SERVICES MEDICARE PAYS MODEL-C PAYS YOU PAY

MEDICAL EXPENSES


treatment, such as physician’s services, inpatient

and outpatient medical and surgical services and

supplies, physical and speech therapy, diagnostic

test, durable medical equipment:



$0

Generally 80%

$183 (Part B

Deductible)

Generally 20%

$0

$0


amounts)

$0

$0

All costs

BLOOD

First 3 pints

Next $183 of Medicare Approved Amounts***

Remainder of the Medicare Approved Amounts

$0

$0

80%

All costs

$183 (Part B

Deductible)

20%

$0

$0

$0


Blood test for diagnostic services

100% $0 $0

PARTS A & B

HOME HEALTH CARE Medicare approved services:

Medically necessary skilled services and medical

supplies.


First $183 of amounts Approved by Medicare***

Remainder of Amounts Approved by Medicare

100%

$0

80%

$0

$183 (Part B

Deductible)

20%

$0

$0

$0

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES MEDICARE

PAYS

MODEL-C PAYS YOU PAY

FOREING TRAVEL Not covered by Medicare:

Medically necessary emergency care services

beginning during the first 60 days of each trip outside

the United States of America.

First $250 each calendar year

Remaining charges

$0

$0

$0

80% to a lifetime

maximum benefit of

$50,000

$250

20% and

amounts over

the $50,000

lifetime

maximum.

***Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk),

your Part B deductible will have been met for the calendar year.


WHAT DOES MEDIGAP MEAN?

The United States Congress approved the Omnibus Budget Reconciliation Act (OBRA), which simplifies and

standardizes Medicare supplementary policies. The new policies will be identified as Medigap models and the

benefits offered will be similar for all insurance companies.

This policy provides benefits to persons who have both coverages of the Medicare Program (Parts A and B) and

is subject to the provisions of the Medicare Program. It insures the eligible person with the acceptable expense

for deductibles and coinsurances in accordance with the charges accepted by the Medicare Program for medical-

surgical services and other health services received under the Medicare Program. The Medicare Program pays

80% of the reasonable charges after the annual deductible. The Medigap policy pays the remaining 20% of the

reasonable charges accepted by the Medicare Program.

Changes to the amounts corresponding to deductibles or coinsurances established by the Medicare Program

that may arise from Federal legislation will be covered by Triple-S Salud in accordance with the provisions of the

policy. The Medigap policy will cover said amounts until they total 100% of the amounts approved by the

Medicare Program in Puerto Rico, based on the usual, customary and reasonable charges.

LIMITATIONS FOR PREEXISITNG CONDITIONS

There will be a waiting period during the first six (6) months of the policy for preexisting conditions. Preexisting

conditions are defined as physical or mental conditions a plan member suffers which became evident just before

the policy was issued or that existed before the policy was issued and for which the person received treatment.

This policy establishes a six-month period for those preexisting conditions before the date the policy became

effective. Said waiting period will not apply:

If the policy replaces another policy in which the waiting period was covered;

If the policy replaces another policy that had been in force for six (6) months or more.

Any waiting period previously mentioned will not apply if the affected person has fulfilled this period under another

Triple-S Salud insurance that expired on the date the person became insured under this policy or will be partially

applied until the waiting period is fulfilled if the person partially fulfilled the waiting period under another insurance.

These provisions apply to all Medigap policies issued with a validity date as of August, 1992 henceforth.

SERVICE AREA

The service area is the area where the plan member is expected to receive most of the medical-hospital services.

For the purpose of this policy, the service area means Puerto Rico. The services provided under this policy are

only available for those people who reside permanently in Puerto Rico.

BENEFITS UNDER MEDICAID

You do not need to have more than one Medicare supplementary policy. If you are 65 years of age or older, you

may be eligible for Medicaid benefits and possibly may not need to have a Medicare supplementary policy.

Premiums and benefits corresponding to the Medicare supplementary policy will be discontinued for a 24-month

period while the plan member is eligible for Medicaid benefits. You should request the suspension of your policy

with the 90-day period following your eligibility for Medicaid. When your eligibility for Medicaid ends, you must

request the reactivation of your Medicare supplementary policy within the 90-day period following the end of your

eligibility for Medicaid.


You may receive orientation on Medicaid through the orientation services available at the certifying units within

the Area Hospitals, Medical Centers and Diagnosis and Treatment Centers of the Health Department of Puerto

Rico.

IMPORTANT QUESTIONS What procedure should I follow to purchase a Medigap Policy?

You must be over 65 years of age or be disabled and must have Medicare Parts A and B. You must request the

Insurance Enrollment Form at Triple-S Salud Offices in San Juan, Ponce, Mayagüez, Arecibo, Caguas, Plaza

Carolina or Plaza Las Américas, either in person, via mail or by phone. If you are an active employee, you

cannot purchase the supplementary policy.

If you are over 65 years of age and you submit your enrollment form within six months following the date in which

you became eligible for Medicare Part B, you will be eligible for the supplementary insurance without evidence of

insurability.

You must fill out the Enrollment Form in all its parts and the Medigap Policy Questionnaire included with the

enrollment form, and submit it together with a photocopy of your Medicare Program ID card showing that you are

enrolled in the Program’s Parts A and B (Hospital and Medical Insurance) and deliver it in person or mail it to

Triple-S Salud.

Should I pay the physician when using his/her services?

If you visit a Medicare and Triple-S Salud participating physician or provider you pay $0. You just have to

show both cards. Please refer to Medicare and Triple-S Salud Directory of Participating Providers. You may

request Medicare’s Directory to the Medicare Program Representative in Puerto Rico. Triple-S Salud’s directory

is available at Triple-S Salud’s Offices.

Remember that the fees established by Medicare and Triple-S Salud non-participating providers may be

different to the fees established by Medicare and Triple-S Salud for their participating physicians and

providers.

If you visit a Triple-S Salud participating physician or provider that does participate in the Medicare Program, you will pay the fee said physician or provider has established for the service. You may request reimbursement for 80% of the reasonable charge to the Medicare Program Representative in Puerto Rico. The remaining 20% must be requested to Triple-S Salud using the Reimbursement Form after Medicare pays you for the services. You must send the Reimbursement Form together with the payment receipt and the Explanation of Benefits issued by the Medicare Program Representative of the area in which the service was rendered. If you visit a physician or provider that is a Medicare participating provider, but that is not a Triple-S Salud participating provider or, if you receive services outside Puerto Rico or receive services not covered under the Medicare Program in a foreign country, you must use the Reimbursement Form. Send it to Triple-S Salud together with the payment receipt and the Explanation of Benefits issued by the Medicare Program Representative of the area in which the service was rendered, to the following address:

PO Box 363628 SAN JUAN, PR 00936-3628

What services are covered under this policy? Some models of this policy cover the deductibles and coinsurances not paid by the Medicare Program, regardless of whether the patient is hospitalized or not. Besides, it reimburses some expenses not covered by the Medicare Program.


Remember that it is important to show your plan ID card to the participating hospital and to the physician, so they will be able to bill directly to Triple-S Salud for the deductibles and coinsurances the Medicare Program did not pay. As a plan member under a Medigap Policy, can I buy a dental coverage? Yes. The persons enrolled in this policy can obtain an optional dental policy that covers basic dental services by paying the corresponding additional monthly premium. Can I enroll to a Medicare Part D Pharmacy coverage and continue to have my Medigap benefits? Yes. You may subscribe to a Medicare Part D Pharmacy Coverage when you have a Medigap policy. Contact Customer Service at 787-774-6060, we will be glad to provide you information on how to subscribe to Medicare Part D Pharmacy Coverage. You may also request this information to the insurance agent that provided you the orientation on your Medigap policy. Enrollment periods established by Medicare may apply. Contact Triple-S Salud, Inc. for further details.

THE MEDIGAP POLICY DOES NOT COVER THE FOLLOWING SERVICES:

Services rendered while the policy is not in force.

Anything the Medicare Program does not considers for payment, except otherwise established in this policy.


GENERAL DISPOSITIONS IDENTIFICATION: Triple-S Salud will issue a card to each insured person, which they will be required to

present to any Triple-S Salud participating provider, from whom services are requested, so that they may be covered by the policy. In addition, the insured person should present a second identification, in the cases that so require it.

PREMIUM PAYMENTS: The main insured shall be liable for the payment of the premium covering the policy, and it is provided that such liability will cover the entire premium indebted up to the date of termination of the policy, in accord with the TERMINATION clause.

In case that the insurance card of the insured is not returned to Triple-S Salud, as provided in the TERMINATION clause of the policy, Triple-S Salud will have the right to collect the premium due or, at its option, to recover the expenses incurred in the payment of claims for services rendered to the insured person whose card has not been returned, and it is provided that the main insured shall be liable for the payment of any of the two amounts claimed by Triple-S Salud.

Triple-S Salud reserves the right to notify to any agency, institution or organization dedicated to credit investigations, detailed information regarding lack of payment by the main insured.

PERSONAL RIGHTS: The insured person may not yield, transfer or waive in favor of third persons any of

the rights and benefits that he/she may claim by virtue of the policy; and it is provided that Triple-S Salud reserves the right to recover all the expenses incurred in case that the insured person, with his/her express or implicit consent, permits non-insured persons to use the insured's card issued by Triple-S Salud, in his/her favor; and it is additionally provided that the recovery of such expenses will not prevent Triple-S Salud of canceling the insurance contract when illegal use of the card is discovered, nor from filing suit to have the insured or uninsured user of the card prosecuted.

TERMINATION: The insured person may return the policy to Triple-S Salud, within the 30 following days to the date in which he/she receives said policy, and will get back the totality of the corresponding premium. Triple-S Salud reserves the right to terminate this policy on the due date of any premium through the delivery to Triple-S Salud of a written notification to the insured person, with not less than 10 days in advance. The insured person may terminate this policy by sending a written notice to Triple-S Salud, so as to make such termination effective, at the receipt of the notice, or in any other ulterior date specified in same, disposing that the main insured shall be responsible for the payment of the premiums until the expiration date of the policy. Immediately after the policy is terminated, the insured person shall return his/her insured card to Triple-S Salud, as well as all his/her dependents cards. The termination will not affect any claim for services rendered, prior to the termination date.

If at the moment of termination the insured person is in the hospital, the hospital benefits will be considered incurred and shall be paid, under the policy. Triple-S Salud will assume liability for the hospital benefits, in accordance to the established benefits by Medicare, during the 31-day period after the termination, or until the discharge’s date, whichever comes first.

DUPLICITY OF BENEFITS: The benefits covered by the policy shall not duplicate the benefits covered by

the Medicare Program or by any other policy. This brochure represents a summary of the benefits and conditions of the MEDIGAP Policy. Its purpose is exclusively informative and its content is subject to the dispositions of the policy. Triple-S Salud is not associated, in any way, to the Medicare Program.


BILL OF PATIENT’S RIGHTS AND RESPONSIBILITIES

Law 194 of August 25, 2000, as amended, known as the “Patient’s Bill of Rights and Responsibilities”, states

the rights and responsibilities of the users of medical and hospital health services in Puerto Rico.

Right to high quality health services

Services consistent with the generally accepted principles of medical practice.

Rights regarding the obtaining and disclosing of information

The patient has the right to receive accurate, reliable, and easy-to-understand information, in english and

Spanish, about his/her health plan such as the:

Covered services, limitations and exclusions

premiums and copayments to pay

directory of providers

access to specialists and emergency services

process of precertifications and grievances

Right regarding the selection of plans and providers

Every individual has the right to:

Choose healthcare plans and healthcare service providers that are adequate and services that best

adjust to their needs without being discriminated for their socioeconomic condition, payment

capacity, preexisting medical conditions or medical history, regardless of their age.

Access to a network of participating providers that is adequate and guarantees that all the services

covered by the plan will be accessible and available without unreasonable delays and within

reasonable geographic proximity from the plan member’s residence or work, including emergency

services available 24 a day, 7 days a week. Any healthcare coverage that offers health care

services in Puerto Rico must allow each patient to receive primary health care from any primary

care service participating provider the person has chosen according to the provisions of the health

care plan.

Allow the person to receive necessary or appropriate specialized services for the maintenance of

the person’s health according to the referral procedures depending on the health care plan. This

includes access of patients with special conditions or special medical or health care needs to

qualified specialist, in order to guarantee those insureds and beneficiaries direct and fast access to

qualified providers or specialists they have chosen within the plan’s network of providers to cover

their health needs. In case a special authorization is required by the plan to access qualified

providers or specialists, the plan will guarantee an adequate number of visits to cover the health

needs of said insureds and beneficiaries.

Patient’s right to the continuity of health care service

In case of termination of the provider or of cancellation of the health plan, the insured member must be notified

of said cancellation at least 30 days in advance. In the case of cancellation, and subject to the payment of

premiums, the plan member will have the right to continue receiving the benefits for a 90-day transition period.

In case the patient confined in a hospital on the cancelation date and the date of release was scheduled

before the termination date, the transition period will be extended to 90 days after the date of the release. In

the case of pregnant women, if the cancellation takes place on the second trimester, the transition period will

be extended until the later of the date in which the mother is discharged or the newborn is discharged. In case


of patients diagnosed with a terminal disease, before the plan’s termination date, and the person continues to

receive services for said condition before the plan’s termination date, the transition period will be extended for

the rest of the life of the patient.

Right regarding access to emergency services and facilities

Free and unrestricted access to emergency services and facilities when and where the need arises

without a prior authorization or waiting periods.

Access to emergency services by non-participating providers, are subject to the copays and/or

coinsurances established in your policy.

Right to participate in the decision-making process regarding your treatment

Right to your full participation or the participation of a person you trust fully participates in the

decisions about your medical care.

Receive all the necessary information and the available treatment options, the costs, risks, and

success probabilities of said options.

Your health services provider must respect and comply with your decisions and preferences

regarding your treatment.

No health care plan can impose gag rules, sanctions, or any other type of sanctions or rules that

interfere with the physician-patient communication.

Any health professional should provide the medical order for laboratory tests, X-rays or prescription

drugs, so that you can choose the facility in which you will receive the services.

Right regarding respect and the same treatment

Right to receive the same treatment from any health service provider at every moment, regardless

of race, color, gender, age, religion, origin, ideology, disability, medical or genetic information,

social status, sexual orientation or ability to pay or payment capacity.

Right to confidentiality of information and medical records

Contact your medical service providers freely and without apprehensions.

Trust that your medical records will be kept under strict confidentiality and will not be disclosed

without your authorization, except for medical or treatment purposes, unless it is required by a

judicial order or specifically authorized by law.

Obtain a receipt for expenses incurred for the total or partial payment copays or coinsurances. The

receipt must specify the date of the service, name, license number and specialty of the provider,

name of the patient and of the person paying for the services, detail of the services, amount paid

and the signature of the authorized officer.

Access or obtain a copy of your medical record. Your doctor must give you a copy of your medical

record within a term of five (5) business days from the date of your request. Hospitals have a

maximum term of 15 business days. They can charge you a fee of up to $0.75 per page but not

more than $25.00 for the record. If the patient-physician relation is broken, you have the right to

request the original record free of charge, even if you have a pending debt with the health service

provider.


Receive a quarterly utilization report that includes, among other things, the name of the insured,

type and description of the services, date and provider that rendered the service and the amount

paid for the service. The policyholder can access the quarterly utilization report that provides the

details of paid services for his or the benefit of his beneficiaries, by registering as a member on the

website of Triple-S Salud (www.ssspr.com).

Rights regarding complaints and grievances

Every health provider or insurer will have available a procedure to solve, in a fast and fair way, any

complaint presented by a plan member and will have appeal mechanisms for the reconsideration of

determinations.

Receive response to the member’s concerns in the language of predilection, may it be in english or

Spanish.

Your responsibility as a patient is:

To provide the necessary information about medical plans and the payment of any account. To

know the rules for the coordination of benefits.

Notify the insurer about any instance or suspicion of fraud against the health plan. If you suspect

fraud against the health plan, please contact our Customer Service Department at 787-774-6060 or

through our website at www.ssspr.com.

To provide the most complete and precise information about your health condition, including

previous diseases, medications, etc. To participate in every decision regarding your medical care.

To know the risks and limits of medicine.

To know the coverage, options, benefits and other details of the health plan.

Comply with your health plan administrative procedures.

To adopt a healthy lifestyle.

To notify the physician of unexpected changes in your condition.

To make known that you clearly understand the course of action recommended by the health

professional.

To provide a copy of previous living wills.

To notify the physician if you anticipate problems with the prescribed treatment.

Recognize the obligation of the provider to be efficient and equitable when providing services to

other patients.

Be considerate, so that your particular behavior do not affect other persons.

Solve any difference through the procedures established by the insurance company.




TRIPLE-S SALUD, INC. PRIVACY PRACTICES NOTICE

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION CAN BE USED AND DISCLOSED AND

HOW YOU CAN GET ACCESS TO THIS INFORMATION.

REVIEW IT CAREFULLY. THE PRIVACY OF YOUR PERSONAL, FINANCIAL AND HEALTH

INFORMATION IS IMPORTANT TO US.

Our legal Duties

Triple-S Salud is firm in its commitment to protect the privacy of your personal, financial and health

information. This notice informs you on our privacy practices and your rights regarding your health

information. We will follow the privacy practices described in this notice while it is in effect.

This notice contains some examples of the types of information we collect and also describes the types of

uses and disclosures we execute. The examples provided are for illustrative purposes and shall not be

construed as a complete listing of such uses and disclosures.

We reserve the right to change our privacy practices and the terms of this notice. Before we make a

significant change in our privacy practices, we will adapt this notice and send an updated document to our

active subscribers.

Organizations Covered by this Notice

TRIPLE-S SALUD, INC.

Summary of Privacy Practices

Our pledge is to follow the minimum necessary guidelines with regards to the information we collect in order to

appropriately administer your insurance products or benefits. As part of our administrative functions, we may

collect your personal, financial or health information from sources such as:

- applications and other documents you have provided;

- transactions you make with us or our affiliates;

- consumer credit reporting agencies;

- healthcare providers;

- Government health programs

Laws and Regulations

HIPAA: Health Insurance Portability and Accountability Act of 1996 implements rules relating to the use,

storage, transmission, and disclosure of protected health information pertaining to beneficiaries in order to

standardize communications and protect the privacy and security of personal, financial and health information.

HITECH: The Health Information Technology for Economic and Clinical Health Act of 2009 promotes the

adoption and meaningful use of health information technology. It also addresses privacy and security

concerns associated with the electronic transmissions of health information, in part, through several provisions

that strengthen the civil and criminal enforcement of the HIPAA rules.

Privacy and Security Rule: Standards for Privacy of Individually Identifiable Health, as well as Security

Standards for the Protection of Electronic Protected Health Information are guided through 45 C.F.R. Part 160

and Part 164.


Uses and Disclosures of Information

We may use and disclose your personal information to our business associates, who provide services on our

behalf and contribute in the administration or coordination of your services. We only share the minimum

necessary information and require from each of our business associates to sign a written agreement in which

they provide satisfactory assurances of compliance with the security and privacy of your health information. If

the business associate goes out of business, we will maintain your information secure to provide the services

you need. We do not use disclose genetic information for underwriting purposes.

As part of our administrative functions, we may use or disclose your information, without your authorization, for

treatment, payment and healthcare operations, and when authorized or permitted by law.

Examples include:

Treatment: We may use your medical information to a physician or other health care practitioner who

provides clinical services to you.

Payment: We may use your medical information to pay your medical claims; to determine your eligibility for

benefits; to coordinate your benefits with other payers; or to collect premiums.

Health Care Operations: We may use your medical information or audits, including fraud and abuse, legal

services, business planning, general administration and patient safety activities, credentialing, disease

management, training of medical or pharmacy students.

We may disclose your health information to another health plan or to a health care provider, as long as the

plan or provider has or had a relationship with you, subject to federal or local privacy protection laws.

Affiliated Covered Entities: We may use your medical information to Covered Entities. These companies

are subject to the same statutes that require protection for your personal and confidential health information.

Your Employer, union or other employee organization: We may use your medical information to your

employer expressing your status of enrollment, including your dis-enrollment in the health plan. Also a

summary of your health information (aggregated claims history, claims expenses or types of claims) to be

used for the administration of the sponsored group health plan.

Disaster relief or emergency situations: We may use and disclose your medical information when required

or permitted by law.

Government Sponsored Benefits Programs: We may use and disclose your medical information when

required or permitted by law.

Public Health and Safety Activities: We may use and disclose your medical information when required or

permitted by law for the following activities:

public health, including disease and vital statistics;

to report child and/or adult abuse or domestic violence;

healthcare oversight, fraud prevention and compliance;

in response to court and administrative orders;

to law enforcement officials or matters of national security;

scientific research

as authorized by state worker’s compensation laws; and

as otherwise required by applicable laws and regulations


Health-Related Products and Services: We may use your medical information to inform you about health-

related products, benefits and services we provide or include in our benefit plans. Also we may use your

medical information for treatment alternatives that may be of interest to you.

With Your Authorization: You may give us a written authorization to disclose your health information to

anyone for any purpose. Activities such as marketing of non-health related products or services or the sale of

health information must be authorized by you. In these cases your health insurance policy and your benefits

will not be affected if you deny the authorization.

The authorization must be signed and dated, it must mention the entity authorized to provide or receive the

information, and a brief description of the data to be disclosed. The expiration date will not exceed 2 years

from the date of signage, except if you signed the authorization for one of the following purposes:

to substantiate a request for benefits under a life insurance policy, its reinstallation or modifications to

such policy, in which case the authorization will be valid for thirty (30) months or until the application is

denied, the earlier of the two events; or

to substantiate or facilitate the communication of an ongoing treatment of a chronic disease or

rehabilitation of an injury.

Any disclosed information acquired by a recipient, pursuant to your authorization, may be redirected to an

unauthorized third party and may not be protected by applicable privacy laws.

You may revoke the authorization in writing at any time. Your revocation will not affect any use or disclosure

permitted by your authorization while it was in effect. We will keep copies of the authorizations and

revocations executed by you.

Family and Friends Involved in Your Care or Payment for Care: We may use or disclose your health

information to a family member or friend you have authorized in your health care, unless you request a

restriction. We will disclose only the medical information that is relevant to the person’s involvement.

Before we make such a disclosure, we will provide you with an opportunity to object. In case of any emergency

we will use our professional judgment to determine whether disclosing your medical information is in your best

interest.

Terminated accounts: We will not share the data of customers who do not maintain a service relationship

with us, except as required or permitted by law.

Security safeguards: We have implemented physical, technical and administrative safeguards to limit access

to your personal information. If any of your information is disclosed with previous authorization, or as

expressed in this notice, we assure that any oral, written or electronic transmissions will be secure. Our

employees and business associates are trained and know their duty to protect and maintain the privacy of your

demographic, financial and clinical information, and are committed to comply with the highest security and

privacy standards to handle your information in a responsible manner.

Individual Rights

Access: You have the right to examine and receive a copy of your protected health information, with regards

to enrollment and medical claims within the limits and exceptions provided by law. You must make a written

request. Upon receipt of your request, we will have thirty (30) days to do any of the following activities:

request for additional time

provide the requested information or allow you to examine your information during working hours

inform you that we do not have the requested information, in which case, we will orient you where to

find it if we know the source

deny the request, partially or in its entirety, because the information originates from a confidential

source or was compiled in anticipation of a legal proceeding, investigations by law enforcement


agencies or the anti-fraud unit or quality assurance programs which disclosures are prohibited by law.

We will notify you in writing the reasons for the denial, except in the event there’s an ongoing

investigation or in anticipation of a legal proceeding.

The first report will be free of charge, but we may charge you reasonable, cost-based fees for subsequent

reports. If you request the report in a special format, you may have to pay an additional charge.

Disclosure Accounting: You have the right to a list of instances after April 14, 2003, in which we disclose

your protected health information for purposes other than treatment, payment, health care operations, as

authorized by you, and for certain other activities.

The report will provide the name of the entity to which we disclosed your information, the date and purpose of

the disclosure and a brief description of the data disclosed. If you request this accounting more than once

during a 12-month period, we may charge you a reasonable, cost-based fee for responding to your additional

requests. The report only covers the last six (6) years.

Amendment: You have the right to request that we amend your medical information. Your request must be in

writing, and it must include explanation and justification. Once the request is received, we will execute within

60 days. If additional time is needed, we will send a written request soliciting an additional period of 30 days.

If we deny your request, we will provide you with a written explanation. You have the right to send a statement

of disagreement and demand it be included with our determination for any future disclosures. If we accept your

request, we will make your amendment part of your record and use reasonable efforts to inform our business

associates and others that may have access to your original medical information.

Restriction: You have the right to request that we restrict the use or disclosure of your medical information.

However, we are not required to agree to your request, if such disclosure may put your life at risk, as in a case

of domestic violence. The only exceptions of not abiding to our agreement are for medical emergency cases

or as required or authorized by law. Any agreement we make to restrict the use or disclosure of your medical

information, must be in writing and signed by an authorized officer.

Confidential Communication: You have the right to request that any communication regarding your medical

information be performed in a confidential setting by alternative means, or be sent in a confidential manner to

alternate locations if you understand your life may be at risk. You must make the request in writing, and must

include that any communication if not received in a confidential setting, could endanger you or your

dependents.

We will accommodate your request, if reasonable, and if it specifies the alternate means or location for this

confidential communication. Also your request will be accepted if there is a continuance to permit us to collect

premiums and pay claims under your health plan, including issuance of explanations of benefits to the primary

insured.

Business closure: In the event of business closure, we will communicate with you to let you know how to

obtain your claims history and any other information.

Notice of security breaches in which your health information may be at risk: You are entitled to be

notified by any means if the security breach is the result of not having your information secured by

technologies or methodologies approved by the Department of Health and Human Services.

Electronic Notice: If you receive this notice on our web site (www.ssspr.com) or by e-mail, you are entitled to

receive this notice in written form.

Non-Discrimination Clause

Triple S Salud, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of

race, color, national origin, age, disability, or sex. Neither do we exclude people or treat them differently

because of race, color, national origin, age, disability, or sex.



Triple S Salud, Inc. provides free aids and services to people with disabilities to communicate effectively with

us, such as:

Sign language interpreters

Written information in other formats such as, documents in large print, or audio, or other accessible

electronic formats.

Triple S Salud, Inc. provides free language services to people whose primary language is not English, such

as:

Language interpreters

Information in other languages.

If you believe that Triple S Salud, Inc. has failed to provide these services or discriminated in another way on

the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person or by mail, fax

or e-mail with:

Compliance and Privacy Office

Phone: (787) 277-6686

Fax: (787) 706-4004

E-mail: [email protected]

Address: P. O. Box 363628, San Juan, PR 00936-3628

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for

Civil Rights, electronically, by phone or by mail:

U.S. Department of Health & Human Serv

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Phone: 1-800-368-1019

TDD: 1-800-537-7697

Address: 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We will not retaliate in any way if you choose to file a complaint with us or with the DHHS.

Questions: For more information about our privacy practices or if you have questions or concerns, please

contact us. All the forms to exercise your rights are available at: www.ssspr.com.

If you are concerned that we or any of our business associates may have violated your privacy rights, or you

disagree with a decision we made about access, use or disclosure of your health information, you may

complain to us by using the contact information:

Compliance and Privacy Office

Phone: (787) 277-6686

Fax: (787) 706-4004

E-mail: [email protected]

Address: P. O. Box 363628, San Juan, PR 00936-3628

You also may submit a written complaint to the Office for Civil Rights (OCR) of the United States Department

of Health and Human Services (DHHS) at:

Region II, OCR, US DHHS

Voice Phone: (212) 264-3313

Fax: (212) 264-3039

TDD: (212) 264-2355

Address: Jacob Javitz Federal Bldg, 26 Federal Plaza, Ste 3312, New York, NY 10278

Si interesa recibir copia de este aviso en español, visite nuestra página:

http://www.ssspr.com/politica-de-privacidad/


http://www.ssspr.com/politica-de-privacidad/


Triple-S Salud, Inc. San Juan, Puerto Rico

Independent Licensee of the Blue Cross Blue Shield Association

MEDIGAP POLICY QUESTIONNAIRE

Name of applicant: Social Security No.:

This questionnaire complements the information included in the Medigap policy enrollment form. The applicant must read all the information carefully and fill out the required information

You do not need to have a supplementary policy to Medicare. If you are 65 or more years of age, you may be

eligible for Medicaid benefits and probably, you will not need a supplementary policy to Medicare.

Premiums and benefits corresponding to the Medicare supplementary policy will be suspended for a period of 24

month while you are eligible for Medicaid benefits. You must request the suspension of your policy within the 90

days following the date of eligibility to Medicaid. When your eligibility under Medicaid ends, you may request the

reactivation of your Medicare supplementary policy within 90 days following the termination of your eligibility to

Medicaid.

You may receive orientation on Medicare supplementary policies at the offices of Triple-S Salud. Orientation on

Medicaid may be obtained at the certifying units located within the facilities of Area Hospitals, Medical Centers or

Diagnostic and Treatment Centers of the Puerto Rico Health Department.

To the best of your knowledge:

1 Do you have another Medicare supplementary policy (including a health care service contract) or with an HMO? Yes ( ) No ( )

If your answer is Yes, indicate the name of the company. ______________________________________________________________________

2 Do you have other health insurance policies that provide benefits that are also covered by the Medicare supplementary policy? Yes ( ) No ( )

a) If your answer is Yes, indicate the company _______________________

b) What type(s) of policy(cies)? ______________________________________________________________________

3 If you answered Yes to questions 1 and 2, Are you interested in replacing said health policies with a

Medigap policy? Yes ( ) No ( ). If you answered Yes, read carefully the Notice to Applicant on the Replacement of a Medicare Supplementary Policy.

4 Are you covered by Medicaid? Yes ( ) No ( )

_____________________________ Applicant’s Signature

_____________________________

Date

NOTE: IF THE POLICY IS ACQUIRED THROUGH AN AUTHORIZED REPRESENTATIVE, BROKER OR ANY

OTHER REPRESENTATIVE, THE AUTHORIZED REPRESENTATIVE, BROKER OR OTHER REPRESENTATIVE

MUST COMPLETE THE INFORMATION ON THE BACK OF THIS FORM AND YOU (THE APPLICANT) MUST

SIGN IT ON THE BACK ALSO.



Independent Licensee of the Blue Cross and Blue Shield Association

MEDIGAP POLICY QUESTIONNAIRE


5. The Authorized Representative, Broker or any other Representative must indicate below other health

insurance policies he/she had sold to the applicant:

a) Policies sold by the Producer or Other Representative ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

b) Policies sold by Producer or other Representative during the past 5 years that are not active at the moment

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

__________________________________________ Signature of Producer or Other Representative,

__________________________________________

Type Name and Address of Producer or Other Representative

__________________________________________

Applicants Signature

__________________________________________ Date


Triple-S Salud, Inc. PO BOX 363628

San Juan, Puerto Rico, 00936-3628 Independent Licensee of the Blue Cross and Blue Shield Association

NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENTARY POLICY


KEEP THIS NOTICE. IT MAY BE USEFUL TO YOU IN THE FUTURE.

According to the information furnished by you, you intend to lapse or otherwise terminate your present Medicare

supplementary policy and replace it with this policy to be issued by Triple-S Salud. Your new policy will provide a

30-day free look period, within which you may decide without cost whether you desire to keep the policy. You should review this new coverage carefully. Compare it with all accident and sickness coverage you now

have. If, after due consideration, you find the purchase of this new Medicare supplementary policy is a wise

decision, you should terminate your present Medicare supplementary policy and evaluate the need for other

accident and sickness coverage you have that may duplicate this policy.

__________________________________________ Signature of Producer or Other Representative

__________________________________________

Typed Name and Address of Producer or Other Representative

__________________________________________ Applicants Signature

__________________________________________

Date



Independent Blue Cross and Blue Shield Association

STATEMENT TO APPLICANT BY ISSUER OR PRODUCER


I have reviewed your current insurance coverage. To the best of my knowledge, this policy will not duplicate

your existing coverage. The replacement policy is being purchased for the following reason(s) (check one):

□ Additional benefits

□ No change in benefits, but lower premiums

□ Fewer benefits and lower premiums

□ Other (please specify)

_______________________________________________________________________________

Health conditions which you may presently have (preexisting conditions) may not be immediately or fully

covered under the new policy. This could result in denial or delay of claim for benefits under the new policy,

whereas a similar claim may have been payable under your present policy.

State law provides that your replacement policy may not contain new preexisting conditions, waiting periods,

elimination periods or probationary periods. Triple-S Salud will waive any time periods applicable to preexisting

conditions, waiting periods or probationary periods for similar benefits in the new policy to the extent such time

was depleted under the original policy.

If, you wish to terminate your present policy and replace it with new coverage, be certain to truthfully and

completely answer all questions on the application concerning your medical and health history. Failure to

include all material medical information on an application may provide a basis for the company to deny any

future claims and to refund your premium as though your policy has never been in force. After the application

has been completed and before you sign it, review it carefully to be certain that all information has been

properly recorded.

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.

__________________________________________ Signature of Producer or Other Representative*

__________________________________________

Typed Name and Address of Producer or Other Representative

__________________________________________ Applicants Signature

__________________________________________

Date

Welcome to Triple-S Salud, Inc. Our priority is to serve ......All, but $1,316 All, but $329 a day...

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Transcript of Welcome to Triple-S Salud, Inc. Our priority is to serve ......All, but $1,316 All, but $329 a day...