Detail Highlights

The Open Enrollment Period is the annual opportunity granted to all beneficiaries of the VITAL Health Plan to make one (1) change of Insurer. This opportunity to change the Insurer will also allow you and your family members to select the primary care physician (PCP) in conjunction with the medical group Primary (PMG) of your choice.

You and your eligible family members can select one of four Insurers that offer the same coverage for medical services throughout the island. Remember that you need to select a primary care physician (PCP) and a primary medical group (PMG) in order to make the desired Insurer change.

Reminder: If you make an Insurer change after the 20th day of the month, that is, from the 21st day of the month until the last day of the month, your new Insurer selection will be valid the first day of the following month.

The following covered benefits will remain the same, regardless of the Insurer you choose, for:

• Dental
• Hospitals
• Mental health services
• Pharmacy
• Physical health services

Specialized care
Beneficiaries who suffer from chronic conditions that cause high costs or high health needs will have access to receive specialized care through a dedicated team of providers focused on managing and treating these conditions:

• Asthma
• Cancer
• Chronic obstructive pulmonary disease
• Diabetes
• End-stage renal disease
• Hypertension and severe heart failure
• Severe emotional disturbances
• Severe mental illness

New Beneficiaries (those who receive their eligibility from November 1 onward)

New beneficiaries who receive their eligibility to the VITAL Health Plan, will have the opportunity to select the Insurer of their choice during the eligibility evaluation appointment conducted by the Medicaid Program. If you do not select an Insurer at your eligibility evaluation appointment, you will be automatically assigned one. However, you will have an opportunity to change the selected or self-assigned Insurer for a period of 90 days, counted from the date of eligibility granted by the Medicaid Program. Once these 90 days have expired, you can only make Insurer changes for Just Cause.

Insurer (MCO)
An Insurer (MCO) is an organization that administers the provision of medical, hospital and dental services in Puerto Rico that has a license to operate as an Insurer contracted for the VITAL Health Plan. The participating Insurers are:

• First Medical Health Plan
• MMM Multi Health
• Plan de Salud Menonita
• Triple-S Salud

Primary Care Physician (PCP)
When you enroll with your Insurer, you must choose a primary care physician or a "primary care physician" (PCP). This will be the main doctor you will see to handle most of your health care. This includes checkups, treatment for colds and flu, health problems and medical exams. Your PCP can find and treat health problems at an early stage. Also, you will have your medical history and you will be able to see the full picture of your health care. Your PCP also keeps track of the health care you need. There are different types of doctors who function as PCPs. These are:

• Family Physicians
• General practitioners
• Geriatrician
• Internists
• Pediatricians

You must choose a PCP for each insured member in your family. Your family members may have different PCPs.

Primary Medical Group (PMG)
Primary Medical Group (PMG) is a group of doctors who help organize your health care services and work with your Insurer to make sure you get the care you need. Your ID card shows the name of your PCP and the number of your Primary Medical Group.

Obstetrician / Gynecologist (OB / GYN)
If you become pregnant, you have the right to choose an obstetrician as your primary care physician. This process can be done directly with your Insurer. If prior to November 1 you were already registered with your obstetrician, you stay with the same doctor.