April 14, 2021

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ASES reaches transition agreement with Molina Healthcare | government

The executive director of the Puerto Rico Health Insurance Administration (ASES), Jorge Galva, announced today that the signing of the transition contract with Molina Healthcare was achieved, which manages to protect the continuity of services to around 100 thousand subscribers of the Puerto Rico Government Plan.

On May 14, Molina informed that he would leave the Vital Plan – where an original number of 168 thousand subscribers remained at the end of May – and would be participating in the Vital Plan until October 31, 2020.

At that time, Galva had reported that none of Molina Healthcare’s subscribers would have interruptions or changes in their benefits and health coverage services, including their previously coordinated medications and clinical procedures.

In addition, by September 14, ASES will assign an insurer where the primary doctor is contracted. Therefore, the beneficiaries will keep the same primary doctor and medical group.

The Secretary of Health, Lorenzo González, said that “now, with the agreement – which has the approval of the Centers for Medicare & Medicaid (CMS) – we increase our guarantees of continuity of care for Vital beneficiaries. As chairman of the ASES board of directors, I appreciate the support of the board members, Molina executives and the ASES team for this achievement. ”

Meanwhile, the executive director of ASES, explained that “the agreement makes the Molina corporation at the central level, which operates and is located in the United States, an unlimited guarantor of the commitments contracted; it is established that by September 15 a restricted reserve equivalent to 125% of pending claims will be established to protect suppliers ”.

In addition, ASES reserves the right to audit the reserve and demand additional capital if the settlement of claims requires it, Galva explained.

Regarding the pending invoices to service providers, Galva showed the agreement where it is added that “Molina committed to maintaining the personnel and resources for the ‘draw out period’, which ends on August 31, 2021 in order to reconcile and pay pending claims ”.

“We also achieved that 70 percent of all clean claims -as defined in article 16 of the contract- will be paid before October 31, 2020. It must be remembered that the selection and change of insurer is a right that you have the beneficiary, who should not be directed in any way by a provider or an insurer ”, added the official.

As an alternative option, beneficiaries who wish to change their insurance company can do so through the portal www.planvitalpr.com available 24 hours a day, seven days a week or by calling the Vital Orientation Center at 1-833-253-7721 from Monday to Friday 8:00 am to 6:00 pm and TTY Service users: (available for audio impaired only ) by dialing 711.

The managed care management organizations (MCO’s) that remain attached to ASES and the approximate number of affiliates are: First Medical, 251,215; MMM, 254,656; Menonita Health Plan, 77,081, and Triple S, 355,230.

The Vital Plan has approximately 1.1 million beneficiaries and the model maintains over five thousand health service providers.

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