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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.
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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***
Remainder 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
Medigap Model FMG 08/92 (Rev. 11/2016)
MODEL B DESCRIPTION
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
SERVICES MEDICARE PAYS MEDICARE MODEL–B
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:
- Additional 365 days
- Beyond the additional 365 days
All, except $1,316
All, except $329 per day
All, except $658 per day
$0
$0
$1,316 (Part A Deductible)
$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
All approved amounts
All, but $164.50 a day
$0
$0
$0
$0
$0
All, but $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 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.
**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.
Medigap Model FMG 08/92 (Rev. 11/2016)
MODEL B DESCRIPTION (CONTINUATION)
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
SERVICES MEDICARE
PAYS
MODEL-B
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 Amounts Approved by Medicare***
Remainder of the Amounts Approved by Medicare
$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 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.
Medigap Model FMG 08/92 (Rev. 11/2016)
MODEL C DESCRIPTION
MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT SERVICES
SERVICES MEDICARE PAYS MODEL-C PAYS YOU PAY
HOSPITALIZATION*
Semiprivate room and board,
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
$1,316 (Part A Deductible)
$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
All approved amounts
All, but $164.50 a day
$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
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 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.
**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.
Medigap Model FMG 08/92 (Rev. 11/2016)
MODEL C DESCRIPTION (CONTINUATION)
MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
SERVICES MEDICARE PAYS MODEL-C 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%
$183 (Part B
Deductible)
Generally 20%
$0
$0
Part B Excess Charges (Above Medicare approved
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
CLINICAL LABORATORY SERVICES
Blood test for diagnostic services
100% $0 $0
PARTS A & B
HOME HEALTH CARE Medicare approved services:
Medically necessary skilled services and medical
supplies.
Durable medical equipment
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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
Medigap Model FMG 08/92 (Rev. 11/2016)
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
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
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/
Medigap Model FMG 08/92 (Rev. 11/2016)
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.
Medigap Model FMG 08/92 (Rev. 11/2016)
Triple-S Salud, Inc. San Juan, Puerto Rico
Independent Licensee of the Blue Cross and Blue Shield Association
MEDIGAP POLICY QUESTIONNAIRE
Name of applicant: Social Security No.:
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
Medigap Model FMG 08/92 (Rev. 11/2016)
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
Name of applicant: Social Security No.:
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
Medigap Model FMG 08/92 (Rev. 11/2016)
Triple-S Salud, Inc. San Juan, Puerto Rico
Independent Blue Cross and Blue Shield Association
STATEMENT TO APPLICANT BY ISSUER OR PRODUCER
Name of applicant: Social Security No.:
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