Program Description

Contracts and negotiates physical, mental, oral health and pharmacy benefit coverage, as established by law, with organizations that are governed by these laws and regulations; known as insurers (MCO's), Mental Health Organizations (MBHO's) and Pharmacy Administrators (PBM). Provides health insurance to qualified government employess, following the directed care model. Currently, the Island has been divided into 8 regions. The organizations that provide health insurance in these regions are: Humana Health Plans of PR (East, Southeast and Southwest), Medical Card System (MCS), (North, Metro-North, San Juan, Northeast and the Virtual Region), physical health care and APS Health Care PR, in mental health (all regions). To offer quality medical services to the population, we have developed a new integrated health care model called My Health.

• Negotiate the best contract with insurers, private entities, community based organizations and health providers to guarantee the best service at the lowest possible cost.

• Facilitate access to health services for a greater number of people by expanding the coverage of the government health insurance and cover the working middle class, small and mid-sized business employees and individuals.

• Establish cost control measures to monitor inadequate use health insurance.

• Develop and maximize services provided by My Health, in order to attain cost stability.

• Strengthen information systems to provide better service to our internal and external clients.

• Oversee funds that the Agency pays insurance companies and funds used for other administrative services. Constantly define and evaluate insurance company and health organization administrative expenses to ensure that they are fair and reasonable in view of the current economic situation.

• Continue negotiations with pharmaceutical companies in order to obtain the best prices and discounts in medications.

• Comply with federal requirements to receive additional funding and identify new funding sources.

• Attain a fairer distribution of premiums and risk.

Statistical Data	2010	2011	2012
Drug Stores	0	865	890
Eligible	1,571,553	1,686,913	1,836,913
Hospitals	316	50	53
Insured	1,243,402	1,583,423	1,633,423
Laboratories	950	534	540
Other	0	1,786	2,000
Primary doctors	0	2,767	2,040
Specialists	2,550	2,413	2,560

*Note: Primary physician includes: generalists, internists, family physicians, pediatricians and obstetricians /gynecologists. Others include: dentists, x-rays, psychiatric centers and hospitals.
The statistical data was provided by the Agency during the Fiscal Year 2011-2012 budget formulation process.

Customers

The general public

Authorized and Proposed Positions	2009	2010	2011	2012
Managerial,Technical, Administrative, and Office Staff	86	75	68	60
Total, Positions	86	75	68	60

FISCAL YEAR 2011-2012 ADOPTED BUDGET

The adopted consolidated budget for Fiscal Year 2011-2012 is $1,994,698,000. The funds include: $3,801,000 from the Joint Resolution, $867,570,000 from Special Appropriations General Fund, $189,300,000 from Other Income and $934,027,000 in Federal General Fund.

Operational Expenses reflect a reduction of $883,000 compared to the funds allocated for Fiscal Year 2010-2011. This reduction will be covered by income generated from medication discounts and rebates.

There is an increase in Federal Grants of $367,329,000 in comparison with the funds received in Fiscal Year 2010-2011. This increase will allow the Administration to insure additional 160,000 customers, change eligibility parameters and implement automatic registry (Auto-Enrollment) where access to medical/hospital services is guaranteed under the My Health coverage for all certified Medicare customers. These funds come from the following federal grants: Title XIX of Medicare, Title XXI of the State Children's Health Insurance Program and Prescription Drug Program Payments. The funds will be used to pay for medical coverage premiums associated with My Health.

Other Income comes from the following contributions: Municipality Income Collection Center, rebates, bank interest and employer payments from public employees that participate in My Health.