How do I sign up for the Vital Plan?

Anyone who wants to know if they can sign up for the Vital Plan, can visit their local Medicaid Office. They will evaluate at the person’s information and tell them if they are eligible for the Vital Plan.

To find out where your Medicaid Office is, call the Medicaid Program Call Center at (787) 641-4224. The call is free, or visit the website www.medicaid.pr.gov.

What if I have a newborn?

If you have a newborn, visit your Medicaid Office and bring them a copy of the newborn’s birth certificate to enroll the newborn in the Vital Plan. If you do not do this, the newborn cannot get services under the Vital Plan. When you have a newborn, you also might be able to get other benefits, it is important to visit the Medicaid Office they will offer additional information.

How do I keep my Vital Plan benefits?

To keep your Vital Plan benefits, you have to go to all your Medicaid appointments. First Medical will send you a letter, ninety (90) days, sixty (60) days and thirty (30) days before the day when your Vital Plan benefits stop. These letters will remind you that you have to go to your local Medicaid Office to maintain your eligibility in the Vital Plan.

If you miss your appointment, call the Medicaid Program Call Center at (787) 641-4224, or visit your local Medicaid Office to ask for a new appointment.

How do I choose an Insurer?

Once you sign up for the Vital Plan, you can choose your Insurer. Your Insurer will work with you and your doctors to keep you healthy.

There is an Enrollment Counselor available in Medicaid Offices and on the phone that can help you choose an Insurer. The Enrollment Counselor does not work for any Insurer or any providers. They are neutral. They can give you information about the Vital Plan and your benefits. They can tell you about the choices available to you and help answer your questions. They can’t choose for you.

They can help you:

• Choose a new Insurer or change Insurers.
• If you change your Insurer, they can also help you change your Primary Care Physician (PCP) or Primary Medical Group (see more information in Part 2 of your Beneficiary Manual).

You can contact the Enrollment Counselor for support:

• Calling at 1-833-253-7721, Monday through Friday, 8:00 a.m. to 6:00 p.m. TTY/TDD Spanish users should call at 1-866-280-2050, and for TTY/TDD English users should call at 1-866-280-2053.
• Visit the Medicaid Offices.

There are Enrollment Counselor staffs in each Medicaid Offices. The offices are open Monday through Friday from 7:30 a.m. to 4:00 p.m. First Medical can tell you the Medicaid Office that is closest to you.

If you do not choose an Insurer, one will be chosen for you.

Can I change my Insurer?

Yes, you can ask to change your Insurer. Once you have chosen an Insurer or one has been chosen for you, you have ninety (90) days to change your Insurer. You can also change your Insurer once a year during the “Open Enrollment Period”, which is from November 1 to January 31.

If you want to change your Insurer, call the Enrollment Counselor at 1-833-253-7721, Monday through Friday, 8:00 a.m. to 6:00 p.m. TTY/TDD Spanish users should call at 1-866-280-2050, and for TTY/TDD English users should call at 1-866-280-2053 or visit your local Medicaid Office. You can also visit the webpage www.planvitalpr.com.

You can also ask to change your Insurer at any time if you have certain reasons, like:

• You are not able to access services or providers.
• You cannot get all related services that you need at one time from the doctors, healthcare professionals and service facilities that work with your Insurer.
• You get poor-quality care.
• You ask for a service that your Insurer does not cover because of moral or religious reasons.
• Your Insurer does not have doctors that are experienced in dealing with your health care needs.

If you want to change your Insurer for one of these reasons, you can ask for this change from the Enrollment Counselor or ASES. ASES will decide if you can change your Insurer or if you have to wait until Open Enrollment Period. If you do not like the decision ASES makes, you can ask them to reconsider. If the decision is still not to your liking, you can ask for an Administrative Law Hearing.

Can they cancel my membership with First Medical?

Yes, your membership with First Medical will be canceled if you:

• Lose eligibility for the Vital Plan.
• Move outside of Puerto Rico.
• Go to prison.
• Give your ID card to someone else to use.
• Move to a long-term care nursing facility or intermediate care facility for the developmentally disabled.

You will not lose your membership with First Medical if:

• You have changes in your health.
• You are using more health care services.

You also might want to stop your membership with First Medical if you no longer need your Vital Plan benefits. If this happens, let your Medicaid Office and First Medical know.

How do I report changes?

The Vital Plan and First Medical are committed to helping you. To support your needs, we need your help.

Please remember to let your Medicaid Office and First Medical know of any changes that may affect your membership or benefits. Some examples include:

• You are pregnant.
• You have a newborn.
• You have changes in your family group (for example, you get married, someone in your family dies, or someone in your family reaches age twenty-one (21)).
• You move or your phone number changes.
• You or one of your children has other health insurance.
• You have a special medical condition.
• You move outside of Puerto Rico.
• Your income changes (for example, you lose your job or get a new job).

To report a change, call the Medicaid Program Call Center at (787) 641-4224, or visit your local Medicaid Office.

It is important to make sure your contact information is up to date with your local Medicaid Office. This is important because Medicaid and First Medical send you important information about your Vital Plan coverage and benefits in the mail. If they don’t have your current address, you could lose your Vital Plan benefits. To report a change or help, call First Medical at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805, or visit your local Medicaid Office.

Your ID Card

Everyone in the Vital Plan has an ID card. This is an example of what it looks like:

Each insured person in your family will have his/her own ID card, even if he/she is a newborn. Your ID card has important information like:

• Your first and last name.
• Your ID number (MPI).
• How to access emergency services.
• Copayment that you will pay for health services.
• First Medical free phone number (on the back of your card).
• The phone number for the free Vital Plan Service Line and the 24/7 Toll-Free Vital Plan Medical Advisory Line (on the back of your card).

If you need to use your health benefits before you get your ID card, use your Notice of decision form given to you by your Medicaid Office.

Remember:

• Always carry your ID card with you.
• Keep your ID card in a safe place so you don’t lose it.
• Take your ID card when you go to the doctor or to the emergency room.
• Be sure they give you your ID card back.

Your ID card is only for you. Don’t let anyone else use your card. If your card is lost or stolen, you can ask First Medical for a new card. You can visit First Medical Service Offices or call them at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805. The phone call is free.

Beneficiary Manual

The Health Insurance Administration (ASES, for its Spanish acronym) has developed this Uniform Guide to informed you about the use of benefits that provide the Government Health Plan of Puerto Rico. This way you can have available the information you need regardless of the company that provides your healthcare services.

If you need a copy of the Beneficiary Manual, please feel free to contact First Medical Customer Service at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805, Monday through Friday from 7:00 a.m. to 7:00 p.m. First Medical will send you free of charge, the Beneficiary Manual in five (5) business days from the date of your request.