Rule for Collective Negotiations between Health Providers and Health Plans Enacted
On August 21, 2026, the Puerto Rico Office of the Insurance Commissioner enacted Rule No. 91 (the “Rule”), establishing the rules for collective negotiations among insurers, health service organizations, pharmacy benefit managers, third-party administrators, and health care providers, while imposing safeguards designed to preserve competition, protect patient access to care, and ensure regulatory oversight by the Office of the Commissioner of Insurance.
The Rule applies to insurers, health service organizations, third-party administrators, pharmacy benefit managers, hospitals, health care facilities, authorized groups of providers, provider representatives, health care professionals, and any individual or entity participating in collective bargaining, arbitration, or rate review processes authorized by Chapter 31 of the Puerto Rico Insurance Code. Medicare Advantage plans, Puerto Rico government health plans, and ERISA-covered plans are not covered by the Rule.
Matters that may be addressed through collective negotiations include professional fees, reimbursement rates and methodologies, clinical practice and coverage guidelines, administrative procedures and payment timelines, dispute resolution processes, referral procedures, quality assurance programs, utilization review procedures, and provider selection and contract termination criteria.
The Rule prohibits conduct that may constitute unfair methods of competition or unfair or deceptive acts or practices during collective negotiations. Prohibited conduct includes unreasonable restrictions on the provision of health care services through boycotts, strikes, or other coordinated actions; coercive conduct by insurers or health service organizations against providers during negotiations, including the unjustified withholding of payments, unwarranted audits, or the recoupment of remittances without prior notice; the representation of providers by entities that compulsorily group health care professionals; the unilateral imposition or modification of provider reimbursement rates without the provider’s prior written consent; and provider participation in multiple collective negotiation structures that could create conflicts of interest or overlapping decision-making authority.
To participate in collective negotiations, providers must organize into authorized groups which may not exceed 40% of the providers within a particular specialty in Puerto Rico. Each authorized group must be represented by an authorized representative meeting the eligibility requirements set forth in the Rule.
Before initiating collective negotiations, a provider group must obtain authorization from both the Insurance Commissioner and the Office of Monopolistic Affairs of the Puerto Rico Department of Justice. The Rule provides procedures for situations in which negotiations reach an impasse and establishes mechanisms for terminating or concluding the negotiation process. Agreements reached through collective negotiations must be submitted with the required related documents to the Insurance Commissioner, the Office of Monopolistic Affairs, and the Puerto Rico Department of Health within fifteen (15) calendar days from execution.
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