Enrollment

You are eligible for membership in our plan as long as:

1. 1 You live in our geographic service area
2. 2 You have both Medicare Part A and Part B
3. 3 You meet the eligibility requirements to enroll in a special needs plan / if applicable.

Important Information About the Enrollment Periods

Instructions to fill out the Triple-S Advantage Enrollment Form

• Please read this information carefully, write clearly, press hard, and use only blue or black ink
• Write the numbers and uppercase letters legibly in the boxes
• Write only one letter per box
• If you make a mistake, write in the space above or below
• When writing dates, use the month/day/year format. No need to include dashes or blank spaces
• Select the Plan you want to enroll in
• Complete your personal information as it appears on your Medicare Card (name, Medicare number, effective date of Medicare Part A and/or B, etc.). If your home and/or mailing address is different from the one on your Medicare Card, make sure to include your current address not the one on your Medicare Card
• Select your preferred payment method (if applicable)
• Provide the information of any other health plan you may have (if any)
• Read the terms and conditions
• Verify that you have completed all the information in the application
• Sign and date the enrollment form
• Keep a copy for your reference
• Mail or fax the form to the provided address/fax number

If you have any questions regarding the Enrollment Form or the enrollment process, please contact our Customer Service Department.

Disenrollment

Member and Plan Rights and Responsibilities upon Disenrollment
If you are a member of Triple-S Advantage and wish to disenroll from the Plan, you should contact our Customer Service Department to receive a complete orientation of the disenrollment process. To disenroll, you must send a written request for disenrollment, including your reason to disenroll. It is important that this request is signed by the member or his/her authorized representative.

Types of Disenrollment

If you decide to change over to Original Medicare, you might be temporarily entitled obtain a Medigap policy (Medicare supplemental insurance), even if you have health problems. For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months, or if you move out of the service area, you may have this special right. Federal law requires the aforementioned protections to be available. Puerto Rico may have other laws that provide more Medigap protections.

If you have questions about Medigap or Medigap Rights in Puerto Rico, you may contact your State Health Insurance Program (SHIP), the Oficina del Procurador de Personas de Edad Avanzada, at 787-721-6121. You may also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week for more information. TTY/TDD users should call 1-877-486-2048.

Organization Determinations

The initial precertification determination is the starting point for addressing requests for coverage of health services that the member needs. Although certain services require prior authorization, there are organization determinations that are not subject to that requirement. All these determinations are processed by the Triple-S Advantage Clinical Operations team, in compliance with current regulations and requirements. In this way, we ensure that both requests requiring prior authorization and those that do not are handled appropriately and in accordance with established guidelines.

Who can request an Initial Determination?

The member, their physician, or any person the member designates as an authorized representative can request an initial determination. This means you can choose a relative, friend, caregiver, physician, or any other person to act on your behalf. If this person is not already authorized by state laws, the member and that person must sign and date an appointment of representative form. This way, that person will have legal permission to officially represent you.

What do I need to request an Initial Determination?

The minimum requirements to process your request are:

• Full name
• Contract number
• Medical order (including date, signature, and license number of the ordering physician)
• Clinical justification for the requested service
• Diagnosis, procedure, and service codes
• Results of previous studies or laboratories (if applicable)
• Referrals (if applicable)

All this information must be sent by fax to one of the following numbers send the order via facsimile to TSA (787-620-0925 or 0926).

What is the Initial Determination process?

Once your physician determines medical necessity for a particular study, service, or procedure that the member needs, they will send the order via facsimile to TSA (787-620-0925 or 0926). Our Triple S Advantage clinical staff will review and process the request and, if additional information is required, our clinical staff will contact the physician and the member.

Some criteria used when evaluating your precertification request:

• The severity of the condition
• The appropriateness of the services
• The medical justification for the requested service
• Results of studies and laboratories relevant to the requested service
• Clinical guidelines based on medical evidence
• Internal medical policies

To meet prior authorization requirements, we rely on various guidelines and regulations. We use National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), as well as Traditional Medicare laws in our region. We also evaluate whether the requested service is reasonable and necessary for your diagnosis or treatment, taking into account your medical history, health status, clinical notes, and your physician’s recommendations.

If there are no specific coverage criteria in laws or regulations, Medicare Advantage (CMS) allows us to create internal policies based on medical evidence. In addition to our own policies, we can use recognized guidelines, such as InterQual criteria or other guidelines from private agencies, government agencies, or professional organizations.

All clinical guidelines we use are publicly available on the Triple-S portal, so that both members and providers can easily consult them.

If it is the member who requests an expedited initial determination without the support of a physician, we will evaluate whether their health requires an expedited initial determination according to the severity of the patient’s condition.

If we determine that your medical condition does not meet the requirements for an initial determination, we will send you a letter informing you how to file a grievance. You have the right to file a grievance if you do not agree with our decision not to consider your request.

When the service meets the criteria, once authorized, the member is contacted by phone and the letter is sent by portal mail. In addition, the authorization letter is sent to the provider via fax or postal mail. The precertification will be valid for a determined time according to the type of service.

If the request is not approved, the member will receive a letter with the reasons and information about their right to appeal.

Triple S will inform you of its determination as soon as your health condition requires, and in no case later than 72 hours for expedited (urgent) cases or 7 days for standard cases. For other items and/or services that do not require prior authorization, notification will be made within a maximum of 14 days. And for medications covered under Part B, we will notify you within a maximum of 72 hours for standard requests, and within 24 hours for expedited (urgent) cases.

Payment Dispute for Non-Contracted Providers

A payment dispute is a disagreement between a non-contracted provider and the Medicare Advantage Organization about the amount or level paid for a service covered by Medicare. The non-contracted provider will have 120 days from the initial determination to request the dispute.

What do you need to do to request a payment dispute?

The non-contracted provider can request the dispute by sending the following forms with the necessary documentation to the following address:

Non-Participating Provider Dispute Form
Waiver of Liability

Triple-S Advantage, Inc.
Claims Department
Re: Provider Payment Dispute
PO Box 11320
San Juan, Puerto Rico 00922-1320

Payment Reconsideration Request for Non-Participating Providers

What do you need to do to request payment reconsideration?

The non-contracted provider can request a payment reconsideration 60 days from the date of payment or denial, by sending the following forms with the necessary documentation to the following address:

Reconsideration Letter
Waiver of Liability

Triple-S Advantage, Inc.
Grievances & Appeals Unit
Re: Payment Reconsideration-Non-Participating Providers
PO Box 11320
San Juan, Puerto Rico 00922–1320

Fraud, waste, and abuse

Health insurance fraud, waste, and abuse affect us all. Help us detect it!

Fraud, waste, and abuse affect you as a plan beneficiary, as well as health plans and service providers. Health resources are sometimes limited, and it is important that they be used appropriately. Using resources inappropriately may result in a lower quality of medical services.

Therefore, it is important that any illegal or fraudulent act is reported immediately.

Code of Business Conduct and Ethics

Grupo Triple-S has a Code of Business Conduct and Ethics, which establishes the Corporation’s commitment to ethics and compliance with federal laws and regulations and the Commonwealth of Puerto Rico. In addition, it describes compliance expectations for all employees, members of the Board of Directors, subcontracted and related entities.

Read the Code of Business Conduct and Ethics, it guides you to know what to do in situations of compliance, fraud, waste or abuse.

Code of Business Conduct and Ethics

If you are aware or suspect of compliance, fraud, waste or abuse situation, contact the Triple-S Advantage Compliance Department through the following effective lines of communication:

Email: moc.e1771408798gatna1771408798vdass1771408798s@ecn1771408798ailpm1771408798oCAST1771408798
Ethics Point (Available 24 hours / 7 days a week)

1-866-384-4277
secure.ethicspoint.com

Triple-S will not discriminate or permit retaliation or intimidation against any person who conducts a report in good faith or participates in an investigation into violations of the Code of Business Conduct and Ethics.

NOTICE INFORMING INDIVIDUALS ABOUT NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS AND NONDISCRIMINATION STATEMENT

 

Discrimination is Against the Law

 
Triple-S Advantage, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex (consistent with the scope of sex discrimination described at 45 CFR § 92.101(a)(2)). Triple-S Advantage, Inc. does not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.

Triple-S Advantage, Inc.:

• Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language assistance services to people whose primary language is not English, which may include:
  • Qualified interpreters
  • Information written in other languages.

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, contact a Service Representative of Triple-S Advantage.

If you believe that Triple-S Advantage, 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 with:

 

Service Representative
Grievances & Appeals Unit
PO Box 11320,
San Juan, PR 00922-1320
Teléfono: 1-888-620-1919, TTY: 1-866-620-2520
Fax.787-993-3261, e-mail: moc.e1771408798gatna1771408798vdass1771408798s@sec1771408798navei1771408798rg-sl1771408798aeppa1771408798
 

You can file a grievance in person or by mail, fax, or e-mail. If you need help filing a grievance, a Service Representative is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services,
200 Independence Avenue SW
Room 509F, HHH Building
Washington, DC 20201,
1-800-368-1019, 800-537-7697 (TDD)
 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. This notice is available at Triple-S Advantage website: sssadvantage.com.

ATTENTION: If you speak English, free language assistance services are available to you. Appropriate auxiliary aids and services to provide information in accessible formats are also available free of charge. Call 1-888-620-1919 (TTY: 1-866-620-2520).

注意：如果您說[中文]，我們可以為您提供免費語言協助服務。也可以免費 提供適當的輔助工具與服務，以無障礙格式提供資訊。請致電 1-888-620-1919 (TTY: 1-866-620-2520) 。

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. También están disponibles de forma gratuita ayuda y servicios auxiliares apropiados para proporcionar información en formatos accesibles. Llame al: 1-888-620-1919 (TTY: 1-866-620-2520).

 
 
Y0082_25CI098E_C

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice is effective as of February 1, 2026.

We understand the importance of, and are committed to, maintaining the privacy of your protected health information (PHI). PHI is health and nonpublic personal financial information that can reasonably be used to identify you and that we maintain in the normal course of either administering your employer’s self-insured group health plan or providing you with insured health care coverage and other services. PHI also includes your personally identifiable information that we may collect from you in connection with the application and enrollment process for health insurance coverage.

We are required by applicable federal and state laws to maintain the privacy of your PHI. We are also required to provide you with this Notice which describes our privacy practices, our legal duties, and your rights concerning your PHI. We are required to follow the privacy practices that are described in this Notice while it is in effect.

We reserve the right to change our privacy practices and the terms of this Notice at any time and to make the terms of our revised Notice effective for all of your PHI that we either currently maintain or that we may maintain in the future. If we make a significant change in our privacy practices, we will post a revised Notice on our web site by the effective date, and provide the revised Notice, or information about the change and how to get the revised Notice, to covered individuals in our next annual mailing.

How we protect your PHI:

• Our employees are trained on our privacy and data protection policies and procedures.
• We use administrative, physical and technical safeguards to help maintain the privacy and security of your PHI.
• We have policies and procedures in place to restrict our employees’ use of your PHI to those employees who are authorized to access this information for treatment or payment purposes or to perform certain healthcare operations.
• Our corporate Business Ethics, Integrity & Compliance division monitors how we follow our privacy policies and procedures.

How we must disclose your PHI:

• To You: We will disclose your PHI to you or someone who has the legal right to act on your behalf (your personal representative) in order to administer your ‘Individual Rights’ under this Notice.
• To The Secretary of the Department of Health and Human Services (HHS): We will disclose your PHI to HHS, if necessary, to ensure that your privacy rights are protected.
• As Required by Law: We will disclose your PHI when required by law to do so.

How we may use and disclose your PHI without your written authorization:

We may use and disclose your PHI without your written authorization in a number of different ways in connection with your treatment, payment for your health care, and our health care operations. When using or disclosing your PHI, or requesting your PHI from another entity, we will make reasonable efforts to limit such use, disclosure, or request, to the extent practicable, to the minimum necessary to accomplish the intended purpose. The following are examples of uses and disclosures of your PHI that we may make without your written authorization:

• For Treatment: We may use and disclose your PHI as necessary to aid in your treatment or the coordination of your care. For example, we may disclose your PHI to doctors, dentists, hospitals, or other health care providers in order for them to provide treatment to you.
• For Payment: We may use and disclose your PHI to administer your health benefits policy or contract. For example, we may use and disclose your PHI to pay claims for services provided to you by doctors, dentists, or hospitals. We may disclose your PHI to a health care provider or another health plan so that the provider or plan may obtain payment of a claim or engage in other payment activities.
• To Family, Friends, and Others for Treatment or Payment: Our disclosure of your PHI for the treatment and payment purposes described above may include disclosures to others who are involved in your care or the administration of your health benefits policy or contract. For example, we may disclose your PHI to your family members, friends, or caregivers if you direct us to do so or if we exercise professional judgment and determine that they are involved in your care or the administration of your health benefits policy. We may send an explanation of benefits to the policyholder, which may include claims paid and other information. We may determine that persons are involved in your care or the administration of your health benefits policy if you agree or fail to object to a disclosure of your PHI to such persons when given an opportunity. In an emergency or if you are incapacitated or not otherwise present, we may disclose your PHI to your family members, friends, caregivers, or others, when the circumstances indicate that such disclosure is authorized by you and is in your best interests. In these situations, we will only disclose your PHI that is relevant to such other person’s involvement in your care or the administration of your health benefits policy.
• For Health Care Operations: We may use and disclose your PHI to support other business activities. For example, we may use or disclose your PHI to conduct quality assessment and improvement activities, fraud and abuse investigations, care coordination or case management, or to communicate with you about health-related benefits, products or services or treatment alternatives that may be of interest to you. We may also disclose your PHI to another entity subject to federal privacy laws, as long as the entity has or had a relationship with you and the PHI is disclosed only for certain health care operations of that provider, plan, or other entity. We may use and disclose your PHI as needed to conduct or arrange for legal services, auditing, or other functions. We may use and disclose your PHI to perform underwriting activities; however, we are prohibited from using or disclosing your genetic information for underwriting purposes.
• To Business Associates for Treatment, Payment or Health Care Operations: Our use of your PHI for treatment, payment, or health care operations described above (or for other uses or disclosures described in this Notice) may involve our disclosure of your PHI to certain individuals or entities with which we have contracted to perform or provide certain services on our behalf (“Business Associates”). We may allow our Business Associates to create, receive, maintain, or transmit your PHI on our behalf in order for the Business Associate to provide services to us, or for the proper management and administration of the Business Associate or to fulfill the Business Associate’s legal responsibilities. These Business Associates include lawyers, accountants, consultants, claims clearinghouses, and other third parties. Our Business Associates may re-disclose your PHI to subcontractors in order for these subcontractors to provide services to the Business Associates. These subcontractors will be subject to the same restrictions and conditions that apply to the Business Associates. Whenever such arrangement with a Business Associate involves the use or disclosure of your PHI, we will have a written contract with our Business Associate that contains terms designed to protect the privacy of your PHI.
• For Public Health and Safety: We may use or disclose your PHI to the extent necessary to avert a serious and imminent threat to the health or safety of you or others. We may also disclose your PHI for public health and government health care oversight activities and to report suspected abuse, neglect, or domestic violence to government authorities.
• As Permitted by Law: We may use or disclose your PHI when we are permitted to do so by law.
• For Process and Proceedings: We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process.
• Criminal Activity or Law Enforcement: We may disclose your PHI to a law enforcement official with regard to crime victims and criminal activities. We may disclose your PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public. We may also disclose your PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
• Special Government Functions: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (i) for activities deemed necessary by appropriate military command authorities; (ii) for the purpose of determination by the Department of Veterans Affairs of your eligibility for benefits; or (iii) to foreign military authorities if you are a member of that foreign military service. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including the provision of protective services to the President or others legally authorized to receive such governmental protection.
• Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you.
• To Plan Sponsors, if applicable (including employers who act as Plan Sponsors): We may disclose enrollment and disenrollment information to the plan sponsor of your group health plan. We may also disclose certain PHI to the plan sponsor to perform plan administration functions. We may disclose summary health information to the plan sponsor so that the plan sponsor may either obtain premium bids or decide whether to amend, modify or terminate your group health plan. Please see your plan documents, where applicable, for a full explanation of the limited uses and disclosures that the plan sponsor may make of your PHI in providing plan administration functions for your group health plan.
• For Coroners, Funeral Directors, and Organ Donation: We may disclose your PHI to a coroner or medical examiner for identification purposes, determining cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.
• Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research purposes and established protocols to ensure the privacy of your PHI, or as otherwise permitted by federal privacy law.
• Fundraising: We may use your PHI to contact you in order to raise funds for our benefit. You have the right to opt out of receiving such communications.
• Limited data sets and de-identified information: We may use or disclose your PHI to create a limited data set or de-identified information, and use and disclose such information as permitted by law.
• For Workers’ Compensation: We may disclose your PHI as permitted by workers’ compensation and similar laws.

Uses and disclosures of PHI permitted only after authorization is received:

We will obtain your written authorization, as described below, for: (i) uses and disclosures of your PHI for marketing purposes, including subsidized treatment communications (except for certain activities otherwise permitted by federal privacy law, such as face-to-face communications or promotional gifts of nominal value); (ii) disclosures of your PHI that constitute a sale of PHI under federal privacy law and that requires your authorization; and (iii) other uses and disclosures of your PHI not described in this Notice.

There are also other federal and state laws that may further restrict our disclosure of certain PHI (to the extent we maintain such information) that is deemed highly confidential.

Our intent is to meet the requirements of these more stringent privacy laws and we will only disclose this type of specially protected PHI with your prior written authorization except when our disclosure of this information is permitted or required by law.

Substance Use Disorder Treatment Records:

As provided for under federal law, we will not use or disclose the content of your protected substance use disorder treatment records in civil, criminal, administrative, or legislative proceedings against you without your written consent or a subpoena or other legal mandate that is accompanied by a special court order providing you or the holder of the record with an opportunity to be heard.

Authorization:

You may give us written authorization to use your PHI or disclose it to anyone for any purpose not otherwise permitted or required by law. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. In the event that you are incapacitated or are otherwise unable to respond to our request for an authorization, (for example, if you are or become legally incompetent), we may accept an authorization from any person who is legally authorized to give such authorization on your behalf. If you share your PHI with persons outside of our company your PHI may not be subject to state or federal privacy laws restricting its use or disclosure.

Individual Rights:

To exercise any of these rights, please call the customer service number on your ID card.

• Access: With limited exceptions, you have the right to inspect or obtain copies of your PHI. We may charge you a reasonable fee as permitted by law. We will provide you a copy of your PHI in the form and format requested, if it is readily producible in such form or format or, if not, in a readable hard copy form or such format as agreed to by you and us. Where your PHI is contained in one or more designated record sets electronically, you have the right to obtain a copy of such information in the electronic form and format requested, if it is readily producible in such form and format; or if not, in a readable electronic form and format as agreed to by us and you.
• Amendment: With limited exceptions, you have the right to request that we amend your PHI.
• Disclosure Accounting: You have the right to request and receive a list of certain disclosures made of your PHI. If you request this list more than once in a 12-month period, we may charge you a reasonable fee as permitted by law to respond to any additional request.
• Use/Disclosure Restriction: You have the right to request that we restrict our use or disclosure of your PHI for certain purposes. We are required to agree to a request to restrict the disclosure of your PHI to a health plan if you submit the request to us and: (i) the disclosure is for purposes of carrying out payment or health care operations and is not otherwise required by law; and (ii) the PHI pertains solely to a health care item or service for which you, or a person on your behalf other than the health plan, has paid the covered entity out-of-pocket in full. We may not be required to agree to all other restriction requests and, in certain cases, we may deny your request. We will agree to restrict the use or disclosure of your PHI provided the law allows and we determine the restriction does not impact our ability to administer your benefits. Even when we agree to a restriction request, we may still disclose your PHI in a medical emergency and use or disclose your PHI for public health and safety and other similar public benefit purposes permitted or required by law.
• Confidential Communication: You have the right to request that we communicate with you in confidence about your PHI at an alternative address. When you call the customer service number on your ID card to request confidential communications at an alternative address, please ask for a “PHI address.”
  Note: If you choose to have confidential communications sent to you at a PHI address, we will only respond to inquiries from you. If you receive services from any health care providers, you are responsible for notifying those providers directly if you would like a PHI address from them.
• Privacy Notice: You have the right to request and receive a copy of this Notice at any time. For more information or if you have questions about this Notice, please contact us using the information listed at the end of this Notice.
• Breach: You have the right to receive, and we are required to provide, written notification of a breach where your unsecured PHI has been accessed, used, acquired, or disclosed to an unauthorized person as a result of such breach, and which compromises the security or privacy of your PHI. Unless specified in writing by you to receive the notification by electronic mail, we will provide such written notification by first class mail or, if necessary, by such other substituted forms of communication permitted under the law.
• Paper Copy: You have the right to receive a paper copy of this Notice, upon request, even if you have previously agreed to receive the Notice electronically.

Complaints:

If you are concerned that we may have violated your privacy rights, you may complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address for the U.S. Department of Health and Human Services upon request.

We support your right to protect the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Office: Compliance Department
Attention: Privacy Officer
Phone Number: (787) 620-1919
Fax: (787) 993-3260
E-mail: moc.r1771408798psss@1771408798ecnai1771408798lpmoc1771408798aapih1771408798
Address: P. O. Box 11320 San Juan, PR 00922

Si usted desea una copia de esta notificación en español, por favor comuníquese con un representante de servicio al cliente utilizando el número telefónico indicado en su tarjeta de asegurado.

Triple-S Advantage, Inc. is an independent Licensee of the Blue Cross and Blue Shield Association.

Triple-S Advantage Inc. cumple con las leyes federales aplicables de derechos civiles y no discrimina en base a raza, color, origen de nacionalidad, edad, discapacidad, o sexo.

Triple-S Advantage Inc. 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。

Triple-S Advantage Inc. complies with applicable Federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, or sex.

ATENCIÓN: si usted habla español, servicios de asistencia lingüística están disponibles libre de cargo para usted. Llame al: 1-888-620-1919 (TTY: 1-866-620-2520). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務 。請致電1-888-620-1919 (TTY: 1-866-620-2520) 。

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-620-1919 (TTY: 1-866-620-2520).

What is the Medicare Star Rating?

Every year, the Centers for Medicare and Medicaid Services (CMS) complete a performance evaluation of all health plans offering Medicare Advantage coverage. CMS gives the plans a score between 1 and 5 Stars, based on the evaluated areas. Some of these areas include:

• How our members evaluate the health plan’s medical and health care services
• How well preventive care and condition management is provided
• How well the plan helps members with their prescription drugs

This assessment is divided into Health Services and Drug Services, obtaining an overall result between the two. This score can vary from year to year, and it greatly depends on member adherence to their health care and medical treatment.

How can I help my plan improve its Stars?

An important part of the Star Rating is the member’s adherence to preventive tests, management of existing conditions, and adequate drug use. We advise you to talk with your primary care doctor or a trusted physician to get these tests done. Your doctor can help you find alternatives to manage your health conditions.

What are preventive tests?

Preventives measures are a series of health indicators that we all must comply with to stay healthy.
These measures fluctuate according to age, gender and existing health conditions.
Complying with preventive measures on time helps your health conditions under control and live with a better quality of life.

Preventive tests for women:

• Preventive measure: Breast Cancer Screening
  Test: Mammography
  Who should have this test: Women between 40 and 74 years old
  Frequency: Every two years

• Preventive measure: Osteoporosis Management in Women Had a Fracture
  Description: Bone Density Test
  Who should have this test: Women 67-85 years of age or after a fracture (within the first six months)
  Frequency: Every two years

Preventive measures:

• Preventive measure: Colorectal Cancer Screening
  Test: May be one of the following:
  • Fecal Occult Blood (once a year)
  • Sigmoidoscopy (every five years)
  • Colonoscopy (every ten years)

  Who should have this test: Anyone from 45 to 75 years old

• Preventive measure: Flu Vaccine
  Description: Vaccine to prevent the spread of influenza
  Who should be vaccinated: Everyone over 50 years of age
  Frequency: Once a year

Preventive tests for patients with diabetes:

• Preventive measure: Glycemic Status Assessment for Patients with Diabetes (GSD)
  Test: Laboratory blood test (HbA1c)
  Who should have this test: Any person with a diagnosis of type I and type II diabetes; between the ages of 18 to 75 years
  Frequency: Every 3 to 6 months (recommended result: less than 9.0%)

• Preventive measure: Eye Exam for Patients with Diabetes
  Description: Test for the detection of diabetic retinopathy.
  Who should have this test: Any person with a diagnosis of type I and type II diabetes; between the ages of 18 to 75 years
  Frequency: Every year

• Preventive measure: Kidney Health Evaluation
  Description: Kidney function test.
  Test: Blood test and urine test.
  • Estimated glomerular filtration rate test (eGFR)
  • Albumin-creatinine test (uACR)

  Who should have this test: Any person with a diagnosis of type I and type II diabetes; between the ages of 18 to 85 years
  Frequency: Once a year

Remember to talk to your doctor about the following topics:

• Bladder Control Problems (urinary incontinence)
• Preventing Falls
• Recommendations for Physical Activity
• Nutrition
• General Care for Your Physical and Mental Health
• Advance Directives
• Annual physical
• Immunizations
• Laboratory analysis
• Medication reconciliation
• Emergency room visits

Triple-S Advantage may choose to reduce its service area or to not renew its contract with the Centers for Medicare & Medicaid Services (CMS) for the following year. As established by federal law, CMS may also decide not to renew its contract with Triple-S Advantage. This could result in contract termination or non-renewal, which may lead to the termination of a beneficiary’s enrollment in Triple-S Advantage.

All benefits and rules described in you Evidence of Coverage and Summary of Benefits will continue until the end of your membership. This means that you will continue receiving your health care and prescription drug benefits through your plan as usual until your membership ends.

If Triple-S Advantage’s contract with CMS is not renewed or is terminated, Triple-S Advantage will give notice by mail to all affected members prior to the effective date of termination.

Members affected by a non-renewal or contract termination are granted a period of time, known as a Special Enrollment Period (SEP), to choose another Medicare Advantage plan. SEPs are periods outside regular enrollment periods that allow members to change to another plan if they have changes residence or if their current plan has ended.

For additional information, we encourage you to contact our Member Service Center at 1-888-620-1919; Monday through Sunday, from 8:00 a.m. to 8:00 pm. TTY/TDD users should call 1-866-620-2520.

At Triple-S Advantage, we keep you informed about Medicare National and Local Coverage Determinations, which are updates to your coverage made by the Centers for Medicare and Medicaid Services (CMS). Use the following link to access important information about changes and updates.

Important: By clicking this link, you will be redirected to the CMS website.

Medicare Coverage Data Base

Health helpline available 24 hours a day, 7 days a week.
Our TeleConsulta nursing professionals will be happy to answer all your health-related questions.

What kinds of medical questions can I ask TeleConsulta?

• You feel ill, you are experiencing pain, and you do not know what to do.
• You have drug-related questions.
• You want more information about conditions such as asthma, diabetes, and hypertension, among others.
• You have questions about a procedure or routine exam.
• You do not know if you should go to the emergency room, make a medical appointment, or if there is anything you could do to relieve your symptoms at home in a safe and reliable manner.

Your calls to TeleConsulta are toll-free, and you may call from anywhere in Puerto Rico or the United States. The phone number appears on the back of your Triple-S Advantage plan membership card. Remember to have your card at hand when you call TeleConsulta.