The ins and outs of living in Puerto Rico

Triple-S Review

This Triple-S review is based on 4 years of being a client. There has been good things and some bad things, but to be fair, I have to admit that Triple-S has been the only health insurance company I have ever used, so consider this when you are reading the “bad” experiences I write, as I am not sure if the other companies would be any different.

From a client perspective, it seems that just about every doctor or hospital accepts Triple-S Salud insurance. The only providers I have heard not to accept Triple-S has been psychologists and speech therapists (I’m sure there are some other providers that don’t accept it). However, this is normally the case because the providers don’t accept ANY health insurance. They simply don’t want to deal with the paperwork or something. In those cases, usually you have to take a receipt from the provider after you pay and ask for reimbursement from the insurance company.

Now, let’s start with my experience with Triple-S Salud.

I will start with the good things:

-Like I mentioned above, Triple-S is accepted just about anywhere. So rest assured that you will have insurance coverage if something were to happen.

-Depending on your plan, your co-pay should be fairly low, especially if you opt for the generic version of a particular medication.

-Vaccines, preventative care, and routine checkups are all covered; for the most part.

-When our daughter was born, I paid a total of $0 because the insurance covered it all (including the epidural anesthesia). This was particularly exciting because when we had our first child in the US, we had a HUGE bill to pay, we had a nightmare fighting with the insurance company because we couldn’t believe how much they did not cover. So, here in Puerto Rico, we had just about the same hospital experience without the big bill in the end, thank you Triple-S for that.

-Dental, same thing, covering all routine checkups. I think I pay about $11 co-pay per checkup. Pediatric dentistry, at least in my plan, routine checkups for our children are completely covered, I have no co-pay there.

-If I ever need a test or something like an MRI or CT-SCAN, there is no pre-approval needed or anything, I just have it done if the doctor says it is needed, simple.

-So, overall there are some good things to Triple-S, especially when I compare my experience with Triple-S with the experiences I had in the US with insurance companies.

Now to the bad things:

-They have some policy in which some medications are not covered until after you have tried another medication first. So the doctor may prescribe you something and when you go to the pharmacy they will tell you that it is not covered, so you have to go to the doctor again and ask for another medication. This happened to me with Nasonex, for some reason I had to go through Flonase before. The doctor told me that Flonase wouldn’t work as well in my case because of reasons I can’t comprehend, but I tried it anyway, and sure enough it didn’t help very much and it also gave me a post-nasal drip that was annoying to say the least. I actually had to use the neb-machine to help me with the constant coughing that the post-nasal drip was causing. So after all that, then finally I could get the Nasonex.

-I guess they pay the providers very little, although this may be industry-wide, but the doctors won’t stop complaining about how little money they get paid, so they charge you for everything they use, and also they jam-pack their schedules to be able to make some money. That’s why you wait for so long for in the waiting room, there are 5 or 6 people scheduled for the same time as you.

-An example is when someone goes to the pulmonologist,   if the doctor uses a mask for a test or something that can’t be used again, they will charge you for those. So you go in thinking of a $10 co-pay and they charge you $22 for the things they used.

-Another bad thing is when we took our daughter to speech therapy, the therapist did not accept any insurance, so she wrote us a receipt that we paid a certain amount and we had to ask for reimbursement since it is supposed to be covered. Well this is what happened. The therapist charged us $50 per hour, the insurance company told me that $30 per hour is what is customary (is not), and of that there is a $10 co-pay, so we only got back $20 per session. Triple-S also did not cover the initial testing done to our daughter to figure out exactly which needs she had and what should be the game plan, the therapist worked with our daughter for over 3 continuous hours doing these assessments, used a lot of tools and it was a comprehensive report that cost us $250 (honestly it was very good), but the insurance company did not cover that at all, I guess the therapists are supposed to start working on people without a clear understanding of what the person needs.

-They say the “cover” certain things, but they will do EVERYTHING POSSIBLE to NOT cover it when doing reimbursements. I have had a year-long battle with them for reimbursements totaling $650. They simply try to do anything they can for you to get tired of trying. They deny my claim and say that I need “X”, so next time I bring“X”, then they deny it and say that I need “Y”, so I bring them “Y”, guess what, DENIED AGAIN, I need “Z”, I’m like “Why the heck do you need ‘Z’!?”, “oh because it is policy”, why didn’t they tell me that before? I don’t know. The best part of it now is that I have to prove that I actually took the medication before they reimburse me! How many times do you have to prove you took your pills before they cover the medicine? Yeah I thought so…This reimbursement thing has truly been a nightmare and the coverage booklet clearly states that those things are covered. I am still fighting with them regarding this issue to I will update this portion when I’m done with it.

In conclusion, my experience has been mostly positive, the reimbursement issues have been a nightmare but if you don’t have a need for reimbursements then you will likely have a good experience with them. In all honesty, it is easy for me to say that I would like to change companies but I honestly don’t know if the rival company HUMANA is any better. Friends of mine have told me that when they changed to HUMANA from Triple-S it was like night and day, but I can’t say that since I have not used HUMANA. However, I am mostly satisfied with Triple-S, and if they stop this reimbursement nonsense I will be happy.

Oh, one more thing; if you have Triple-S and you go to the US to visit, the insurance will only cover you if you have an emergency. This is supposed to also include urgent care visits. This was confusing to me because we don’t have “Urgent Care” centers, only “Emergency”, so when I asked customer support one time while I was visiting the US, they could not help me. I had to call my daughter’s pediatrician on her cell phone and she helped us that way. I met with Triple-S representatives personally and they did confirm that coverage in the US will include only Emergency and Urgent care visits. How much would they cover? I’m not sure, it depends on your plan I suppose.

I hope this Triple-S review helps.

Update 12/8/2012: My reimbursement claim was denied once again. I provided everything they asked for last time. Now they denied it because they need the name of the anesthesiologist that administered the anesthesia and the code of the reason for the anesthesia. (Watch out, don’t ever get yourself into an emergency situation in which you may need emergency surgery, the anesthesia for the procedure will not be covered!)

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  1. 4 years ago, here in the states I paid $380, a month for my own basic health insurance policy. If it is not prying, could you tell what the Triple-S costs per month? Just to give me an idea of costs? Thank you.

    • Jay-Webmaster

      Hello, thank you for the question. Well the costs greatly depend on the coverage and whether you will be paying it all or if it is through an employer. I pay just under $200 a month for a fairly comprehensive coverage (which also includes dental and vision) for my entire family with very low co-pays, but it is through my employer. I know someone who also has insurance covered through her employer and she pays nothing per month but the co-pays are high, roughly 30% for medications and 40% for blood-work. However, if you are to pay everything yourself because you are self employed or whatever reason, you can probably look at around $350 per month for a fairly comprehensive plan (that’s according to a friend who has it and has no complaints).

      However, if all you want is a basic plan, you can look into “Triple-S Directo Plus 2” where a basic coverage (without maternity) with Dental could be roughly $90-$100 per month for someone around 30-39 years of age, but keep in mind this is a basic plan and some co-pays are pretty high, for example the co-payof an MRI are about 50%!

      I want to tell you though that my experience with insurance companies here in PR has been WAY BETTER than my experiences in the states. Recently I have had some issues with my insurance company but still nowhere near as bad as what I went through up in the states. Health insurance is one of the reasons why we like it here so much.

      Triple-S (Blue Cross/Blue Shield) is by far the most popular company (although not necessarily the best one) and it is accepted just about everywhere.
      Their phone number is 787-774-6060 and then press 2 (I think) for English.
      If you would like to look at the individual plan details here’s a link to see the coverage (click English at the top if it comes out in Spanish):

      Let me know if you need more info!

      Take Care!

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