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Transition committee briefed on confidential health-insurance negotiations, data mismatches and auditor concerns
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Summary
At a transition committee briefing, staff discussed ongoing confidential negotiations over health-insurance contracts, a new federal system that produced reconciliation discrepancies, pharmacy network coverage for people with HIV, and auditor allegations that were later clarified; a report will be sent to the governor and legislature.
Unidentified Speaker 1, speaking at a transition committee briefing, said the session was primarily informational and that a small portion had been held in executive session because some data were confidential and could affect negotiations. “No podemos dar los detalles porque podemos afectar las negociaciones,” the speaker said, explaining the goal was to outline where negotiations stand and how payments are flowing so the incoming administration would have a clear picture.
Committee members raised several substantive concerns. An attendee (Unidentified Speaker 2) referenced an Inspector General report that, he said, briefly put about $440 million in federal Medicaid funds at risk; he added there had been a delay in fund requests that “ya se subsanó.” Unidentified Speaker 1 confirmed he had not attended the prior hearing and did not have all details but said colleagues who were present could provide further data.
The briefing also addressed pharmacy access. Unidentified Speaker 1 cited a certification saying the system lists 938 pharmacies and said that, for people with HIV (approximately 16,000 people), about 7,385 are enrolled in Plan Vital and receive pharmacy services. The speaker noted Walgreens currently dispenses high-cost HIV medications through central processing, meaning patients are being served even where a pharmacy is not formally listed in the reform network.
Staff and committee members described technical reconciliation work after the May implementation of the federal MMAIS system. A committee participant identified as Speaker 7 said the MMAIS rollout exposed data mismatches among pharmacy benefit managers, ASEF, Medicaid and providers, and that two plans initially reported discrepancies on the order of about $70 million. Speaker 7 said final effects would depend on reconciliation steps and potential provider-level recoveries: “cuando se implementó en en mayo, pues, parece que habían algunas discrepancias entre ciertos datos…,” he said.
Committee members also flagged vendor responsiveness. Unidentified Speaker 1 noted a company named Astra had been slow to respond to billing documentation submitted in April 2024; more than six months had passed without a substantive reply, prompting committee members to consider revisiting vendor performance.
On a separate matter, Unidentified Speaker 4 asked whether the secretary of corrections’ case would be referred to the Department of Justice after a letter from Audicorp alleged the secretary had lied. Unidentified Speaker 1 said the person who raised the claim in a prior hearing later clarified and retracted the incorrect information; nonetheless, he recommended the incoming corrections secretary review audit reports and take any appropriate determinations to protect health-and-corrections operations.
The committee’s next step is to have staff draft a report that will be submitted to the governor, the Puerto Rico Legislature and the Office of the Comptroller. No formal votes or motions were recorded during the briefing.
