Yes, Puerto Rico has Medicaid. The island runs its own program, which covers roughly 1.4 million residents, with another 47,000 children enrolled through the Children’s Health Insurance Program (CHIP).1Puerto Rico Government. 2024 Puerto Rico Medicaid Annual Report to Congress Between the two, close to half of the island’s 3.2 million people are enrolled. The rules on who qualifies, what’s covered, and how you get care differ in some important ways from Medicaid in the 50 states.
Who Qualifies
Eligibility is based on your modified adjusted gross income and household size. The current thresholds, effective April 2026 through April 2027, are tied to the Puerto Rico Federal Level:2Medicaid.gov. Medicaid and CHIP in Puerto Rico
- Household of 1: up to $1,835 per month
- Household of 2: up to $2,489 per month
- Household of 3: up to $3,142 per month
- Household of 4: up to $3,795 per month
Coverage groups include pregnant women, children, parents and caretaker relatives, individuals with disabilities, and elderly residents. Children under 19 have broader eligibility. Puerto Rico has also expanded Medicaid to the adult group authorized under the Affordable Care Act.3MACPAC. Medicaid and CHIP in Puerto Rico Aged, blind, and disabled residents can also qualify through the medically needy pathway, which uses a separate income calculation.
What Medicaid Covers in Puerto Rico
The program pays for a broad range of care:
- Primary care, specialist, and sick visits
- Inpatient hospital stays and outpatient procedures
- Prescription drugs, managed through contracted pharmacy benefit companies
- Lab work and imaging, including X-rays and diagnostic tests
- Inpatient and outpatient mental health and substance use treatment
- Preventive care such as mammograms, colonoscopies, and routine screenings
- Dental services
What It Does Not Cover
Puerto Rico’s Medicaid does not cover home health services, durable medical equipment and supplies, or nursing facility care.4Medicaid.gov. Managed Care in Puerto Rico Those are mandatory benefits in the states, so residents accustomed to stateside Medicaid should not assume nursing home care or home health is available here. The gap is tied to the fact that federal funding for Puerto Rico’s Medicaid is capped rather than open-ended, forcing the territory to leave some benefits out.
How You Get Care: Plan Vital
Since 1994, most Medicaid beneficiaries have received care through managed care rather than fee-for-service. The current program is called Plan Vital.4Medicaid.gov. Managed Care in Puerto Rico When you enroll, you choose one of four private plans:
- First Medical Health Plan
- Triple-S Salud
- MMM Multi Health
- Plan de Salud Menonita
Your plan handles medical, primary, and specialty care. Two pieces are carved out: behavioral health services run through a separate island-wide managed care organization, and prescription drugs go through contracted pharmacy benefit companies.4Medicaid.gov. Managed Care in Puerto Rico The Puerto Rico Health Insurance Administration, known by its Spanish acronym ASES, oversees the system and the contracts.2Medicaid.gov. Medicaid and CHIP in Puerto Rico
If You Have Both Medicare and Medicaid
Dual-eligible residents can enroll in Medicare Platino, a voluntary Medicare Advantage program that layers Medicaid benefits over standard Medicare. Enrollment is optional.4Medicaid.gov. Managed Care in Puerto Rico
Medicare Platino is worth a close look for anyone eligible, because it actually covers services regular Plan Vital does not: nursing facility care, home-based services, and transportation. Three plans participate: MCS Advantage, MMM Healthcare, and Triple-S Advantage.4Medicaid.gov. Managed Care in Puerto Rico
How to Apply
You can apply online at medicaid.pr.gov or in person at a local Medicaid office. A call center is also available.5Departamento de Salud PR. Programa Medicaid
Gather these documents before you apply:
- Photo ID (driver’s license or voter registration card)
- Social Security cards, originals and copies, for every household member
- Proof of income: pay stubs, Social Security benefit letters, pension statements, or documentation of any other income
- Proof of residency: a water, electric, or phone bill
- Marriage certificate, if applicable
- Proof of U.S. citizenship or legal residency for non-native residents
- School enrollment records for any children in the household
After you submit your application and documents, the program reviews eligibility and notifies you of the decision. If you’re approved, you pick one of the four Plan Vital managed care organizations. Once enrolled, keeping your certification current with your chosen plan is your responsibility.5Departamento de Salud PR. Programa Medicaid
A Note on Funding and the 2028 Cliff
Federal Medicaid funding for Puerto Rico is capped by Congress under Section 1108 of the Social Security Act rather than provided as open-ended matching funds the way it is for states.6Social Security Administration. Social Security Act Title 11 – 1108 Once the cap is reached, Puerto Rico covers the rest with its own money. The federal matching rate is currently 76% through September 30, 2027, under the Consolidated Appropriations Act of 2023.2Medicaid.gov. Medicaid and CHIP in Puerto Rico
Unless Congress acts, both the matching rate and the total federal contribution drop sharply starting in fiscal year 2028. The current allotment for FY 2026 is approximately $3.6 billion; a reversion to the pre-supplement formula would leave the island covering a much larger share of costs, with services or enrollment potentially on the table. If you rely on Medicaid in Puerto Rico, this is the schedule to watch.