Medicare Advantage Design and Innovation Constraints in Puerto Rico

The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the Department of Health and Human Services that administers Medicare, including Medicare Advantage (MA), a privately delivered program that sets payment, quality, and provider network requirements shaping healthcare delivery, and is committed to improving access, quality, and cost efficiency. This project examines how MA design in Puerto Rico constrains healthcare delivery innovation and overall system performance, a critical issue given the territory’s high MA dependence, persistent funding disparities, workforce shortages, and growing chronic disease burden, and what targeted adjustments could improve outcomes. The team synthesized academic research, policy papers, peer-reviewed articles, and insights from stakeholder interviews within Puerto Rico to address this issue. Their findings highlighted actionable recommendations for CMS, including a diagnostic financial analysis built from CMS and HRSA data with a literature review examining value-based care feasibility, supplemental benefit constraints, and comparative models. These recommendations aim to diagnose CMS Puerto Rico’s challenges to advance value-based healthcare for the territory.