ORLANDO, Fla. �� Maria del Carmen Gonzalez started to feel ill a few weeks after arriving in Orlando with her husband.
The anxiety of abandoning their battered home in Bayamon, Puerto Rico, quickly developed into a concerning chest pain. In a matter of days, she received a cardiac catheterization and was hospitalized at Orlando Health's Dr. P. Phillips Hospital.
"Scared is what I am, for when I get the medical bill," said Gonzalez, 70. "My doctor back home warned me, 'Get ready for the huge bill you're about to get.'"
In the midst of a humanitarian crisis that has already brought more than 143,000 people into the state since Oct. 3, Puerto Ricans arriving in Florida _ like Gonzalez _ are finding a confusing health care system, with deductibles higher than those they are used to on the island and private insurance plans that don't transfer smoothly.
She is a beneficiary of a private Medicare Advantage plan unique to Puerto Rico. Medicare will cover any emergency treatments she receives off the island, but she will have to pay for all other medical services out of pocket if they are not considered emergencies.
"I'm still informing myself. I thought I could just use my Medicare coverage, but the deductible is too high and I was told I don't qualify for Medicaid," Gonzalez said. "This is a horror story."
For many Puerto Ricans who expect to return home, switching to a mainland insurance plan is not an ideal choice. But conditions on the island remain bleak, and many of them could decide to stay permanently.
Keina Matias, a coordinator for the Health Insurance Store in Kissimmee, volunteers at the welcome center at the Orlando International Airport to help newly arrived Puerto Ricans understand the insurance system and their options.
She said people with health insurance from Puerto Rico can sign up for Medicare without penalties under a special enrollment period, which applies to people who've experienced life-changing events like moving.
In most cases, Matias said, qualifying insurance providers could honor a government waiver that offers relief under a state of emergency declared by President Donald Trump and the Health and Human Services secretary to reduce administrative burdens.
Among the requirements that could be waived for health care providers are pre-approval requirements, limitations on using out-of-network providers and certain payment limitations under the Medicare Advantage program.
Not all health-care providers are aware of the existing provisions.
Grace Torres' grandmother, Mirta Perez, had a stroke in Puerto Rico before Hurricane Irma struck the island.
Days after Hurricane Maria, she came to Florida with the first wave of Puerto Ricans displaced by the crisis.
Perez had a panic attack just after getting off a plane in Orlando and was transported to Florida Hospital East. Once she was there, she was told she needed intensive rehabilitation to recover from her stroke.
But because her Medicare Advantage plan was from Puerto Rico and the facility did not take her plan, she was told she would be released from the hospital, Torres said.
"It's infuriating," she said. "I have lived in Florida since I was 12. I've been voting for years. ... My grandmother deserved the treatment that we all deserve as American citizens."
A day later, Torres was able to change her grandmother's address to Orlando, which let her receive rehabilitation treatment in part at Orlando Regional Medical Center.
Florida Hospital said it could not confirm that Perez was a patient because of laws that protect patients' privacy.
Monica Corbett, a spokeswoman for the Florida Hospital Association, said none of the federal or state relief packages have provisions that require plans to ensure that Puerto Ricans have in-network coverage in Florida, but state hospitals are ready to help anyone in need.
Some providers are taking a slightly different approach, choosing to still accept private Puerto Rican plans without prior authorization in the hopes that they will be reimbursed.
Ruth Miranda, an administrator at PHCA Medical Group in Central Florida, said most private insurance companies in Puerto Rico are making exceptions through the emergency.
"We would submit the claim like we always would. We're taking insurance companies' words, basically assuming that risk that insurance companies will pay us back," she said.
"It can be a hassle. ... It might take a little for partners to get paid but in reality, they do have the coverage," Miranda said. "All of our doctors are bilingual, and we took it upon ourselves" to offer these services.
Access to prescription medicine away from Puerto Rico is another challenge.
"Some agencies and pharmacies like Publix and Wal-Mart, they're filling people's prescriptions at no additional cost for the first 30 days," Matias said. "But when will they stop doing this? We don't know."
A spokeswoman for Wal-Mart said Puerto Ricans with existing prescriptions can get 30-day refills at their pharmacies in Florida through Dec. 2, and they will work with patients' current insurance.
A spokesman for Publix did not respond to a request for comment.
Gonzalez's husband, Oswaldo Rivera, 74, has Parkinson's disease and his health has deteriorated since the storm. He used to walk around the house and make coffee for his wife every morning. Now, he is completely dependent on others for simple tasks.
Without power or water and unreliable access to a hospital, she admits they cannot yet return to the island.
"I know I have to move on and think of what I will do," Gonzalez said. "I feel like old age has just fallen on me. I feel crushed."
