Health

Regulate the way to apply the cap on coinsurance collection – Comercio y Justicia

The norm contemplates that the increase in the value of the quota will have a maximum of 90% of the Ripte index of the month immediately prior to the one published for those who have a net income of less than six minimum wages, vital and mobile. To obtain the benefit, the interested parties must, between the 1st and 20th of each month, declare this situation on the website of the Superintendence of Health Services. (See annexes)

Resolution 2/23-SSS

City of Buenos Aires, 01/02/2023

HAVING SEEN File EX-2022-139504773- -APN-GGE#SSS, Laws No. 23,660, No. 23,661 and No. 26,682, Decrees No. 1993 of November 30, 2011, No. 66 of January 22, 2019, and No. 743 of November 6, 2022, Resolutions No. 201 of April 9, 2002, No. 1991 of December 28, 2005, Resolution No. 58 of January 12, 2017, No. 867 of April 29, 2022, No. ° 2577 of November 9, 2022 and No. 1 of January 2, 2023, all from the MINISTRY OF HEALTH, and

CONSIDERING:

That Law No. 26,682 established the regulatory framework for prepaid medicine, reaching any natural or legal person, regardless of the type, legal figure and name they adopted, whose purpose was to provide services for the prevention, protection, treatment and rehabilitation of human health to users, through a modality of voluntary association through payment systems of adhesion, either in own effectors or through third parties linked or contracted for the purpose, whether by individual or corporate contracting.

That by Resolution No. 201/02 of the MINISTRY OF HEALTH and its amending and complementary regulations, the MANDATORY MEDICAL PROGRAM (PMO) was established, which determines the essential basic benefits that Health Insurance Agents and Prepaid Medicine Entities must guarantee to its affiliates and affiliates.

That the aforementioned Mandatory Medical Program (PMO) established the coinsurance that Health Insurance Agents and Prepaid Medicine Entities can receive for certain medical practices with their corresponding values.

That, due to the lack of updating of the established coinsurance values, by Resolution No. 58/17 of the MINISTRY OF HEALTH, the amount of the fees provided for in ANNEX I of Resolution No. 201/02 was modified by those authorized in the ANNEX of that norm and its automatic update was ordered, in the same terms and percentages established for the Minimum, Vital and Mobile Salary provided for in Law No. 24,013.

That the values ​​resulting from the aforementioned tariff readjustment were set as the maximum limit, providing, in Article 3 of Resolution No. 58/17, that the Health Insurance Agents and the Prepaid Medicine Entities will determine the place and the operating modality in which they will be paid.

That, subsequently, by article 2 of Decree No. 743/22, it was established that Prepaid Medicine Entities must offer their users, as of January 1, 2023, identical coverage plans. to the one they currently have without copayments, including copayments on first and second level benefits, at a price of at least TWENTY-FIVE PERCENT (25%) lower than the plan without copayments.

That said norm was complemented by article 5 of Resolution No. 2577/22 of the MINISTRY OF HEALTH, which established that the copayment values ​​for first and second level benefits in the coverage plans that Prepaid Medicine Entities must offer in accordance with article 2 of Decree No. 743/22, they will be subject to the controller of the SUPERINTENDENCY OF HEALTH SERVICES.

That, in terms of financing, the Social Work System established by Laws No. 23,660 and No. 23,661 constitutes a solidarity system of mandatory contribution, which is nourished by a percentage of the income of employees in a dependency relationship, small affiliated taxpayers to the simplified regime of Law No. 24,977 and personnel from private homes reached by Law No. 26,844.

That, for its part, the prepaid medicine system constitutes a voluntary affiliation regime that is financed, fundamentally, by the out-of-pocket contribution made by the users.

That, based on the different financing modalities of the indicated systems, and in accordance with the provisions of Article 2 of Decree No. 743/22 and Article 5 of Resolution No. 2577/22 of the MINISTRY OF HEALTH, it is It is clear that the co-payments to be received by Prepaid Medical Entities for services included in the MANDATORY MEDICAL PROGRAM (PMO) are subject to a special regime and with different rules from those applicable to Health Insurance Agents.

That, based on this, by Resolution No. 1/23 of the MINISTRY OF HEALTH, the SUPERINTENDENCY OF HEALTH SERVICES was instructed to establish a system of co-payments and caps for Prepaid Medicine Entities, by virtue of the provisions of Article 2 of Decree No. 743 of November 6, 2022 and to issue the pertinent measures for this purpose.

That, in compliance with the provisions of article 5 of Resolution No. 2577/22 and article 1 of Resolution No. 1/23, both of the MINISTRY OF HEALTH, it is appropriate to regulate the first and second level benefits that may give rise to the collection of co-payments in the coverage plans that the Prepaid Medicine Entities must offer, in accordance with article 2 of Decree No. 743/22.

That, in turn, by article 1 of Decree No. 743/22, a maximum limit was set, as of February 1, 2023 and for a period of EIGHTEEN (18) months, to the authorized increases of the value of the installments of the prepaid medicine contracts that must be paid by the contracting holders who have net income less than SIX (6) Minimum, Vital and Mobile Salaries, of NINETY PERCENT (90%) of the Average Taxable Remuneration Index of Stable Workers (RIPTE) of the immediately preceding month published.

That the net income of the contracting parties, both of those who work in a dependency relationship and as their own account, constitutes an amount that varies from month to month for most of them.

That it corresponds to regulate the way in which the aforementioned limit will be verified and applied.

That the Strategic Management, Benefit Control, Economic-Financial Control, Information Systems, Legal Affairs and General Management departments have taken the intervention of their respective powers.

That this is issued in use of the powers and attributions conferred by Decrees No. 1615 of December 23, 1996, No. 2710 of December 28, 2012, and No. 307 of May 7, 2021.

Thus,

THE SUPERINTENDENT OF HEALTH SERVICES

RESOLVES:

ARTICLE 1.- In accordance with the provisions of Article 1 of Resolution No. 1/23 of the MINISTRY OF HEALTH, entities registered in the National Registry of Prepaid Medicine Entities (RNEMP) may only collect copayments or coinsurance for the first and second level benefits included in ANNEX I (IF-2022-140106763- -APN-GCP#SSS) which is approved and forms part of this Resolution.

ARTICLE 2.- The entities registered in the National Registry of Prepaid Medicine Entities (RNEMP) must submit to the SUPERINTENDENCY OF HEALTH SERVICES, for verification and registration, the plans with copayments offered under the terms of article 2 of the Decree No. 743/22. Together with the plans, their rate tables must be submitted with the detail of the copayment values ​​for each service included.

For this purpose, the Prepaid Medicine Entities (EMP) must complete and generate, for each of the comprehensive coverage plans that they market to the general public, the SWORN STATEMENT FORM FOR THE REGISTRATION OF COMPREHENSIVE COVERAGE PLANS WITH COPAYMENT, which It will be available on the institutional website of the SUPERINTENDENCY OF HEALTH SERVICES, whose model is included in ANNEX II (IF-2022-139613439-APN-GGE#SSS), which is approved and forms an integral part of this Resolution.

ARTICLE 3.- The SUPERINTENDENCY OF HEALTH SERVICES will publish the lists of reported co-payments on its institutional website.

In the event that the rate tables have not been presented with the detail of the copayment values ​​for a comprehensive coverage plan with copayments, the current values ​​for Resolution No. 58/17 of the MINISTRY OF HEALTH will be applied additionally.

ARTICLE 4.- The plans with co-payments that are in force and have been contracted prior to the entry into force of Decree No. 743/22, will remain in force under the same terms in which they were contracted.

ARTICLE 5.- The values ​​of co-payments must be duly and reliably informed to the users at the time of affiliation, giving them a copy of them and keeping due proof of their conformity.

They may only be increased on the same occasions and up to the same proportion as the Health Cost Index approved by article 1 of Resolution No. 1293/22 of the MINISTRY OF HEALTH.

ARTICLE 6.- The affiliation holders who want the limit provided for in article 1 of Decree No. 743/22 to be applied to them must complete, from the 1st to the TWENTY (20) day of each month, a declaration income sworn corresponding to the immediately preceding calendar month, entering through the application that will be available on the institutional website of the SUPERINTENDENCY OF HEALTH SERVICES, through authentication through your CUIT/L and tax code.

From day TWENTY-ONE (21) and until the end of the month, the SUPERINTENDENCY OF HEALTH SERVICES will make available to each Prepaid Medicine Entity, on its website, the corresponding information on the affidavits submitted by its users, to the effects of applying the corresponding limits in the corresponding cases.

The presentation of income affidavits for months prior to the one foreseen according to the upload date will not be accepted, nor will the application of the cap be applied retroactively.

ARTICLE 7.- The monthly increases that are applied in accordance with the provisions of article 1 of Resolution No. 2577/22 of the MINISTRY OF HEALTH must be calculated on the amount of the fee invoiced in the immediately preceding month.

ARTICLE 8.- This Resolution will enter into force the day after its publication in the Official Gazette.

ARTICLE 9°.- Register, communicate, publish, give to the NATIONAL DIRECTORATE OF THE OFFICIAL REGISTRY and, opportunely, archive.

daniel alejandro lopez

N. of R.- Published in the Official Gazette of the Nation No. 35,081 of January 3, 2023.

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