Family Health Insurance

On the first day of September 2007, the Family Health Insurance (SFS) established in article 118 of Law 87-01 that creates the Social Security System came into force.

The three fundamental principles that make up this system are: comprehensive protection of the physical and mental health of the member and his family, as well as universal coverage without exclusions by age, sex, social, labor or territorial status, guaranteeing regular access to social groups more vulnerable and ensuring financial balance, by rationalizing the cost of benefits and the administration of the system.

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For their affiliation, a person hires a Health Risk Administrator (ARS) according to the current rules and by virtue of which their dependents are also beneficiaries, including the risks of health promotion, prevention and treatment of diseases, rehabilitation , pregnancy, childbirth and its consequences.

It is very important to point out that the affiliate to the SFS has a series of guaranteed rights protected by the current legislation of the Dominican Social Security System, which were not recognized in the previous health insurance scheme.

In this sense, the beneficiary has the right to be affiliated with the Health Risk Administrator (ARS) of their choice, regardless of social condition, sex, health and age; before the age and suffering from a preexisting condition were limiting conditions to be able to enter a Medical Insurance; In addition, the beneficiary has the right to affiliate his family nucleus to: spouse, children under 18, children up to 21 years if they are students, children for life if they are disabled, parents, other family members who depend on the member or the pensioner, as long as it covers the cost of your protection.

Likewise, the affiliate already has the right to change ARS once 12 contributions have been paid.
The administrative resolution number 175-09, issued by the Superintendency of Health and Occupational Risks (SISALRIL), prohibits the undue payment for health services in emergencies to the members of the Contributive Regime and orders the ARS and the Occupational Risk Manager (ARL) ) to include in the contract with the Health Service Providers (PSS), a series of services.

The objective of the resolution is to clarify and ratify the coverages to which the beneficiaries are entitled when they receive services in hospitalization, Intensive Care Unit, Surgery Room and Emergency Room.

These details are due to the fact that the SISALRIL verified that some PSS had been billing and performing undue actions and collections to the detriment of the rights of the affiliates, despite the fact that the Health Services Plan’s Catalog of Benefits (PDSS) details the types of coverages to which affiliates have access.

In explaining the scope of the provision, La SISALRIL objected that in some medical centers claim to collect separately activities, equipment and services that are inherent in a procedure.
The ARS and the ARL have the responsibility to ensure and avoid that these aforementioned services are charged to the affiliates as differences or expenses in addition to their billing.

After the implementation of this resolution, the ARS and ARL must include as part of the medical procedures performed and billed within the coverage contracted with the Health Service Providers, the use of equipment, expendable equipment, diagnostic means and medicines. in hospitalization, as well as medical fees in hospitalization and general services.

The regulations also provide that the ARS and the ARL reimburse affiliates the amounts charged for the contracted PSS, when they come from an overcharge to the copayments, fixed or variable moderator fees that correspond to the affiliate. In the same way, it has to reimburse the affiliates for the expenses incurred as a result of coverage contained in their plans or in the Occupational Risk Insurance, as well as order the ARS to ensure that the PSS do not withhold the membership cards.

Currently in the National Congress is a draft amendment to the Law 87-01 of which the FSS is expected to provide significant changes for the benefit of affiliates and the health sector of the Dominican Republic.

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