Law For The Modification Of Articles 9, 19 And 27 Of The Technical Regulation Of The Caixa Andorrana De Seguretat Social, From 13-7-92

Original Language Title: Llei de modificació dels articles 9, 19 i 27 del reglament tècnic de la Caixa Andorrana de Seguretat Social, de 13-7-92

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Law for the modification of articles 9, 19 and 27 of the technical regulations of the Andorran Social Security approved by the Hon. General Council in regular session of the day July 13 1992 exhibition of illustrations and the proposals for the amendment of articles 9 and 19 of the technical regulation reproduce exactly the text of the former article 17 of the regulation of Application No. 20. Given that the regulation of application No. 20 has undergone a subsequent restructuring, has been fitting the text of the former article 17 in the articles of the technical regulation that seemed most appropriate, in this case the 9 and 19.

The text of the former article 17 of the regulation of Application No. 20 was unintentionally omitted in the draft amendment of the regulation of Application No. 20 that was discussed with the doctors in 1988, because it was based on a translation of the French regulation not contemplated. It is to fix this error in not having any desire on the part of the Caixa Andorrana de Seguretat Social, to delete the text in question.

With regard to article 27, the approval of this proposed new wording of this article of the technical regulation, does not mean any change on the current form of determination of the rates of the CASS but simply a systematization of all the possibilities that exist at the present time to determine these rates.

During the last twenty years, have appeared other types of liability rates that set out in the agreements with health care providers in Andorra: the rates applied by health care centres that belong to the Spanish social security bodies or French or have agreements with these bodies (see the rates for the centres of the Spanish social security or for private and public clinics in France). These rates have always been considered as a liability rates of the CASS.

The prices of derivative liability of CASS agreements with foreign institutions, private or public health care (see the rates with health care working girl or the CHRU of Toulouse).

The proposed new wording of article 27 systemize all these possibilities and incorporates the legal systematic practice in the last twenty years in relation to the determination of the rates of responsibility.

Furthermore, this proposal allows regular established practice-level regular in the agreements with the health professionals of Andorra to reimburse the services of professionals who have not signed these Agreements in one third of the established rates.

This practice was assumed in the agreement between the CASS and the health professionals the rights of third parties (insured) not involved in the agreement. The proposal to amend article 27 statutory level rises to this practice. It must be said also that, in the negotiation of the agreement with the doctors of 1991, the CASS had committed, at the request of doctors, to present during the year 1991 a regulatory amendment proposal in this regard in order to remove the clause in the agreement of reimbursement to third.

For the reasons mentioned above, the General Council has approved the following law: Article only modify the articles 9, 19 and 27 of the technical regulation of the Caixa Andorrana de Seguretat Social, that are written in the following way: Article 9 refund benefits include: The general and special medical expenses coverage, within the limit of the liability rates of the CASS.

The coverage of the costs of pharmacy, depending on the prices practiced in the sale to the public.

The coverage of the costs of hospitalization, i.e., the costs of the stay and the derived from medical activities carried out in a hospital establishment and during hospitalization. The decision to charge the costs of hospitalization made in hospital establishments that do not have an agreement with the CASS will be carried out on the basis of the rates of the CASS. The decision to charge the costs of hospitalization made in hospital establishments who have established an agreement with the CASS will be carried out under the conditions defined in this agreement.

The coverage of the costs of recognisements dentistry, optical, orthotics and prosthetics, under the conditions laid down in the specific texts.

The coverage of the costs of maternal protection.

The coverage of the expenses for transfer by ambulance, both inside and outside the territory of Andorra. Transfers out of Andorra will only be covered when the specialty of the doctor trying to not be carried out in the valleys. The transfers between the interior points of other countries or among other countries will not be covered in any case.

The coverage of the costs previously defined it may be carried out by means of the payment system in the Act, within the limits defined in the preceding paragraphs, or by means of the global payment system.

The global payment will be anchored in the global costs caused by the recipients of the CASS in a health care institution and should take into account the refund percentages defined in articles 10, 12 and 15 of the technical regulation and the regulation of application No. 22. The system will be developed in the framework of the agreement between the CASS and each one of the affected health care entities. The basic guidelines of these Agreements will be defined in a text application.

Article 19 in order to obtain the benefits of the sickness insurance, maternity and employment injury, the beneficiary must: 1. Be enrolled in CASS as the worker is or was registered as a successor or person in charge of an insured worker.

2. To present, in each demand for benefit, your secured card as well as all the supporting parts, a list of which will be published in a particular text.

3. Exhibit a full of illness with list of the stamps of the doctor, the pharmacist and eventually of the hospital setting, and the price of the drugs and the corresponding labels.

4. Exhibit a recipe which appears obligatorily the date and the name of the patient. This recipe will be returned to your interested.

5. Submit a salary according to the model that will be fixed in a particular text.

6. Send CASS a work stoppage, in the event that the insured will put in the work, and always within forty-eight hours in which he has started defaulting.

7. in case of transfer by ambulance, put on a prescription from the doctor trying to figure where the date and the name of the sick and indicated the need to move the patient in ambulance. If the transfer takes place outside of Andorra, you will need the doctor trying to Andorra indicated in the


prescription the need to go to a specialist outside of Andorra.

8. Submit to any examination or control that is determined by the CASS.

Article 27 in terms of coverage of the refund provisions defined in this Regulation, the rates of liability are established by the Board of Directors of the CASS, in accordance with the provisions that follow: 1) as a general rule, these rates will be fixed in the agreements in force between the health professionals practicing in Andorra and the CASS and the agreements in force between the healthcare centres in Andorra and the CASS. Of these agreements not to exist, the rates of responsibility shall be freely set by the Board of Directors.

2) However, establish the following exceptions to the legal policy: a) in the event that a health professional practicing in Andorra has in force an agreement signed with the CASS, the rates of responsibility for the performance of the members of the same health profession they exert in Andorra and who have not signed this agreement will be equivalent to the third of the liability rates fixed in paragraph 1) of the present article , that is to say, will be equivalent to one-third of the fees fixed in the agreement.

b) the rates of responsibility for the performance of healthcare providers Spanish, French and Portuguese have agreements and current social security agencies with Concerts of their countries, as well as the rates of responsibility for the performance of health professionals not working in Andorra, and healthcare centres abroad, which have an agreement in force with the CASS will be fixed in accordance with the provisions of these Conventions or Concerts.

In all other cases, the applicable liability rates will be fixed according to the provisions of paragraph 1) of the present article.

The agreements signed between the CASS and the healthcare providers mentioned in the preceding paragraph may include the clause of "third party Payer", particularly as relates to the costs of hospitalization. This clause will become general in the area of work-related injury insurance.

Casa de la Vall, 13 July 1992 Jordi Farràs Forné Syndic General

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