Regulatory Medicine Prepaid

Original Language Title: Marco Regulatorio de Medicina Prepaga

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MEDICINE prepaid 26.682 law medicine regulatory framework prepaid. Passed: May 4 2011 promulgated: May 16, 2011 the Senate and Chamber of deputies of the Argentina nation gathered in Congress, etc. they attest to the force of law: under regulatory medicine prepaid chapter I provisions general article 1 - object. This law aims to establish a regime of regulation of the business of medicine prepaid, voluntary membership plans and useful or complementary plans for major services marketed the agents of the insurance of health (ASS) covered by laws 23.660 and 23.661. Excluded cooperatives and mutuals, associations and foundations; and Trade Union social works.
Article 2º - definition. For the purposes of this law, health insurance companies are considered to any natural or legal person, whatever the type, legal and denomination adopted whose object is to provide prevention, protection, treatment and rehabilitation of human health benefits to users, through a form of voluntary association through systems membership payments , either effectors themselves or through third-party linked or contracted to the effect, either by individual or corporate recruitment.
Article 3º - limitations. Can not act as owners, founders, directors, administrators, members of the boards of surveillance, Trustees, liquidators or managers of the entities included in this law: 1) those affected by disabilities and incompatibilities laid down by article 264 of the Law 19.550; (2) the disabled Court to exercise public office; (3) those who by final judgment had been declared responsible for irregularities in the Government or administration of the subjects covered by article 1 of this law. Chapter II of the implementing authority article 4º - enforcement authority. Application authority of this law is the Ministry of health of the nation In regards to the relationship of consumption and to the defense of the competition will be enforcement in 24.240 and 25.156 laws and their amendments, where appropriate.
Article 5º - objectives and functions. Objectives and functions of the enforcement authority: to) monitor compliance with this Act and its regulations in coordination with the health authorities in each jurisdiction; (b) create and maintain up-to-date national register of subjects covered by the article 1 of this law and the national registry of users, for the sole purpose of being used by the public health system, in relation to the application of this law, and must in any case contain no data that may affect the right to privacy; (c) determine technical conditions, solvency financial management capacity, and benefits, as well as required formal care institutions for their entry in the register referred to in the preceding paragraph, guaranteeing free competition and access to the market, way to not generate damages to the general economic interest; (d) monitor compliance by the subjects covered by article 1 of this Act, the performance of the obligatory medical programme (PMO) and any other that has been incorporated into the signed contract; e) granting authorization to operate at the subjects covered by the article 1 of this law, evaluating the characteristics of health programs, the history and responsibility of applicants or members of the Board of Directors and the requirements provided for in subparagraph (c)); (f) authorize and oversee the model contracts that celebrate the subjects covered by article 1 of this law and users in all types of contracts and plans, under the terms of article 8 of this law; (g) authorized under the terms of this law and review the values of the quotas and their modifications that propusieren covered subjects in article 1; (h) overseeing the payment of allowances made and carried out by public hospitals or other effectors of the public sector national, provincial or municipal, according to the values established by the regulations in force; (i) implement the necessary mechanisms in each jurisdiction, to ensure the availability of updated and necessary information so that people can consult and decide on the entities registered in the register, their conditions and plans of the services provided by each of them, and thus also on aspects related to effective compliance; (j) have the necessary mechanisms in each jurisdiction to receive complaints made by users and system providers, referred to conditions of care, services and non-compliance; (k) establish a system of categorization and accreditation of the subjects covered by article 1 of this law as well as settlements and own or contracted providers evaluating structures, procedures and results; (l) require periodically with character of affidavit subjects included in article 1 of this law demographic, epidemiological, performance and financial reports, without prejudice to the provisions of the Law 19.550; (m) transfer in the event of bankruptcy, closure or cessation of activities of the covered subjects in article 1 of this law the health coverage with their affiliates to other providers enrolled in the registry that have similar coverage of health and share mode. The transfer will be granted within the framework of Permanent Coordination Council laid down in article 27 of this law and will be held respecting apportionment according to actuarial criteria, and must have the consent of the user
Article 6º - Permanent Commission. Created as a organ of articulation of the functions laid down in the present law a Standing Committee that will be composed of three (3) representatives from the Ministry of health and three (3) of the Ministry of economy and public finances. CHAPTER III OF BENEFITS

Article 7th - obligation. The subjects covered by article 1 of this law should cover, at least in their coverage plans medical assistance applicable mandatory medical program according to resolution of the Ministry of health of the nation and the system of basic benefits for persons with disabilities provided by 24.901 law and its amendments. The subjects covered by article 1 of this law only can offer partial coverage plans in: to) dental services exclusively; (b) services medical emergencies and health of people; (c) those who develop their activity in a unique and specific location, with a registry of users less than five thousand. The enforcement authority may propose new plans of partial coverage on the proposal of the Standing Committee provided for in article 6 of this law. All partial coverage plans must conform to the provisions of the enforcement authority. In all healthcare coverage plans and the partial coverage, information users should truthfully explain benefits covered and which are not included. In all cases the prescription of drugs should be performed according to law 25.649. Chapter IV of contracts article 8 - models. The subjects covered by article 1 of this law only can use standard contracts previously authorized by the enforcement authority.
Article 9º - termination. Users can at any time terminate the contract concluded, without limitation and without any penalty, truthfully and must notify this decision to the other party thirty (30) days in advance. The subjects included in the ar article 1 of this law only can terminate the contract with the user when it is incurred, as a minimum, the lack of three (3) consecutive payments or when the user has falsified the affidavit. In the event of non-payment, after the established and prior to the termination, unpaid term subjects covered by article 1 of this law should communicate informing the user the Constitution arrears applied to the adjustment within a period of ten (10) days.
ARTICLE 10. -Shortcomings and affidavit. Contracts among the subjects covered by article 1 of this law, and users may not include periods of lack or waiting for all those benefits that are included in the compulsory medical program. Other performance modalities and times specified in the agreement as grace period must be sufficiently explicit in the contract and approved by the enforcement authority. Pre-existing diseases can only be drawn from the affidavit of the user and may not be criteria of refusal of admission of users. The enforcement authority shall authorise duly justified differential values for the admission of users who have preexisting conditions, according to what established regulations.
ARTICLE 11. -Adverse admission. Age cannot be taken as a criterion for refusal of admission.
ARTICLE 12. -People over the age of 65. In the case of persons over the age of sixty-five (65) years, the enforcement authority must define the percentages of increase of costs according to risk for different age ranges. Users more than sixty-five (65) years old who have one antiquity of more than ten (10) years in one of the subjects covered in the article 1 of this law, cannot be applied the increase because of their age.
ARTICLE 13. -Death of the holder. The death of the holder does not imply the rights of his family group members of the contract expiration.
ARTICLE 14. -Coverage of the family group. (a) is defined as primary family group the integrated by the spouse of the Member holder, unmarried children up to twenty-one (21) years, not emancipated by qualification activity professional, commercial or labour, unmarried children over the age of twenty-one (21) years of age and up to twenty-five (25) years inclusive, are a charge affiliated licensee who pursue regular studies officially recognized by the appropriate authority , disabled and in charge of the affiliate owner, children over the age of twenty-one (21) years, the children of the spouse, the children whose guardianship and conservatorship has been agreed by judicial or administrative authority, which fulfil the requirements laid down in this subparagraph; (b) the person who live together with the affiliated incumbent on the union in fact, whether or not of different sex and their children, according to the accreditation that determine regulation. Benefits will not be limited in any case for preexisting conditions or qualifying periods or may give rise to different fees.
ARTICLE 15. -Corporate procurement. The user bonded group or corporate recruitment had ceased their working relationship or bond with the company that held the contract with one of the subjects covered by article 1 of this Act is entitled to continuity with their seniority recognized in one of the plans of one of the subjects covered by article 1 of this law If requested within the period of sixty (60) days from the cessation of his employment relationship or bond with the company or corporate entity which is played. The subject understood in article 1 of this law must keep the provision of the Plan until the expiry of the period of sixty (60) days.
ARTICLE 16. -Contracts. The entry into force of the present cannot generate any kind of prejudice to the situation of the users with existing contracts.
ARTICLE 17. -Fees of plans. The enforcement authority supervise and ensure the reasonableness of the assessments of benefits plans. The enforcement authority shall authorize the increase of fees when it is based on changes in the cost structure and reasonable actuarial calculation of risks. The subjects covered by article 1 of this law can establish differential pricing for performance plans, at the time of his hiring, according to stripes age with a maximum variation of three (3) times the price of the first and the last age. CHAPTER V OF THE LENDERS

ARTICLE 18. -Tariffs. The enforcement authority should set mandatory minimum tariffs that ensure the efficient performance of public and private providers. The lack of enforcement of tariffs or the delay in payment to providers makes subject, the subjects covered by article 1 of this law of the sanctions provided for in article 24 of the present.
ARTICLE 19. -Contract models. Models of contracts among the subjects covered by article 1 of this law and lenders must conform to models that establish the enforcement authority. CHAPTER VI OF OBLIGATIONS ARTICLE 20. -Public hospitals. Although without prior agreement, the subjects covered by article 1 of this law must be paid to public hospital or other effectors of national, provincial or municipal public sector, and those of Social Security, benefits carried out and invoiced according to the values established by the Superintendence of health services for the health insurance agents. They must have the corresponding validation according to the regulation. They are expressly exempted authorization or validation, the situations of urgency or emergency of health of users, that will proceed to the attention of the patient, having a term of three (3) days for further validation. In the case of controversial rejection of a benefit by a public hospital or other effector, the intervention of the enforcement authority may be required.
ARTICLE 21. -Minimum capital. The health insurance companies that act as entities in the health care coverage must establish and maintain a minimum Capital, which is set by the enforcement authority. The health insurance agents referred to in article 1 of this law are governed, in this aspect, by the resolutions issued by the enforcement authority.
ARTICLE 22. -Financial information and accounting. The agents of health insurance marketed voluntary accession plans or useful or complementary plans for major services should carry a system differentiated information asset and accounting records for the purpose of control and control of the contributions, contributions, and other resources provided by 23.660 and 23.661 laws.
ARTICLE 23. -Adhesion and solidarity redistribution Fund plans. By accession plans voluntary or useful or complementary plans for major services marketed health insurance agents will be no contributions to the solidarity fund for redistribution or be received refunds or other type of contributions by the administration of special programs. Chapter VII of sanctions article 24. -Sanctions. Any infraction of this law shall be punished by the enforcement authority in accordance with the following: a) a warning; (b) fine whose minimum value is equivalent to the value of three quotas that marketed the offender and the maximum value shall not exceed thirty percent (30%) of the turnover of the previous year; (c) cancellation of the registration. This penalty can only be applied, in case of extreme severity and recidivism. 19.549 administrative procedures Act shall apply for the purposes of the conduct of the proceedings. All sanctions can be appealed to the National Chamber of appeals, contentious administrative Federal. The resource must stand and melts within a period of ten (10) business days of the authority that issued the decision, who may refer the proceedings to the competent court without any further formality. Without prejudice to the penalty imposed, the obligated subject must provide the provision required urgently. CHAPTER VIII FINANCING OF ARTICLE 25. -Resources. Resources of the Ministry of health in relation to this law, are constituted by: a) annual tuition paid by each entity, whose amount shall be fixed by regulation; (b) the fines paid by the subjects covered by article 1 of this law to the enforcement authority; (c) gifts, bequests, and grants it receives; (d) any other income compatible with its nature and purpose. CHAPTER IX SPECIAL PROVISIONS ARTICLE 26. -Right to users. Notwithstanding that establish other rules of application, users enjoy the following rights: to) right to emergency benefits: users are entitled, if in doubt, to receive emergency benefits, corresponding shaped back solve if covers are by the contracted plan; (b) the right to equivalence: users have the right to an adequate equivalence of the quality of the services contracted for all of the contractual relationship.
ARTICLE 27. -Created as an advisory body to a permanent coordination Council, comprising representatives from the Ministry of health, the enforcement authority of the Act 24.240, of the subjects covered by the article 1 of this law, users and the entities representing lenders at the national or provincial level or of the autonomous city of Buenos Aires Bono. The Ministry of health will dictate the rules of functioning of the aforementioned Council.
ARTICLE 28. -Public order. This law is of public order, applies throughout the national territory and shall enter into force after its publication in the Official Gazette. article 29. -Regulation. The Executive branch must regulate this law within one hundred twenty (120) days from its publication.
ARTICLE 30. -The subjects covered by article 1 of this law have a period of one hundred and eighty (180) days from the publication of this adaptation to the present regulatory framework.

Date of publication: 17/05/2011