|Act No. 24/AN/14/7th L establishing a universal health insurance system.|
NATIONAL ASSEMBLEE A ADOPTETHE PRESIDENT OF THE PROMULGUE REPUBLICI'll tell you what.
VU The Constitution of 15 September 1992;
The Council of Ministers heard in its meeting of September 10, 2013.
General principles of insurance
Article 1: A health insurance system is established based on the principles of national solidarity, law and access to health for all enshrined in law n°48/AN/99/4th Guidance to Health Policy.
Article 2: The health insurance system is a prevention and social protection against the risks of the disease. It provides basic medical coverage to the entire population living in the territory of the Republic of Djibouti and provides compulsory health insurance for the active population.
Article 3: The universal health insurance system (AMU) includes, on the one hand, the compulsory health insurance plan (AMO) and on the other hand, the social health assistance program (SSA).
Compulsory health insurance (AMO)
Chapter I - Recipients
Article 5: Based on the contributory principle, compulsory health insurance includes three plans:
Article 6: The compulsory health insurance system covers the rights of persons identified as subject to this coverage, provided that no other coverage of this nature is claimed.
Article 7: Dependant children are reported only by one of the parents in order to avoid double registrations to the AMO regime.
Chapter II - Guaranteed benefits
Article 8: Compulsory health insurance is entitled to access to care for the categories of beneficiaries referred to in section 6.
Article 9: The details of the health care benefits guaranteed by the AMO regime, the costs of health transport and the rates of care are defined by decree jointly taken by the Minister for Health and the Minister for Social Security.
Article 10: The benefits not available in the treated care centres will only be taken care of when they meet a healing need.
Article 11: The body responsible for monitoring and monitoring the implementation of the conventions, according to criteria defined by the Ministry of Health, will be responsible for defining acts that meet a healing need.
Article 12: The costs related to the care of ODA recipients are covered by the managerial organization (CNSS) in two ways:
Article 13: Reimbursement or care for expenses incurred by recipients of compulsory health insurance is made:
The conditions for the care and reimbursement of care expenses required by the recipient's state of health will be defined by decree.
Article 14: Guaranteed benefits under compulsory health insurance can only be refunded or taken care of if the care has been prescribed and performed by registered health-care providers.
Methods of financing
Article 15: The AMO's resources consist of:
Article 16: As the contribution rate is set at 7%, it will be distributed as follows:
Article 17: Depending on the categories of recipients, the financing of the compulsory health insurance plan is based on:
Article 18: In addition to these financing methods based mainly on social contributions and other contributions from social insurance, moderator tickets and admission fees or complementary participations of insured persons will be instituted by regulation.
Article 19: The managerial body has the obligation to establish:
Chapter I - Recipients
Article 20: The plan of the social health assistance program based on a subsidized plan covers all persons not covered by the compulsory health insurance system and previously identified as having “no income” by the competent authorities.
Article 21: Can claim the Social Health Assistance Program:
Article 22: In addition to the universal package that is served free of charge and without distinction to the entire population, the beneficiaries of the Social Health Assistance Program receive the following care:
Chapter III-Making arrangements
Article 23: Diseases covered by national programmes are provided free of charge in the universal package. The other costs of basic care benefits (base package 1 and base package 2) are covered by the Solidarity Fund of the Social Health Assistance Program, created by regulatory act.
Any extension of the rights to hospital care benefits will be covered under the same conditions with the participation of the beneficiaries to be determined by regulatory action.
Chapter IV-Financing modalities
Article 24: Funding for the Social Health Assistance Program (SAP) is provided through the Universal Health Insurance Solidarity Fund.
Part IV- Conventioning system
Chapter I- Conventional framework
Article 25: The relationship between the managerial body and care providers is governed by medical agreements concluded, separately:
Article 26: Health providers exercising a liberal role and having made the choice to exercise under the conventional regime conclude medical conventions directly with the managerial body.
Article 28: The medical convention determines, inter alia:
Article 29: Conventions, annexes or amendments come into force only after their approval by order on the proposal of the Minister for Social Security.
CHAPTER II-LE CONTROLE MEDICAL
Article 30: Medical control on behalf of the managerial body is provided by general practitioners and consulting specialists, pharmacists-advisors and dentists responsible for the missions and powers provided for in this letter.
Article 31: These medical consultants are responsible for conducting medical checks to verify compliance with the care requirements, verifying the quality of the services, detecting abuses and frauds in terms of requirements, care and billing.
Article 32: The terms, conditions and deadlines in which medical control is exercised are determined by decree.
The procedures for the exercise of consulting physicians are defined by regulatory action.
Monitoring and evaluation of the implementation of conventions
Article 33: This Act establishes a National Health Insurance Commission, a consultative body composed of representatives of the managerial body, care providers, the public authority and representatives of insured persons, responsible for monitoring the effective implementation of medical conventions.
Article 34: The modalities for the organization and operation of this body of consultation will be defined by decree.
Chapter I- of the AMU management organization
Article 35: The management of universal health insurance is entrusted to the CNSS.
Article 36: The administrative organization provided for by law n°212/AN/07/5th The establishment of the National Social Security Fund (N.C.S.S.) will be amended with respect to the prerogatives of the NSSC in the area of care.
To this end, the introduction of the universal health insurance system requires the NSS to not accumulate the functions of care provider and insurance manager.
The CNSS's organizational structure that takes into account the UA reform will be proposed by the CNSS management to the Board of Directors upon promulgation of this Act.
Article 37: It is established by order a commission to assess the movable and real estate heritage as well as the financial assets of the two CNSS care centres.
Chapter II- of the care provider organization
Article 38: It is established a public health institution, which is the result of the separation of the employee and family care centres of the National Social Security Fund. This institution is a health care provider and has a moral personality and financial autonomy.
Part VII- Insurance Plans
Article 40: Care benefits not covered by AMO's basic plans will be covered by optional supplementary insurance plans.
Part VIII - Final provisions
Article 41: Pending the establishment of the AMU, care benefits will be guaranteed by the NSSC health centres without discontinuity to the insured.
Article 42: All provisions contrary to this Act are repealed, in particular, the provisions of section 28 of Act No. 212/AN/07/5th The establishment of the National Social Security Fund (CNSS).
Article 43: This Act comes into force three months after its promulgation.
|Done in Djibouti on 05/02/2014 |
President of the Republic,
Head of Government
ISMAÏL OMAR GUELLEH