Co-payment in social security and prepaid health insurance: how to know if what they want to charge me is legal

The co-payment is an additional amount that users of prepaid or social security plans must pay at the time of receiving a medical service, outside their coverage plan.

Each provider decides to charge these extra amounts outside the agreements they have with the funders, and it is passed on to the affiliates.

The co-payment works as a percentage of the value of the medical benefit. The percentage varies according to the user's coverage plan and the type of benefit received.

How do I know if what I am being charged is legal?

The co-payment is legal in Argentina, but it is regulated by the Superintendence of Health Services (SSSalud). The agency establishes the maximum amounts that prepayment companies can charge for co-payment.

Since October 2023, the"minimum ethical medical fee", an additional charge of more than $6,000 for affiliates of social security and prepaid medicine, has been implemented.

The measure, promoted by more than 30 medical associations in the country, generated controversy as it was a unilateral decision of the professionals without the endorsement of the entire healthcare system.

The implementation of co-payments evidenced a crisis that deepens with time. The root of the problem lies in the incompatibility of the two logics that govern the privately managed health system.

On the one hand, its main income depends on workers' salaries, while, on the other hand, costs (technology and drugs) are dollarized.

Affiliates can find out if what medical professionals want to charge as co-payment is legal by consulting the following information.

Maximum co-payment amounts

The Superintendence of Health publishes on its web page the maximum coinsurance values authorized under the Compulsory Medical Program that Health Insurance Agents may charge.

Coverage Plan

Each member's coverage plan contract must include the corresponding co-payment percentage for each type of benefit.

The medical chart

The value of the medical benefit to be received must appear in the medical booklet of the prepayment or social work.

Users who are charged a co-payment that exceeds the maximum values established by the Superintendence of Health Services, or who are not provided with clear information about the co-payment, may file a claim before the agency.

The purpose of the Superintendence of Health Services is to protect the rights of users, promote the quality of health care, supervise and control the entities of the health system and resolve disputes between members and the entities.

However, all social security and prepaid health insurance companies must provide at least the Mandatory Medical Program (PMO) imposed by the Superintendence of Health Services.

Some social security and prepaid health insurance companies have notified their members that they can report these additional expenses to the companies, with the invoice corresponding to the payment, and they will grant them a reimbursement.

Which specialists adhere to the co-payment system?

The associations that implemented the"minimum ethical medical fee" issued a communiqué. In it, they pointed out that the value of the medical consultation experienced a significant drop in the last few years. This situation was aggravated by the delay in the payment of fees and high inflation.

They pointed out that the new "minimum ethical medical fee" will be adjusted bimonthly in accordance with the inflationary index.

The communiqué was signed by the following associations and groups:

Agremiación Argentina de Ortopedia y Traumatología and Asociación Argentina de Ortopedia y Traumatología; the Asociación Argentina de Cirugía; La Asociación Argentina de Cirugía de Cabeza y Cuello; the Asociación Argentina de Controversias en Obstetricia y Ginecología, the Asociación Argentina de Ginecología Oncológica; the Asociación Argentina de Menopausia Andropausia; the Argentine Association of Neurosurgery; the Argentine Association of Clinical Oncology; the Argentine Association for the Study of Climaterium; the Argentine Civil Association of Pediatric Surgery; the Buenos Aires Association of Otorhinolaryngology; the Association of Professionals of Santa Isabel; the Argentine Medical Association of Contraception and the Argentine Urogynaecological Association.

Also adhered: Argentine College of Cardiology; the Argentine Federation of Gynecology and Obstetrics Societies; the Argentine Federation of Otorhinonaringology Societies; the National Federation of Neurosurgery; the Buenos Aires Society of Gynecology and Obstetrics; the Argentine Society of Obstetrics and Gynecology of the Province of Buenos Aires; the Argentine Society of Plastic, Aesthetic and Reconstructive Surgery; the Argentine Society of Gynecologic and Reproductive Endocrinology; the Argentine Society of Cardiology; the Argentine Society of Dermatology; the Argentine Society of Cardiac Electrophysiology; the Argentine Society of Endometriosis; the Argentine Society of Child and Adolescent Gynecology; the Argentine Society of Mastology; the Argentine Society of Reproductive Medicine; the Argentine Society of Emergency Pathologies and Emergentology; the Argentine Society of Rheumatology; the Argentine Society of Urology and the Argentine Society of Gynecological Surgery.

The Argentine Council of Ophthalmology; the Argentine Federation of Radiology; the Argentine Federation of Cardiology; the Argentine Society of Radiology; the Argentine Society of Ultrasonography in Medicine and Biology and the Argentine Society of General Internal Medicine also joined.