Health insurance - AMO
Accreditation of healthcare providers
Relations between CANAM and private, public and community health centres are governed by an agreement between the two parties. The agreement includes, amongst other things:
- The obligations of the parties,
- Reference rates for healthcare services,
- Measures to control healthcare expenditure,
- Tools for ensuring the quality of care,
- Procedures for the reimbursement of healthcare costs,
- Mechanisms for resolving disputes.
Treatment is only covered by the AMO if it is provided within a healthcare facility approved by the CANAM, unless the patient is completely unable to travel for medical reasons.
Only healthcare facilities, pharmacies and health laboratories approved by the State may be registered under the Compulsory Health Insurance (AMO) scheme. This applies in particular to:
- Community pharmacists,
- Public, community and private health centres,
- Dentists,
- Private practising doctors,
- Medical analysis laboratories,
- Nurses, midwives and other paramedical professionals. (D.4 – 10-577).
Agreements are concluded for a period of three years, except in special cases. At the end of the standard term, the terms of the agreement may be renegotiated.
Before they come into force, agreements must be approved by the Minister responsible for social protection.
To facilitate their identification, CANAM issues a unique code to each contracted healthcare provider, specifying its business name, specialism and address. This identifier must be displayed at the main entrance of each contracted healthcare provider.
Reimbursement for care covered by the AMO is made, regardless of the provider, on the basis of the national reference tariff set out in the agreement.
This national reference rate is set by the Minister responsible for Health.
CANAM reimburses healthcare providers directly for outpatient and hospitalisation costs, excluding the patient contribution.
Doctors and pharmacists approved by CANAM carry out medical checks on the provision of healthcare services and medicines covered by the agreement.
Practitioners acting as medical or pharmaceutical advisers may not simultaneously act as contracted healthcare providers.