Health insurance - AMO
Accreditation of Healthcare Providers
Being enrolled in the Mandatory Health Insurance (AMO) program does not mean that you are eligible for coverage at any healthcare facility.
The agreement identifies which providers participate in the system and sets the rules governing care, rates, and payment.
1. What is an approved provider?
An accredited provider is a healthcare professional or facility that is linked to the health insurance system through an agreement.
This agreement specifies, in particular:
- the obligations of the parties;
- the reference rates;
- billing and payment procedures;
- measures to control expenditures;
- requirements regarding the quality of care;
- dispute resolution procedures.
In this way, it governs the relationship between the health insurance system and the providers who treat its beneficiaries.
INPS, the accreditation process.
2. Which providers may be involved?
The network may include various categories of facilities and professionals:
| Category | Examples |
|---|---|
| Healthcare facilities | Public, community, and private facilities |
| Medical professionals | Private practitioners and dentists |
| Pharmacies | Retail pharmacies |
| Laboratories | Medical testing laboratories |
| Paramedical professionals | Nurses, midwives, and other relevant professions |
A license to practice and participation in the AMO network are two different things. A facility can operate legally without necessarily participating in the AMO healthcare network.
3. Why check for contract status before receiving care?
AMO coverage is organized through a network of contracted providers. Before a scheduled appointment, a test, or a medication purchase, it is therefore advisable to verify that the provider is actually part of the network.
Ministry of Social Protection, AMO healthcare network.
You can ask at the front desk:
- whether the provider is currently approved;
- whether the requested treatment or medication is covered;
- what documents you need to present;
- how much you will have to pay out of pocket.
Example: A clinic may offer a medical exam that isn’t necessarily covered by AMO. Checking these two points helps avoid confusing the facility’s acceptance of AMO with the coverage of each specific service.
4. How does payment work?
The AMO uses direct billing: the insurance pays the portion of the costs it covers directly to the provider.
The beneficiary pays the copayment, that is, the portion they are responsible for.
For expenses eligible for coverage, the levels set by the INPS are:
| Type of Care | AMO Share | Copayment |
|---|---|---|
| Outpatient care, without hospitalization | 70% | 30% |
| Care during hospitalization | 80% | 20% |
These percentages apply in accordance with coverage rules and reference rates.
INPS, coverage of medical care.
Example: For a covered medical visit with a base rate of 10,000 FCFA, the AMO’s share is 7,000 FCFA and the beneficiary’s share is 3,000 FCFA. Uncovered services may result in additional costs.
5. What is the purpose of the reference rate?
The reference rate is the basis used to calculate coverage. It allows for the application of common rules to the relevant services.
It is therefore important to distinguish between the amount billed, the amount approved by the insurance provider, and the amount remaining to be paid. An agreement with an insurance provider does not constitute a promise of full reimbursement for all expenses.
Before undergoing costly or scheduled treatment, requesting a written explanation of the costs allows you to better anticipate the expense.
6. What is the role of medical review?
Medical review verifies that the treatments and medications submitted for coverage comply with the guidelines.
Doctors and pharmacists approved by CANAM are involved in medical review. Their oversight role must be distinguished from that of the healthcare professional who provides the care.
To make it easier to track your case, keep your prescriptions, invoices, and proof of payment.
7. Key Points
- A contracted provider is part of the AMO’s healthcare network.
- A license to practice does not automatically constitute an agreement with the AMO.
- The fact that a facility is under contract does not mean that all of its services are covered.
- Coverage depends on approved services and reference rates.
- The beneficiary generally pays a portion of the costs.
- Checking coverage before scheduled care helps you better anticipate expenses.