Health insurance - AMO
Services Covered by AMO
The Mandatory Health Insurance (AMO) helps cover the healthcare expenses of insured individuals and their dependents when they are eligible for coverage.
It covers medical and maternity care, within the limits set by law. Being covered by AMO does not mean, therefore, that all care is free or automatically reimbursed.
1. Outpatient Care
Outpatient care refers to care received without hospitalization. It includes, in particular, doctor visits, nursing care, laboratory tests, medical imaging, minor surgery, and covered dental care.
To be covered, care must be provided by an approved facility. Certain frequent doctor’s visits require prior authorization, except in emergencies as defined by law. Dental services require a detailed prior estimate.
Decree No. 09-552/P-RM of October 12, 2009, Articles 28 through 32.
2. Medications
Covered medications are listed on an official list compiled primarily by International Nonproprietary Name (INN), which is the name of their active ingredient.
For a pharmaceutical product, coverage is based on the retail price of the reference generic, if one exists. A prescription therefore does not guarantee full reimbursement for all prescribed products.
Decree No. 09-552/P-RM, Articles 44–46.
Before the medication is dispensed, ask the pharmacist which products are covered and how much you will have to pay.
3. Maternity Benefits
Coverage includes medical, pharmaceutical, diagnostic, and hospitalization costs related to pregnancy, childbirth, and the postpartum period.
The decree requires registration in the third month and three checkups: in the third, sixth, and then seventh or eighth months. The specific coverage period extends up to eight weeks after childbirth, with provisions for complications.
Decree No. 09-552/P-RM, Articles 47 through 55.
These formalities do not replace the medical care appropriate for each pregnancy.
4. Inpatient Care
Eligible expenses may include the hospital stay, medical and surgical procedures, and certain medical transportation. Personal expenses are excluded from the covered hospital accommodation costs.
Decree No. 09-552/P-RM, Articles 34–37.
For a scheduled hospitalization, ask the facility for a breakdown of the costs and the procedures for coverage.
5. How much do you have to pay out of pocket?
| Type of Covered Care | AMO Share | Beneficiary’s share |
|---|---|---|
| Outpatient care | 70% | 30% |
| Hospitalization | 80% | 20% |
The beneficiary’s share is called the copayment. The calculation is based on reference rates. The managing agency pays its share directly to the provider: this is known as third-party payment.
Decree No. 09-552/P-RM, Articles 58–62.
Example: For a covered medical visit with a base rate of 20,000 FCFA, the AMO pays 14,000 FCFA and the beneficiary pays 6,000 FCFA.
If an additional expense is not covered, it may be added to this 6,000 FCFA. It is therefore important to distinguish between the billed rate, the base amount used by the insurance, and the final amount to be paid.
6. What services are excluded?
The law establishing AMO specifically excludes:
- eyeglasses;
- dental prosthetics;
- cosmetic surgery;
- certain alternative medicine services;
- any other services excluded in accordance with applicable laws.
Dental care should therefore not be confused with dental prosthetics, nor should ophthalmological care be confused with the provision of eyeglasses.
Law No. 09-015 of June 26, 2009, establishing the AMO system.
Similarly, a reconstructive procedure should not automatically be classified as cosmetic surgery: its nature and eligibility for coverage must be reviewed.
7. How do you prepare a claim for coverage?
Before scheduled treatment, ask yourself five questions:
- Am I eligible for AMO coverage?
- Is the provider contracted with the system?
- Is the treatment or medication covered?
- Is prior authorization required?
- How much will I have to pay out of pocket?
Keep your prescriptions, estimates, invoices, and proof of payment. They make it easier to track your claim and understand the amounts billed.
8. Key Points
- AMO covers a portion of medical and maternity expenses.
- Coverage depends on eligible services and reference rates.
- Outpatient and inpatient care have different coverage rates.
- Certain procedures and medications are excluded or subject to specific conditions.
- Checking your coverage before scheduled care helps you plan for the costs.