Services covered by AMO

Compulsory health insurance entitles the beneficiary to reimbursement of costs relating to curative, preventive and rehabilitative care required for health reasons or in connection with maternity. These healthcare services must cover both outpatient and inpatient care.

Outpatient care

Outpatient care is reimbursed at a rate of 70 per cent, with the remaining 30 per cent paid by the patient as a co-payment. This covers treatments required due to the state of health of a beneficiary who is not hospitalised.

This includes consultations with general practitioners or specialists, nursing care, laboratory tests and examinations, minor surgery, medical imaging, dental care (excluding prostheses) and ophthalmological care (excluding spectacles).

Unless prior authorisation has been granted by CANAM, the following will not be covered:

• More than one consultation for the same condition within 24 hours, except in cases of emergency medical care,
• More than one consultation with the same medical specialist within 7 days, except in cases of emergency medical care,
• prescription renewals without a medical prescription.
• More than three obstetric ultrasound scans during pregnancy, unless there is an established foetal or maternal condition.
• Prescriptions for medication as a precaution for travel or for emergency kits.

Pharmaceutical products

These are reimbursed at a rate of 70 per cent, with the remaining 30 per cent payable by the beneficiary. Medicines eligible for reimbursement under the Compulsory Health Insurance scheme are listed, by Joint Order of the Ministers of Health and Social Protection, by International Non-proprietary Name (INN) and by pharmaceutical class (D-44).

This provision means that off-formula medicines are only eligible for reimbursement if no INN medicines exist for that condition.

The list of medicines, laboratory tests and medical imaging procedures eligible for reimbursement under the Compulsory Health Insurance Scheme is provided to healthcare providers by CANAM.

The reference price for medicines is the retail price set by the Ministry of Health.

Maternity benefits

These cover medical, pharmaceutical, laboratory and hospitalisation costs related to the pregnancy and childbirth of an AMO beneficiary. Coverage applies from the date of the beneficiary’s declaration until the eighth week following childbirth, including any complications arising from the pregnancy.

To be eligible for maternity benefits, the beneficiary must undergo three antenatal examinations carried out in the 3rd month, the 6th month and the 7th or 8th month of pregnancy respectively (D.50-54).

Hospital care

These costs are reimbursed at a rate of 80 per cent, with the remaining 20 per cent payable by the patient. Hospitalisation cover applies to both routine hospital admissions and admissions involving surgical procedures, with the exception of cosmetic surgery.

Specifically, this covers medical accommodation costs, medical and surgical procedures carried out on the hospitalised beneficiary, transport costs to the healthcare centre, transfer to another healthcare facility and return to the patient’s home by ambulance.

The following are not covered by compulsory health insurance

• Eyewear,
• Acupuncture,
• Homeopathy,
• Mesotherapy,
• Thalassotherapy,
• Spa treatments,
• Cosmetic surgery,
• Dental prostheses,
• Alternative medicine (or traditional medicine) services.

The insured person may take out, either individually or as part of a group scheme, private or mutual supplementary insurance to cover the patient’s contribution and services not covered by the AMO.

Homeopathy involves administering low doses obtained by diluting and agitating a substance chosen on the basis of the patient’s physical or psychological symptoms. The choice of substances is based on the principle of similarity, according to which a patient is treated with a substance that produces symptoms in a healthy person similar to those of the condition in question.

Cosmetic surgery repairs or reshapes a part of the body (face, hands, burns, etc.)

A spa treatment is a medical treatment at a spa resort during which the patient is treated using natural mineral waters from thermal springs.

Acupuncture is a branch of traditional Chinese medicine based on the insertion and manipulation of fine needles.

Mesotherapy uses intradermal injections to treat rheumatic conditions and for cosmetic purposes.

Thalassotherapy involves the combined use, under medical supervision, of the benefits of the marine environment for preventive or curative purposes.

 Alternative medicine refers to a variety of non-scientific treatment methods based on traditions that are sometimes centuries old.

Only treatment prescribed and carried out within Mali will be covered by the Compulsory Health Insurance scheme (Article 18).

The health insurance beneficiary is free to choose their practitioner in accordance with the national healthcare system.