Health insurance - AMO
The Operating Principles of the AMO
The Mandatory Health Insurance (AMO) provides group coverage for health care expenses. It operates on the basis of four principles: solidarity, contributions, risk pooling, and direct billing.
Law No. 09-015 of June 26, 2009, Article 4.
What do these principles mean for the insured person and their family?
1. Solidarity: Contributing According to One’s Means
Premiums help fund care for beneficiaries who need it. This solidarity exists between healthy and sick individuals, as well as among insured individuals with different income levels.
Example: An insured person who rarely sees a doctor helps finance the care of other beneficiaries. When they become ill, they in turn benefit from this collective protection.
2. Contributions: Regularly funding the system
The AMO operates through the payment of premiums. How these premiums are allocated depends on the insured person’s status.
| Situation | Allocation of Contributions |
|---|---|
| Employee | One portion is paid by the employer and one portion by the employee |
| Retiree | A contribution paid by the retiree |
| Self-employed person enrolled in the system | A contribution paid by the insured person |
For employees, the employee’s share may not exceed 50% of the total contribution rate. This cap applies to the split of contributions between employer and employee; it does not correspond to the percentage of medical expenses reimbursed.
The employer withholds the employee’s share and pays the required contributions to the administering agency. For retirees, the pension agency ensures the payment of the corresponding contributions.
Law No. 09-015 of June 26, 2009, Articles 47 and 48.
3. Pooling: Sharing the Financial Risk
Pooling involves combining the resources and risks of many people.
Contributions go toward a collective fund. They do not constitute personal savings that each insured person would use solely up to the amount of their own payments.
Example: A hospital stay may cost more than the contributions already paid by an insured person. Pooling resources makes it possible to cover this expense, in accordance with the plan’s coverage rules.
INPS: Pooling of Risks and Resources.
4. Third-party payment: limiting out-of-pocket expenses
With direct billing, the insurance provider pays the portion of the care it covers directly to the provider. The beneficiary pays the portion remaining at their own expense, known as the copayment.
The coverage levels provided by the INPS are as follows:
| Type of Care | AMO Coverage | Beneficiary’s Share |
|---|---|---|
| Outpatient care | 70% | 30% |
| Inpatient care | 80% | 20% |
These percentages apply to eligible expenses, based on applicable rates.
INPS, coverage, and third-party payment.
Example: For a covered medical visit costing 10,000 FCFA, the AMO covers 7,000 FCFA and the beneficiary pays 3,000 FCFA.
5. Non-discriminatory coverage
The law provides for coverage without discrimination based on, among other things, age, gender, occupation, income level or type, medical history, or place of residence.
This principle applies to individuals covered by the program. The conditions for enrollment, eligibility, and coverage must still be met.
Law No. 09-015 of June 26, 2009, Article 4.
6. Key Points
- Solidarity enables insured persons to participate in a shared system of protection.
- Premiums finance the system.
- Pooling distributes healthcare costs among the members of the group.
- The third-party payment system eliminates the need to pay out-of-pocket for the portion covered by the AMO.
- The copayment remains the responsibility of the beneficiary.
- Non-discrimination is a fundamental principle of coverage.