Risks covered by health insurance legislation

Risks covered by health insurance legislation

health insurance legislation


The Algerian Social Security system includes all the branches provided for by modern social security systems, i.e. the nine branches listed by Convention No. 102 of the International Labor Organization (ILO), namely:
Health insurance;
• Maternity insurance;
• Disability insurance;
• Death insurance;
• Work accidents;
• Occupational diseases;
• Unemployment insurance;
Retirement;
• Family benefits.

4 - Risks covered by Algerian health insurance legislation:

4.1 - health insurance:

Their purpose is to cover medical expenses and to provide replacement income to salaried workers forced to stop their work because of illness or accident other than an industrial accident.

- Coverage of care or benefits in kind:

     It consists of reimbursement of the costs of curative or preventive health care (benefits in kind).
The benefits in kind relate to medical, surgical, medical imaging, biological analysis, pharmaceuticals, hospitalization, dental care and prostheses, equipment, medical optics, family planning, rehabilitation and vocational rehabilitation, thermal or specialized cures, medical transport and movement of the patient.
    Reimbursement is made at the minimum rate of 80% of the rates set by regulation and without limitation of duration, except for spa treatments which are limited to 21 days.
    This rate is raised to 100%, in particular in the event of long-term or chronic illness, for important acts or because of the social situation of the insured.
    The patient has the free choice of doctor, certain services are subject to the prior agreement of the fund concerned.
    The care provided by public health structures is free, it is funded by the State and an annual flat rate paid by social security called "hospital package".

cash prestations:

They are granted exclusively to salaried workers.
The insured person receives a daily allowance for the duration of sick leave prescribed for health reasons.

 - The daily allowance is equal to:

- 50% of the salary subject to net contribution during the first 15 days of sick leave;

- 100% from the 16th day or from the 1st day in the event of hospitalization or long-term illness.

The reference salary cannot be lower than the amount of the SNMG.
- maternity insurance:
- The advantages relate to:
- reimbursement of medical and pharmaceutical care and expenses incurred for pregnancy and childbirth.
-the reimbursement at the rate of 100% of the hospital costs of the mother and infant in the delivery clinics, including the costs of incubators. hospitalization in public health facilities is free.
In addition, if the parturient is a salaried worker, she benefits from a maternity leave of 14 weeks paid 100% of the salary subject to contributions.

It should be noted that the benefits provided by Algerian social security legislation in the field of maternity insurance are comparable to or even greater than those of certain developed countries.

- Disability insurance:

    It consists in granting a pension to the insured person under the age of 60, with a disability which reduces his capacity for work or earning by at least 50%.
There are 3 categories of disabled and pensioners whose rate varies from 60 to 80% depending on the severity of the condition. This rate is increased by 40% for invalids requiring the assistance of a third person.
Regarding the self-employed, they benefit from a pension in the event of total and final invalidity, the rate of which is 80% of the reference income.

- Death insurance:

    Its purpose is the payment of a death benefit to the beneficiaries of the deceased social insured.
The death benefit is equal to 12 times the amount of the salary for the best month in the last year preceding the date of death or 12 times the monthly amount of the pension or annuity if it is a retiree, an invalid or a holder of a pension for an industrial accident or an occupational disease.
The amount of the death benefit cannot be less than 12 times the amount of the SNMG if the de cujus is a working worker and 12 times the legal minimum amount of the retirement pension in the case of a holder of a security benefit social.
If it is a self-employed worker, the amount of the death benefit is equal to the annual income subject to contribution.

- Additional services:

Legislation has provided for the establishment of an aid and relief fund responsible for granting benefits in certain exceptional situations for the benefit in particular of low-income social security recipients.

In addition, collective actions in the form of health and social benefits for the benefit of social insured persons and their dependents are carried out by social security organizations.

4.2- Retirement insurance in algeria :

retirement insurance

A retirement pension is granted to the worker who fulfills the following conditions:
1- Be 60 years old (65 for the self-employed);
2- Having worked for 15 years, at least 7 and a half years of which have given rise to actual work and payment of contributions. This duration is halved for mujahideen workers. A working woman can receive a retirement pension at the age of 55. It also entitles you to a reduction of one year per child, up to a maximum of 3 children.

No age condition is required:
- for the salaried worker who has gathered 32 years of activity,
- for the moudjahid having obtained a pension rate of 100%,
- for the worker suffering from a total and final disability but not fulfilling

the conditions for receiving a disability pension.

The legislation also provides for the possibility of providing active workers, at their request, with a proportional pension if they are at least 50 years old and have at least 20 years of activity. The age and minimum working time are reduced by 5 years for female employees.

Each year of work is validated at the rate of 2.5% for retirement (3.5% for the years of participation in the national liberation war).
The full retirement pension rate is 80% (100% for the mujahideen).
The reference salary for calculating the retirement pension is that of the last 5 years of activity or the best 5 years of the salaried worker’s career and the 10 best annual earnings for the self-employed.
The minimum amount of the pension cannot be less than 75% of the SNMG (2.5 times the SNMG for the moudjahid) whatever the contributory rights.
When the worker does not have 15 years of activity but has at least 5 years or 20 quarters of work, he can benefit from a retirement allowance calculated under the same conditions as the retirement pension. The age for the benefit of the retirement allowance is fixed at 60 years for the employee and 65 years for the self-employed.

The holder of a retirement pension or allowance is entitled to an increase for a dependent spouse.

- The annual revaluation of pensions:

    Compared to international practices, Algerian legislation is among those few in number which inscribe in the body of the law the principle of systematic annual revaluation. In addition to the exceptional revaluations granted by the public authorities, the annual revaluations of pensions and retirement allowances from the pension funds' own funds have enabled an overall revaluation of pensions in the order of 55% during the period 2000-2010.

4.3- Work accidents insurance and occupational diseases:

Social insurance legislation provides compensation for employees in the event of:
Work accidents insurance

- an accident at work proper which occurred as a result of or at the time of work or during a professional mission;
- commuting accident as defined by law;
- occupational disease linked to activities carried out for a fixed period and appearing in a list fixed by regulatory means.

The services granted in this context are as follows:

-Reimbursement at the rate of 100% of the care and granting of a daily allowance at the same rate during the period of temporary incapacity.
- Granting of an annuity in the event of sequelae. However, if the rate of permanent disability is less than 10%, a single capital is allocated;

Cash benefits are calculated on the basis of:

-the salary subject to contribution without it being lower than the SNMG with regard to the daily allowance;
-the salary subject to contribution during the last twelve months with regard to the annuity.
In addition, the CNAS carries out actions in the area of prevention of occupational risks.

4.4- Insurance against the risk of job loss:

Protection against involuntary loss of employment for economic reasons was the last risk covered by social security from 1994.
The unemployment risk compensation is made through the allocation of an unemployment allowance granted by the National Unemployment Insurance Fund (CNAC) and an early retirement whose management is entrusted to the National Pension Fund (CNR) ).

 4.5 - Family benefits:

Before and after the unification of the national social security system, family allowances were financed by a contribution paid exclusively by the employer.
From July 1, 1994, in accordance with Legislative Decree No. 94-O8 of May 26, 1994 on the Supplementary Finance Law for 1994, family allowances were paid for from the state budget.
This measure was taken at the time of the introduction of unemployment insurance, under which the employer paid 2.5% and the employee 1.5% (overall share: 4%).
From 1999, a new approach to family allowances was enshrined in the 1999 finance law, which again provided for the financial coverage of family benefits by the employer, with a transition period fixed as follows:

 Year 1999: 75% borne by the State,
25% payable by the employer,
Year 2000: 50% borne by the State,
50% payable by the employer,
 Year 2001: 25% at the expense of the State,
75% payable by the employer,
From 2002: 100% payable by the employer.

However, Law No. 01-12 of July 19, 2001 on the supplementary finance law for 2001 has transferred family allowances to the State budget.
The beneficiaries of family allowances are salaried workers and retirees from the salaried scheme.

These family allowances are paid according to the following criteria:

- for each child, from the 1st child up to the age of 17, with the possibility of extension up to 21 years in the event of further education, training or illness of the child concerned.
- The resources of the recipient and the rank of the child in siblings:
• 600 DA per month per child, if the salary or income of the recipient is less than or equal to 15,000 dinars per month and up to the 5th child;
• 300 DA per month and per child, if the salary is more than 15,000 DA as well as for children beyond the 5th row.

V / The social security reforms of the 2000s:

The social security reforms

In order to improve the performance and the quality of services provided by the social security system, a **major reform program has been tee developed and implemented from the 2000s.
The objectives of this program are:

1- improving the quality of services, in particular with:

• the extension of the network of local structures,
• the extension of the third-party payment system (drugs and health care),
• the development of health actions through the creation of regional medical imaging centers and specialized clinics,
• measures to improve the purchasing power of retirees.

2- modernization, in particular through:

• the rehabilitation of existing infrastructure,
• the generalization of the IT tool,
• human resources development,
• the introduction of the electronic card of the social insured "CHIFA".

3- preserving the financial balance of social security organizations, in particular through:

• reform of the instruments for collecting contributions,
• reform of social security financing,
• the implementation of a new drug reimbursement policy through the promotion of generic drugs, the reference price and the encouragement of national production.

V-1 Reforms of the legislative and regulatory system:

The social security reform program was initiated by the adaptation of certain legislative and regulatory texts.

In this context, it is worth mentioning in particular:

- Law n ° 04-17 of November 10, 2004 modifying and supplementing law 83-14 of July 2, 1983 relating to the subjection to social security which allowed the widening of the prerogatives of the agents of control of social security and empowering labor inspectors to identify breaches of social security legislation;
- the supervision of the procedures for approving social security supervisors and the conditions for their exercise through Executive Decree No. 05-130 of April 24, 2005;
- Law n ° 08-01 of January 23, 2008 modifying and supplementing law n ° 83-11 of July 2, 1983 relating to social insurance and its implementing decree, which constitutes the legal anchor of the electronic card of the “Chifa” social insured;
- Law No. 08-08 of February 21, 2008 on social security litigation which introduced new measures aimed, on the one hand, at facilitating the forced collection of contributions, measures applicable against taxable persons not fulfilling their legal obligations in terms of social security and, on the other hand, promoting the regularization of the situations of bona fide employers experiencing financial difficulties;
- Law n ° 11-08 modifying and supplementing law n ° 83-11 relating to social insurance, which provides for the possibility of extending social coverage to new specific categories of the population, improving social coverage of women, improving the quality of services by integrating the specific features of the great south and the highlands, widening the scope of new information and communication technologies and confirming the reform of the financing of the system social security;
- The 2010 finance law (article 67) which enshrined the reform of the financing of the social security system by the creation of the national social security fund, fed by the proceeds from the tobacco tax, from the tax to purchase of pleasure boats and levy on the net profits from the importation of medicines.






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Risks covered by health insurance legislation Risks covered by health insurance legislation Reviewed by Pedro on May 09, 2020 Rating: 5

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