Table 6 Benefit Package Design and Provider Payment Methods
Country | Range of services covered by the benefit package | Degree of cost-sharing for the subsidized | Degree of portability | Provider-payment mechanisms |
|---|---|---|---|---|
Bolivia | SSPAM: outpatient care, diagnostic services, dental care, hospitalisation, drugs SUMI: eventually extended to 547 services related to pregnancy, neonatology, paediatrics, dental care, diagnostic services, and all other services not on the list of excluded services (such as high cost interventions, chemotherapy, radiotherapy, transplantations, orthodontics) [70] | None [53] | National portability [54] | Primary care: fee-for-service Higher levels: Budget allocations [53] |
Chile | Plan AUGE started with 53 pathologies of outpatient, inpatient and specialist care services and includes 80 pathologies since 2005 [47, 82] Extension of Plan AUGE has to remain within the established amount of the “Universal Premium” within the next 12 months FONASA also provides coverage of extended primary health care and catastrophic diseases [71] | None for FONASA groups A and B [47] | National portability [31] | Primary care: Fixed rate per capita and a budgeted amount; Public hospitals: 50% historical budget; 50% payment for “treatment package”; Ambulatory hospitals: Pay-per-visit rate (fee-for service) for AUGE services Catastrophic diseases: per case payment Private hospitals: Diagnosis Related Groups [27] |
Colombia | Mandatory Benefit Package for the Subsidized Regime: Outpatient care, specialized care for catastrophic illnesses, limited coverage for most inpatient care [21, 79] Since 2012, the benefit packages of the contributory and subsidized scheme are harmonized [83] | Lowest income group: no co-payment; 2nd and 3rd lowest income level: co-insurance of 10% Ceiling: monthly minimum wage [84] | National portability [85] | Preventive and primary care services: Capitation Specialist and hospital care: Fee-for-service [79] |
Costa Rica | No explicitly defined benefit package nor positive list: drugs and services at all levels of care are covered [86] Implicit rationing through waiting lists [46] | None [49] | National portability in case of emergencies [87] | Primary Care Units: Capitation, adjusted for sex, age and area-specific infant mortality [88]; Secondary and tertiary care: Budgets; fee for service for medicines) [27] |
Dominican Republic | Health promotion and disease prevention, primary health care, in-patient and surgical care services, outpatient care services and drugs, diagnostic tests, preventive dental care, complementary provisions for people with disabilities. The cost of the benefit package of the subsidized regime is of US$60 per year (US$240 per year for the contributive regime) [32] Catastrophic illnesses fund (Fondo para enfermedades catastróficas) [81] | None [89] | n/a | Fee-for-service [32] |
Mexico | Fund for Allocations of Health Services: Essential in-patient and out-patient care services (the Universal Health Services Catalogue includes 284 interventions and 522 drugs) Fund for Protection against Catastrophic Expenses: Specialized care services Medical Insurance for a New Generation: any other services not covered above for children below 5 years (131 interventions) [20] | None907 | National portability [91] | Universal Health Services Catalogue interventions: Capitation payment Catastrophic illnesses: Per-case payment [22] |
Peru | Essential Health Insurance Plan: 140 health interventions and services (covering about 65% of disease burden) [23, 30, 34] | None [33] | n/a | Fee-for-service [30] |
Uruguay | Integrated Health Care Plan for all insured: Broad benefit package with services at all levels of care and drugs [77] | None [92] | n/a | Risk-adjusted per capita payment [68], piloting of Diagnosis Related Groups [93] |