Spanish
The project, which is based on technical studies carried out under the instruction of the National Council for Social Security (CNSS) through resolution 563-01 of 2023, proposes a distribution of SFS funds to the ARS based on the claims experience and risk profile of its affiliates, initially starting from their age and sex, variables that, to a greater extent, define the utilization profile of the Basic Health Plan.
This would mean that the Health Insurance Companies (ARS) with high-risk populations —such as elderly people or women in reproductive stages— would receive an economic allocation according to the expected expenditure, allowing them to manage the needs of their affiliates, within a framework of equity and sustainability.
For example, to cover the health management of the female population over 50 years old, up to three (3) times the current per capita value (RD$1,683.22) would be needed, compared to what is needed to manage the health of a male population of 20 years old, which requires just over a third (37%) of the current per capita.
The proposal, focused on the Contributory Regime, seeks to strengthen the coverage of services for affiliates by ensuring that resources among the ARS are allocated in a balanced manner, which contributes to continuing to improve timely access to medical care, without affecting the quality of service, the benefits, and current rates (economic contributions) of users.
Furthermore, it contemplates a gradual implementation process over 18 months, so that the ARS have reasonable and prudent time to adapt in an orderly manner to the changes.“More than a technical adjustment, this model would be a social and justice pact to prioritize those who need it most. Its success will depend on a gradual implementation and a monitoring system that ensures transparency and measurable results,” stated Superintendent Miguel Ceara Hatton.
This financial adjustment plan would not alter the existing payment mechanisms between the ARS and the Health Service Providers (PSS), which would continue their operations in accordance with their contractual commitments, supporting a more effective system.
The differentiated per capita model is established in article 169 of law 87-01, which creates the Dominican Social Security System, which empowers the Superintendency of Health and Occupational Risks to carry out the corresponding technical studies to present a proposal to the National Council of Social Security (CNSS), an entity that has the power to establish the value for each affiliated person based on their individual risk.
The Family Health Insurance has precedents in the application of the differentiated per capita model. During the pandemic, this methodology was used to allocate resources to the ARS for outpatient health care due to Covid-19, a process that was positively valued by the actors in the system.
Open dialogue with the ARS
SISALRIL regulates and supervises a portfolio of 17 ARS, with which it has held direct meetings and working tables on the subject. These conversations are part of the process of transparency and collaboration around the proposal, which reinforces the stability of the system as a whole without affecting the operability of any actor.
The institution remains open to continuous dialogue and the search for solutions, safeguarding long-term sustainability and the constant improvement in the quality of care within the Dominican Social Security System.
About SISALRIL
The Superintendence of Health and Occupational Risks (SISALRIL) is the institution responsible for guaranteeing the right to health and protection against occupational risks for the population in a timely and quality manner, through regulation and supervision in the Dominican Social Security System (SDSS).It is an autonomous entity of the State, established on May 9, 2001, by Law No. 87-01.
