The main structure of health in Chile is the National System of Health Services (SNSS), which is constituted by the National Health Fund (FONASA), which represents the public health of the country, and the Previsional Health Institutions (ISAPRE) which represents the private sector.
The SNSS is a social construction, created on July 2, 1979, from the existing National Health Service (SNS) and National Medical Service for Employees (SERMENA), and seeks to centralize and organize the health services provided to the population, based on the principles of equity, participation, and solidarity.
Fonasa: how it works and who has access?
Membership in Fonasa corresponds to the procedure by which dependent and self-employed, retired, and private workers become part of the public health system.
With this, they and their legal dependents (spouse, sons, daughters, or whoever meets the requirements) have the right to access medical benefits in the public or private health network.
People who join Fonasa must contribute 7% of their taxable salary monthly, whose maximum legal limit is 80.2 Unidad de Fomento (UF), and cannot belong to another health system (Isapres, Capredena, or Dipreca), as the two systems are incompatible (except those belonging to a repair program, such as the PRAIS).
Who is it for?
- Dependent workers
- Seasonal workers
- Newly recruited workers
- Lack of resources (section A)
- Beneficiaries of Family Allowance (SUF)
- Beneficiaries of the Basic Solidarity Pension (PBS) for Disability or Old Age
- Pregnant women, and children up to six years old
- People included in the Comprehensive Health and Rights Reparations and Assistance Program (PRAIS)
- Chileans, foreigners, and foreign beneficiaries of international agreements that protect contributory pensioners and their family groups. To effect this benefit, people need to go to the Superintendence of Pensions (SP) to request the document that they must present at any Fonasa branch.
- Foreigners and foreigners included in the refugee agreement
- Foreigners and foreigners irregular or without documents
- Health sector employees
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Fonasa classification groups
Fonasa classifies its beneficiaries in groups A, B, C, and D, according to their income. Check below the characteristics of each group:
Group A - This group includes people with less financial resources and belonging to the social programs of the Chilean government.
Group B - This group includes people whose monthly taxable income is $ 276,000 or less and people receiving basic solidarity pensions, for whom they are treated free of charge in hospitals and public offices.
Group C - People with monthly taxable income greater than $ 276,001 and less than or equal to $ 402,960 are included in this group, so they pay a 10% fee in public hospitals. With three or more dependent family members, you will move to group B.
Group D - People with a monthly taxable income greater than $ 402,961 are considered in this group and pay 20% of the fee in public hospitals. With three or more dependent family members, you will move on to group C.
Service modalities at Fonasa
At Fonasa there are two types of assistance, namely the Free Choice Mode (MLE) and the Institutional Assistance Mode (MAI). At MLE, people can be served in private establishments or with a health professional who has insurance.
For MAI, medical benefits will be granted to beneficiaries in public establishments that make up the health network, namely:
- CESFAM (Family Health Centers)
- SAPU (Primary Care Service)
- CRS (Health Reference Centers)
- CDT (Therapeutic Diagnostic Centers)
- Public hospitals
Who can be helped in this modality (MAI)?
People from groups B, C, and D can be served in this modality and, for this, they can purchase a service voucher. The value is related to the enrollment level of the professional or establishment where the service is provided, which can be levels A, B, or C.
ISAPRE: How does it work?
ISAPRES are private pension health institutions, charged with financing health benefits and benefits for people who contribute 7% or more of the agreed amount of their monthly health income. See below the modalities existing at ISAPRE.
Modality of providers with contract or preference
In this modality, Isapre covers health benefits through a specific provider or network of individual providers in the plan, with a preferred provider, with the highest bonus if attended with the provider established in the plan. Thus, it also covers health benefits under the free choice modality, but with fewer bonuses.
Free Choice Mode
ISAPRE will subsidize any medical provider in which the affiliate or beneficiary is served.
Closed mode or family doctor
IASPRE will reimburse the affiliate or beneficiary if it is attended only by the provider indicated by the health plan.
Source: Superintendência de Saúde do Chile and Chile Atiende