On August 12, 2013, the Federal Official Gazette published a Ruling approving the General Rules on the Indirect Provision of Medical and Hospital Services as well as on the Partial Reversion of Employee-Employer Dues Paid to the Mexican Social Security Institute (the IMSS, per its Spanish acronym), which will become effective as of the day following publication.
Such Ruling establishes that the agreements for subrogation of medical services may be executed only for the benefits granted under Illness and Maternity Insurance and Labor Risk Insurance coverage, with partial reversion of the employee-employer dues at the various levels of medical care.
In addition, it also contemplates the possibility to agree on the indirect payment of subsidies by employers and the reimbursement of such payments.
- Subrogation of medical services
- Eligibility - For the execution of the above-mentioned agreements, eligible employers are those who have directly established --or have outsourced-- medical and hospital services, to provide their employees and their beneficiaries with medical, surgical, pharmaceutical, and hospital care benefits under Illness and Maternity Insurance and Labor Risk Insurance coverage.
- Requirements - Some of the requirements set include that the employer must be current in the compliance with tax obligations in Social Security matters, and that the services must be performed at least in the same conditions as in the IMSS.
The IMSS may authorize the execution of the agreements in those cases where it cannot directly meet the demands of all of the beneficiaries entitled to its services within the geographical area where the employer's work site is located, or in those cases where there are financial advantages for the IMSS in providing such services on an indirect basis.
- Procedure - The execution of the agreement must be applied for by the employer in writing before the Office of Tax Collection and Audits, after obtaining the employees' consent and demonstrating its capability to provide the services.
After evaluating the corresponding application, the same will be submitted for authorization by the Technical Council and approval by the IMSS's Legal Director.
- Reversion of dues - The Finance Office will determine, in each case, the reversion percentages applicable to the amount of employee-employer dues paid for the Illness and Maternity Insurance and Labor Risk Insurance, considering the calculation methodology set forth in the annex on the "General Rules on the Indirect Provision of Medical and Hospital Services as well as on the Partial Reversion on Employee-Employer Dues."
- Partial Temporary Disabilities and Eligibility for Labor Risk Insurance - In the case of certificates of temporary disabilities for occupational purposes, notices for determination of an occupational accident, notices of medical care, determination of a probable occupational hazard, and/or opinion on a probable relapse due to occupational hazards, these will be issued by the treating doctor providing the subrogated services and delivered to the patient in order for the latter to submit such documents to the doctor at the corresponding IMSS's Family Medicine Unit.
Certificates of disability for occupational purposes and evaluations of total or partial permanent disabilities derived from occupational hazards will be invariably made by IMSS staff.
- Cause for termination of agreements - One of the main causes for termination of the agreements is meeting the effective term indicated in the agreement, an employer substitution, merger or spin-off, or any legal situation that modifies the nature of the employer. In the last case, the IMSS will determine the continuity of the agreement.
- Indirect payment agreements and reimbursement of subsidies
Irrespective of the subrogation of medical services, the reimbursements derived from the execution of agreements for the indirect payment of subsidies due to temporary disabilities for occupational reasons will be made on the basis of the reimbursement system that the IMSS has.