Health Insurance for the Family: When there is a subordinated and remunerated labor relationship, the employers have the obligation to affiliate their workers in the Compulsory Regime of the Mexican Institute of Social Security (IMSS), a regime that includes all the insurance offered by the IMSS: Occupational Hazards, Diseases and Maternity, Disability and Life, Retirement, Unemployment in Old Age and Old Age, Nursery and Social Benefits.
But what happens to people who for various reasons are in the case of not having an employment relationship? Do they have the possibility of receiving the medical services of the IMSS? And in your case, what is the mechanism for it?
Health Insurance for the Family
It is worth knowing that there is an alternative contemplated in the Social Security Law (LSS), by means of which people who do not have a health service can access it by paying an annual fee; this alternative is the Family Health Insurance.
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In this regard, some questions arise: What is Family Health Insurance? Who is entitled to access to this insurance? What is the cost?
- What is Family Health Insurance? It is a health insurance to which people can voluntarily join to contract the benefits in kind of the Sickness and Maternity Insurance (SEM) for themselves and their families, paying an annual fee, according to their age.
The Family Health Insurance, which is based on Article 240 of the LSS, offers coverage to all families that enter into an agreement with the IMSS for the granting of benefits in kind from the SEM; grants medical, surgical, pharmaceutical, hospital and maternity assistance.
This insurance covers only the Insurance of Diseases and Maternity, that is to say, it does not cover Risks of Work, Disability and Life, Retirement, Unemployment in Advanced Age and Oldness, Nurseries and Social Benefits.
- Who is entitled to access to this insurance? Article 240 of the LSS literally states: “All families in Mexico have the right to health insurance for their members and for this purpose, they may enter into an agreement with the Mexican Social Security Institute for the granting of insurance benefits in kind. of Diseases and Maternity, in the terms of the respective regulation. “
This insurance can include those who are not subject to a mandatory regime in a social security system, as established in Article 95 of the LSS Regulation on Affiliation, Classification of Companies, Collection, and Control (RACERF).
Articles 95 and 96 of the RACERF provide that, in addition to the applicant for Family Health Insurance, at least one other person must be insured: spouse, concubine or concubine, children, parents, grandparents, grandchildren, siblings, cousins, children of the brothers, brothers of the parents of the insured.
- What is the cost? All persons who voluntarily join the Family Health Insurance will pay an annual fee, classified by the age range to which they belong. The annual fee is determined per person and will be paid for each of the people who have joined this insurance
How does it work?
- It is a health insurance to which any person and their family members can voluntarily join, provided that:
- Carry out the process through IMSS Digital or our sub-delegations.
- Do not have a social security scheme in another public institution.
- Do not have pre-existing diseases.
- It is contracted voluntarily, through the conclusion of an agreement with the IMSS.
- The subjects covered by this insurance are the insured and their family nucleus:
- Spouse or concubine,
- Children (as), father and mother of the applicant for the Insurance and,
- Grandparents, grandchildren, siblings, cousins, children of siblings and siblings of the parents of the insurance subject
- An annual fee that covers the right to medical services coverage during that period is covered (see table).
- The fee is charged for each family member who joins the insurance.
- Start your coverage on the first day of the month immediately following your contract.
- If the insured wishes to continue with their insurance, it must be renewed within 30 calendar days before the end of the calendar year.
What rights do you grant?
- The insurance covers medical, surgical, pharmaceutical, hospital and maternity assistance.
- In the case of maternity, attention is given during pregnancy, delivery, and the puerperium.
- There are preexisting diseases that prevent their incorporation, conditions with certain waiting periods, as well as some exclusions (cosmetic surgery, lenses, hearing aids, treatment of chronic conditions that require permanent therapeutic control).
Requirements to join
- Go to the sub-delegation that corresponds to the address of the insured, from Monday to Friday from 08:00 to 15:30 hours.
- Present official identification, birth certificate, CURP and proof of address, if applicable, marriage certificate, the holder and the relatives to incorporate
- Provide general information and fill out a medical questionnaire.
- Cover the payment of the annual fee.
- In addition for Mexicans abroad: proof of domicile abroad and a power of attorney (in the case of a Mexican abroad, the latter may carry out the process through a relative or trusted person).
- Social Security number
Depending on the age of the applicant, the annual fee to be covered in advance by each insured is determined.
The main characteristic of this insurance is its wide coverage, which facilitates access to the medical service to the economically active population that does not have a formal work relationship and, therefore, does not have the benefit of the mandatory regime.
Background and current benefit
The LSS of 1973 contemplated the scheme of protection of the facultative insurance with which the following in-kind benefits were obtained:
1. Medical, surgical, pharmaceutical and hospital care.
2. Obstetric care.
3. Help in kind for six months of breastfeeding.
4. Basket at birth the son.
However, these benefits were only for the insured, who had to meet certain requirements, such as waiting for the expected date for incorporation, although the original objective of the facultative insurance was to offer professionals and independent workers, artisans, ejidatarios and members of agrarian communities, among others, an insurance modality of a social nature that protects them individually or collectively against accidents, illnesses, and maternity.
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This insurance was disconnected from the income of insurable subjects since there was no salary that served as a basis to set the contributions and benefits.
With the SSF, these services are available to the insured, the legal beneficiaries and the additional beneficiaries; The persons included in articles 13 and 218 of the LSS also obtain the service, in accordance with the following:
1. Workers in family industries and independent workers, such as professionals, small traders, artisans, and other non-salaried workers.
2. Domestic workers.
4. Employers individuals with insured workers at your service.
5. The workers at the service of the public administration of the federation, municipalities and federal entities that are excluded or not included in other laws or decrees as subjects of social security.
6. Insured persons who have contributed at least 52 weeks before leaving and who wish to continue voluntarily.
In addition, it should be noted the inclusion of Mexican workers who are working abroad, according to Title IV, Chapter II of the RACERF, understanding that the right extends not only to Mexicans by birth but to everyone of Mexican origin that has relatives in our country.
Due to the importance and coverage of these benefits, it was considered of vital importance to establish the legal basis from the same LSS, assigning articles from 240 to 245; In addition, the guidelines for handling this insurance were included in articles 95 to 109 of the new RACERF.
This insurance replaces the following optional insurance:
c) For Mexican workers abroad.
a) Includes the family group.
b) By means of an additional fee, other relatives can be included.
c) It has a lower cost than the optional insurance.
In terms of articles 95 and 96 of the RACERF , to be included in this insurance, in addition to the subject of insurance, at least one of the persons referred to in sections III to IX of article 84 of the LSS must be insured, without considering the requirements of coexistence , economic dependence and checking of studies, or an additional family member.
The following will be considered as additional family members, for purposes of the SSF: grandparents, grandchildren, siblings, cousins, children of siblings and parents of the parents of the insurance subject.
Subjects covered by the insurance
1. Legal beneficiaries:
a) The owner of the insured family unit.
b) The spouse or, in the absence of this, the concubine or the concubinage of the insured owner (the husband or cohabiting will enjoy this right, provided that it depends economically on the insured).
c) The children of the insured holder up to the age of 16 or up to the age of 25, if they study in the national education system or its equivalent abroad, or when they can not keep up for their own work, due to a chronic illness, physical defect or psychic suffered at a later date to the insurance contract.
d) The father and the mother of the insured owner who live in the latter’s home and who depend economically on it.
2. Other relatives:
a) Grandparents, grandchildren, brothers, uncles, cousins, brothers and children of the brothers who live and depend economically on the owner of the insured family unit, generally up to the third degree of kinship.
b) Children over 16 years of age of the owner of the insured family nucleus who are not studying and the children of the wife (or) or concubine (river), provided that they live with and depend economically on the insured.
c) For Mexican workers abroad, the coexistence requirement does not apply.
How to access the Insurance Contract
The contracting of the SSF can be carried out through the signing of an agreement to grant benefits in kind for the insurance of diseases and maternity.
The agreement may be made individually or collectively, personally or through an attorney or legal representative.
According to Article 102 of the RACERF, the Collective Incorporation Agreement must contain, at least, the following:
1. Assurance subjects.
2. Denomination or corporate name of the legal entity, who will be required to pay accordingly.
3. Benefits and rules related to its granting.
4. Procedures for collective incorporation and payment of fees.
5. Causes of termination of the agreement.
6. Penalties for non-compliance.
However, in the case of collective incorporations, the first registration must be made within 30 calendar days after the signing of the agreement.
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If within this period, the registration notices of the minimum number of insurance subjects were not received by the IMSS or were submitted extemporaneously, the agreement will not have any legal effect, therefore, the registrations already received may be processed by the institute, as if it was an individual incorporation, of course, with the prior consent of the interested parties.
According to the LSS, Family Health Insurance is an accessible option for those who do not have a health service because they do not have an employment relationship. It is convenient that they are incorporated into this insurance as a backup to give the security to the family that they have the right to receive medical services in case of illness.