Draft bill 3.

Summary.

The draft bill proposes a special procedure to cover expenses incurred by Social Security Fund insured persons who must temporarily purchase medicines from authorized pharmacies because the institution cannot supply them. It seeks to maintain continuity of treatment, protect health and social security benefits, reduce the financial burden of shortages, and strengthen oversight of pharmaceutical management. It defines insured person, shortage, certification of a shortage, reimbursement, direct compensation, and continuity of treatment. Its scope covers medicines prescribed by the institution’s physicians that appear on its current lists.

When an institutional pharmacy does not have the medicine, it must issue a shortage certificate on the same day the patient requests it. The certificate will identify the patient, prescription, and medicine, including its dosage and form; it will record the date, the temporary lack of stock, and the responsible official’s signature. The Social Security Fund will maintain a digital record of these certificates to support applications and audits. After obtaining the certificate and purchasing the medicine from an authorized private pharmacy, the insured person may request reimbursement using the institutional form, prescription, certificate, original tax invoice, proof of payment, and documents strictly necessary to verify the application. The application may be submitted in person or digitally within 30 business days after the purchase. Correctable deficiencies must be remedied within 5 business days after an administrative request.

The National Directorate of Health Services and Benefits (Dirección Nacional de los Servicios y Prestaciones en Salud), or the office designated by the regulations, will process and decide the applications. The Social Security Fund must issue a reasoned decision within 30 business days after receiving a complete application. If that period expires without an express decision, the applicant may file an administrative complaint with the Social Security Fund’s General Directorate (Dirección General de la Caja de Seguro Social), in addition to pursuing other legal remedies. The decision will state the established facts, the amount approved, its legal basis, the payment method, and the available appeals. The amount will be the lower of the price paid and the institution’s acquisition cost, subject to possible exceptional adjustments under the regulations. Limits may be set per treatment or annual period while ensuring continuity of treatment. Payment will be made within 20 business days after a favorable decision becomes final.

The Social Security Fund will implement an electronic module to record inventory, issue certificates, receive applications, allow applicants to track them, and generate statistics. It will publish data on shortages, applications, reimbursed amounts, and corrective measures every six months. The National Executive Directorate of Internal Audit (Dirección Ejecutiva Nacional de Auditoría Interna) will conduct periodic checks; false documents will give rise to administrative, civil, and criminal liability, and improper payments may be recovered. The Executive Branch (Órgano Ejecutivo) will issue regulations for the proposed law within 6 months after its promulgation. The institution will make the necessary adjustments; these provisions would supplement its health benefits framework and take effect 6 months after promulgation. The provisions also concern authorized private pharmacies, insured persons, and patients who need ongoing treatment.