The Health Insurance Council is preparing to launch the benefits package, updated insurance coverage limits and guidance on insurance drugs, starting next October.
The benefits package includes the addition of 18 new benefits to the health insurance policy and the improvement of 10 other benefits, so that work on renewed policies issued on October 1, 2022 begins.
Official Health Insurance Council spokesperson Nasser Al-Juhani confirmed that a number of updated benefits have been added related to exploratory preventive exams, vaccinations and a focus on women’s health, obesity and kidney transplant operations, and mental health coverage was increased to 50,000 instead of 15,000 for acute and chronic cases, and the value of hemodialysis coverage and other benefits.
The document aims at 7 main objectives, namely, the prevention of beneficiaries, the promotion of health, the reduction of disease complications, the improvement of the capacities and functions of the beneficiaries, the facilitation of access to the service category, making the beneficiaries responsible and improving the quality and efficiency of the service.
He explained that the updates will come into force from 1 October, to be applied to private health policies issued or renewed on this date and beyond.
Maximum benefit for one person
The document specified a maximum of one million riyals for the benefit of each person for the policy year, provided that small and medium-sized enterprises are supported for more than 500,000 by the guarantee fund program.
emergency treatment services
Regarding emergency services, no percentage of the urgent medical care required by the beneficiary’s condition is deducted following the occurrence of an event, accident or emergency medical condition that requires rapid medical intervention, depending on the levels of medical assistance urgent, which includes resuscitation, emergency and the urgent situation that can lead to the loss of life or one or more organs of the body, or to the occurrence of permanent or permanent disability.
Outpatient clinics
As regards the costs of outpatient treatment, the beneficiary is obliged to pay the deductible, which includes all the consultations that the doctor does, the required laboratory tests, radiographs and any therapeutic supplies, as well as a follow-up visit and referral for the same ailment and not for each procedure separately, with the exception of medicines.
The beneficiary who visits primary care clinics, which include family and general medicine, pediatrics, general internal medicine, obstetrics and gynecology and others, pays a rate of 0-5% with a maximum of 25 riyals, provided that the primary care clinic is approved by the Board.
She sustains 0-10% during a visit to specialized clinics after obtaining a referral from primary or emergency care clinics, with a maximum of 75 riyals, while bearing 0-50% when visiting them without obtaining a referral from the care clinics primary, with a maximum of 500 riyals.
pharmaceutical
In the event that generic drug and non-prescription drugs are available, the beneficiary will support 20%, provided that the maximum contribution to the payment is 30 riyals, while the beneficiary will support in case of innovative treatment and the absence of an alternative generic 0-50%, provided that the maximum payment is determined by mutual agreement between the owner of the Work and the insurance company.
Benefits covered by the policy:
The document specifies the costs of a common room with a maximum of 500 riyals per day, while the daily limit for accommodation and subsistence for utilities is 150 riyals per day in the common room.
Regarding pregnancy and childbirth expenses, the expenses for their coverage are on the mother’s document and maximum 30 days from the date of birth until they are added to the document with retroactive effect from its date, and their expenses will be be a maximum of 15,000 riyals during the period of the document, and the complications of pregnancy and births are covered with the maximum benefit of the document.
The costs of infants are covered on the mother’s ID up to a maximum of 30 days from the date of birth until they are entered into the document retroactively from her date It also includes the birth and care of premature babies, up to maximum benefit of the policy.
The document covers the costs of dental care, up to a maximum of 1200 riyals for basic and preventive dentistry, with no deductible during the policy period, while it covers emergency cases and root canal treatments up to 800 riyals, with a 20% incurred during the policy period.
With regard to eyewear, the policy provides for the costs of a maximum of 400 riyals for children under 14 during the policy, as well as the costs of interventions for the correction of functional vision, within the maximum limit of the policy.
It also includes expenses for dialysis with a maximum of 180,000 riyals, expenses for kidney transplants with a maximum of 250,000 riyals, expenses for the treatment of psychological diseases with a maximum of 50,000 riyals, the return of the deceased’s body to the his original home with up to 10,000 riyals, and hearing aid costs up to 6,000 riyals, and heart valve damage costs, up to 150,000 riyals, and conducting an organ donation process with a maximum of 50 thousand riyals, the costs of Alzheimer’s disease, with a maximum of 15 thousand riyals, and the costs of autism cases with a maximum of 50 thousand riyals.
The document included the costs of the national program for the early visit of newborns to reduce the disability up to a maximum of 100 thousand riyals, the costs of cases of disability up to a maximum of 100 thousand riyals, the costs for covering surgery for obesity with a maximum of 15 thousand riyals, the tolerance ratio 0-20% and the maximum payment of 1000 SR, in addition to the costs of male circumcision cases of up to 500 riyals, contraceptives of up to 1500 riyals and the complications of dealing with a benefit covered by the policy.
Cases not covered by the document:
And outside the scope of the policy benefits, complications resulting from an intentional injury caused by a person to himself, illnesses resulting from the intentional misuse of certain drugs, stimulants or sedatives, non-reconstructive plastic surgery, comprehensive examinations, vaccinations or drugs that do not require medical attention.
Also excluded are treatment that the insured receives free of charge, recovery programs and general physical health, all costs of dental implantation or an injury that derives directly from the insured’s profession, the procedure for correcting vision for diseases of the eyes that do not lead to blindness and the cost of transporting the person within the Kingdom by means other than the authorized ground ambulance.
The policy does not cover hair loss, allergy tests, cases of congenital malformation, with the exception of those that represent a current or future threat to the life of the insured, any costs during hospitalization and hospital stay other than accommodation and stay, acne treatment, organ transplant, joint replacement and personal risks, Medicines and alternative medicine means, prostheses and assistance, diseases classified as epidemics or pandemics by the Ministry of Health, eyeglasses for those over 14 years old, complications arising from any illness or injury excluded according to the provisions of the document, long-term care and hypnosis for the rehabilitative treatment of alcohol or drug abuse.
Cases of transfer of the body to the country of origin not covered by the document:
The document states that health benefits or repatriation of the deceased will not be covered in the event of war, invasion, acts of foreign aggression, ionizing radiation or radioactive contamination from any nuclear fuel or nuclear waste, radioactive, toxic or explosive properties, o the practice of the insured person O his participation in the service of the armed forces or the police or their operations, o riots, strikes, terrorism, accidents or chemical, biological or bacteriological interactions.
Artificial milk cover cases:
The document deals with infant milk in case of metabolic diseases, diseases of the National Program for Early Newborn Screening for Disability Reduction, sensitivity to milk or sugar, absorption problems, premature or underdeveloped baby or age overweight gestational and independence diseases.
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