DHA Medical Insurance - FAQ 1. What is DHA? Dubai Health Authority (DHA) is a government organisation overseeing the health system of Dubai, United Arab Emirates. It was formed in 2007 under the directives of Sheikh Mohammed bin Rashid Al Maktoum, the Vice President, Prime Minister, and Ruler of Dubai. The program was launched in March 2008. 2. What is Dubai’s Mandatory Health Insurance Law? A new law has made health insurance coverage compulsory for every resident in Dubai starting 2014. The minimum requirements (premium and annual coverage) will be defined by law and cannot be changed. 3. What are the Mandate Implementation deadlines? The coverage will be rolled out in three phases from 2014 until mid-2016, with all workers requiring at least the basic package. Each phase has a defined end point. By the relevant deadline, all in each phase must have insurance. There is no defined start date for each phase. Enrolment can commence at any time. Phase 1 – 1000+ employees - End of October 2014 Phase 2 – 100-999 employees - End of July 2015 Phase 3a – Below 100 employees - End of June 2016 Phase 3b – Spouses and dependents - End of June 2016 Phase 3c – Domestic Workers - End of June 2016 4. Who all are covered under this scheme? All Nationals and residents including the dependents must have the insurance coverage in place to pay for emergency and curative healthcare needs. 5. Who will pay for the insurance for all the above categories? Nationals – The Government will fund the program for the Nationals. Residents – The Employer is responsible to provide cover for the Employed Residents. Spouses and Dependents – The coverage for spouses and dependents is not mandatory right now, however, DHA encourages employers to cover them as well. The employer will not pay for the same but the dependents and spouses can be included within the scheme as seperate category and the employer can deduct the premium amount from the employee’s salary. If the employer is not providing cover for the dependents and spouses then it is the responsibility of the employee to arrange for insurance coverage with an insurance company and pay the premium directly. Domestic Workers – The sponsor, National or resident, must arrange and pay for the insurance coverage. 6. What is the estimated Gross Written Premium once the Mandatory cover is established? Total GWP for Blue Collar – Over AED 1.2 Billion Total GWP for White Collar – Over AED 4.5 Billion 7. What is the geographical scope of the coverage under the Basic Plan? Within the Emirate of Dubai. The cover in other Emirates or countries will be at the discretion of the Insurer. 8. What is the Annual aggregate claims limit including the co-payment and deductibles? The annual aggregate limit will be AED 150,000/-. 9. Which hospitals, clinics and pharmacies are covered under the basic plan? The Network will be designed by the insurer, however, DHA will ensure that the Network provides reasonable geographic access for the insured in relation to the place of work and residence. 10. From where can I access the Network list of RAK Insurance Company? Once you are insured through RAK Insurance, we will provide you with the Welcome Letter, while the Network List will be available in the website. 11. Is the Pre-existing and Chronic conditions covered or not? Treatment for Chronic and Pre-existing conditions are excluded for the first 6 months of first scheme membership and will be included thereafter. 12. Does the Basic Plan cover the Out Patient and In Patient services related to maternity? Yes. The female employees between the age group of 18 to 45 who are married are covered for the Out Patient and In Patient services related to the maternity or pregnancy. 13. What are the maternity services covered under the basic plan for the eligible females? The maternity services will be based on DHA Antenatal Protocols. The same is yet to be declared by DHA. 14. What is the maternity limit and is there any co-payment/deductible for the IP maternity services? Maximum limit for the Normal delivery is AED 7,000/- The maximum limit for medically necessary cesarean, complications and for medically necessary termination is AED 10,000/10% co-payment is applicable and the limits specified include the co-insurance. 15. Should I take an approval for the maternity admission? Yes. All In Patient admission requires prior approval from the Third Party administrator (TPA). 16. What are the types of health insurance plan which the employer should provide? Essential Benefit Plan (EBP) – DHA has specified minimum level of benefits that must be provided in any Health Insurance plan offered in the Emirate of Dubai. This constitutes the EBP. Enhanced Products – Any Health Insurance plan which offers ‘Significantly Higher Benefits’ than those required by the EBP. ‘Significantly Higher Benefits’ will be defined by DHA. 17. What are the enhancements which can be done? The enhancements can be as follows : • Lower co-insurance • Additional Benefits like Dental or Optical coverage • Higher annual aggregate limit • Riders on exclusions
• Wider scope of coverage • Wider Network
18. Who are covered under the EBP? The employees who are earning a gross salary of AED 4,000/- or below must be provided a cover that meets the EBP minimum levels of cover. 19. What about the other employees who are earning a gross salary more than AED 4000/-? These employees can be provide with the Enhanced Products. 20. Can the EBP be purchased from any insurance company? DHA has selected 7 insurance companies after a thorough process to ensure that good quality service will be provided to the members. They met additional requirements and have been awarded Participating Insurer (PI) status. RAK Insurance is one among the 7 PI companies. Only these companies can provide the health insurance solution for the pool of individuals earning a gross salary of AED 4000/- month or less. 21. If an employer wishes to provide an enhanced product for his employees earning a gross salary of less than AED 4000/- or less, then can he approach any insurer who does not have PI status but has HIP? No. Even if the employer wants to purchase a higher plan for his employees who are earning a gross salary of AED 4000/- or less, he must buy it only from one of the 7 insurers who have the PI Status. 22. What is HIP? HIP is Health Insurance Permit. DHA has awarded HIP to 43 insurers in Dubai and only them can offer health insurance plans in the Emirate of Dubai. In order to acquire HIP, insurance companies were required to meet many requirements covering financial, licensing, customer service and data security as well as meeting many technical requirements in relation to claims processing and reporting via the DHA electronic platform – eclaimlink.ae However, the companies with only HIP status can only sell the Enhanced Product and not the Essential Benefit Plan. RAK Insurance was awarded the HIP and PI status by DHA. RAK Insurance is authorised to sell Essential Benefit Plan and Enhanced plans. 23. Is Visa renewal linked to the Medical Insurance? Yes. Visa issuance and renewal will be linked to the condition that each employee should have a medical insurance coverage provided by the employer. The implementation will be based on the end dates of the phases mentioned in question no. 3. 24. What is the Premium for the EBP of Dubai? Each year DHA sets a price range within which the PI must set their premium for the EBP. For the year 2014, the range was set at between AED 500 - 700 per insured member per year. The PI’s were required to submit to DHA what is known as their Index rate which is the premium for the EBP. The PI’s are allowed to deviate from this Index rate by plus or minus AED 25/-. 25. Will this rate be revised? If yes, how often? The PIs can apply to DHA each September for an amendment to the Index Rate that will apply for the following calendar year. 26. What is Insured Capitation Schemes? Is it allowed as per the new rules in Dubai? Insured Capitation Scheme is a scheme where the risk is primarily carried by an insurance company but where the administration is undertaken by a TPA which is given by the insurance company a maximum claim limit to work with per insured member (hence capitation). The TPA has to manage its claims within this capitation figure or risk losing money if claim exceed the capitation figure. Yes. This is allowed by DHA however these schemes must satisfy the following criteria: • The scheme benefit must meet or exceed those of the EBP. • For lower salary workers the cover must be provided by the Participating Insurers • The insurer must accept ultimate contractual liability for treatment costs that fall within the scope of the benefits offered. • The TPA must not mitigate poor financial performance by restricting or denying treatment. Individual activity will be monitored via the eClaimLink portal. 27. What are Self- funded schemes? Is this allowed under DHA? Self-funded schemes are those where the employer funds the treatments but the administration is carried out by Insurance company/TPA/Broker. As per DHA policy, all schemes should be fully insured. DHA will require that such schemes be restructured as fully insured schemes by the first contract renewal date after the relevant implementation deadline and no later than 12 months following that deadline. 28. What is fully insured, insurer administered schemes? Is this allowed under DHA? These are schemes where the insurance company assumes all risk and administers the scheme in-house. Yes. This is allowed under DHA provided they meet the below criteria. • The scheme benefits must meet or exceed the EBP • For lower salary workers the cover must be provided only by the Participating Insurers. 29. What is fully insured, TPA Administered schemes? Is this allowed by DHA? Insured scheme where the insurance company assumes all risk but administration is carried out by a third party health insurance management company (TPA). Yes. This is allowed under DHA provided they meet the below criteria. • The scheme benefits must meet or exceed the EBP • For lower salary workers the cover must be provided only by the Participating Insurers. 30. Who is the TPA or Health Insurance Management Company of RAK Insurance? RAK Insurance will be administering the EBP through Amity Health. 31. Can a company split the members and insure under different insurers? The company can split only into two – individuals earning a gross salary of AED 4000/- or less and those earning above AED 4000. However, it is practically difficult for the employer as there will be two different TPAs involved and two different insurers which means different policies and protocols. 32. The companies who are already insured with any other insurer who is not a PI, then when should they change the insurer? The employers must restructure their existing arrangements where necessary to meet the criteria outlined by DHA by the first renewal date and no later than 12 months.
