1. Eligibility for treatment for program beneficiaries:
Conditions for being eligible for treatment:
2.1 The establishment of the health insurance policy holder (the employer) must be small or medium according to the classification of the Small and Medium Enterprises General Authority (Monsha’at).
2.2 A holder of a health insurance policy approved by the Council.
2.3 No additional health insurance.
2.4 The period of eligibility to benefit from the program support coincides with the validity period of the policy for the specified categories, provided that the period of benefit from the program coverage does not exceed 12 months for each policy.
2. Health insurance beneficiaries program coverages:
Taking into account the categories eligible to benefit from the program coverage for the following:
3.1 The program’s coverage includes medical claims for beneficiaries who have exceeded the maximum benefit limit of the policy, while adhering to the exclusions provisions stipulated in the policy.
3.2 The program coverage limits for the beneficiary include the maximum benefit.
3.2.1 The program covers the case in the event that there is no alternative insurance for the beneficiary and the presence of an ongoing illness that led to the continuation of hospitalization even if the policy expires, according to the period required by the case, provided that this period does not exceed 365 days from the date of the beginning of the ailment that required hospitalization and within the limits of the benefit limit
3.3 The program stops covering any new case of the eligible categories to benefit from the coverage in the event that the financial allocation to support the program has been exhausted.
3. Department of Admission of Medical Cases in the Health Insurance Beneficiaries Coverage Program:
4.1 Medical conditions subject to eligibility for treatment in the program include the following:
4.1.1 Hypnotic state in hospital at the time of application.
4.1.2 Emergency condition: It is the emergency medical treatment required by the beneficiary’s medical condition following the occurrence of an event, an accident or an emergency health condition that requires rapid medical intervention according to the following levels
(1- Resuscitation. 2- Emergency. 3- Urgent (leading to loss of life, organ or disability)) from the levels of urgent medical care as described in the Private Health Institutions Law and its Implementing Regulations approved by the Ministry of Health, which determines the triage of emergency cases
4.1.3 Admission cases in order to provide a health service are provided only through hospitalization in the hospital.
4.1.4 Hemodialysis for non-hypnotic cases.
4.1.5 Cases need coverage for home care, care centers, and also need to complete the treatment plan outside the hospital after the end of hospitalization in the hospital. Provided that the beneficiary coverage program manager studies the case in coordination with the medical team in the council.
4.1.6 Cases from small and medium enterprises are covered according to the limit of the policy, exceeding 500 thousand
To request coverage of the program, I hope to communicate through e-mail:
DhamanFund@chi.gov.sa
INFO@chi.gov.sa
dhamanapprovals@globemedsaudi.com
