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جمان مجلس الضمان الصحي Council of Health Insurance Basic Health Insurance Policy public [Non-Text] [Non-Text] [Non-Text] [Non-Text] Basic health insurance policy Subject Page <table><tr><td>Contents</td><td>1</td></tr><tr><td>Health Insurance Policy objectives</td><td>3</td></tr><tr><td>Chapter One — Definitions</td><td>4</td></tr><tr><td>Chapter Two - Recoverable Expenses/Benefits</td><td>13</td></tr><tr><td>Chapter Three - Controls and Exceptions</td><td>15</td></tr><tr><td>Chapter Four - General Conditions</td><td>19</td></tr><tr><td>Chapter Five- Insurance Drug formulary (IDF)</td><td>33</td></tr><tr><td>Chapter Six- Provider Network</td><td>37</td></tr><tr><td>Chapter Seven- Health Benefits Schedule (1)</td><td>43</td></tr><tr><td>Chapter Eight- Basic Health Insurance Policy Schedule (2)</td><td>48</td></tr><tr><td>Chapter Nine- Policy Appendix</td><td>53</td></tr><tr><td>Chapter Ten- Guidance Suggested Benefits</td><td>64</td></tr></table> 2 pshan مجلس الفيمان الصحي Council of Health Insurance public [Non-Text] [Non-Text] [Non-Text] [Non-Text] [Non-Text] [Non-Text] [Non-Text] [Non-Text] [Non-Text] Key Objectives of Health Insurance Policy The following Health Insurance policy is developed to target seven key objectives based on the vision of the Council to be an international leader in promoting preventive therapy and enhancing the quality and efficiency of health care services for health insurance beneficiaries. Health Promotion Women Health - Child Health - Teeth - Family planning - Psychological Health Improvement of Beneficiaries' functions and capacities Vision - Rehabilitation - Surgical procedures Beneficiaries Empowerment Hospitalization - outpatient clinics visits - emergency treatment 2 4 6 7 Protection of Beneficiaries Early and exploratory examination - vaccines - coverage of Sexually Transmitted Diseases. Reduction of Disease Complications Congenital Malformations - Acquired valvular heart disease Kidney dialysis - comprehensive diabetes program Facilitating Beneficiaries Access to Services for the Home Care - Telemedicine- Insurance Drug Formulary (IDF) Enhancement of the Quality and Efficiency of the Service Medical equipment - Chronic diseases 3 pshan مجلس الفيمان الصحي Council of Health Insurance شمان مجلس الضمان الصحي Council of Health Insurance Chapter One Definitions public [Non-Text] The terms and expressions mentioned herein shall have the meanings ascribed thereto, and expressions that are not defined herein shall have the same meanings ascribed thereto in the Law or the Implementing Regulations: 1. Kingdom: Kingdom of Saudi Arabia 2. Council: The Council of Cooperative Health Insurance and its General Secretariat. 3. Law: The Cooperative Health Insurance Law applied in the Kingdom. 4. Executive regulations: Executive bylaw Regulation. 5. Policy: This basic health insurance policy, including its schedule, appendices, and annexes. 6. Health insurance: Health insurance is established by the Law and its implementing regulation under this policy, with its schedule, appendices, or annexes and it is practiced by cooperative insurance companies licensed to operate in the Kingdom under the Insurance Companies Control Law. 7. Health insurance term: The period indicated in the policy schedule for which health insurance remains valid. 8. Effective period: The number of days during which the policy will be effective if the full subscription indicated in the policy schedule is not paid. 9. Start date: The date indicated in the policy schedule at which insurance coverage begins. 10. Effective date: The date on which a person becomes eligible for coverage under this policy or to add or delete an insured person in the policy. 11. Benefit: Cost of providing healthcare services included in the insurance coverage within the limits indicated in the policy schedule 12. Insurance coverage: Basic health benefits available to the beneficiary as specified in the policy 13. Coverage limits: The maximum liability of the insurance company as specified in the policy schedule for any insured person before applying the deductible. 14. Insurance parties: Insurance Company, brokerage firm, service providers, revenue cycle Management Company, third-party administrators (TPAs), policyholder, beneficiary and anyone considered a party to the insurance parties under the Executive Regulations. 5 سمان مجلس الفيمان الصحي Council of Health Insurance public 15. Insurance company: A cooperative insurance company licensed by SAMA to operate in the Kingdom and accredited by the CHI to provide cooperative health insurance. 16. Policy Holder: A natural or corporate person in whose name the policy is issued 17. Beneficiary or insured: A natural person (or persons) to whom coverage is provided under the policy. 18. Employer: A natural or corporate person employing one or more employees 19. Employee: Every natural person working for and under the management and supervision of an employer in return for a wage, even if the employee is not under his immediate supervision 20. Dependent(s): Husband or wife, sons up to the age of twenty-five and unmarried daughters in addition to orphans fostered by foster families, receiving compulsory health insurance. 21. Service provider: healthcare facilities (governmental/non-governmental) licensed to provide healthcare services in the Kingdom under relevant laws and rules approved by the Council, such as hospitals, general, and specialized medical complexes, diagnostic centers, clinics, pharmacies, laboratories, physiotherapy, or radiotherapy centers. 22. Preferred Provider Network (PPN): A group of healthcare service providers approved by the CHI and specified by the insurance company to provide healthcare services to the insured. These services are directly credited to the insurance company's account. This network includes the following levels of health services: - Level 1 (primary health care). - Level 2 (public hospitals). - Level 3 (specialized or reference hospitals). - Other complementary health service provider centers (such as One-day surgery centers, pharmacies, physiotherapy centers, eyeglasses shops, Telemedicine, Home health care). 23. A hospital: A health facility approved by the CHI, accepted by the policyholder and the insurance company, and licensed to work as a hospital under the regulations to provide health services for which compensation may be claimed under this policy. 24. Licensed doctor: Practicing the medical profession with the appropriate scientific qualification according to the classification of the Saudi Commission for Health 6 صوان مجلس الفيمان الصحي Council of Health Insurance public [Non-Text] [Non-Text] Specialties (SCFHS) and is licensed to practice the medical profession by the Ministry of Health. 25. Primary care: Health services provided by medical teams under the supervision of qualified practitioners so that these services are comprehensive, continuous, coordinated and based on Value-Based Healthcare. Primary care ranges from counseling and prevention to treatment of organic and psychological diseases for all ages and categories of beneficiaries, maternity care and child health services, rehabilitation, palliative care, urgent care services, chronic disease care, population health and others as needed to serve beneficiaries registered with primary care providers and under approved medical best practices. 26. Disease: Illness or conditions that affects the insured person and necessarily requires medical treatment from a licensed doctor before and during the period of health insurance. 27. Accident: The sudden and unexpected, unforeseen, occurrence physical event during the health insurance period. 28. Traffic accident: Any accident that results in serious or light damage or partial or total material loss to property inadvertently due to the use of the vehicle while in motion. 29. Vehicle: Every means of transport on wheels or track, and are driven or carried by automatic or animal force, including any mechanical or electric vehicle, whether it is a car or bus, private or public. 30. Employment “occupational” injury: Any accident suffered by the beneficiary during performance or because of his work. or on his way from his dwelling to his workplace and back, or on his way from his workplace to the place where he usually takes his meal or gives his prayer and back. or a the disease established to be caused by work. The occupational disease duly determined in accordance with the occupational diseases schedule, taking into account the date of the first medical diagnosis of the disease is regarded as the date on which the injury is sustained. 31. Personal risks: Any act or practice performed by a person is recognized as a risky activity if it carries a risk of illness or accident or is expected to cause complications of a previous illness or injury that are a result of actions not associated with the work of the insured or regular daily practices such as: dangerous sports (judo, boxing, karate, wrestling, combat sports), motor, boat and motorcycles racing, paragliding, parachuting. 7 سمان مجلس الفيمان الصحي Council of Health Insurance public 32. Emergency: Urgent medical treatment required by the medical condition of the insured as a result of an accident or a case requiring prompt medical attention, depending on the following levels of urgent medical care (1. Resuscitation, 2. Emergency, 3. Urgent condition that may be resulting in death, loss of one or more organs, or the occurrence of an accidental or permanent disability situation) as described by the Private Health Institutions Law and Regulations approved by the Ministry of Health, which determines how to dispatch emergency cases. 33. Outpatient treatment: The beneficiary visits outpatient clinics for diagnosis or medical treatment. 34. Day care surgery or treatment: A patient admitted during the course of a day with the intention of receiving care who does not require the use of a hospital bed overnight and who returns home as scheduled. It should be noted that their coding and pricing is in accordance with the hospital's procedure for admission 35. Inpatient (hospital admission): Registration of the insured person as a patient for admission in the hospital until at least the next morning, including a Patient admitted with this intention who leaves hospital for any reason without staying overnight 36. Long-term care: A variety of services that include medical and non-medical care provided to people who are unable to perform activities essential to daily living for people suffering from a chronic illness or disability, or cannot care for themselves for long periods. long-term care focuses on individual and coordinated services that promote independence, improve patients' quality of life, and meet patients' needs over a long period. 37. Telemedicine: Using electronic information and communication technology means to provide diagnostic, screening, and medical inspection services to the patient, including, for example, telemedicine and health using smartphones (Health Mobile). Other forms telemedicine includes (teleconsultation, tele-expert consultation, remote assistance, other medical opinions) 38. Alternative medicine (complementary): A variety of healthcare systems, practices and products that are not part or extension of modern medical practice. Complementary medicine is used in conjunction with modern medicine, while alternative medicine is not used with modern medicine at the same time. Examples include but are not the 8 سمان مجلس الفيمان المصري Council of Health Insurance public [Non-Text] limited to herbal treatment, cupping, Chinese medicine, hypnosis, osteopathy, chiropractic, acupuncture. 39. Health: A state of complete physical, mental and social health, not just lack of illness or disability. 40. Allergies: In particular, the individual is sensitive to certain types of food, medicine, weather, pollen or any other triggers from plants, insects, animals, minerals, elements or other substances. The individual experiences physical reactions caused by direct or indirect contact with those substances that cause conditions such as asthma, dyspepsia, friction, hay fever, eczema, and headache. 41. Congenital Defect: Functional, chemical or structural dysfunction that is usually present before birth, whether through heredity or as a result of environmental factors according to medical custom. 42. Pregnancy and childbirth: Any pregnancy or birth, including natural, cesarean and abortion. 43. Preterm Baby: a baby born before the 37th week of pregnancy (three weeks before the birthdate) 44. Psychological cases: A disorder of thinking, mood, perception, memory or mental abilities, some or all of them. 45. Disability cases: Disability means having a total or partial impairment permanently or for a long period of life in one of the physical, sensory, mental, communicative, educational or psychological abilities, and causes that the disabled person cannot meet the requirements of normal life and rely on others to meet them. Or the need for a special tool that requires training or special qualification for its proper use. 46. Vision correction interventions: Interventions to improve vision and have no effect to prevent vision loss such as LASIK, lenses and eyeglasses 47. Functional vision correction interventions: Interventions to improve vision that are important for vision preservation “avoiding vision loss”. For example strabismus and Amblyopia procedures for children less than 14 years and keratoconus, cataract, glaucoma for all age groups. 48. Human organ: Any part of the human body (dead or alive), its tissues or any of its components, which can be used by transplanting them into another human body, except for blood. 9 مجلس الفيمان الصحي Council of Health Insurance public 49. Transplant of Human Organs: A medical operation through which the human organ is removed, or part of it, from the donor's body and implanted in the patient's body, by any medical and approved means. 50. Rehabilitation: An essential part of comprehensive health care and its applications to return a person suffering from an occasional or persistent weakness, failure, or defect to the best level of performance in their family and social life in line with the definition of health and the application of best approved medical practices. 51. Essential Dental Procedures: Any of the following medical procedures that include 1. Preventative services (dental consultations, annual examination of teeth and assessment of their problems, cleaning each beneficiary once a year (including fluoride), 2. Treating procedures include (fillings, periodontal treatment, teeth extract). 52. Reconstructive surgery: Reconstructive plastic surgery is performed to correct defects, abnormalities or injuries caused by an accident, infection, tumor or disease. 53. Innovative “Brand” Name: Preparations that contain a new active substance and are offered under a brand name on the market by the innovative company. 54. Generic medication or treatment: is a product equivalent to the innovative product in pharmaceutical form, concentration, method of administration, quality, effectiveness, and therapeutic claim. 55. Premium (subscription): Amount paid by the policyholder to the insurance company for the insurance coverage provided by the policy during the insurance term. 56. Deductible (Co-payment): Amount, if any, payable by the beneficiary upon receiving outpatient treatment as specified in the policy schedule, excluding emergencies and inpatient treatment. 57. The basis of the direct entry or in company's account: Facilities of non-payment appointed by the company and available for the insured. All expenses incurred at the facilities are directly debited from the company's account. 58. Allowance compensation basis: The method used to compensate the policyholder for the reimbursable expenses incurred by the insured and submitted a claim for them, after applying the deductible. 59. Reimbursable Expenses: Expenses paid in return for services, materials and equipment not excluded under Chapter 3 of this policy that is prescribed by a licensed physician due to the illness of the insured, provided such expenses are 10 مجلس الغمان الصحي Council of Health Insurance public [Non-Text] [Non-Text] [Non-Text] necessary, reasonable, and normal in the relevant time and place based on best approved medical practices. 60. Claim: A request, accompanied by supporting financial and medical documents, submitted to the insurance company or representative thereof by the service provider, the insured or the policyholder for indemnification of expenses of healthcare services covered by the policy. 61. Supporting documents for a claim: All documents proving the insured's age, weight and height, nationality, identity, the validity of insurance coverage, the circumstances of the occurrence of the event resulting from that claim and proof of reimbursement of costs. It also includes other documents such as a police report, invoices, receipts, prescriptions, doctor's report, referral and recommendations, and any other relevant documents the insurance company may request. 62. Fraud: when any of the Insurance Parties performs or refrains from performing an act aimed at gaining an unfair or unlawful advantage for the benefit of the fraudster or other parties, or an act that involves fraud or deception that results from obtaining benefits or money, or providing benefits excluded or exceeding the permissible the limits to an individual or entity, and the like, according to the Law and Regulations. 63. Abuse: Practices by any insurance party which may lead to obtaining benefits or privileges they are not eligible to receive; without the intent to defraud, deceive, misrepresent, or distort facts to obtain such benefits and privileges and what comes under it under the Implementing Regulations, for example but Not limited to - exaggerating diagnostic tests and medications. 64. Negligence: Providing insurance/medical procedures without exercising the duly recognized reasonable amount of medical or insurance precautions that result in material or moral harm to one of the insurance parties, and which would not have occurred but for how the negligent person who acted. 65. Age calculation: Process by which age is calculated according to the calendar year starting at the beginning of January and ending at the end of December. 66. Personal data protection system: The Personal Data Protection Regulations issued by Royal Decree No. (M/19) dated 9/2/1443 H (16/9/2021) 11 سمان مجلس الفيمان الصحي Council of Health Insurance public demal مجلس الضمان الصحي Council of Health Insurance Chapter Two Recoverable Expenses/Benefits public [Non-Text] [Non-Text] [Non-Text] For purposes of this policy, recoverable expenses shall mean the actual expenses incurred for services, supplies and equipment, which are not excluded under Chapter Three (3) herein, provided that it shall be prescribed by a licensed physician as a result of an illness suffered by the insured. Said expenses shall be necessary, reasonable and customary in the relevant time and place. Recoverable expenses shall include: (1) Costs of preparation and repatriation of the insured corpse to the home country specified in the employment contract, if the cause of death shall not be one of the exceptions stipulated in Chapter 3 herein. (2) Health benefits: A. Expenses of medical examination, diagnosis, treatment and medicine as shown in the policy schedule. B. Preventive measures, such as vaccinations including seasonal vaccinations and maternity and childcare, in accordance with the instructions issued by the Ministry of Health, as stipulated in Annex 1 attached to this Policy. C. Expenses of hospitalization, including surgeries, same-day surgeries or treatment, pregnancy, and delivery. D. Treatment of all Hereditary Diseases. E. Disability cases within the limits specified in the Policy Schedule. F. Medical interventions for long-term care that are life sustaining or affect outcomes with the exception of what have been exempted as stipulated in Chapter 3 herein. G. Functional vision corrective intervention that prevent vision loss. H. Medical equipment, and in order to describe the medical equipment systematically by a physician licensed from a certified center, the following must be complied with: 1. The Insured shall have the relevant illness or condition, including heart diseases, hypertension, diabetes, and respiratory diseases. 2. The medical equipment, licensed by the Saudi Food & Drug Authority, shall be provided through the preferred provider network accredited by the Insurance Company, according to the normal and reasonable prices, one time throughout the validity period of the policy, provided that the lifespan of the current equipment that it owns (if any) shall be expired. 3. If the Insured requests a new medical equipment, there shall be a medical reason – during the effective period of the Policy – necessitating replacement of the current equipment. In addition, the Insurance Company may ask for the old equipment for replacement. 4. The best medical practices shall be referred to and shall be linked to the principle of value-based health care when approving the insurance coverage. In addition, it shall be advised to consult the impact value study published by the international and local health technology assessment centers, if available. I. Health benefits shall also include all the benefits stated in the schedule provided in Schedule (1) herein. 13 سمان مجلس الفيمان الصحي Council of Health Insurance اسمان مجلس الضمان الصحي Council of Health Insurance Chapter Three Controls and Exclusions public [Non-Text] (A) This policy will not cover claims resulting from 1. Complications from self-inflicted injury, excluding the costs of treating emergency cases (life-threatening injuries) as described by the Private Health Institutions Law and Regulations approved by the Ministry of Health, which determines how to dispatch emergency cases. 2. Complications from diseases resulting from the intentional abuse of some medications, stimulants, sedatives, substance abuse, etc., excluding the costs of treating emergency cases (life-threatening injuries) as described by the Private Health Institutions Law and Regulations approved by the Ministry of Health, which determines how to dispatch Emergency cases. 3. Non re-constructive cosmetic surgeries. 4. General examinations, vaccines, drugs or preventive measures that do not require medical treatment or are not mentioned in this Policy (except for the preventive measures stipulated in the Policy or determined by the Ministry of Health, such as vaccinations as well as maternity and childcare). 5. Treatment received by the insured free of charge. 6. Recreational therapy, general physical health programs, and treatment in social welfare institutions. 7. Any illness or injury arising directly from the profession of the Insured. 8. All costs related to dental implants, dentures, crowns, bridges or cosmetic procedures including, but not limited to, teeth whitening, except for the benefits outlined herein. 9. Vision correction surgeries, excluding procedures that prevent vision loss. 10. The expenses of the transportation of the insured within and between cities in the Kingdom by means of transportation other than the licensed ground ambulance. 11. Hair loss, baldness or artificial hair. 12. Allergy tests of any nature, excluding those related to the medical cases that can only be treated through these tests, or those related to prescribed medications, according to the medical proof and evidence. 15 سمان مجلس الفيمان الصحي Council of Health Insurance public 13. Equipment, treatments, drugs and hormone procedures, surgeries or treatment aimed at regulating reproduction, contraception, impotence, infertility, in-vitro fertilization, or any other method of artificial fertilization. 14. Any congenital weakness or deformity, unless it has a current or future life-threatening impact on the Insured. 15. Any additional costs or expenses incurred by the companion of the Insured during its stay at the hospital, except for hospital accommodation charges for one companion, as required by the best medical practices. 16. Treatment of acne. 17. Cases of human organ transplantation, according to the definition set out in the First Chapter of the Policy, excluding the additional benefits regarding organ transplantation. Knowing that artificial organs are managed as per the benefits and exceptions of the policy. 18. Joint replacement with exception to what have been listed as benefits or for the treatment of complications arising from a covered benefit such as joint replacement due to cancer or a trauma. 19. Personal risks set forth in Chapter 1 (Definitions) herein. Any sport other than what is mentioned in the definition chapter, must be submitted to the Council for decision. 20. Alternative medicine procedures and medications. 21. Artificial and ancillary limbs. 22. Diseases that are classified by the Ministry of Health as pandemics or natural disasters, and based on decision released by the Council. 23. Eye glasses for persons over fourteen (14) years old. 24. Complications resulting from any previous illness or injury shall be excluded under the provisions of this Policy. 16 سمان مجلس الفيمان الصحي Council of Health Insurance public 25. Long-term care (Care for a long period) that are limited to nursing care or personal care with exception to the benefits listed in this policy. 26. Rehabilitation admissions for management of addiction and alcohol abuse (B) Except for the provisions of Section 2 herein, this policy shall not cover health benefits or corpse repatriation to home country in claims resulting from the following: 1. War, invasion, acts of (foreign) aggression whether or not war is declared. 2. Ionizing radiations and pollution from radioactive activity of any nuclear fuel or waste resulting from the combustion of nuclear fuel. 3. Radioactive, toxic, explosive or other hazardous properties of any nuclear plant or any of its nuclear components. 4. The Insured service or participation in armed forces or police operations. 5. Riots, strike, terrorism, or its equivalents. 6. Accidents or chemical, biological, or bacteriological reaction, if those accidents or reactions are a result of occupational injury or occupational risk. (c) Hotels, dormitories, guest houses, resorts, convalescent centers, sanatoriums, places for the care of persons in custody, nursing home, or schools/institutes specialized in teaching deaf, autistic, etc. shall not be included under the concept of the Hospital described in this Policy. 17 صوان مجلس الفيمان الصحي Council of Health Insurance قيمان مجلس الضمان الصحي Council of Health Insurance Chapter Four General Conditions public Policy Conditions (1) Proof of Validity: This policy represents the basic level of insurance cover granted to the insured individual. This Policy shall not be valid unless confirmed by a schedule duly signed by an employee officially authorized by the Company. Likewise, any addition to this policy shall not be valid unless confirmed and accompanied with signed annex by an officially authorized assigned employee of the insurance company. (2) Effective Dates of Coverage: A. For Workers: Coverage shall become effective for the active employee as of the inception date shown in the Policy schedule, or from the date of employment contract for the workers joining work in a later time. B. For Dependents: Insurance cover shall become effective for dependents as of the date, during which the worker supporting them becomes insured or from the date they become dependents. C. For Fetus and Newborn infants: 1. The insurance coverage for fetuses shall begin from the beginning of their inception until one month after birth, and its coverage shall be according to the limit of the Policy. 2. Insurance coverage for newborn infants shall enter into effect immediately after delivery to a maximum of 30 days from the date of delivery, and its coverage shall be according to the limit of the mother policy. (3) Termination of the Insurance Coverage of the Insured Individuals: A. For Workers: Coverage of any worker under the Policy shall be automatically terminated in the following cases: 1. If the Policy period ends or if it is canceled, as stipulated in the Policy Schedule. 19 سمان مجلس الفيمان الصحي Council of Health Insurance public [Non-Text] 2. Upon the exhaustion of the maximum limit of benefits stipulated in the Policy. 3. If the Insured dies, without prejudice to paragraph (1) of Chapter 2 herein and as per the benefits limits in Policy Schedule. 4. If the Insured leaves the Kingdom permanently. 5. If the Insured transfers to a new employer. B. For Dependents: coverage under this Policy shall be automatically terminated in the following cases: 1. The dependent no longer qualifies as “dependent” as defined in Chapter 1 herein. 2. If the Policy period ends as specified in the schedule. 3. Upon the exhaustion of the maximum limit of benefits provided for in the Policy. 4. If the Insured dies, without prejudice to paragraph (1) of Chapter 2 herein under the benefits limits stipulated in the Policy Schedule. 5. If the Insured leaves the Kingdom permanently. 6. If the Insured transfers to a new employer. (C) Payment of recoverable expenses of any current illness, which requires continued hospitalization, shall continue on the date of termination of coverage for the period necessary for treating such illness, provided that such period shall not exceeds 365 days as of the date of onset of said illness and within the limits of the maximum coverage amount stipulated in the Policy Schedule. (4) Payment of Premiums (subscriptions): A. The Policyholder shall pay the health insurance premium due on each insured individual as agreed upon with the Company as of the effective date of the insurance coverage. B. If any portion of a premium is not paid, the Policy shall not be valid for a period longer than that covered by the portion paid, and the Company shall notify the Council accordingly. (5) Cancellation: The Policyholder may cancel this Policy at any time under a written notice sent to the Company within a minimum of 30 business days prior to the date required for cancellation, taking into account the rules governing forming 20 جلس الفمان الصحي مجلس الفمان الصحي Council of Health Insurance public and managing insurance risk pools. In such case, the Policyholder and the Insurance Company shall comply with the following: A. The Insurance Company shall inform (under an official notice) the Council and the Preferred Provider Network once it receives a notice from the Policyholder – employer or the Insured – with regard to the Cancellation of the Policy. B. In the event of transferring the employment contract, the Employer shall execute another insurance policy with a qualified company, or the Employer shall include the insured individuals in a health coverage under another insurance coverage program approved by the Council. The new insurance coverage shall start as of the day following the cancellation of the previous policy. C. The employer may remove one or more employees from the Policy, after the Insurance Company receives proof that the Insured has left the Kingdom or transferred to a new employer. D. In the event of the cancellation of a Policy or removal/ deletion of an Insured, the Company shall ensure updating the data of the developed policy issuance system, according to the codes of cancellation or deletion. In such case, the Company shall be liable to provide the Policyholder, within 60 business days from the cancellation date, with the remaining part of the premium for each insured individual whose claims did not exceed 75% of the annual premium. The refundable amount shall be calculated on proportional basis: (Refund = annual premium ÷ 365.25 days X the number of the remaining days) E. If the Policyholder refrains from paying the Company the expense exceeding the maximum limit of benefit within the period specified in Article (11) (Basis of Direct Debiting on the Company Account for the Service Provider Network) of the General Conditions of the Policy and due as a result of the arrangement for direct billing of the Company, the Company has the right to withhold refund of premiums, if any, and use such amounts to compensate for the expenses paid to the service 21 سمان مجلس الفيمان الصحي Council of Health Insurance public [Non-Text] [Non-Text] providers which should have been paid to the Company by the Policyholder. F. The Policyholder shall pay all expenses due to the Insurance Company within the specified period, and if such period expires, the Insurance Company has the right to refer to SIMAH as well as to the Insurance Company, in case the beneficiary is entitled to the benefit. Data: (6) Records and Reports: The Policyholder must maintain a record for all of its employees and their insured dependents. This record shall include the individual's full name, sex, age, nationality, weight, height, classification and other basic information that might affect the management of this health insurance and the report on the premium rates. The insurance company shall be given access to such records to verify the accuracy of the information provided by the Policyholder, whenever needed. The Company shall, when requested, provide the Policyholder with any information about the Insured, in a manner consistent with the provisions of Personal Data Protection Law. (7) Adding and Deleting the Insureds and Related Contributions: A. The Policyholder shall immediately and officially notify the Company regarding all workers or dependents to be covered under the Health Insurance at the Policy effective date. The policyholder has the right to add an Insured on a proportional basis if there is a proof that the Employee joined the work for the employer, or requested deleting it in case it moved to work for another employer. B. For additions, to which what is mentioned in paragraph (A) here above does not apply, the addition of the numbers of new Insureds shall be effective as of the date of issuing the Policy, and its/their coverage shall be valid from the date of addition. 22 سمان مجلس الفيمان الصحي Council of Health Insurance public [Non-Text] (8) Eligibility: A. For Workers: Any person satisfying the definition of "Worker" shall be qualified for insurance in accordance with the Policy Schedule. B. For Dependents: Any person satisfying the definition of "Dependent" shall be eligible for insurance in accordance with the Policy Schedule. Duplication of Insurance Coverage: (9) Duplication of Insurance Coverage: If any person is identified as Dependent, in addition to being eligible for insurance as a worker, its health insurance as dependent will cease hereunder. When the husband and wife permanently reside together and have insurance as workers, the children in this case shall become eligible only as dependents of the husband, unless the employer wishes to add dependents - children - within the insurance coverage of the wife, provided that there shall be no Beneficiary who has two different insurance coverages during the same period. 23 pshan مجلس الفيمان الصحي Council of Health Insurance public [Non-Text] (10) Non-Duplication of Benefits: If there is a claim for recoverable expenses due under this Policy to the Insured, and these expenses are covered under another insurance, plan, program, etc., the Company shall then be responsible for paying such expenses and request the third parties to pay their proportional shares of such claim on behalf of the Insured. Financial Considerations (11) Basis of the direct entry or in company's account at the Service Providers' Network: A. The service providers appointed by the Insurance Company shall send all medical expenses incurred hereunder, on a monthly basis and without prejudice to the days and periods specified in the document cycle in accordance with Article No. (90) of the Implementing Regulations. The Company shall evaluate and process such expenses, and notify the Policyholder when the expenses reach the maximum benefit limit, provided that the Company shall provide all information related to the remaining insurance limit for benefits and the Policy to the service provider before notifying that the expenses has reached the maximum benefit limit. B. If this limit is exceeded and the Company has already incurred it, it becomes entitled to claim for the refund of such expenses within a period not exceeding (60) business days from the date of informing the Policyholder of these expenses. C. If the Policyholder fails to comply with the reimbursement of such expenses to the Insurance Company within the specified period, it becomes entitled to refer to the Council to take the necessary action. D. The Insurance Company has the right to refer to SIMAH (SAMA) if the Policyholder fails to pay the expenses due to the Insurance Company 24 سمان مجلس الفيمان الصحي Council of Health Insurance public [Non-Text] [Non-Text] [Non-Text] [Non-Text] within the specified period, as well as to the Insurance Fund, if the beneficiary is entitled to the benefit. (12) Canceling a Service Provider from the Preferred Service Providers Network A. After issuing the Policy to the Employer, the Company is not entitled to delete or replace a health service provider from the Preferred Provider Network during the Insurance Period, except in the following cases: 1. If the health service provider has committed a fundamental breach of service provision, such as negligence or fraud. 2. Upon termination of the Contract by the health service provider, provided that the Company shall provide a substitute for it at the same level in coordination with the Policyholder. 3. Upon suspension/cancellation of its approval by the Council, provided that the Insurance Company shall provide a substitute for it at the same level in coordination with the Policyholder. In all cases, the specified warning period and the cancellation conditions stipulated in the contract between the Insurance Company and the health service provider shall be observed. If a service provider is removed from the minimum network, it will continue to receive previously approved applicable policies until their expiry date. Insurance Company shall notify the Council when moving a service provider from an insurance category to another. (13) User charges (Copayment): A. Based on an agreement between the Policyholder and the Insurance Company, the deductible amount shall not exceed the amount specified herein. It shall be a binding and an obligatory condition for the Insured to pay the user charges amount (if any) as specified according to the contract concluded between the Policyholder and the Insurance Company. Any attempt by the Insured to refrain from the payment shall be considered a 25 سمان مجلس الفيمان الصحي Council of Health Insurance public violation of the Policy provisions and its terms and conditions. It shall become invalid for it until the payment of this amount. B. Cases of emergency and inpatient admission shall be excluded from Paragraph (A). C. The copayment amount charged to the Beneficiary shall not exceed what is specified in the Schedule of Health Benefits contained in Appendix No. (1). D. The amount of deductible or copayment for the outpatient clinics shall be separated from the service of dispensing medicines for one visit. E. The maximum deductible amount for medicines shall be calculated based on the price of the generic medicine or the brand Innovative medicine in the absence of a generic medicine registered with the Saudi Food & Drug Authority. F. The copayment for brand names with alternative generic is 0-50% based on the agreement between employer and insurance company. G. Service provider must prescribe medical devices on the scientific name basses without specification of a trade name. H. An automatic substitution of the device name shall be done based on the beneficiary policy with accounting for the following exceptions: a. if the healthcare provider requested no substitution with the following considerations: i. To rely on a reasonable medical justification and attach documents justifying the application for approval by the Insurance Company, in case of obtaining the approval of the Company. ii. If the Insurance Company deems that the medical justification is not possible, the beneficiary's shall pay the difference between the price of the two devices. b. If the beneficiary request dispensation of the medical devices as per the requested name, the beneficiary shall pay the difference between the price of the two devices. 26 جلس الضمان الصحي مجلس الضمان الصحي Council of Health Insurance public I. The amount of deductible must be clarified to the Beneficiary in details before providing the service based on the Policy. J. The Insured must be enabled to identify the costs of each health service provided to it upon its request. K. The Insured must be provided with the invoice for the health services provided. L. The Insured is entitled to obtain a proposal of the expected value of the costs and the copayment amount before starting the treatment. M. The deductible shall be calculated on the net value of the medical bill, with the exception of the price difference for innovative medicines. (14) Reimbursement Basis: A. In cases of emergency, the Insured may obtain urgent medical treatment in centers other than the agreed upon with the Company on reimbursement basis. In such case, the Company shall, in accordance with the policy terms, conditions, limitations and exclusions, compensate the policyholder within a period not exceeding 15 business days for recoverable costs and expenses on the basis of prevailing prices, provided that it shall provide the Company with the supporting documents it requires within 30 business days as of the date of incurring such expenses. B. The Beneficiary has the right to upgrade his/her insurance category to a higher one in accordance with the provisions of the Contract of the Insurance Company with the employer or the dependent. In this case, the Beneficiary shall pay the difference between his/her insurance category and the higher insurance category, if approved. (15) Approvals: 27 psm مجلس الفيمان الصحي Council of Health Insurance public In accordance with Article (90) of the Implementing Regulations, the parties to the insurance relationship, with respect to the obligation of each party individually, shall undertake the following: A. The service provider shall send a request for approval to cover the cost of treatment for the beneficiaries to the Insurance Company within a maximum of fifteen (15) minutes from the time of filling the application by the physician. B. The service provider shall, upon applying for approval for providing treatment to beneficiaries, ensure that the health services that will be provided to the Insured meet the criteria for the approval request. C. The service provider shall ascertain the limits of the subsidiary benefits provided to the Insured. D. The service provider shall ascertain that all basic data and information that support the approval request are submitted. E. The Insurance Company shall respond to the request submitted by the service provider for the approval of providing treatment to the Beneficiaries within a period not exceeding sixty minutes (60) from the time of submitting the request for approval. In case of disapproval, the reasons shall be formally clarified. F. The service provider shall respond to the Insurance Company's queries within 30 minutes of receipt of the query. G. All procedures related to the request for approving the provision of treatment between the Insurance Company and the service provider shall not exceed 60 minutes from the time of submitting the request. (16) Compensation for Expenses from a Traffic Accident: A. The Insurance Company that is notified of the traffic accident shall cover the Beneficiary's costs and follow up its medical treatment. The Insurance Company shall be liable for compensating the expenses of a medical claim resulting from a traffic accident, whether the Beneficiary is the perpetrator or the damaged, provided that the vehicle shall be licensed. 28 سمان مجلس الفيمان الصحي Council of Health Insurance public B. The Insurance Company shall replace the Beneficiary (i.e. the injured person) in requesting third parties to pay their proportional share of that claim if such claim expenses are compensable for the injured person, meaning that they are covered under any plan, program, other insurance, etc. C. The Insurance Company is entitled to recourse against the Beneficiary if it waived the party causing the accident. (17) Expenses of Complications resulting from a Benefit Treatment: A. The Insurance Company shall cover any costs for treating the complications arising from a benefit covered by the Policy according to the maximum limit specified herein, unless these complications are arising from negligence or medical error by the service provider, and a proof shall be given under a decision by the ministry of justice, establishing the responsibility of the parties of insurance relationship. B. The Insurance Company shall calculate the incidence of complications resulting from the treatment of the covered benefits, create an indicator based on the best common medical practices for follow-up, and inform the Council if the indicator is exceeded by one of the service providers. (18) Reasonable and Ordinary Medical Expenses: In contrast to the price lists agreed upon between the Insurance Company and the service provider for the services and medical expenses, the approved and customary medical expenses provided for the Beneficiary for emergency health services or outside the medical network are considered according to the level of the medical network assigned to the Insured. (19) Expenses of Corpse Repatriation to Home Country: The Insurance Company shall cover all costs of preparation and repatriation of the corpse of the Insured to the home country specified in the employment contract according to the maximum limit specified in the Policy. 29 جمان مجلس الفمان الصحي Council of Health Insurance public [Non-Text] (20) Calculating the Amortization of the Benefit Limits It shall be obligated to calculate the costs of the amortization of the benefit limits for the Insured by calculating the total cost on the Net basis, not the Gross bill. General Conditions: (21) Personal Hazards The Council shall have the power to determine the hazard criteria for activities likely to involve personal hazards, and shall measure the extent to which it is subject to insurance coverage. (22) Verification of the insured's Health Condition: A. The Company has the right to and shall be given the opportunity, by an accredited medical entity, to examine the Insured requesting Recoverable Expenses at the expense of the Company for up to two times within sixty (60) business days following submission of the claim. B. The Policyholder or the Insured shall cooperate with the Company and allow all necessary measures that may reasonably be required by and paid for by the Company for the purpose of preserving any rights, claims, or legal compensations from third parties. The Policyholder may not assign such rights except with the Company's explicit or implicit consent. (23) Notices: A. All notices or other correspondence to the Company between all parties shall be formal. B. The Insurance Company shall notify the Policyholder with the Policy renewal or expiry date as follows: 1. Sending a preliminary reminder notice to the Policyholder prior to the Policy expiration date of not less than 60 days. 2. Sending a second reminder notice to the Policyholder prior to the Policy expiration date of not less than 30 days. 30 جلس الضمان الصحي مجلس الضمان الصحي Council of Health Insurance public 3. Sending a third reminder notice to the Policyholder prior to the Policy expiration date of not less than 15 days, and notifying the Council of it. C. The Insured (Policyholder) shall be obligated to notify the Insurance Company whenever any of its contact information, or of its subsidiaries, is changed. (24) Medical Declaration Form: A. The Insurance Company shall adhere to the Unified Medical Declaration Form approved by the Council. The Policyholder shall submit such Form to the Insurance Company in case it is requested, provided that the Beneficiary shall fill it. B. Filling the Medical Declaration Form shall not require the insurance policies of the large and mega large enterprise (Except for beneficiaries added after issuing the Document). (25) Compliance with Policy Provisions: As a precondition to any liability of the company, the Policyholder and beneficiaries shall strictly comply with and execute all requirements, conditions, obligations and commitments stated in this Policy. (26) Construction: Unless the context otherwise required, or expressly stated the opposite: A. Any reference to a masculinity shall include femininity in its meaning. (27) Any reference to this Document shall include in its meaning any amendments hereto or relating bylaws. Penalties: Any disagreement or dispute arising out of or relating to the Policy shall be settled in accordance with Article (14) of the Cooperative Health Insurance Law. (28) Policy update: The council of health will be updating the policy every 3 years شمان مجلس الضمان الصحي Council of Health Insurance Chapter Five Insurance Drug formulary (IDF) public [Non-Text] Insurance Drug Formulary A. The service provider shall prescribe medications, according to the generic name of the medicine, and shall observe the rules of the Saudi Food and Drug Authority regarding the exceptions. B. The service provider shall prescribe medications, according to the medical indications associated with ICD-10, as approved in the basic benefits package. C. A pharmacist shall automatically replace a brand name with the generic one if the drug is prescribed in a specific trademark, based on the Insured Policy, taking the following exceptions into account: 1. Irreplaceable generic drugs according to the regulations of the Saudi Food and Drug Authority. https://www.sfda.gov.sa/sites/default/files/2021- 08/SFDADDD.pdf 2. If the Insured requested to be dispensed a drug with a specific trade name, the copayment amount shall be applied as specified in its policy. (0-50% of the selected trade name price) 3. If the treating physician requested not to replace the brand name for innovative drug, taking into consideration the necessity of the following: i. To rely on a reasonable medical justification and attach documents justifying the application for approval by the Insurance Company, in case of obtaining the approval of the Company, the copayment amount shall be applied only on the basis of the price of the approved generic as per its Policy. ii. If the Insurance Company deems that the medical justification is not possible, the copayment amount will be as 0-50% of the selected trade name price based on the policy type. D. The medication cost shall be covered based on the scientific name according to the Insurance Council approved formulary( IDF) E. The Approved IDF that is based on scientific name is binding for health care providers and insurance companies, and selection of the trade name 33 سمان مجلس الفيمان الصحي Council of Health Insurance public [Non-Text] [Non-Text] [Non-Text] to be covered is acc provided and insurance comp Providers and insurance company shall comply with the IDF guidelines. In case the disease indication is not listed within the IDF, Evidence based clinical guidelines shall be considered (except for the diseases excluded from the coverage of the Policy). G. The Insurance Company may, in coordination with the Policyholder, expand the drug services - i.e. providing the medication according to the brand name, coverage of acne treatment, reduction and cancellation of the deductible percentage according to the Policy agreement. H. The service provider shall report any unavailability of drugs via the following e-mail to Saudi Food and Drug Authority: Shortage.Drug@sfda.gov.sa I. The maximum deductible percentage for drugs shall be calculated according to the price of the generic (or the innovative if there is no generic alternative) based on agreement between the Health care provider and insurance company and product registered price in the Saudi Food and Drug Authority. J. The service provider shall provide an alternative for the generic name within the same price range in case the suspension of drugs was not included in the suspended drugs in the local market by Saudi Food and Drug Authority. K. The Insurance Company shall, in coordination with the service providers, work on updating the IDF and providing an alternative brand name in case of suspension, withdrawal or stopping any of the drugs included in IDF by Saudi Food and Drug Authority. L. The service provider shall follow the regulations of Saudi Food and Drug Authority regarding dispensing and distributing pharmaceuticals https://sfda.gov.sa/sites/default/files/2020-12/SFDA28122020aa1.pdf. The service provider shall follow the procedures and controls of the Saudi Food and Drug Authority in terms of prescribing and dispensing narcotic drugs and psychotropic substances https://old.sfda.gov.sa/ar/drug/drug_reg/DocLib/Drug12112019a1.pdf. M. The service provider shall apply hazard reduction methods for approved and declared pharmaceuticals by the Saudi Food and Drug Authority: https://www.sfda.gov.sa/ar/RMM https://sfda.gov.sa/en/RMM. N. The Insurance Company shall provide Pharmacy benefit management (PBM) to connect with service providers and undertake immediate adjudications of medication orders. In the absence of a PBM program, the IDF is set as the reference to providers. O. 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Minimum Network: It refers to the network of service providers that covers all Kingdom's regions and cities and its geographical scope, provided that it shall include all levels of health service. B. Preferred Providers Network (PPN): A group of health service providers approved by the Council and identified by the Health Insurance Company to provide the service to the Insured. This is done directly by debiting the Insurance Company's account, provided that this network shall ensure the following levels of health services: - Level One (Primary health care). - Level Two (Public Hospitals). - Level Three (Specialized or Reference Health Care). Other complementary health services centers (such as: One-day surgery centers, pharmacies, Physical Therapy Centers, optical stores) C. The Insurance Company shall provide the minimum network according to the Law of the Council of Health Insurance, taking into account that, when designing the minimum network, that government health facilities are include within the network for Saudi Beneficiaries for policies in accordance to article 11. D. The Insurance Company shall provide the following speciali …(174,846 more chars)