HEALTHCARE INSURERS POLICY MANUAL. empowering you to achieve excellence. version 1.0. HAAD Insurers Manual Final File.indd 1

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1 empowering you to achieve excellence version 1.0 HEALTHCARE INSURERS POLICY MANUAL HAAD Insurers Manual Final File.indd 1

2 II PREAMBLE The Health Authority - Abu Dhabi ( HAAD ) is the regulator of the Abu Dhabi health system. HAAD has simplified the Health Regulations for the Emirate into two levels: Policies and Standards. The Health Regulations collectively translate federal UAE and Abu Dhabi Laws into a simple, practical set of tools to help drive compliance and improve quality and cost-effectiveness across the system. The Health Regulations have been drafted in collaboration with Abu Dhabi and international healthcare experts including the Joint Commission International ( JCI ), other health regulators, local and international legal advisors (Al Tamimi and Wragge and Co.), and delegates from Abu Dhabi and international Providers, Professionals and Payers. The HAAD process for developing and reviewing Policies and Standards follows the Organisation for Economic Development and Cooperation Guiding Principles for Regulatory Quality and Performance. In particular, a structured consultation process has been established comprising the formation of a permanent HAAD Policy Advisory and Consultative Panel and formal sector-wide consultation (8-12 weeks). Regulatory Impact Assessment will apply to major proposed policies and standards, in the future. In drafting the Abu Dhabi Health Regulations, HAAD completed a full review of the relevant international, UAE Federal and Abu Dhabi Laws, Regulations and Decrees related to the health system to assure legal authority and enforceability of the Abu Dhabi Health Regulations (HAAD Policy Manuals Version 1.0) under HAAD establishing Law No. 1 of In addition, HAAD set out a clear plan for implementation, which includes impact assessment on Abu Dhabi health system, and the amendment of existing and/ or creation of new advisory bodies for oversight and enforcement of regulations to assure general wellbeing of the citizens and residents of Abu Dhabi. In this chapter, we anchor a Definition of Health, set out the Structure of the Abu Dhabi Health Regulations, and state the Key Principles that apply across the Policies and Standards. HAAD Insurers Manual Final File.indd 2

3 III STRUCTURE OF ABU DHABI HEALTH REGULATIONS The Health Authority - Abu Dhabi was established by Law No. 1 of (2007) concerning the establishment of the Health Authority - Abu Dhabi; HAAD s purposes are defined in Article 1 (clauses 1 and 2) of Law No. 1 (2007), which are to achieve the highest standards in health, curative, preventive and medicinal services and health insurance and to advance these in the health sector; and to follow-up and monitor the operations of the health sector to achieve an exemplary standard in provision of health, curative, preventive and medicinal services and health insurance. In order to achieve its purpose, the HAAD establishing Law No. 1 of (2007) empowers HAAD, in particular, a. To apply the laws, rules, regulations and policies which are issued as they are related to its purposes and responsibilities, in addition to what is issued by respective international and regional organisations in line with the development of the health sector (Article 5 clause 2); b. To approve rules and procedures which are required for operating health and curative establishments; to approve procedures and methods of treatment; and to lay down policies and programs for satisfying the needs of the health sector in the Emirate (Article 5 clause 4); c. To develop and apply integrated systems for the control of government and private health sectors in the Emirate (Article 8 clause 12). With this mandate, and by virtue of Article 8 clause 12, HAAD has created an integrated Health Regulations system, comprised of Policies and Standards for the Emirate to regulate, control and monitor the implementation of federal and local health laws and best practices in health, curative, preventive and medicinal services and health insurance in the health sector. Figure 1 is a schematic of the hierarchy of the Abu Dhabi integrated Health Regulations. All health entities operating, or to be established in the future, in the health field, be it governmental or private, must carry out their responsibilities in accordance with the rules, regulations and decisions issued by HAAD (Article 6). Governmental health sector entities include the Abu Dhabi Health Services Company (SEHA) incorporated by virtue of Emiri Decree no. (10) of 2007 and the National Insurance Company (DAMAN) incorporated by virtue of Emiri Decree no. (39) of 2005, which are responsible for executing their objectives as incorporated companies in accordance with the rules, regulations and decisions issued by HAAD. HAAD Insurers Manual Final File.indd 3

4 IV Figure 1: Hierarchy of Abu Dhabi Integrated Health Regulations Law (Federal and Abu Dhabi) Taken as reference starting point 1. HAAD Enabling Regulation Mandates key policy manuals in context of Law Ties into disciplinary committee Legal authority only 2. Policy Manuals (40-80 pages each) Specify and compel behaviours of Actors in the Abu Dhabi health system 4 manuals specifying responsibilities and provides details on role: 1. Healthcare Provider 2. Healthcare Professional 3. Healthcare Insurer 4. Healthcare Regulator (External Focus) Refer to Standards 3. Standards (10-30 pages each) Define good across: Inputs Processes Outcomes HAAD development (e.g. data directory) International standards (without adaptation) International adaptation (e.g. Canada and UK) 4. Checklists Identify base for audit procedures Map to policies and standards Identify priority areas linked to HAAD Patients Safety Goals Policy Policies define the roles and responsibilities of Providers, Professionals, Payers and the Regulator in the health system, and their interactions. Policies are arranged in four Policy Manuals: 1. Providers 2. Professionals 3. Payers, and 4. Regulator (in Abu Dhabi, HAAD is the unified healthcare sector regulator). REGULATOR INSURER PROVIDER PROFESSIONAL HAAD will consistently monitor the effectiveness of the Policy Manuals in driving compliance, quality and cost-effectiveness, and will make changes where these are required. However, HAAD intends that Policy Manuals will remain stable over time, to help provide regulatory consistency within the health system. Figure 2: Four HAAD Policy Manuals fit together to form the complete Abu Dhabi Health Regulation, with the Patients Charter interacting with each of the four. HAAD Insurers Manual Final File.indd 4

5 V The four Policy Manuals have been drafted to fit together forming the complete Health Regulations for Abu Dhabi (see Figure 2). In addition, there is a (non-binding) Patients Charter which sets out the rights and the responsibilities of those using the Abu Dhabi health system. The Manuals set out reciprocal binding responsibilities in support of the Patients Charter. Standards Under the Policy Manuals, Standards add further definition around practice, establishing both acceptable minimum and aspirational levels. Whereas Policy is intended to provide regulatory consistency, Standards are intended to adapt as medical practice and the Abu Dhabi health system continue to evolve. HAAD continues to develop Standards for clinical care in consultation with providers. The focus is on clinical services for which the evidence base for specificity is strong, and those services that create the greatest impact on delivery against the HAAD strategy; for example, those that are high volume, high aggregate cost, and important determinants of public perception. DEFINITION OF HEALTH The Health Authority - Abu Dhabi (HAAD) has adopted the World Health Organisation s ( WHO ) definition of health: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity 1. In this context, HAAD defines the goals of the healthcare system as: 1. Increasing length of life; and/or 2. Improving quality of life. HAAD does this through ensuring everyone has access to healthcare, with world-class quality care and outcomes, and a full spectrum of health services (including preventive, curative and palliative). In addition, HAAD has a clear definition of quality (set out in the Key Principles below); HAAD monitors performance across the system in delivering this, publishing the data to drive informed choice by customers. Providers (and by extension Professionals) in Abu Dhabi are independent from the Regulator; that is, HAAD does not provide clinical services itself or manage service delivery operations. Providers are predominantly private; Payers are equally independent from the Regulator. As such, the responsibility for ensuring reliable quality is shared by Providers, Professionals, Payers, and the Regulator. Providers, Payers, Societies and Bodies operating in the health field and any establishment to be created in the future (such as Professionals Broads) are required to comply with the Abu Dhabi Health regulations (Article 6 of the HAAD Establishing Law No. 1 of 2007). Each should work together to optimize high quality, cost-effective healthcare for individuals, and the population as a whole. Mandatory health insurance helps ensure access to healthcare for all Abu Dhabi residents (including UAE National citizens and Non-National expatriates). The health insurance system is flexible to enable responsiveness to an evolving burden of disease, and an evolving healthcare sector. 1 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April The definition has not been amended since HAAD Insurers Manual Final File.indd 5

6 VI KEY PRINCIPLES This section sets out the principles that underpin all HAAD Policies and Standards. Quality Quality is the ability to deliver Reliable Excellence in Healthcare in line with the International Standards Organisation ( ISO ) standard ISO 9000, HAAD defines quality as: Degree to which a set of inherent characteristics fulfills requirements 2 In the context of healthcare, these requirements are the ability to deliver increased length of life, and/ or improved quality of life in a cost-effective manner. The HAAD Vision defines the dimensions of World Class Healthcare (quality, access and cost) for Abu Dhabi; HAAD, with input from its advisory panels and committees (including the Professional Boards), sets policies and standards for each dimension, and the Clinical Quality Panel 3 sets and maintains quality metrics for the health system. The delivery of quality requires continuous improvement, and the routine, iterative audit of delivery by Providers, Professionals, Payers, and the Regulator. HAAD defines two key elements to quality in healthcare Reliability and Excellence: Reliability The systematic reduction in errors or untoward events defined in HAAD Standards Monitored through self-checking, clinical audit, and regular inspections by HAAD (the Regulator) Excellence The continuous improvement, beyond minimum Standards, of clinical care delivery, customer satisfaction and cost-effectiveness. Underpinned by the routine collection, analysis and use of health data for routine clinical audit by Providers (and Departments) and Professionals. Driven towards continuous improvement through a clear pay for quality incentive system. Pay for Quality : HAAD intends to create a clear incentive for Providers and Professionals to improve quality. Data transparency ensures that enlightened patients can choose the highest quality, driving the volume of care to those with the best outcomes. In addition, HAAD intends to offer preferential tariffs for Healthcare Providers that deliver higher quality. The framework will be specified in the HAAD Standard for Clinical Quality Indicators in the Emirate of Abu Dhabi and will be iteratively improved on the basis of measured outcomes. 2 ISO 9000:2005, Quality management systems Fundamentals and vocabulary. International Organization for Standardisation. Available at 3 Clinical Quality Panel is an advisory body established by HAAD and comprised of experts from the Abu Dhabi healthcare sector. HAAD Insurers Manual Final File.indd 6

7 VII Accountability Providers, Professionals, Payers and the Regulator are all accountable for the delivery of quality. Each should act to enhance quality within their scope of control in the interests of delivering world-class healthcare. Abu Dhabi Health Regulations contain a nested approach to assuring quality, specifying five layers of nested responsibilities for patients quality and safe care; assurance multiplies across successive layers to optimise quality overall. In this model, Providers, Professionals, Payers and the Regulator are held accountable for their respective responsibilities; but each plays a central role in holding others accountable. The five layers are: 1. Within each interaction between Professional and patient; 2. Each Professional ensuring continuous education and improvement throughout their career (across patient interactions); 3. Each Provider; and 4. Supervision across Professionals under HAAD established Professional Boards; 5. Across the healthcare system driven by the Regulator HAAD in coordination with public and private service providers. These are set out in Figure 3 below. Patient Physician Conduct & Self Lifelong Learning Clinical, Departmental & Provider Oversight Professional Board Oversight Regulatory Oversight Figure 3: Nested approach to accountability HAAD Insurers Manual Final File.indd 7

8 VIII Clinician Competence Clinician competence is the ability of Professionals to deliver quality. It comprises: a. Relevant and current: i. Technical knowledge; and ii. Practical skills; b. Relevant and recent experience; c. Appropriate supervision in practice; d. Regular quality audit; and e. Reasonable support and back-up in practice in case of problems. Accountability for competence must be satisfied at three layers: Professionals, the supervisory/peer group, the Provider and Professional Boards. Whilst the Professional Boards advise on and recommend Clinician Competence Standards, the Regulator HAAD approves and issues the Standards, licenses professionals and audits and enforces compliance with these HAAD Standards. Scope of Practice and Privileges With recommendation from the Professional Boards, HAAD issues Standards for professionals Scopes of Practice and Privileging Framework for implementation by healthcare providers. Healthcare Providers and Healthcare Professionals are expected to operate at all times within their competence and in accordance with the HAAD Standards, except in an emergency and/or life-threatening situation in which case they must use best endeavours in the interests of preserving health. Healthcare Professionals are expected to be aware of the boundaries of their competence at all times and, where possible, seek to improve their competence through Continuing Professional Development. Those with a supervisory role (Regulator (HAAD), Providers and supervising Professionals), or advisory oversight (Professional Boards) are expected to act cautiously in setting and maintaining scope of practice in line with good industry practice and in accordance with regulatory (HAAD) Standards. The addition of new clinical services will require an additional period of close supervision. The Regulator (HAAD) regulates Providers and Professionals; in turn, Providers must supervise Professionals. The Standards for supervision, and the reporting of the results of supervision, must be based on the competency framework recommended by Professional Boards and approved by HAAD, and this framework will be set out in clear HAAD Standards. Provided the initial period meets a predetermined quality bar, under appropriate supervision, additional scope of practice and privileges may be added in line with clear Standards approved by HAAD, with advice set and maintained by the Professional Boards. Regular quality audits may lead to a review of Healthcare Professional privileges by the Provider with oversight from the Professional Boards, and in accordance with the HAAD Standard for the Privileging Framework. In case of serious untoward events and/or serious complaints, and where the Provider and/or Professional are permitted to continue practising, there may be a remedial period of closer scrutiny; the nature and duration of this period will be set by the supervisor or a disciplinary or review committee (where applicable). HAAD Insurers Manual Final File.indd 8

9 IX Obligation to Notify Providers, Professionals and Payers must notify the Regulator of any factors that jeopardise, or carry substantial risk of jeopardising quality. In addition, they have an obligation to act to remedy those factors, and/or notify the relevant supervisor and regulator in accordance with the layers of accountability (Figure 3). The Regulator (HAAD) will act to prevent any adverse consequences, and to enforce the regulations, where applicable. Proportionality The HAAD Health Regulations are a tool to ensure Reliable Excellence in Healthcare. Their effectiveness relies on both completeness and clarity. In this context, the Health Regulations have been drafted as concise, simple documents that are proportional to the issue(s) being addressed and that can be used freely across the healthcare system. Additional detail is included where required to define more precisely certain elements in light of the evidence base and/or risk analysis of specific issues such as errors, complaints or malpractice. Through iterative improvement (based on feedback and consultation with actors in the health sector, and impact assessment for major change) the Regulator (HAAD) will add detail where required, and remove unnecessary detail where this is not required. HAAD has put in place a framework for the development and review of existing Policies and Standards to ensure high quality regulations 4. The framework is consistent with the Organisation for Economic Cooperation and Development (OECD) Guiding Principles for Regulatory Quality and Performance. Data Transparency Integral to HAAD s vision is that everyone has access to healthcare and is free to choose their provider. Data transparency and better public information are foundations to informing capacity needs and patient choice. Data transparency enables Providers, Professionals, and Payers to improve performance by benchmarking their performance against others and encourages payers and public programs to reward quality and improved outcomes. The HAAD Data Standards and Procedures establish governance structures and regulatory parameters to oversee the collection, use, sharing and publication of data in line with internationally-recognized principles to protect and respect the individual s rights for consent, privacy and confidentiality. 4 Chapter I: HAAD Healthcare Regulator Policy Manual HAAD Insurers Manual Final File.indd 9

10 X HAAD STRATEGY Here we set out the HAAD strategy for health. Vision The Health System of the Emirate of Abu Dhabi is comprehensive, encompassing the full spectrum of health services and is accessible to all residents of Abu Dhabi. The system is driven towards excellence through continuous improvement, and monitored for achievement of targets. Providers of health services are independent, predominately private and follow highest international quality standards. The system is financed through mandatory health insurance. In the Emirate of Abu Dhabi, everyone has access to healthcare and freedom to choose their provider. An open system for all certified (HAAD licensed and registered) providers of health services delivers world-class quality care and outcomes in compliance with the highest international standards. A system encompassing the full spectrum of health protecting, promoting, sustaining and restoring services across the territory of the Emirate. Quality driven by ambitious improvement targets set by the regulatory authority of the Emirate and reflected in the regularly monitored and published key performance indicators of the system. Providers are independent and predominantly private. The health system finances itself through a mandatory health insurance for all AD residents. The financial system should be flexible in order to manage for change over time and the degree of subsidy. Mission Ensure reliable excellence in healthcare for the community Define the strategy for the health system and set Public-Private Partnership roadmap Monitor and analyse the health status of the population and performance of the system Shape regulatory framework for the health system Audit against regulations and enforces standards Encourage adoption of world-class quality and performance targets Plan capacities and service levels Drive programmes to improve societal health Define minimum standards for health service providers and health professionals Regulate scope of services and premiums and reimbursement rates of providers and payers Values 1. Commitment to the Community We Serve We recognize our responsibility to the community in which we reside and serve. We are committed to promoting wellness, preventing illness and fostering development of programs and services appropriate to the community we serve. We are committed to providing the highest standard of care delivered in a learning environment. HAAD Insurers Manual Final File.indd 10

11 XI 2. Pursuit of Excellence and Continuous Improvement We believe that exemplary, effective and accessible services are developed and achieved through research, education and the application of best evidence-based practice. We believe in fostering the development of creative, leading edge solutions and implementing technologies that enhance services and improve productivity. 3. Respect and Compassion We believe that all people have the right to be treated with dignity. We care about the individuals and communities we serve. 4. Integrity We believe in honest, ethical and professional behavior. We believe in being sincere, open and truthful, fostering trust in relationships. We make decisions based on sound, ethical principles. We honor our obligations. 5. Accountability We believe in regularly reporting our performance to our stakeholders. 6. Collective Wisdom of Teamwork and Collaboration 1. We believe that communication, teamwork and partnership is essential. 2. We believe that collaboration with our partners will achieve positive results. 3. We work towards common goals through open communication, mutual support and win-win attitudes. 4. We respect our differences and build on our strengths. STRATEGIC PRIORITIES Fill critical gaps in capacity and insurance coverage 2. Improve medical outcomes 3. Inspect and control for quality 4. Improve health professional education 5. Increase Emiratisation of health sector 6. Improve public health 7. Create customer transparency 8. Pay-for-quality 9. Increase private sector investment 10. Be prepared for emergencies 11. Automate internal processes 12. Develop quality workforce and plan succession HAAD Insurers Manual Final File.indd 11

12 HEALTH INSURERS POLICY MANUAL TABLE OF CONTENTS CHAPTER I. OVERVIEW OF THE HEALTH INSURANCE SCHEME IN ABU DHABI 6 1 Health Insurance Scheme 6 2 Financing the Health System of Abu Dhabi 6 Financing by Employers and Sponsors 7 Financing by Government 7 Finance Objectives 7 3 Regulator s Responsibilities 8 4 Compliance 8 5 Interpretation 9 CHAPTER II. OBLIGATIONS OF EMPLOYERS AND SPONSORS 10 6 Introduction 10 7 Entry to the Emirate for a Limited Time or Purpose Entry to the Emirate to Reside and/or Work Entry to the Emirate to Study Sanctions CHAPTER III. HEALTH INSURANCE PRODUCTS Introduction 14 PART A: GENERAL REQUIREMENTS HAAD Approval of Health Insurance Policies Validity and Renewal 14 HAAD Insurers Manual Final File.indd 12

13 14 Benefits and Exclusions Policy Documentation PART B: BASIC PRODUCT Benefits and Exclusions Premium and Tariffs PART C: ENHANCED PRODUCT Benefits and Exclusions Premium and Tariffs PART D: VISITOR PRODUCT (EMERGENCY HEALTHCARE) Benefits and Exclusions Premium and Tariffs CHAPTER IV. PARTICIPATION IN THE HEALTH INSURANCE SCHEME Introduction 21 PART A: PARTICIPATION OF INSURERS, BROKERS AND THIRD PARTY ADMINISTRATORS Application for Authorisation to Participate in the Health Insurance Scheme Application Approvals and Denials Information Obligations Data Management 23 HAAD Insurers Manual Final File.indd 13

14 23 27 Market Exit PART B: PARTICIPATION OF HEALTHCARE PROVIDERS Application for Authorisation to Participate in the Health Insurance Scheme Application Approvals and Denials Information Obligations Further Obligations Data Management Market Exit PART C: RELATIONSHIPS WITH OTHER PARTICIPANTS IN THE HEALTH INSURANCE SCHEME Agreements Between any Authorised Parties Conflicts of Interest Further Matters Between Parties 29 CHAPTER V. HEALTH INSURANCE CLAIMS MANAGEMENT Introduction Reimbursement Methodologies Monitoring Payment Levels, Utilisation, and Provider Performance Corrective Actions HAAD Insurers Manual Final File.indd 14

15 CHAPTER VI. HEALTH INSURANCE FRAUD AND ABUSE Introduction Health Insurance Fraud, Abuse, Misuse and Mistakes and Errors General Duties Duties on Payers Policies Duties on Payers and Providers Reporting Powers of HAAD Confidentiality Sanctions Appeals 36 CHAPTER VII. HAAD REGULATION INSPECTIONS, COMPLAINTS, APPEALS AND SANCTIONS Introduction Inspections Complaints Appeals Sanctions CHAPTER VIII. INTERPRETATION AND DEFINITIONS Interpretation Definitions 43 HAAD Insurers Manual Final File.indd 15

16 6 CHAPTER I. OVERVIEW OF THE HEALTH INSURANCE SCHEME IN ABU DHABI 1 Health Insurance Scheme 1.1 The Health Insurance Scheme in Abu Dhabi is established and regulated by the following Law 23 of 2005 Regarding the Health Insurance Scheme for the Emirate of Abu Dhabi (the Law), Executive Regulations for Law 23 of 2005 Regarding the Health Insurance Scheme for the Emirate of Abu Dhabi (the Regulations), any Decision of the Executive Council relating to, or amending the Law or the Regulations (Executive Decisions), any applicable laws in the UAE, this Policy Manual, any relevant Standards and Circulars issued by HAAD. 1.2 The Health Insurance Scheme places responsibilities on any Insurer, Broker, Third Party Administrator, Healthcare Provider, Employer, Sponsor (including educational establishments), Limited Income Investor and Insured Person who is required to participate in the Health Insurance Scheme. Chapter VI of this Manual also places obligations on Healthcare Professionals. 1.3 All people involved in the Health Insurance Scheme or who may require the use of health services in Abu Dhabi under the Health Insurance Scheme must ensure that they are fully aware of the provisions of each of the above legislative instruments that apply to them. 1.4 The contents of this Policy Manual and the Standards are supplementary to the Law, the Regulations, HAAD Circulars and any Executive Decisions. Where this Policy Manual or any Standard refers to the provisions of the Law and the Regulations, such references will be selective, and be used in order to provide appropriate background to the supplementary obligations imposed by the Policy Manual or Standard or Circular, not repeat the provisions of the Law, the Regulations or the Executive Decisions in full. 2 Financing the Health System of Abu Dhabi 2.1 The healthcare system of Abu Dhabi is financed through universal, mandatory health insurance which has three main sources of financing Employers or Sponsors, the Government, individuals. HAAD Insurers Manual Final File.indd 16

17 7 Financing by Employers and Sponsors 2.2 The Law and the Regulations make health insurance mandatory for non-nationals residing and/or working in the Emirate or visiting the Emirate under certain visa types. The Law requires that Employers or Sponsors provide health insurance coverage to all non-nationals under their employment or sponsorship and their dependents. 2.3 This Manual covers this stream of funding and the mandatory provisions relating to non-nationals. Financing by Government 2.4 Thiqa, the government funded, single-payer health insurance scheme for Nationals, was mandated by Resolution No. (83) of 2007 of the Abu Dhabi Executive Council concerning the application of the Law to Nationals and those of similar status in the Emirate. Thiqa is administered by the national health insurance company, Daman, and is regulated by HAAD. 2.5 Nationals may privately purchase health insurance coverage in addition to the coverage provided under the Thiqa. In such cases, only chapters IV to VIII of this Manual will apply. 2.6 The Government also funds defined mandates for healthcare services and programmes that serve public good and that are not covered by the Health Insurance Scheme (Funded Mandates). Finance Objectives 2.7 Central to this financing structure are the Government s objectives that In the Emirate of Abu Dhabi, everyone has access to healthcare and freedom to choose their provider, The health system finances itself through a mandatory health insurance for all Abu Dhabi residents, The financial system should be flexible in order to manage the change over time and the degree of subsidy, The health system is quality-driven by ambitious improvement targets set by HAAD, the regulatory authority of the Emirate and reflected in the regularly monitored and published key performance indicators of the system. 2.8 The Abu Dhabi Government has charged HAAD with the responsibility to implement an efficient regulatory and governance model for healthcare to ensure delivery of these objectives. HAAD Insurers Manual Final File.indd 17

18 8 3 Regulator s Responsibilities 3.1 HAAD plays key roles in relation to the management of an efficient private health insurance system. In particular, HAAD is responsible for enforcing the provisions of the Law and the Regulations, administering and overseeing the operation of the Health Insurance Scheme, licensing, registering and inspecting Authorised Insurance Providers and Authorised Healthcare Providers in relation to the Health Insurance Scheme, prescribing and collecting fees for the registration and licensing of Authorised Insurance Providers and Authorised Healthcare Providers, setting the reimbursement rates (Standard Tariff), rules and mechanism for the Health Insurance Scheme, determining and enforcing the implementation of applicable standards to be met by Authorised Insurance Providers and Authorised Healthcare Providers relating to the Health Insurance Scheme, investigating and resolving disputes 3, suspected cases of fraud and abuse, and complaints regarding other parties in the Health Insurance Scheme, conducting inspections and investigations to ensure that all participants in the Health Insurance Scheme comply with the Law and the Regulations, HAAD Circulars and any Executive Decisions, overseeing and conducting the appointment of authorised inspection officers, and working where appropriate with other emirate and federal authorities to ensure compliance with the Law and Regulations. 3.2 In addition, HAAD collects and publishes statistical data on the rates of participation in and utilisation of the Health Insurance Scheme, 4, collects and disseminates information about private health insurance to enable consumers to make informed choices. 4 Compliance 4.1 All regulated persons (including any Insurer, Broker, Third Party Administrator, Healthcare Provider, Employer, Sponsor and Insured Person who is required to participate in the Health Insurance Scheme) are responsible for their own compliance with the legislative provisions of the Health Insurance Scheme. Such persons must document and keep records that evidence their compliance. 1 Regulations: article 2. 2 Law: article Standard for Claims Adjudication, Mandatory Tariff and Associated HAAD Claims and Adjudication Rules, Standard Provider Contract, Chapter VII HAAD Regulations Inspections, Complaints, Appeals and Sanctions (Healthcare Insurers Manual) 4 Chapter VI: Healthcare Regulator Manual 5 HAAD Data Standards and Procedures Standard HAAD Insurers Manual Final File.indd 18

19 9 4.2 HAAD assists compliance by Authorised Insurance Providers and Authorised Healthcare Providers by standardising contracts, data submission, reporting templates, claims and adjudication rules and audit requirements 4, 5, 6, 7 to support in the ongoing review and monitoring of compliance. 4.3 HAAD also seeks to support compliance by checking upon receiving a complaint 8, other than suspicion of fraud, abuse, misuse and/or mistakes and/or errors 9, on resolving the complaint internally, and by ensuring that internal dispute resolution procedures have been exhausted, conducting inspections and compliance reviews which are used to determine and address areas of non-compliance, and reviewing the arrangements for audits. 5 Interpretation 5.1 Where this Policy Manual refers to provisions of the Law or the Regulations, it will summarise the legislative provisions. 5.2 At all times the wording of the Law and the Regulations will remain authoritative and, if there are any issues of contradiction between the Law and/or the Regulations and this Policy Manual, the Law and/or the Regulations will have precedence Standard Provider Contract, Mandatory Tariff and HAAD Claims and Adjudication Rules 7 [HAAD Standard for Auditing] 8 HAAD Standard for Complaints Management 9 Chapter VI: Healthcare Insurers Policy Manual 10 Law: article 26. HAAD Insurers Manual Final File.indd 19

20 10 CHAPTER II. OBLIGATIONS OF EMPLOYERS AND SPONSORS 6 Introduction 6.1 All non-nationals who enter the Emirate to work and/or reside (except for those entering on a tourist visa) must have the appropriate level of health insurance cover (as described fully in the Law and the Regulations and added to by this Policy Manual). 6.2 This Chapter further describes the obligations of Employers to provide health insurance coverage to their non-national Employees together with a limited number of the dependents of such Employees, Sponsors to provide insurance coverage to those Resident Expatriates under their sponsorship who are not covered by employment-based health insurance. 6.3 The Law provides for HAAD to impose financial penalties on Employers and Sponsors who do not subscribe, on behalf of their employees or sponsored persons, as required to the Health Insurance Scheme or who do not renew Health Insurance Policies where required Entry to the Emirate for a Limited Time or Purpose 7.1 The Regulations specify that Employers or Sponsors must cover the following persons with the Visitor Product persons sponsored for a visit visa of more than two (2) months 12 (but under six (6) months) duration (excluding persons entering on tourist visas), non-permanently-residing dependent children of Resident Expatriates The Regulations provide that Employers or Sponsors may provide cover to such persons specified in paragraph 7.1 above under an Enhanced Product In respect of persons entering the Emirate on a mission visa, Employers or Sponsors of such persons must purchase the Visitor Product for that person for the same period as that specified in the person s issued mission visa, provided that the mission visa is issued for no longer than 6 months. 11 Law: article 24 and Regulations: articles 11(10) and 12(9), and Schedule 4 paragraph 1 and Regulations: article 4(6). 13 Regulations: article 6(2)(b). 14 Regulations: articles 4(6) and 6(2)(c). HAAD Insurers Manual Final File.indd 20

21 11 8 Entry to the Emirate to Reside and/or Work 8.1 The Law restricts non-nationals from being issued a work permit 15, residency permit 16, or from having a residency permit renewed 17, unless proof of insurance cover is furnished to the immigration authority. 8.2 The Regulations require that (except in cases where an exemption is permitted) Employers purchase health insurance coverage 19 for any non-nationals it employs, Employers purchase health insurance coverage for the dependents of a male Employee where such dependents intend to reside in the Emirate, but the Employer shall not be obliged to cover more than one wife and up to three children under the age of 18 years 20, Sponsors purchase health insurance coverage 21 for any non-nationals who they sponsor to reside in the Emirate for any duration (such duration being specified on that person s issued residency permit) where that person is not entitled for health insurance coverage by an Employer The Regulations establish that (except in cases where an exemption is permitted) an Employer is responsible before the Sponsor for purchasing health insurance coverage for non-nationals it employs The Regulations provide that, unless one of the conditions in applies, where the person to be insured receives a monthly compensation level that is lower than the income threshold set by the Regulations, Employers or Sponsors must purchase the Basic Product 24, but may purchase the Enhanced Product, greater than the income threshold set by the Regulations, Employers or Sponsors must purchase an Enhanced Product 25, 15 Law: article 5 and Regulations: article 11(9). 16 Regulations: article 12(3). 17 Regulations: article 12(5). 18 Law: article 3 and Regulations: article 5 and Schedule 4 paragraphs 19, 26 and Regulations: article 6(2) requires at least the Basic Product to be obtained. 20 Law: article 5 and Regulations: article 11(3). 21 Law: article 5 and Regulations: article 12(1). 22 Law: article Regulations: article 11(1), (2) and (3). 24 Regulations: article 6(2)(a), as amended by Executive Decision 47 of 2008, and Schedule 4 paragraph Regulations: article 6(2)(c). HAAD Insurers Manual Final File.indd 21

22 paragraphs and do not apply where an exception applies, or the person to be insured is a non-national who is eligible for the Visitor Product 26 or is a dependent of a non-national employee who is not eligible for health insurance coverage by the employee s Employer The Employer 28 or Sponsor 29 is liable for the cost of providing Health Insurance (Basic or Enhanced Product) for persons sponsored by them and penalise Employers or Sponsors if they pass any of this cost onto the Insured Person The Regulations make the Employer and/or Sponsor, in the absence of the required coverage, responsible for the costs of any healthcare services incurred by any non-nationals under their sponsorship Employers must obtain health insurance for the dependents of a female non-national employee who intend to reside in the Emirate if the female employee is a widow who maintains and sponsors her children, provided that a judgment rendered by an Abu Dhabi Sharia Court regarding the children s maintenance by the mother is submitted, or female employee s spouse is deemed medically incompetent as evidenced by a certificate issued by the HAAD Medical Committee in the Emirate and the female employee sponsors her husband and any children. 9 Entry to the Emirate to Study 9.1 Where a non-national, aged 18 years and over, is studying at a recognized educational establishment in the Emirate, and are not sponsored by parents residing in the Emirate, the educational establishment must act as that student s Sponsor and purchase the Basic Product. 26 Regulations: article 6(2)(b). 27 Regulations: article 6(2)(a) such persons are eligible for the Basic Product. 28 Regulations: article 11(4). 29 Regulations: articles 11(2) and 11(6). 30 Regulations: articles 11(4) and 12(6), and Schedule 4 paragraph Regulations: articles 11(5) and 12(2). HAAD Insurers Manual Final File.indd 22

23 13 10 Sanctions 10.1 The Law pronounces that HAAD is in charge of enforcing the Law, and the Regulations give HAAD the power to prescribe and collect fines for breaches of the Health Insurance Scheme HAAD may impose sanctions 33 on relevant parties for breaches of the obligations set out in this Policy Manual and any Standards issued under it. 32 Law: article 22 and Regulations: articles 2 and 17(9), 22 and Schedule Chapter VII: HAAD Regulations - Inspections, Complaints, Appeals and Sanctions (Healthcare Insurers Manual). HAAD Insurers Manual Final File.indd 23

24 14 CHAPTER III. HEALTH INSURANCE PRODUCTS 11 Introduction 11.1 The Law and the Regulations establish three types of private health insurance product which may be sold to non-nationals or administered by Authorised Insurance Providers to cover Insured Persons under the Health Insurance Scheme The Basic Product for individuals (including limited income investors) with limited income in accordance with the threshold set by the Regulations and dependents of non- Nationals who are not eligible to be covered by the non-national s employment based insurance, The Enhanced Product for individuals above the income threshold set by the Regulations for the Basic Product and available to all non-nationals, The Visitor Product for visitors to the Emirate holding certain types of visas 34. PART A: GENERAL REQUIREMENTS 12 HAAD Approval of Health Insurance Policies 12.1 The Regulations provide for a penalty to be imposed if HAAD approval of a health insurance policy is not obtained and if amendments are made to a health insurance policy without approval by HAAD HAAD will not approve any health insurance policy that does not comply with the requirements under the Law, the Regulations, or this Policy Manual. 13 Validity and Renewal 13.1 The Regulations specify that health insurance policies will be valid for a minimum of one (1) 36 year from the commencement date of the policy, except the visitor health insurance product Regulations: article 5(6). 35 Regulations: Schedule 4, paragraph Regulations: article 6(4). 37 Regulations: article 6(7). HAAD Insurers Manual Final File.indd 24

25 15 14 Benefits and Exclusions 14.1 The Regulations require all Insurers to ensure that their health insurance policies include the minimum requirements regarding policy benefits and exclusions as set out by the Law and the Regulations 38, provide cover to an Insured Person for a High Cost Medical Condition following the elapse of six months from the commencement of the policy Insurers must, in all health insurance policies not impose an age limit on health insurance coverage, include coverage for work-related injuries and illnesses HAAD will, review the definition of High Cost Medical Conditions for which Insurers should provide coverage. 15 Policy Documentation 15.1 The Law and the Regulations require Insurers, in relation to all individual policies, to issue the Insured Person with a health insurance card 40, document explaining the key terms of the policy, including the benefits and exclusions 41, the network and the rights and responsibilities of the Insured Person 42 and the Insurer (the Policy Summary). 38 Law: articles 12 and 13, and Regulations: article 6(6) and Schedules 1, 2 and Regulations: article 6(10). 40 Law: article 16 and Regulations: article 6(12). 41 Law: article [HAAD Patient Charter] HAAD Insurers Manual Final File.indd 25

26 Payers must, following a request from (or on behalf of) an Insured Person, provide a copy of the Policy Summary to the Insured Person Payers must, in relation to all group policies, issue the Employer or Sponsor purchasing the group policy with the health insurance card, the Policy Summary including the benefits schedule, exclusions list and provider network, the premium receipt and debit note, retain evidence of the above communication for the purposes of a HAAD inspection Employers or Sponsors purchasing a group policy must, on receipt of the same from the Payer, distribute to the Insured Persons their health insurance card and the Policy Summary. PART B: BASIC PRODUCT 16 Benefits and Exclusions 16.1 The Law sets out the benefits and exclusions for the Basic Product and allows HAAD, subject to approval by the Abu Dhabi Executive Council, to add or delete benefits and services from time to time The Regulations provide further detail relating to the healthcare services that should be covered under the Basic Product 44 and the healthcare services that are excluded from cover under the Basic Product 45, establish penalties for authorised Insurers who amend the Basic Product (as determined by HAAD 46 ) or provide less cover than that required for the Basic Product without obtaining approval from HAAD Insurers must ensure that the Basic Product must provide reasonable and timely access to covered inpatient and outpatient services within the Emirate and to emergency services within the UAE HAAD controls the Basic Product Provider Network. 43 Law: articles 12 and Standard for Healthcare Services for Work-Related Injuries and Specified Occupational Diseases 45 Regulations: article 8(1) and 10(1), and Schedules 1 and Regulations: Schedule 4, paragraph Regulations: Schedule 4, paragraph 8. HAAD Insurers Manual Final File.indd 26

27 17 17 Premium and Tariffs 17.1 The Regulations state that the Premium for the Basic Product will be determined by an Executive Decision 48 and that penalties will be imposed on Insurers who fail to comply with the approved cost of the Basic Product 49, state that the premium for Basic Product cannot be refunded 50, allow HAAD to set the reimbursement rate (Standard-Tariff) 51, price list for services covered in the Basic Product 52, and establish penalties for Authorised Insurers and Authorised Healthcare Providers who fail to comply with the approved HAAD reimbursement rates Employers, Sponsors, Insurers must comply with the eligibility requirements for the Basic Product. PART C: ENHANCED PRODUCT 18 Benefits and Exclusions 18.1 The Regulations provide that an Insurer must not exclude from an Enhanced Product any of the benefits covered under the Basic Policy 54, an Insurer may design Enhanced Products which extend the benefits of the Basic Product to provide additional health insurance cover for healthcare services which are specifically excluded from the Basic Product 55, where an Enhanced Product is sold without a sample policy being approved by HAAD 56, that HAAD may impose a penalty. 48 Regulations: article 6(5). 49 Regulations: Schedule 4, paragraph Regulations: article 6(4). 51 Standard Provider Contract, Mandatory Tariff Price List Application Rules 52 Regulations: article 8(5). 53 Regulations: Schedule 4 paragraphs 17 and Regulations: article 10(3). 55 Law: article 17 and Regulations: article 10(3). 56 Regulations: Schedule 4, paragraph 24. HAAD Insurers Manual Final File.indd 27

28 HAAD will publish a Standard relating to the development of policy enhancements Insurers must ensure that the enhancements of an Enhanced Product comply with the Law, the Regulations, this Policy Manual and the Standard relating to the development of policy enhancements, prior to permitting the sale of an Enhanced Product, ensure that the initial terms (including details of all proposed policy benefits and exclusions) of the policy are submitted to HAAD for approval, prior to implementing any amendments to a policy approved by HAAD, resubmit the amended terms for re-approval by HAAD, ensure that an Enhanced Product is renewable with any increase in the Premium; a minimum of 30 days notice must be provided to the Insured before implementing any increased Premium, group-underwrite policies for Employers with eleven (11) or more employees per product Individually-underwrite all Enhanced Products which were purchased for individuals Insurers may individually-underwrite Enhanced Products (individual policies) which were purchased for a group where an Employer has ten (10) or fewer employees per product. 19 Premium and Tariffs 19.1 The Regulations provide that the Premium for the Enhanced Product is to be determined by market rates 58, 59 and that the parties to the Health Insurance Policy may agree on the terms on which a refund of Premiums may be recovered Insurers must not sell any Enhanced Product for less than or equal to the Premium determined for the Basic Product, not set the reimbursement rates for the Enhanced Product above the price cap or below the price floor set by the Standard Provider Contract between the Authorised Healthcare Provider and the Payer, submit the reimbursement rates for the healthcare services covered by the Enhanced Product which have been negotiated between the Insurer and Authorised Healthcare Provider to HAAD for approval. 57 Standard Insurance Product Enhancement Guidelines accompanying Form-CR4 & [HAAD Standard for Product Enhancement] 58 Regulations: article 10(3). 59 HAAD Mandatory Tariff Price List Application Rules 60 Regulations: articles 6(4). HAAD Insurers Manual Final File.indd 28