10 questions about health insurance coverage

10 questions about health insurance coverage

The Medical insurance They are being a recurring theme in the national press due to the conflict that the Dominican Medical College maintains with the current system.

The union demands, among other things, improve rates paid by the Health Risk Administrators (ARS). And in his activism he has affected members of the ARS Mapfre Salud, Monumental, Simag, Renacer, Universal and Primera.

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To better understand how insurance coverage works Medical insurance in the current Dominican Social Security System, Free Daily asked 10 basic questions to the Dominican Association of Insurance brokers (Adocose), so that less knowledgeable members can orient themselves.

Do all people who have health insurance within the Dominican Social Security System have the Basic Health Plan?

Yes, all the people included in the System of Social Security They have a Basic Health Plan (PBS).

According to what is indicated by the Law 87-01which creates the Dominican Social Security System (SDSS), currently there are operating the following regimes: contributory and subsidized.

  • Contributory Regime: Covers all public or private salaried workers, being financed by contributions from workers and employers.
  • Subsidized Regime: It is fully financed by the Dominican State, its objective is to protect the unemployed, disabled and indigent.

What does the Basic Health Plan cover at a general level?

The Basic Health Plan grants coverage for prevention and promotion, outpatient care, dental services, emergencies, hospitalization, births, surgeries, diagnostic support in hospitalizations such as outpatients, high-cost or highly complex care, rehabilitation, hemotherapy, and outpatient medications, as set by Catalog of Health Services Benefits (PDSS).

This catalog can be reviewed in any moment by the National Social Security Council (CNSS), with a view to modifying both scope and coverage.

An example of this was Resolution No. 553-02, dated September 22, 2022, where various improvements were made, highlighting some such as: expansion and unification of Coverage of Medicines of High price related to Cancer Treatments, Neoadjuvants, Adjuvants and Palliatives from 1,000,000 pesos to 2,090,000 pesos; extension of the coverage of High Cost Medications to 1,000,000 pesos for other non-oncological pathologies such as: Rheumatoid Arthritis, Systemic Lupus Erythematosus, Kawasaki Disease, Hemophilia, reduction of the Variable Moderating Fee from two (02) minimum wages to one (01 ), among others.

Why do insurers also sell insurance called supplementary?

The add-on plans are those prepaid services that customers purchase to cover their needs when they are not affiliated with Social Security or wish to expand the coverage of procedures, network of centers or affiliated doctors to those included in the Basic Health Plan (PBS).

What does this complementary insurance cover different from the Basic Health Plan?

The add-on plans They tend to cover those services, activities, procedures or interventions that are not included in the Basic Health Plan, or that are offered under different or additional conditions.

For example, a supplemental plan may expand room coverage In addition to that already defined by the PBS, cover procedures with greater technological advances, and even, depending on the plan, even provide reimbursements for procedures performed outside the network of providers affiliated with the ARS or insurer where the contracted complementary plan is located.

If a person only has the Basic Health Plan, in which cases is it recommended that they also opt for a complementary one?

Despite the benefits of Basic Health Planalways is recommended to count with a add-on plan that adds greater freedom in the network of providers and coverage for those diseases or procedures that do not appear in the catalog of services provided by the PBS.

Can a person have insurance from a company that covers the Basic Health Plan and have a complementary one from a different company? If so, how is the process done?

I understand that you mean if you can have the Basic Health Plan in an ARS and have a private “complementary” plan hiring a different ARS or insurer. The answer is yes, but it is not recommendedbecause it is not a complementary plan, but rather a voluntary plan or private.

A voluntary or private plan It is a plan obtained in a particular way in an insurer or ARS by a person who is affiliated with an ARS other than the one of your Basic Health Plan.

These voluntary or private plans are not related to PBS coverage, but rather are limited to the catalog of benefits contracted with that ARS or specific insurer.

The recommendation is that, if you are in this condition, decide which ARS or insurer you want to stay with and make a transfer process of the plan to unify the coverage in the same.

Why does the insured – who pays his monthly rate – sometimes have difficulties for his insurance to cover his medical needs?

As we have explained above, all health planwhether it is the Basic Health Plan, Complementary Plan or Voluntary Plan, has a catalog of benefits and affiliated networks.

Many of the difficulties stem from lack of knowledge of the management processes of said plans. Hence the importance of always having the appropriate advice from an insurance promoter or broker who can accompany the affiliate or insured by the hand during the different processes to be exhausted, whether this is for the PBS as complementary or voluntary plans.

One of the biggest challenges in this regard is to achieve the review agility of the catalogs of benefits, which is balanced with the rapidity of technological advances in the medical sector. In this sense, we must highlight that the catalogs of private plans are carried out at least once a year and the last revision of PBS was made last September 22, 2022.

Why is it that when someone suffers from an illness or condition and applies for new insurance, that insurance often doesn’t cover that pre-existing condition?

As regards the Basic Health Plan East does not limit pre-existing conditions at the time of admission.

Now, in the case of add-on plansas they are dealt with by private agreement between the ARS or insurer with the affiliate, they are governed by said contracts where existing diseases or health conditions would be established as excludedunless explicitly stated otherwise in the issuance of this new plan.

What do you recommend to a person when choosing their health insurance, so that they have coverage according to their needs?

First of all, carry out these steps accompanied by a promoter or insurance broker with experience and who can offer you different alternatives that adapt to your specific needs.

It is recommended that they can contract the plan before they arise diseases or pre-existing. Subsequently, a provider and/or plan must be selected that adapts to the needs and scope of the member, taking into account the coverage, the network of providers, etc.

What does the association understand is necessary for the insured to feel real coverage and consider themselves supported in the face of their health needs?

We understand that the best association that an insured can make is be accompanied from the moment you make the decision of a promoter or broker of insurance that can clarify the different alternatives that are adapted to cover your needs.

The insurance promoter or brokerwith his experience, can guide you through the processes to obtain the best results and in the shortest possible time, thus generating greater satisfaction when requiring the services of your health plan.

Economics editor and journalism teacher. She has specialized in investigative, multimedia and data journalism.

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