In a follow-up to our previous article regarding the launch of the Qatar Social Health Insurance Scheme, we now take a look at the implementing regulations that have been published in respect of the Health Insurance Scheme. The Health Insurance Scheme is currently intended to be rolled out in five phases in Qatar. Pursuant to Article 29 of Law No 7 of 2013 concerning the Social Health Insurance Scheme (the Health Insurance Law), the Minister of Public Health (and Secretary General of the Supreme Council of Health (SCH)) is tasked with issuing “Executive Regulations” to the Health Insurance Law. The executive regulations have been issued pursuant to Resolution No 22 of 2013 of the Minister of Public Health Issuing the Implementing Regulations for Law No 7 of 2013 concerning the Social Health Insurance Scheme (the Executive Regulations) and were published in the Official Gazette in Issue No. 16 dated 28 October 2013. The Executive Regulations contain a number of conditions which impact the operation of the Health Insurance Scheme and its participants.
Health insurance providers
Article 1 of the Health Insurance Law distinguishes between “Basic Healthcare Services” and “Additional Healthcare Services”. Basic Healthcare Services are defined as “A range of Healthcare services, which shall be provided to the Beneficiaries in accordance with the provisions of this Law.” Additional Healthcare Services are defined as “A range of Healthcare services, which may be provided, in addition to the Basic Healthcare Services, to the Beneficiaries in accordance with the provisions of this Law.”
Article 28 of the Executive Regulations provides that “the National Health Insurance Company shall be solely responsible for providing the insurance coverage for the Basic Healthcare Services…” (our emphasis). Thus, in accordance with Article 11 of the Health Insurance Law, which provides that “The Council shall license Health Insurance Providers to market and sell insurance policies in respect of Additional Healthcare Services after fulfilling all licensing conditions to be set forth by the Regulation”, mandatory insurance cover for all Basic Healthcare Services will be provided by the National Health Insurance Company (NHIC) alone. Accredited health insurance companies will be entitled to offer insurance cover for Additional Healthcare Services only (ie the private insurance market will not be entitled to offer cover for Basic Healthcare Services).
The types of services included in Basic Healthcare Services are distinguished based on one’s nationality and residency status in Qatar. Table 1 contains the schedule to the Executive Regulations details the various services included in Basic Healthcare Services.
The top-up coverage or services included in Additional Healthcare Services (and by definition excluded from Basic Healthcare Services) will be a key component in determining the level of participation of health insurance providers in the Health Insurance Scheme. It is not yet clear whether the NHIC will also participate in offering insurance cover for Additional Healthcare Services.
In order for health insurance providers to participate in the Health Insurance Scheme, Article 16 of the Executive Regulations requires that a health insurance provider’s place of business be inside Qatar and be licensed by the competent governmental authority in Qatar. Thus, in addition to licensing by the SCH, it would appear likely that any health insurance provider will also have to be licensed by the Qatar Central Bank (QCB). We would expect that insurance companies registered in the Qatar Financial Centre (QFC) will also be eligible to provide insurance for Additional Healthcare Services under the Health Insurance Scheme. The procedure for health insurance providers to obtain authorisation from the SCH to provide health insurance coverage is detailed in the Executive Regulations and contains specific timeframes within which applications must be considered by the SCH and may be appealed by applicants.
It is not indicated in the Executive Regulations whether the NHIC will be subject to and regulated by the QCB, whose extended role now includes the licensing and supervision of insurance companies in Qatar. We understand that the QCB is still working on a set of new insurance regulations for the local industry.
Article 16 of the Executive Regulations also provides that health insurance providers “shall not manage or run, either solely or jointly, any healthcare services rendered to the beneficiaries inside the State.” The relationship between health insurance providers and healthcare providers will have to be managed appropriately by the SCH and market participants after the implications of the prohibition are further defined.
Article 25 of the Executive Regulations sets out a number of terms which must be included in a customer agreement (ie the insurance policy) for the provision of Additional Healthcare Services, such as
- exclusions under the insurance policy, including any pre-existing conditions excluded, or limitations on the insurance coverage under the insurance policy;
- the basis upon which the premiums are to be calculated;
- a statement of any deductibles or co-payments which beneficiaries are required to make in addition to the Additional Healthcare Services under the health insurance contract;
- the limits applicable to particular elements of the Additional Healthcare Services which are generally available under the health insurance contract; and
- the network of Healthcare Providers available for the beneficiaries.
In order to participate in the Health Insurance Scheme, health care providers will be required to obtain SCH approval in order to offer some or all of the Basic Healthcare Services. The Executive Regulations, pursuant to Article 9, specify the conditions and controls for health care providers to subscribe to the Heath Insurance Scheme, including requirements such as appropriate licensing and use of a medical coding system approved by the General Secretariat of the SCH. The General Secretariat of the SCH is also tasked with making recommendations to the Minister and the SCH on the amount of any co-payments which may be payable for Basic Healthcare Services.
Amongst other things, Article 9 of the Executive Regulations requires health care providers to sign a service contract with the NHIC in order to participate in the Health Insurance Scheme which must include the following obligations:
- conduct all the insurance-related activities honestly and professionally;
- provide the Basic Healthcare Services to the beneficiaries subject to the granted licence and in compliance with the standards prescribed by the SCH in relation to the Social Health Insurance Scheme, and in accordance with the internationally recognised standards;
- abide by the instructions issued by the SCH with respect to the implementation of the Social Health Insurance Scheme, and the provision of the Basic Healthcare Services;
- provide the Basic Healthcare Services as per the tariffs agreed upon with the NHIC;
- follow the prescribed dispute resolution mechanism with beneficiaries;
- obtain written consent from patients when the Healthcare Provider discloses its records to the NHIC;
- follow the rules on which the NHIC will safeguard the privacy of any patient records it receives from a Healthcare Provider; and
- keep all records and information related to the Basic Healthcare Services provided, so that they are readily accessible in case of the need to continue patient’s treatment, and for the purposes of auditing or dispute resolution.
Health insurance premiums
Article 13 of the Health Insurance Law provides that the Government of Qatar shall be responsible for paying health insurance premiums for Qatari nationals. It would also appear likely that the Government of Qatar will cover the health insurance premiums of Gulf Cooperation Council (GCC) nationals although there is no explicit article mandating such in the law.
Stakeholders will also be interested to know that employers and sponsors are responsible for paying health insurance premiums for their employees (and their families) and sponsored persons, respectively. Visitors are responsible for paying their own health insurance premiums for the duration of their stay in the country, which will be payable prior to issuance or renewal of a visa pursuant to Article 15.
Article 18 prohibits employers and sponsors from recovering any health insurance premiums from employees (and their families) or sponsored persons, respectively. Employers and sponsors are eagerly awaiting further guidance on the amount of health insurance premiums payable under the Health Insurance Scheme.
The amount of health insurance premiums is required to be based on “generally accepted actuarial principles” to be paid in accordance with the ratios and measure prescribed in the Executive Regulations pursuant to Article 12 of the Health Insurance Law. The SCH is responsible for setting the amount of health insurance premiums according to Article 14. The Executive Regulations do not set out the amounts of health insurance premiums payable for Basic Healthcare Services, nor any tariffs that might apply to Additional Healthcare Services. Nor do the Executive Regulations presently provide any indication as to whether there will be any mandatory premiums applicable to, for example, lower income residents.
However, the Executive Regulations do set out the basis on which premiums will be charged. Article 2 of the Executive Regulations provides that health insurance premiums shall be set without discrimination between beneficiaries in respect of age, gender, previous health status or any other risk factors. Article 2 goes on to provide that “The premiums shall be paid as a percentage of all costs of the healthcare activities, in addition to the actuarial forecasts and modeling set by the Council, provided that such premiums shall not include profits.” It is unclear exactly what this formula entails, but it seems that the Executive Regulations envisage that the ability of insurance providers to include a percentage of any premium as profit may be curtailed. Exactly what form of profit margin will be permitted remains to be seen.
It is also envisaged that there will also be a period between the launch of Phase 1 and Phase 4 whereby the provision of cover mandated under the Health Insurance Scheme will work concurrently with existing private health insurance policies. The SCH has indicated that: “This period is designed to allow employers the time to reconcile the coverage of employees between their existing health insurance plans and the National Health Insurance scheme. By removing the elements of double coverage, they [Employers] can recover the portion of fees paid for their existing plans.” The mechanisms by which the SCH will seek to protect employers and sponsors from paying for both private and public health insurance policies during the roll out phases of the Health Insurance Scheme, and the manner in which double insurance will be avoided going forward, have, so far as we are aware, yet to be defined.
In order to avoid potential increases in prices of health care services during the implementation phase of the Health Insurance Scheme, the SCH has instituted a moratorium on price increases for health care services offered by private health care providers until the Health Insurance Scheme is fully implemented. According to SCH Circular No 7 of 2013, the SCH has indicated that “all private healthcare facilities in The State of Qatar should comply with the price list approved by the department of healthcare Quality and Patient safety. Furthermore, the department will not accept any price increase requests for health services provided by all health institutions in the country until the completion of the application of the heath insurance system. The only exception to this decision is adding new medical services after getting the approvals required by the department.”
Confidentiality and grievance procedures
The Executive Regulations also include various articles concerning patient confidentiality, including the principle of “patient-doctor confidentiality”. The disclosure of patient files is prohibited in Article 27 of the Executive Regulations except in specific circumstances required for the operation of the Health Insurance Scheme or pursuant to government action.
Article 32 of the Executive Regulations introduces a complaint and grievance submission procedure for “[a]ny person who is harmed as a result of the violation of the Law and these Regulations…”. The Executive Regulations permit complaints to be submitted in Arabic or English.
The issue of the Executive Regulations provides further details in respect of the establishment of the Health Insurance Scheme as a significant step by the Qatar government to overhaul healthcare funding in Qatar. The system put forward by the Health Insurance Law and the Executive Regulations contemplates an employer-funded fee-for-service proposal, with the government bearing the costs for Qatari nationals. In this sense, it is similar to the schemes instituted in Abu Dhabi and Saudi Arabia (and the newly-promulgated scheme in Dubai).
From the insurance industry perspective, the Executive Regulations further confirm that, apart from the current third party administrator role for the NHIC, the opportunities for private healthcare insurance providers (and service providers such as brokers and TPAs), once the scheme is fully rolled out, appear to be restricted solely to offering cover for Additional Healthcare Services. Since NHIC will be the mandatory provider of health insurance in respect of Basic Healthcare Services, the opportunities for the private sector are therefore likely to be limited.
The issue of the Executive Regulations assists all stakeholders in understanding how the Health Insurance Scheme will be implemented and the effect it will have. Nonetheless, employers and sponsors will remain interested in knowing the costs that they will incur and the scope of coverage that will be mandated. Health care providers will similarly be interested in any ramifications on the scope of services and fees they may charge under the scheme. Health insurance providers will also need to understand the scope of cover that they might be able to offer in respect of Additional Healthcare Services, and the regulatory requirements that this might be subject to. Cover that is currently provided or administered by insurers and service providers based outside the country will need to be reviewed given the in-State requirements contained in the Executive Regulations. Whilst the health insurance premiums applicable to basic Healthcare Services and Additional Healthcare Services are not specified in the Executive Regulations, there are indications that the levels of such premiums will be subject to legislative requirements, and a limit on profits. It will remain to be seen whether the levels of premium permitted will make for an attractive market for private market insurers.
The introduction of the scheme also comes at a time when regulation of the insurance sector in Qatar is being overhauled generally, and the new health insurance requirements are likely to become a feature of the Qatari insurance regulatory landscape going forward.
If you would like further information on any issue raised in this update please contact Wayne Jones.
Note: all Qatari Laws quoted in this article are issued in Arabic and there are no official translations. For the purposes of drafting this article Clyde & Co has used its own translation and interpreted the same in the context of Qatari laws, regulation and current market practice.
The following schedule to the Executive Regulations details the various services included in Basic Healthcare Services:
Click here to view table.