The coverage of the PBS or Basic Social Security Plan can be complemented by complementary insurance that broadens or improves the benefits offered by the former, as well as the network of medical providers that is made available to you. If you are not on a payroll, you can also take out family, individual or corporate health insurance on a voluntary basis, that is, without any link to the social security system.
SCOPE OF BENEFITS
- Hospitalization, Room and Board, Physician Fees, and Intensive Care
- Emergency
- Visits to Doctors and Specialists
- Laboratories and Special Diagnostic Studies
- Outpatient treatments, physical therapies
- Surgeries
- Prescription
- Maternity and Newborn Care
- Emergency Medical Evacuation
- Dental and Ophthalmological Treatment
- Preventive Medicine, Vaccines
- Catastrophic Illnesses, Organ Transplantation
CLASSIFICATION OF AVAILABLE PLANS: In general, the health insurance plans of the different insurers could be grouped according to benefits, coverage amounts, provider network and of course, the price.
BASIC SOCIAL SECURITY PLAN (PBS OR PDSS): It is the same plan with the same benefits independently. of the insurer to which you are affiliated.
It is a state regulated plan available only to people enrolled in a payroll and who contribute to social security. Its benefits can be extended or combined with separate acquisition of supplementary plans.
- No-Capped Coverage Limit per Case
- Hospitalization @ 85% coverage with a difference cap or copay of two national minimum wages
- Room and Board of RD$1,800 per day
- Closed Provider Network (you can only go to providers who are affiliated with the plan)
- No refunds or reimbursement of any kind
- 80% Outpatient Coverage
- Prescription Medicine @ 70% capped to RD$8,000 per person/ per year.
- Catastrophic coverage at 80% starting with an annual cap of RD$150,000 and gradually as the person contributes can reach in 12 months up to RD$1,000,000 maximum per year
- Maternity with Caesarean section at 80% without limit, Natural Childbirth 100% without limit. Newborn Care is also covered.
PRIVATE BASIC COVERAGE PLANS:
- Coverage Limits per year or per case between RD$200,000 to RD$350,000
- Hospitalization 100% with room and board limits of between RD$2,500 and RD$3,000 daily
- Closed Provider Network (you can only go to providers who are affiliated with the plan)
- There is no Refund or reimbursement except in consultations and emergencies with limits between RD$500.00 and RD$1,000.00.
- Ambulatory coverage between 80% and 85%
- Limited Catastrophic Coverage between RD$300,000 and RD$400,000 per year
- Maternity RD$100,000 with variations between plans
- In this group we find the Plan Royal of Humano Seguros, Plan Vital of Seguros Universal, Plan Corporativo Superior of Mapfre Salud and Senasa’ s Plan Avanzado, among others
PRIVATE INTERMEDIATE COVERAGE PLANS:
- Coverage Limits between RD$400,000 to RD$500,000 per case or per year
- 100% hospitalization with room and board limits between RD$3,000 and RD$4,000 daily
- Open Provider Network (allow you to go to providers who are not affiliated with the plan)
- Reimbursement applies on all services between 80% and 85% of the insurer's fee rates with an affiliated provider. In consultation the refund amount is limited and ranges between RD$1,500.00 and RD$2,500.00
- Outpatient coverage between 80% and 85%
- Catastrophic Illnesses Coverage ranges between limits of RD$500,000 and RD$750,000.
- Maternity and Newborn care RD$200,000 with some variations
- In this group we find the Alpha and Absoluto Plans of Universal, Plan Max de Humano, Plan Corporativo Plus of Mapfre Salud and Senasa’ s Plan Maximo, among others
PRIVATE ADVANCED COVERAGE PLANS:
- Coverage Limits between RD$1,500,000 to RD$2,000,000 per year or per case
- Hospitalization 100% with room and board coverage starting at RD$7,000 to RD$10,000 to no cap per day.
- Open Provider Network (allows you to go to providers who are not affiliated with the plan)
- Allow reimbursement in all services at 90% of what is actually incurred, although in some insurers it is based on customary agreed fee rates, especially in consultations where they pay a maximum of RD$ 4,000.
- 100% Outpatient Coverage
- Catastrophic Illnesses Coverage between RD$1,500,000 and RD$2,000,000
- Maternity RD$400,000, some plans have that the newborn is automatically insured up to the full limit of coverage.
- In this group we find the Prestige Plans of Mapfre Salud, Plan Exclusivo of Universal, Planes Prime and Platinum of Humano and Plan Premium of Senasa, among others
