What benefits does Family Health Insurance have?

The Family Health Insurance (SFS) as one of the insurances of the Social Security System, was implemented after several postponements on the first day of September 2007, however, to date many of us as affiliates and contributors to Social Security we do not know the mechanisms to access the benefits of this insurance, and even more, we ignore what these benefits are.

In accordance with the provisions of articles 118 and 119 of Law 87-01 created by the Dominican Social Security System, the SFS aims at the comprehensive protection of the physical and mental health of the member and his family, as well as achieving a Universal coverage without exclusions. It also includes the promotion of health, the prevention and treatment of diseases, the rehabilitation of the sick, pregnancy, childbirth and its consequences.

Article 5 of the Law in its literal A, states that they are beneficiaries of this insurance without any discrimination, all Dominicans and foreign citizens who have established their residence in the national territory and have the corresponding documentation.

Greater diffusion is warranted about the benefits of the System so that all of us are fully aware of these benefits.

It is important to point out that as affiliates to the SFS we have a series of rights under the framework of this Social Security system, which were not recognized in the health insurance scheme that was in force before. In this sense, the beneficiary has the right to be affiliated with the Health Risk Administrator (ARS) of their choice, regardless of social condition, sex, health and age; previously the age and suffering from a preexisting condition were limiting conditions to be able to enter a Medical Insurance. In addition, the beneficiary has the right to affiliate his family nucleus, that is, the spouse, children and stepchildren under 18, up to 21 years if they are students, and for life if they are disabled, as well as parents and older children of 21 single years, if they are economic dependents, paying the corresponding quota to their affiliation. Also, we have the right to change ARS once per year.

With regard to health coverage, this insurance offers us a basic portfolio of benefits that includes:

Immediate labor and emergency care.
Emergency care with unlimited coverage at 100% and no difference payment.
Prevention and promotion 100% and without payment of difference.
Outpatient care with unlimited coverage.
Hospitalization with unlimited coverage without deposit and payment of difference equivalent to 15% of the total, which in no case should exceed two national minimum wages.
Unlimited coverage for surgeries with a difference payment equivalent to 15% of the total that also should not exceed the two national minimum wages.
Inpatient coverage, outpatient diagnostic means with unlimited coverage and a 20% co-payment.
Dental care.
Rehabilitation with unlimited coverage and a payment of 20% difference, which includes consultations, therapies, appliances and prostheses.
Attention to high-cost diseases.
Right to coverage of ambulatory medications, paying a difference of 20% and up to RD $ 8,000.00 per year.
This insurance also includes economic benefits that are the subsidies for common illness and for maternity and lactation.
It is with the resolution of the National Social Security Council No. 375-02 dated October 29, 2015, that the coverage of medicines is increased from three thousand to 8 thousand pesos per year, the exclusive denomination is approved by active principles of the ambulatory medications, and the inclusion of all presentations (pill, tablet, syrup, etc.) and concentrations (5 milligrams, 10 milligrams, 150 milligrams, etc.) was included.

We consider that one of the great challenges of the Dominican Social Security System is to extend the coverage of Family Health Insurance, with the inclusion of new procedures, as well as new substances in the catalog of medicines and the increase in the annual available amount , in such a way that we can count on a true integral health protection system. In addition, a greater dissemination of the benefits of the System is warranted so that all of us are fully aware of these benefits and enjoy Social Security as our right.

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