In Dubai, healthcare is more than just a service—it’s a commitment to ensuring the well-being of every resident. And, health insurance here isn’t just an option; it’s a legal requirement, guaranteeing that essential healthcare services are within everyone’s reach. Enter the Essential Benefit Plan (EBP)—a thoughtfully designed health insurance package that sets the foundation for affordable and accessible healthcare in the emirate.
Tailored for workers earning AED 4,000 or less per month, the EBP bridges the gap between affordability and comprehensive coverage. But its benefits extend beyond just employees—it’s also a practical solution for dependents and domestic staff. This article unpacks the EBP’s key features, benefits, and limitations, helping you make informed decisions about your healthcare needs if you are residing in the Emirate.
Essential Benefit Plan (EBP) – What is it exactly?
The EBP is a health insurance plan mandated by the Dubai Health Authority (DHA) as the basic standard for all health insurance in Dubai. It supports Dubai’s vision of making healthcare accessible and affordable for everyone, especially low-income residents and their families. The plan provides essential and comprehensive healthcare services to ensure no one goes without coverage. It is particularly helpful for low-income workers but is also available for dependents and domestic staff.
Features of the Essential Benefit Plan in Dubai and the UAE:
Let’s have a look at the features, benefits and specialised services the plan offers:
1. Annual coverage limit
The EBP offers a good amount of annual claims limit to ensure residents receive adequate healthcare without financial stress.
- Annual upper limit: The EBP covers healthcare costs up to AED 150,000 annually, including coinsurance and deductibles
This limit covers various medical needs, from routine checkups to emergency treatments, ensuring financial protection for the insured.
2. Geographic coverage
The plan offers flexibility in geographic coverage, making healthcare accessible across Dubai and the UAE:
- Basic healthcare: Coverage is provided within Dubai.
(Note: Insurers may choose to extend coverage beyond Dubai to other emirates or countries based on their discretion.)
- Emergency medical treatment and ambulance charges: Available across all emirates of the UAE.
This ensures that policyholders have access to necessary medical care whether they are at home, at work, or travelling within the UAE.
3. Provider network
- Offers access to a limited yet comprehensive network of hospitals, clinics, and pharmacies.
- The provider network must offer adequate geographic access for residents relative to their work and home locations.
- Designed to provide cost-effective healthcare services without compromising quality or convenience.
4. Coverage for pre-existing conditions
Pre-existing conditions are a common concern, and the EBP provides specific provisions for these.
- Benefit: Insurance providers cannot deny coverage solely due to the presence of pre-existing conditions.
- Conditions: Coverage for pre-existing or chronic conditions begins after six months of membership in the first insurance scheme within the UAE.
- Emergency coverage: Any condition developing into an emergency during the exclusion period is covered up to the annual aggregate limit.
4. In-patient treatment benefits at authorised hospitals
Key in-patient services:
The EBP covers essential in-patient services to ensure comprehensive care during hospital stays.
Tests, diagnosis, and surgeries (Non-urgent cases)
- Coinsurance: 20% payable by the insured per encounter
- Limits: AED 500 cap per visit and AED 1,000 annual cap; 100% coverage beyond these caps.
- Approval: Need to get approval from the insurance company beforehand.
These services include necessary diagnostic tests and procedures required during hospital admission.
Emergency treatment
- Approval: Must be obtained within 24 hours of hospital admission.
Emergency services ensure immediate medical attention without delay, saving lives in critical situations.
Room accommodation
- Shared rooms with two or more beds are covered.
- But requires beforehand approval from the insurance company.
This guarantees comfort and affordability during hospital stays.
Medical transport
- Coverage: Ground transportation for medical emergencies is provided by authorised services in the UAE.
Ensuring safe and swift transportation during emergencies is a key benefit of the EBP.
Companion accommodation
- Limit: AED 100 per night for children under 16 or adults in cases of medical necessity.
- Accommodation of a companion in the same room is recommended by the treating doctor.
- Requires prior approval from the insurance company.
This benefit provides peace of mind for families accompanying a loved one during hospitalisation.
Organ transplantation
- Coverage: AED 100,000 limit for recipients only.
- Coinsurance: 20% for outpatient visits.
This ensures financial assistance for complex and life-saving procedures like organ transplants.
Dialysis treatment
- Coverage: AED 60,000 annually.
- Coinsurance: 20% payable by the insured per visit.
This benefit provides crucial support for patients requiring regular dialysis treatments, reducing their financial burden.
5. Out-patient treatment benefits at authorised hospitals and clinics
Key out-patient services:
The EBP provides essential out-patient services, including consultations, diagnostic tests, radiology services, etc, to ensure accessible and timely healthcare outside of hospital stays.
Examination and diagnostics
Outpatient services under this include routine, virtual check-ups and follow-up examinations.
- Coinsurance: 20% per visit.
- Follow-up visits: No coinsurance if the follow-up is within 7 days.
This encourages regular checkups without financial strain.
Laboratory and radiology services
- Coinsurance: 20% payable for tests and scans.
- Approval: In non-emergency situations, you must get approval from the insurance company before undergoing procedures such as MRIs, CT scans, or endoscopies.
These services ensure timely and accurate diagnosis for effective treatment planning.
Physiotherapy
- Limit: 6 sessions per year.
- Coinsurance: 20% per session.
This benefit supports recovery and rehabilitation needs.
Prescription medications
- Annual Limit: The cost of drugs and medicines is covered up to a maximum of AED 2,500 per year, including any coinsurance paid by the insured.
- Coinsurance: The insured must pay 30% of the cost of each prescription.
Affordable medication ensures ongoing care for chronic and acute conditions.
Vaccines and immunisations
- Essential vaccinations:
- Includes vaccines for newborns, children, and adults as mandated by the DHA (currently aligned with Federal MOH guidelines).
- Coverage is limited to AED 100 per year.
- Influenza vaccine:
- Mandatory and provided annually. Uptake will be strictly monitored.
- Adult pneumococcal conjugate vaccine:
- Covered based on DHA Adult Pneumococcal Vaccination guidelines. Uptake will also be monitored.
Preventive services
- Diabetes screening:
- Frequency:
- Every 3 years for individuals aged 30 and above.
- Annually for high-risk individuals aged 18 and above.
- Frequency:
- Hepatitis C and B screening and treatment:
- To be provided following the guidelines under the Basmah program.
- Cancer screening and treatment:
- Coverage and procedures aligned with the Basmah program guidelines.
- New preventive services:
- Any new services added by DHA will be notified to insurers three months in advance and covered from the implementation date.
Disease management programs
- Insurers must provide evidence of programs for managing diabetes, hepatitis, and cancer as stipulated by DHA guidelines.
This ensures coverage for critical vaccinations and screenings, with strict adherence to DHA policies and guidelines for preventive healthcare.
6. Maternity coverage
Maternity care is integral to the EBP, ensuring comprehensive coverage for mothers and newborns.
Out-patient maternity services
- Approval: Requires prior approval from the insurance company.
- Coinsurance: The insured pays 10% of the costs.
- Services:
- Includes 8 visits to a Primary Healthcare Center (PHC).
- A PHC obstetrician provides care for low-risk pregnancies and a specialist obstetrician for high-risk pregnancies.
- Initial investigations may include tests like:
- Blood counts, blood group, and antibodies.
- Rubella, HIV, and Hepatitis C (for high-risk cases).
- Diabetes screening due to high prevalence in the UAE.
- Ultrasound scans: Coverage for up to 3 scans.
- Visits and tests follow DHA Antenatal Care Protocols.
These tests are critical for ensuring the health and safety of both mother and baby during pregnancy.
In-patient maternity services
- Coinsurance: 10% payable by the insured.
- Approval: Need prior approval from the insurance company or within 24 hours of emergency treatment.
- Coverage limits:
- AED 10,000 for normal delivery.
- AED 10,000 for medically necessary C-section, complications, or termination. (This all limits include coinsurance)
The plan ensures financial support during delivery and related medical needs.
Newborn coverage
Coverage for the newborn is extended to match the mother’s insurance for the first 30 days after birth.
This includes:
- Vaccinations (e.g., BCG and Hepatitis B).
- Neo-natal screening tests for conditions like:
- Phenylketonuria (PKU).
- Congenital Hypothyroidism.
- Sickle cell screening.
- Congenital Adrenal Hyperplasia.
After 30 days, the newborn must be enrolled in their insurance plan (as a dependent or individual policy).
This ensures the baby’s health is monitored and supported in the crucial first month.
Additional features and benefits of the Essential Benefits Plan:
7. Mental health
Mental health support is a vital aspect of the EBP.
- Outpatient Coverage: AED 800 for counseling.
- Coinsurance: 30% per visit.
This benefit makes mental health care accessible and affordable in the Emirate.
8. Dental care
Dental care is included under the EBP, covering basic treatments.
- Coverage: AED 500 annually for consultations, attractions, x-rays, fillings, scaling, root canals, prophylaxis and antibiotics.
- Coinsurance: 30% for outpatient services. (Note: No coinsurance if a follow up visit is made within seven days.)
This ensures access to essential oral healthcare.
9. Repatriation costs
- Coverage: AED 5,000 for transporting mortal remains to the insured’s home country.
This provides financial support during unfortunate circumstances.
Limitations and exclusions from the Essential Benefits Plan:
1. Excluded healthcare services except in cases of medical emergencies:
- Hearing and vision aids: Excluded unless required for medical emergencies.
- Vision correction by surgeries and laser: Covered only in emergencies and subject to 20% coinsurance.
2. General exclusions (non-basic):
Some services fall outside the scope of the EBP, including:
The following services are not covered under the Essential Benefit Plan unless stated otherwise:
- Services that are not medically necessary.
- Dental prostheses, orthodontic treatments, and similar expenses.
- Care is provided for the purpose of travelling.
- Custodial care includes non-medical services that don’t improve the patient’s medical condition.
- Services that don’t require continuous care from specialised medical staff.
- Personal comfort items like TVs, beauty services, or guest services during treatment.
- Cosmetic procedures, except when medically necessary (e.g., post-mastectomy breast reconstruction).
- Weight control treatments, including surgical and non-surgical obesity care.
- Experimental treatments or unapproved medical procedures.
- Services provided by healthcare providers who are not authorised.
- Treatment for hair loss, dandruff, alopecia, or wigs.
- Smoking cessation programs or treatments for nicotine addiction.
- Treatments for contraception.
- Treatments for sterilisation, infertility, sexual dysfunction, or sex change (except when sterilisation is medically indicated).
- External prosthetic devices and other medical equipment.
- Injuries or treatments resulting from professional sports or extreme activities (e.g., racing, mountaineering, bungee jumping).
- Growth hormone therapy, unless deemed medically necessary.
- Costs related to hearing tests, hearing aids, or vision aids.
- In-patient mental health treatments, unless for emergencies.
- Supplies like elastic bandages, diabetic test strips, or non-prescription drugs, unless required during a medical emergency.
- Allergy testing and desensitisation, except for medication-related allergies.
- Services provided by a medical provider who is a relative of the patient.
- Enteral feeding (tube feeding) and nutritional supplements, unless necessary during in-patient care.
- Spinal adjustments or treatments for subluxation.
- Alternative treatments include acupuncture, massage therapy, homoeopathy, or aromatherapy.
- Treatments related to IVF, embryo, ovum, or sperm transfer.
- Elective vision correction treatments and diagnostic services.
- Treatments for nasal septum deviation and nasal concha resection.
- Treatments for viral hepatitis, except for Hepatitis A, B, and C.
- Services for birth defects and congenital conditions, unless untreated, could cause an emergency.
- Care for conditions like senile dementia or Alzheimer’s disease.
- Unauthorised medical evacuations or transportation services.
- In-patient treatments without prior insurance approval, unless notified in emergencies within 24 hours.
- Treatments or procedures that can be done as an outpatient service.
- Tests or investigations for non-medical purposes (e.g., employment, travel, or licensing).
- Non-medical items like mouthwash, skincare products, shampoos, or air purifiers.
- Multiple consultations with the same specialist on the same day unless referred by a treating doctor.
- Services related to organ or tissue donation by the insured person.
- Expenses for immunomodulators or immunotherapy unless medically necessary.
- Treatments for sleep disorders.
- Educational services or programs for individuals with disabilities (physical, mental, or psychological).
3. Healthcare services outside the scope of health insurance:
(In Emergency cases as defined by PD 02-2017, the following must be covered until stabilisation at minimum):
- Injuries from military operations.
- Illnesses or injuries from acts of war or terrorism.
- Treatments for injuries from nuclear or chemical contamination.
- Injuries from natural disasters such as earthquakes.
- Road traffic accidents.
- Injuries related to criminal acts or resisting authority.
- Work-related injuries or illnesses.
- Complications from alcohol or drug use.
- Self-inflicted injuries or suicide attempts.
- HIV/AIDS and related complications.
- Epidemics recognised locally or internationally.
- All types of hepatitis (except A, B, and C).
How to access specialist care under your plan?
This is a referral procedure for members of the Essential Benefit Plan (EBP) and outlines how specialist or consultant services are covered:
1. Initial consultation with a GP:
- The insured must first consult a General Practitioner (GP) (or equivalent) licensed by the Dubai Health Authority (DHA) or another official source of the UAE authority.
- The GP acts as the first point of contact and evaluates the patient.
2. Referral requirement:
- If further treatment, advice, or consultation by a specialist or consultant is needed, the GP must provide a referral.
- The referral must include reasons for the specialist or consultant’s involvement.
3. Referral system:
- The GP must submit the referral through the DHA e-Referrals system or an alternative temporary manual system.
4. Insurance coverage condition:
- The insurer will not cover any costs for specialist or consultant services unless the referral process is followed and the claim is submitted correctly.
This process ensures proper gatekeeping, minimises unnecessary specialist visits and aligns with the DHA’s healthcare regulations.
How can you make the most out of your Essential Benefits Plan?
1. Start with a General Practitioner (GP)
- For any specialist consultation, obtain a referral from a GP.
2. Secure pre-approvals
- Prior insurer approval is mandatory for non-urgent treatments, diagnostic procedures, or surgeries.
3. Understand coinsurance
- Pay your share of coinsurance (e.g., 20% for outpatient visits) and track annual caps to maximise benefits.
4. Use emergency services wisely
- Notify your insurer within 24 hours of hospital admission during emergencies to ensure claims are processed.
5. Leverage preventive care
- Schedule regular check-ups and screenings as outlined in DHA’s preventive care guidelines. Examples include diabetes screening every three years for individuals over 30, annual screenings for high-risk individuals aged 18 or above, and cancer screenings following the Basmah program guidelines.
What’s the bottom line?
The Essential Benefit Plan ensures every resident has access to reliable and affordable healthcare in Dubai and the UAE, supporting the emirate’s goal of universal health coverage. By focusing on essential services and making healthcare accessible to low-income earners, the EBP plays an important role in promoting equitable healthcare for all.
Understanding key aspects like pre-existing conditions, coinsurance, and deductibles can help you make the most of your plan and avoid surprises during medical claims. Additionally, exploring health insurance’s importance and critical illness insurance’s role in financial planning can empower you to make well-informed decisions.
By familiarising yourself with its benefits, limitations, and processes, you can make the most of your coverage. For further details or specific queries, consult your insurer or refer to the Dubai Health Authority (DHA) guidelines. With the EBP, you are not just insured—you’re equipped with the peace of mind to focus on what matters most: your health and well-being.
Frequently Asked Questions (FAQs)
Q. Who is eligible for the EBP?
The plan is available to employees earning AED 4,000 or less per month, domestic staff, and dependents.
Q. Are pre-existing conditions covered immediately?
No, there is a six-month waiting period for new members, except in emergencies.
Q. What are the annual coinsurance caps?
For outpatient services, the cap is AED 500 per encounter and AED 1,000 annually.
Q. Does the plan include dental services?
Yes, basic dental consultations, extractions, and fillings are covered up to AED 500 annually, with 30% coinsurance.
Q. Can newborns be added to the policy?
Newborns are covered for the first 30 days under the mother’s policy but must be enrolled independently after that period.
