Mandatory Health Insurance & Iqama Renewal in Saudi Arabia — 2025 Guide

Essentials: Saudi law requires employers to provide private health insurance for expatriate workers (and commonly for eligible dependents). For Iqama issuance/renewal, systems check active coverage via the Council of Health Insurance (CHI) integration; you can also verify your policy online with your ID. Family coverage and limits follow the Unified Health Insurance Policy benefits schedule and insurer/network specifics. citeturn8search21turn8search4turn8search1

TL;DR

• Mandatory: Employers must arrange health insurance for expat workers; coverage is tied to Iqama issuance/renewal.

• Check your status: Use CHI’s Insurance Information Inquiry to look up active policy, insurer, and network.

• What’s covered: The Unified Policy defines minimum benefits (e.g., annual limits, maternity caps, mental health updates); insurers can add more.

• Family add‑ons: Spouses and children are typically added by the employer or privately—rules vary; verify eligibility and contributions with HR/insurer. CHI FAQs discuss dependents’ scenarios.

• NPHIES: Providers and insurers use NPHIES to validate eligibility, pre‑authorizations, and claims—expect real‑time checks at clinics/hospitals.

Who must be insured?

• Expat employees: Employers are responsible for arranging a valid policy that complies with the Unified Health Insurance Policy and CHI rules.

• Dependents: Employers often facilitate adding spouse and children; exact obligations and cost‑sharing depend on company policy and employment contract. CHI FAQ addresses scenarios for spouses without jobs accompanying insured employees.

• Visitors/students: Separate visitor/student policies exist; this guide focuses on expat residents with Iqama (work or dependent).

Employer vs private policies (who pays?)

Practical tip: Ask HR for your policy document, benefits schedule, network tier, and TPA (claims administrator).

Family coverage & eligibility (common cases)

• Spouse (husband/wife) and children: Usually eligible. The Unified Policy notes dependents categories; insurers mirror this in their family add‑on rules.

• Age limits: Boys often covered up to 25 if unmarried/unemployed; girls unmarried/unemployed have broader age flexibility—check your policy wording. (Examples appear in public guidance; verify with your insurer.)

• Newborns: Covered from birth once added; submit documents promptly to avoid gaps.

• Parents/extended family: Typically not covered under employee policy; requires separate private plans if available.

What the Unified Policy covers (benefit highlights)

The Unified Health Insurance Policy sets minimum benefits. Insurers can exceed these but cannot offer less.

Examples from the Unified Policy / Health Benefits Schedule:

• Overall annual limit: Defined in the schedule (insurers may show “maximum benefit per person per policy year”).

• Emergency services: Covered subject to medical necessity and policy caps.

• Maternity & newborn care: Maternity management pathways; delivery up to the stated limit (e.g., SAR 15,000 in older references—confirm your insurer’s current summary).

• Mental health: Updates have increased limits for selected conditions in recent iterations—check your insurer’s 2025 summary and CHI circulars.

• Vaccinations & preventive care: Included within policy schedules and national programs.

Networks: Benefits depend on network tier (A/B/C etc.) and the contracted providers. Choose hospitals/clinics in network to avoid high co‑pays.

Exclusions & co‑pays to watch

• Cosmetic procedures without medical necessity.

• Experimental treatments not on the approved list.

• Non‑network providers (unless emergency).

• Pre‑existing conditions: covered per policy wording and waiting periods (varies by insurer).

• Maternity services: caps and room class limits apply; check your plan summary.

• Dental/optical: often limited or excluded on basic policies; top‑up may be needed.

Always ask for the Benefits Schedule and Exclusions sheet from your HR or insurer—and save a PDF copy.

Iqama issuance/renewal: how insurance ties in

• System link: Iqama issuance/renewal checks for active insurance via CHI’s systems; renewals commonly fail if coverage lapses. You can confirm status on CHI’s e‑service with your ID/iqama and insurer details.

• Renewal windows: Employers manage policy start/end to align with visa/iqama dates. Keep HR informed of dependent additions before renewal time.

• Penalties for late renewals: Separate from insurance, Iqama renewal penalties exist—renew on time to avoid fines.

Using your insurance (NPHIES basics)

• Eligibility check: Hospitals/clinics query NPHIES for your coverage and plan details before treatment.

• Pre‑authorization: Certain procedures/medications require digital pre‑auth; your provider submits this through NPHIES.

• Claims & e‑claims: Providers submit claims via NPHIES; you’ll see approvals/denials at reception or via insurer apps.

Practical clinic script:

“Kindly check my eligibility via NPHIES; if a pre‑auth is needed, please submit it now. Here is my policy number and ID.”

Upgrading coverage (add‑ons & top‑up plans)

• Network upgrade: Pay extra to access a higher hospital network or VIP room classes.

• Dental/optical riders: Add if your basic plan excludes or caps these.

• International cover: Some insurers sell global emergency riders; confirm if Saudi primary coverage remains primary when abroad.

Claims, complaints & appeals

1) Collect documentation: doctor notes, invoices, pre‑auth approvals. 2) Appeal path: Start with insurer/TPA; escalate to CHI if unresolved—use the CHI site for complaint channels. 3) Keep receipts: For reimbursements (out‑of‑network emergencies), submit within the window in your policy.

FAQs

Renewal calendar & HR checklist

90–60 days before Iqama renewal

• Confirm policy expiry in the insurer app or via CHI e‑service.

• If adding a newborn or new dependent, submit documents now.

60–30 days

• HR requests renewal quotes; ask for benefits summary and network details (note any changes from last year).

• Check pre‑auth requirements for planned procedures so they won’t collide with renewal week.

30–0 days

• Verify the new policy number and validity; download the updated e‑card.

• Keep a screenshot of policy number, network tier, and TPA at reception on your next visit.

HR request list (copy‑paste):

• Policy start/end dates • Benefit schedule • Network list by city • Co‑pay table • Maternity limits • Mental health benefits • Dental/optical status • Insurer app links • TPA contact • Emergency hotline.

Clinic journey — what to expect

1) Reception: Present Iqama or e‑card; provider runs NPHIES eligibility. 2) Triage/doctor: If tests or imaging are needed, staff may request pre‑auth via NPHIES (you may be asked to wait). 3) Pharmacy: Approved meds dispensed per formulary; ask about generic equivalents to reduce co‑pays. 4) Follow‑up: Keep SMS/notifications of approvals; they help if claims are queried later.

Reading your policy (how to decode the fine print)

• Annual limit (per person): Your maximum claimable amount per policy year.

• Room class: General/Semi‑private/Private; upgrades may require extra payment.

• Co‑pay/coinsurance: Your share at the point of care (e.g., 10–20% on GP visits).

• Deductibles: Less common in basic plans; check if your plan uses them.

• Sub‑limits: e.g., maternity, mental health, physiotherapy—verify numbers and visit caps.

• Network: Providers categorized by tiers; out‑of‑network care may be denied except emergencies.

Example scenarios (how to use the system)

• Maternity: Book an in‑network OB‑GYN early; verify that hospital delivery is in network and confirm maternity limit and room class; secure pre‑auth for scans if required.

• Orthopedics/physio: Check number of physiotherapy sessions allowed; arrange pre‑auth for post‑surgery sessions.

• Mental health: Ask your insurer if your plan includes the updated mental health benefits; obtain referral/pre‑auth as required.

• Emergency visit while traveling inside KSA: Go to the nearest ER; providers should validate eligibility; call the insurer once stabilized for any transfer approvals.

What’s not covered (typical)

• Elective cosmetic and non‑medical procedures

• Non‑formulary drugs without approval

• Routine dental/optical (unless your plan includes these)

• Overseas treatment unless your plan offers a rider

Always request the exclusions list for your exact policy.

Glossary

• CHI — Council of Health Insurance (regulator).

• Unified Policy — Minimum benefits document governing coverage.

• NPHIES — National platform linking providers and insurers for eligibility, pre‑auth, and claims.

• TPA — Third‑Party Administrator handling claims on your insurer’s behalf.

• Network (A/B/C) — Hospital/clinic groupings that determine where you can go and your co‑pays.

Final checklist for expats

• Verify active policy and network on CHI site.

• Keep policy number and e‑card on your phone.

• Ask HR for benefits schedule and exclusions PDF.

• Before big procedures, confirm pre‑auth via NPHIES.

• Align policy renewal with Iqama dates; don’t let coverage lapse.

Adding a dependent — step‑by‑step

1) Collect documents: Iqama(s), passport(s), birth/marriage certificate as applicable. 2) Ask HR whether they submit the request or you submit through the insurer/TPA app. 3) Timing: Add dependents before the policy renewal window to avoid prorated complications. 4) Confirmation: After approval, you’ll receive a new e‑card and can verify on CHI e‑service the next day.

Employer policy vs private top‑up — who needs what?

Final exit & insurance housekeeping

• Before last working day: Book pending appointments and complete diagnostics—coverage typically ends on policy end date (ask HR).

• Keep copies: E‑cards, approvals, invoices; claims after exit can be difficult to chase.

• Close the loop: If you move insurers mid‑year (job change), re‑register at clinics and re‑obtain pre‑auth when needed.