Paramedical Treatments and Diagnoses for Children (Child Development Services) (Right)

From All Rights (Kol-Zchut) (www.kolzchut.org.il)

הקדמה:

The health plans are responsible for providing paramedical treatments for children
Children who receive paramedical treatments as part of special education do not lose eligibility to receive them from their health plan as well
The health plans are required to provide a reimbursement for diagnostic and treatment services that were purchased privately in all cases in which the waiting time at the health plan was longer than that which has been established by the Ministry of Health
For more information, see Medical Administration Circular 19/2013
  • According to The National Health Insurance Law, the state is responsible for providing paramedical treatments (child development services) to children who require them due to developmental or medical problems.
  • Children are entitled to receive the treatment from the health plan in which they are enrolled, in accordance with a professional staff diagnosis.

Diagnoses:

  • A psychological diagnosis will be provided for children whom the treatment team has decided require it.
  • Following initial diagnosis, up to 2 diagnoses may be conducted during the 6 years of eligibility.
  • A repeat diagnosis will not generally be conducted within one year of the previous diagnosis, although each case is examined on an individual basis.

Treatments:

  • The types of paramedical treatments included in the healthcare basket are: Physical therapy, occupational therapy, speech therapy, psychological and psychosocial therapy, and social work.
  • The treatments are provided by a multidisciplinary professional staff, including: medical specialists in pediatric neurology or pediatrics with experience in the field of child development; psychologists; physical therapists; social workers; communications clinicians; and occupational therapists.
  • Each treatment session performed by a healthcare professional should be one hour long, and never less than 45 minutes. Treatments may also include instruction and guidance for parents.

Who is Eligible and for Which Treatments?

  • Children up to age 9 are eligible for diagnosis and treatment by a multidisciplinary professional staff.
  • Children diagnosed as having a somatic developmental disability are entitled to unlimited paramedical treatments until age 18 according to need.
  • Children up to age 6 are entitled to treatment for Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ADHD).
  • Children between the ages of 4 and 9 who do not suffer from a somatic developmental disorder or complex disability, may undergo diagnosis by a qualified medical professional, even if they are not in a facility or department which is recognized by the Ministry of Health.
  • Children who do not suffer from a somatic developmental disability, but who do suffer from a complex developmental problem (children with a disorder/disability in more than one field of child development) will be diagnosed and treated at a facility or department recognized by the Ministry of Health.
  • Children requiring treatment in a field of child development due to other medical problems that are not developmental (such as recovery from a specific type of surgery or medical care after an accident) will receive it according to the medical necessity of these services, regardless of eligibility for the developmental services basket.
  • For more information regarding different children's populations, see the "More Information" section below.

Number of Treatments for Which Children are Eligible

  • Children not suffering from a somatic developmental disorder are entitled to the following number of treatments:
    • For children ages 0 to 3: An unlimited number of treatments are provided according to need and based on the professional opinion of the health plan's medical specialist.
    • For children ages 3 to 6: Up to 27 treatments per year per paramedical profession (with the total number of treatments not to exceed 54) are provided according to need and based on the professional opinion of the health plan's medical specialist.
    • For children ages 6 to 9: Up to 9 treatments per year per paramedical profession (with the total number of treatments not to exceed 18) are provided according to need and based on the professional opinion of the health plan's medical specialist.
    • Children receiving a diagnosis before age 6 are, in the first year of treatment (for the issue that was diagnosed), entitled to the number of treatments to which they were entitled on the day of the diagnosis.
    • Children with a somatic developmental disability are entitled to unlimited treatments according to need.
    • The number of treatments given to children who do not have a somatic developmental disability is based on individual need, overall goals, and the objectives set by the professional staff in accordance with that which has been established by a qualified medical or healthcare professional.
  • Through the supplementary health insurance policies, the health plans have expanded upon the number of treatments established in the law. Those with supplementary health insurance should check the arrangements specific to their plan and level.

How to Claim It?

  • Diagnostic and treatment services are only provided with health plan approval provided by a medical specialist in pediatric neurology or pediatrics with experience in the field of child development. The attending pediatric physician may provided a referral for diagnosis.
  • Diagnostic services are provided at a child development center or developmental treatment department recognized by the Ministry of Health. Click here for a listing of recognized child development facilities.
  • The health plans must provide the healthcare services themselves or through service providers.
  • Parent may choose an attending medical profession from among the service providers with whom their health plan has arrangements. If the health plan is connected to more than one service provider, the health plan will established the arrangements regarding the extent of personal choice.
  • Treatments must be provided within a reasonable amount of time and within a reasonable distance from the patient's residence.
  • Stopping treatment - Treatment may only be stopped before the full number of treatments established in the healthcare services basket have been used up according to a professional opinion.

Wait Times for Diagnosis and Treatment

  • The waiting time for treatment after diagnosis is established according to a professional medical opinion.
  • The maximum waiting time for diagnosis and beginning treatment (from the initial health plan request) may be no more than 3 months.
  • Priority for diagnosis and treatment in the first year following their referral is given to:
    • Children with a developmental disorder requiring immediate therapeutic intervention.
    • Immigrant children with a developmental disorder who are waiting during their first year after aliyah for developmental diagnosis so they can claim their National Insurance and special education benefits.
    • Premature infants born at a birth weight of less than 1500 grams and before week 32 of pregnancy (their wait time may not exceed 2 months from the date of the request).
  • Parents are entitled to a reimbursement from their health plan for all private services paid for in cases where the waiting time exceeded the maximum wait time - Parents of children forced to wait longer than the maximum wait time may pay for diagnostic and treatment services from private developmental service providers meeting Ministry of Health requirements, and the health plans are required to reimburse for these expenses up to the amounts established by the Ministry of Health, as long as the number of treatments did not exceed the number of treatments to which they were entitled.
  • Children not diagnosed within the maximum wait time are entitled to utilize the right to reimbursement regarding both diagnostic services and treatment services in any field, according to what has been established by the diagnosis.
  • Children diagnosed within the maximum wait time, but for whom treatment according to the diagnosis was not provided according to the established wait times are entitled to utilize the right to reimbursement regarding the treatment services that they did not receive within the reasonable period of time.
  • Policyholders entitled to a reimbursement may choose between continuing to receive reimbursements for the service and receiving the service through the health plan.
  • Policyholders are also eligible for a reimbursement if they were given an appointment within the permitted wait time, but the wait time between the appointments for that service was more than a month.

Payment for Services

  • Treatment by a multidisciplinary professional staff is provided in exchange for a co-payment from the policyholder.
  • The co-payment for a child between ages 3 and 9 who does not suffer from a somatic developmental disorder for services in the field of child development is established in Section 6 of the second addendum to the National Health Insurance Law, and is updated every year according to the increase in the healthcare cost index (as of 07.2013, this amount was 28 NIS).
  • Additional treatments provided through supplementary insurance also require a co-payment which varies by health plan. Supplementary insurance policyholders should check their arrangements according to their plan and level.

Exemptions from Co-Payments

  • Children up to age 3.
  • Children diagnosed as having a somatic developmental disability (if they receive the treatments through the health plan).
  • Health plan policyholders entitled to income support (an income supplement) (as of 01.08.2005).

More Information

Premature Infants, Babies and Children at Risk for Developmental Disorders

  • Special newborn care units must refer any newborn weighing less than 1500 grams for a developmental examination and assessment at a recognized facility for child development and rehabilitation, and the wait time may not exceed 2 months from the date of the request. For more information, see: Early Referral of Premature Infants to a Child Development Center.
  • Additionally, there is a list of cases for which the Ministry of Health recommends early referral of newborns, infants and children at risk for developmental disorders to child development centers. For more information, see: Medical Administration Circular 28/2000 from 06.08.2000 - early referral of children at risk for developmental disorders to child development centers.

Children in Rehabilitative Day Care

  • According to the law, all children in rehabilitative daycare are entitled to receive paramedical treatments as part of the day care.
  • These treatments are funded by the health plan to which the toddler belongs, and there is no eligibility for treatments beyond them.

Children Receiving Paramedical Treatments as Part of Special Education

  • Receiving treatments from the health plan is not conditional on the school in which the child learns or the basket of services to which he/she is entitled.
  • The treatments provided as part of a special education framework in a special education school or as part of an integrated framework in a regular school do not replace the treatments to which a child is entitled from the health plan.
  • The treating professional at the health plan receives the child's personalized curriculum (TALA) established by the education system, which includes the type and number of paramedical treatments a child receives at school.
  • When making professional decisions, the treating professional at the health plan may take into account the fact that a child receives treatments at school.
  • When making professional decisions, the treating professional at the health plan may take into account the fact that a child is not receiving necessary treatments at school.

Children with Somatic Disorders

  • The basket of services for children under the age of 3 who have somatic disorders is generally provided in the framework of rehabilitative daycare in accordance with each child's specific needs.
  • Children of this age who are not in rehabilitative daycare are entitled to receive the services through their health plan.
  • From age 3 and up, the services are provided through the health plan.
  • There is no annual or other form of restriction or limitation placed on the number of treatment sessions children are entitled to through this framework.
  • The number of treatment sessions and their frequency should be in accordance with each child's specific needs, according to the decision of the health plan's treating professional (this is generally up to 3 treatments per week total in all fields of treatment).
  • Parents of children with somatic disorders are exempt from co-payments for treatments provided through the health plan.

Children with ADD/ADHD

Children with Autism

Children with Hearing Impairment

Please Note

  • Those for whom a health plan has refused to provide paramedical services may contact the National Health Insurance Law Ombudsman at the Ministry of Health.
  • Parents wishing to submit a claim against their health plan may do so through the regional labor court in their area of residence.

Court Rulings

Aid Organizations

  • For a comprehensive categorized listing of healthcare organizations offering assistance and support, click here.

Government Agencies

Laws and Regulations

Additional Publications

Sources