Payment Ceiling for Medical Foods/Nutraceuticals (Right)

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

הקדמה:

Health plan policyholders are entitled to an exemption from paying for medical foods/nutraceuticals beyond the monthly payment ceiling established for them
A small portion of medical foods/nutraceuticals are are considered medicines and not food and therefore the corresponding payment is not included in the payment ceiling for food, but within the Medication Payment Ceiling for the Chronically Ill.
For more information, see the Ministry of Health website

According to Section 14a of the second part of the second addendum to the National Health Insurance Law, there is a co-payment ceiling on medical foods/nutraceuticals for health plan policyholders. Section 24a of the first part of the second addendum specifies the types of foods/nutraceuticals included in the arrangement.

  • After reaching the payment ceiling, the health plans must supply the medical foods/nutraceuticals included on the list free of charge.
  • A small portion of medical foods are considered medications and not food and are therefore not included as part of the payment ceiling arrangement for medical foods/nutraceuticals. Such foods are included as part of the medication payment ceiling arrangement for the chronically ill.
  • In addition to the medical foods/nutraceuticals included in the healthcare basket, there are a number of types of medical foods/nutraceuticals that are not in the basket, but are sold at prices that are subsidized by the Ministry of Health and they may be purchased in pharmacies and stores.
  • The list of eligible products may be found on the Ministry of Health website.

Who is Eligible?

  • Israeli residents who are covered by national health insurance and require medical foods/nutraceuticals are eligible so long as the required product is included in the healthcare basket, has indications relevant to the policyholder's medical condition, and the medical food/nutraceutical is provided with a prescription from a doctor or clinical dietitian.

How to Claim It?

  • According to Deputy Ministry of Health Director Circular 11/2012, as of 01.05.2013, payment ceilings are calculated in a computerized system such that recipients of medical foods included in the healthcare basket from the health plans will automatically not be required to pay any co-payments once the payment ceiling has been reached.
  • Once the computer system has been updated, policyholders should ensure that their doctor indicates this appropriately in the health plan computer system.
  • Health plan pharmacies and other pharmacies with whom the health plan has an arrangement will be connected to the same computerized system in order to ensure that policyholders are not required to pay anything once the legally-established payment ceiling has been reached.
  • Policyholders should verify that their health plan's computerized calculation system is working properly. Policyholders in health plans that have not yet activated this system must request reimbursements for any payments over the payment ceiling.

Different Health Plan Ceilings

  • The following table provides information about the different health plans' payment ceilings, as of May 2017.
  • It is recommended to verify the most up-to-date information with the health plans regarding which foods are included on the approved list, if there have been any changes with regard to the ceiling, specifics regarding coverage as part of a SHABAN (Additional Health Services plan).
Health Plan Monthly Payment Ceiling
Clalit Health Services 706 NIS
Leumit Health Fund 704 NIS
Maccabi Healthcare Services 682 NIS
Meuhedet Health Services 704 NIS

Government Agencies

Laws and Regulations

  • Section 14a of the second part of the second addendum (Services Requiring a Co-Payment from the Policyholder) - Entitlement to the payment ceiling
  • Section 24a of the first part of the second addendum (Medical Food According to a Prescription from the Attending Physician or Clinical Dietician) - Listing of the types of medical foods/nutraceuticals included as part of the entitlement

Additional Publications

Sources