Hebrew source: הסדרי הבחירה של קופות החולים
From All Rights (Kol-Zchut) (www.kolzchut.org.il)
Health plans have arrangements related to the choice of service providers (either those operated by the health plan or providing services on its behalf) given to policyholders
For information about the right of policyholders to select healthcare providers see Choosing Medical Service Providers.
For more information, see Assistant Director of Health Plan and Additional Healthcare Services Supervision Circular 06/2011
The health plans pay medical service providers, such as hospitals and other facilities, to provide various healthcare services to their policyholders.
- Health plans have arrangements related to the choice of service providers (either those operated by the health plan or providing services on its behalf) given to policyholders.
- Information about the health plans' service provider choice arrangements may be obtained at health plan clinics and on the health plans' websites.
- Every policyholder has the right to receive a copy of their health plan's service provider choice arrangements at no cost.
- According to the law, all policyholders are entitled to chose among the service providers with which their health fund has arrangements, for their own and their children's health care needs.
- The right to choose a service provider is subject to each health plan's choice arrangements.
- For more information, see: Choosing Medical Service Providers.
Principles and Limitations Related to Choice Arrangements
- Health plans' choice arrangements must meet the requirements set forth in the Law regarding "reasonable wait time, reasonable distance, and reasonable quality".
- Reasonable distance and reasonable wait time
- If there is no medical facility within a reasonable distance from a policyholder's home or there isn't one which can provide a required service within a reasonable wait time, the health plan must provide the required service at a different facility, even if it does not have an agreement or arrangements with that facility.
- The law does not define what "reasonable distance" or "reasonable wait time" are, and so these definitions are open to interpretation.
- If a health plan refuses to issue a payment voucher (Form 17) for a specific service provider, and the policyholder claims that this refusal violates his/her right to services within a "reasonable distance" or "reasonable wait time", the health plan's decision may be appealed. (see below)
- Urgent visit to an emergency room - An urgent visit to the emergency room of a general hospital is not limited to specific hospitals, and therefore is not subject to any health plan agreements or choice of service provider arrangements.
- Hospitalization - If a certain hospital is included in a health plan's choice arrangements, its policyholders may receive services at that hospital without any pre-conditions or other limitations on the part of the health plan, with the exception of the requirement to obtain a referral from the attending physician or any other relevant approval/documentation from a professional at the health plan, as well as a payment voucher (Form 17). In accordance with these guidelines, the health plan may not refuse a policyholder's request to be hospitalized in such a hospital due to any ranking, prioritization or cost.
- Maintaining Continuity of Care (Principle of Treatment Continuity) - Health plans are required to allow policyholders to continue receiving care or treatment at the medical facility in which it was begun, regardless of service provider agreements or arrangements, such that no patient may be forced to switch treatment facilities while being treated for the same illness or condition. This principle applies in cases where maintaining treatment continuity holds importance with regard to a patient's health. For more information, see: Maintaining Continuity of Care (Principle of Treatment Continuity).
- Providing different treatments in one facility - If an illness or medical condition requires various types of intensive treatments, policyholders should be able, to the greatest extent possible, to receive all of the treatments they require in the same medical facility.
- Specialized Medical Service
- If an illness or medical condition justifies medical treatment at a specific specialty medical facility, policyholders are entitled to receive the medical services they require at that facility regardless of whether or not their health plan has agreements or arrangements with that facility.
- If a specialty medical facility is included in a health plan's choice arrangements, its policyholders may receive services at that facility without any pre-screenings or other limitations on the part of the health plan, with the exception of the requirement to obtain a medical referral and a payment voucher (Form 17). Moreover, the health plan may not refuse a policyholder's request to receive medical services at such a facility due to any ranking, prioritization or cost.
- Referral/approval according to the type of service and not the service provider - For services requiring a doctor's referral (or any other relevant approval/documentation from a professional at the health plan), this referral/documentation may only be provided for the required service with no reference to a specific service provider, and no requirement for a referral may be established with any reference to a specific service provider.
- Arrangements must be equitable - The choices offered according to the various arrangements must be equitable and based on equal conditions for all policyholders.
Appealing Health Plan Refusal to Provide a Referral to a Specific Medical Service Provider
- A policyholder whose request for a payment voucher (Form 17) to receive a specific treatment from a specific service provider has been denied, and that service provider is included in the health fund's service selection arrangement or the patient is entitled to be treated with the same service provider under the principle of continuity of care or under any other cause making the patient eligible for treatment with the same service provider, is entitled to do the following:
- Submitting a Complaint to the Health Fund by contacting the person appointed by the health fund for public inquiries.
- Submitting a Complaint to the National Health Insurance Law Ombudsman by contacting the ombudsman appointed in accordance with the National Health Insurance law.
- Submitting a claim in a court of law (it is recommended to get legal advice before filing a claim).
Health Plan Choice Arrangements
- Clalit Health Services choice arrangements
- Maccabi Health Services choice arrangements
- Meuhedet Health Services choice arrangements
- Leumit Health Plan's choice arrangements- there is no document summarizing the choice arrangements (as of March 2016) though general information may be found on the Leumit website.
Publicizing Choice Arrangements
- The health plans are obligated to publicize the arrangements for choice of service providers.
- The arrangements must be available for policyholders to review in health plan clinics.
- All policyholders have the right to receive one copy of every choice arrangement and every choice arrangement update from their health plan upon request and at no cost.
- The health plans are obligated to publicize the arrangements for choice of service providers on their website.
- The health plan must provide reimbursement due to delayed treatment
- The health plan was obligated to pay for catheterization for a resident of the North who decided to have the procedure performed at a hospital in the center of the country
Laws & Regulations
- The National Health Insurance Law - Sections 3(d) and 23(a)
- National Health Insurance Regulations (Arrangements for Selection of Service Providers), 5765-2005 (on the Nevo website)
- Assistant Director of Health Plan and Additional Healthcare Services Supervision Circular 06/2011 from 09/06/2011 - Implementation of National Health Insurance Regulations (Arrangements for Selection of Service Providers), 5765-2005
- Original information provided by the Mazor Clinical Center - Providing Legal Advice Regarding Patients Rights in Israel.
- Original translation by AACI's Shira Pransky Project.