Introduction:

Chronically ill patients, are entitled to an exemption from payment for Medications in the Healthcare Basket which they must purchase, beyond the specific ceiling established for them.
The ceiling varies between the health funds.
Chronically ill patients, who have reached retirement age, and who receive an income supplement or Old Age Disability Pension are eligible for a discount of half of the ceiling established for the rest of the chronically ill


According to The National Health Insurance Law, the chronically ill are entitled to payment assistance for Medications in the Healthcare Basket (including medications which are not directly related to the chronic illness). This is done through the establishment of a quarterly or semi-annual co-payment ceiling on purchasing medications.

  • The National Health Insurance Law sets a maximum amount (payment ceiling) that may be collected from chronically ill patients for medications (regular and otherwise) that they require throughout the month.
  • Beyond this amount, the health plans provide the medications at no cost.
  • Chronically ill patients who have reached retirement age and who receive an income supplement or Old Age Disability Pension are eligible for a discount of half of the ceiling established for the rest of the chronically ill.

Who is Eligible?

  • Those who have been recognized by the Ministry of Health as being chronically ill are eligible to pay only up to the established ceiling as detailed below (medications included in calculating the ceiling).
  • Eligibility for payment of half the established ceiling is provided to one who is determined as chronically ill, has reached retirement age, and who receives one of the following:
  • A "chronically ill patient" is someone that meets one of the following three conditions:
    • He is treated with regular monthly treatments of a medication that is on the list of medications determined regarding this issue.
    • He is sick with an illness that is on the list of illnesses determined regarding this issue.
    • He receives one or several medications, by doctors prescription, continuously for at least half a year.
  • For a list of medications and chronic illnesses see Chronically Ill Patients.

Medications Included in Calculating the Ceiling

  • The medications and equipment included in calculation of the payment ceiling must meet all of the following conditions:
    • The medications (or disposable equipment such as syringes) are in the basic healthcare basket (i.e. not those covered by supplemental insurance), including medications the patient purchased that are not related to the chronic illness.
    • They have been purchased through the health plan (i.e. with a prescription from a health plan doctor and funded by the health plan as opposed to being purchased privately).
    • They have been purchased during the same calendar quarter (January through March, April through June, July through September, October through December), or half year (January through June, July through December) - in accordance with the health plan's procedures.
  • Medical foods included in the healthcare basket are not included when calculating the ceiling; they have a separate ceiling.

Payment Ceilings for Different Health Plans (correct as of May 2019)

  • The following table provides information about the different health plans' payment ceilings.
  • These numbers change from time to time and it is recommended to verify the most up-to-date information on the kupot cholim websites.
Health Plan Payment Ceiling Payment Ceiling for Old Age Pension Income Supplement Recipients
Clalit Health Services 992 NIS quarter 496 NIS quarter
Maccabi Healthcare Services 930 NIS quarter 465 NIS quarter
Meuhedet 324 NIS per month (calculated each half year) 162 NIS per month (calculated each half year)
Leumit Health Fund 993 NIS quarter 496 NIS quarter
Example
A diabetes patient (who has been recognized as chronically ill) is insured by Clalit, where the monthly payment ceiling is 330 NIS (992 NIS/quarter).

In July and August she spent 350 NIS on medications each month. In September, in addition to her regular medications, she also purchased medicine for an ear infection and syringes, such that the sum of her purchases totaled 400 NIS.

According to a quarterly calculation, her purchases amounted to 1,100 NIS, but she was only charged up to the payment ceiling of 992 NIS by her health plan.
Example
An elderly man receiving an Old Age Pension income supplement, is insured by Leumit, suffers from chronic heart failure and requires 220 NIS worth of medications every month (a total of 660 NIS per quarter). As a member of Leumit, he is entitled to a quarterly ceiling of 496 NIS, so instead of being charged 660 NIS per quarter, he would only have to pay 496 NIS.

How to Claim It?

  • According to Ministry of Health directives, the health plans are responsible for identifying and following up with the chronically ill so that the ceiling is calculated for them automatically.
  • It is recommended for chronically ill patients to verify that they are recognized as such in their health plan's records. If not, they must contact their attending physician to receive confirmation.
  • Sometimes the payment ceiling goes into effect automatically at the time of payment, while sometimes the patient receives a reimbursement at the end of each quarter. (see the example Explanation for Maccabi Members on their website)

Please Note

  • Payments for visits to medical specialists and medical centers are not included in the payment ceiling arrangements, but there is a Per Family Health Plan Payment Ceiling for these payments that all policyholders are entitled to (and not only those who are chronically ill).

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