Medication Payment Ceiling for the Chronically Ill (Right)

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

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?

Medications Included in Calculation of 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 20.08.2017)

  • 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 "Kol HaBriut" website and with the health plans.
Health Plan Payment Ceiling Payment Ceiling for Old Age Pension Income Supplement Recipients
Clalit Health Services 951 NIS quarter 476 NIS quarter
Leumit Health Fund 957 NIS quarter 480 NIS quarter
Maccabi Healthcare Services 910 NIS quarter 455 NIS quarter
Meuhedet 924 NIS quarter 462 NIS quarter
Example
A diabetes patient (who has been recognized as chronically ill) is insured by Clalit, where the monthly payment ceiling is 317 NIS (951 NIS/quarter).

In July she spent 300 NIS on medications and the same amount in August. 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 360 NIS.

According to a quarterly calculation, her purchases amounted to 960 NIS, but she was only charged up to the payment ceiling (951 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 480 NIS, so instead of being charged 660 NIS per quarter, he would only have to pay 480 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 facilities are not included in the payment ceiling arrangements, but there is a quarterly family ceiling for payments for all insured parties (not just those who are chronically ill).

Government Agencies

Laws and Regulations

Additional Publications

Credits