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|
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.
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)
- 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).
Laws and Regulations
- The National Health Insurance Law
- Deputy Ministry of Health Director for Health Plan and Additional Health Services Supervision Circular 14/10 from 01.11.2010 - Definition of chronic illness for purposes of establishing a medication payment ceiling for the chronically ill
- Deputy Ministry of Health Director for Health Plan and Additional Health Services Supervision Circular 13/11 from 15.11.2011 - Definition of chronic illness for purposes of establishing a medication payment ceiling for the chronically ill - Update
- Deputy Ministry of Health Director for Health Plan and Additional Health Services Supervision no. 5/2017 from 18.10.2017 - Update on payments for services and medications for 2017.
- The Senior Citizens Regulations (Benefits for Senior Citizens that Receive an Old Age Disability Pension
- Guide to Health Insurance - Insurance for Medication Funding on the Capital Market, Insurance and Savings Authority website
- Rights of Chronic Patients on the Ministry of Health's "Kol HaBriut" website.
- Quarterly Self-Payment Ceiling for Medications - Limit for Chronically Ill Patients on the "Kol HaBriut" website.
- English translation and maintenance by The Shira Pransky Project.