Gabriel Pransky (talk | contribs)
Gabriel Pransky (talk | contribs)
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* The issues related to application of the Principle of Treatment Continuity are complicated, and there are cases where the health plan will refuse to continue funding a a medical treatment/service or medication.
 
* The issues related to application of the Principle of Treatment Continuity are complicated, and there are cases where the health plan will refuse to continue funding a a medical treatment/service or medication.
 
* In cases where the health plan refuses to continue funding a medical treatment/service or medication that was previously provided (i.e. by refusing to issue a [[Obtaining a Payment Voucher (Form 17) from the Health Plan|payment voucher (Form 17)]] or paying for a medication), the policyholder may do the following:
 
* In cases where the health plan refuses to continue funding a medical treatment/service or medication that was previously provided (i.e. by refusing to issue a [[Obtaining a Payment Voucher (Form 17) from the Health Plan|payment voucher (Form 17)]] or paying for a medication), the policyholder may do the following:
:* [[Submitting a Complaint to the Health Plan|Submit a complaint to the health plan]]
+
:* [[Submitting a Complaint to the Health Fund|Submit a complaint to the health fund]]
 
:* [[Submitting a Complaint to the National Health Insurance Law Ombudsman|Submit a complaint to the National Health Insurance Law Ombudsman]]
 
:* [[Submitting a Complaint to the National Health Insurance Law Ombudsman|Submit a complaint to the National Health Insurance Law Ombudsman]]
 
:*  Submit a claim in a court of law
 
:*  Submit a claim in a court of law

Revision as of 17:06, 26 July 2017

Introduction:

According to the Principle of Treatment Continuity, no policyholder may be forced to switch treatment facilities while being treated for the same illness or condition
Health plans are required to maintain continuity of medical services (continuity of care) regardless of any changes with regard to service provider agreements that may impact policyholders
The Principle of Treatment Continuity is also applicable with regard to medications
In rare cases, a decision may be made to deviate from the Principle of Treatment Continuity due to professional considerations given to the improvement of treatment, and with health plan administrative approval
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The Principle of Treatment Continuity requires the health plans to allow their policyholders to continue receiving treatment for a given illness or medical condition at the same facility or service provider, regardless of any changes with regard to agreements or arrangements.

  • The Principle of Treatment Continuity requires the health plans to maintain continuity of medical services (continuity of care) provided to a policyholder being treated for a given illness or medical condition regardless of any changes with regard to agreements or choice of service provider arrangements.
  • This principle is based on the notion that, in some cases, quality of care and provision of medical care at a reasonable level require maintaining continuity of a patient's medical care.
Example
A health plan policyholder with severe and prolonged chronic pain problems who was successfully treated for a year at a specific pain clinic after treatment at other medical facilities proved unsuccessful will not be forced to receive treatment at a different pain clinic even if his health plan changes its arrangements with the aforementioned clinic.
  • The Principle of Treatment Continuity is also applicable with regard to medications. If a health plan stops providing a specific medication to its policyholders and a patient's doctor claims that the patient's condition requires provision of the medication s/he was already taking, the health plan is obligated to continue providing the medication to that policyholder.
Example
A patient suffers from a chronic illness and was treated with a specific brand-name drug. His health plan stopped providing that drug and began providing a generic alternative. The patient's attending physician claims that his condition requires that he continue taking the brand-name drug. Due to the Principle of Treatment Continuity, the health plan must continue providing the patient with the original brand-name drug.

Who is Eligible?

  • From time to time, the Ministry of Health publishes a list of medical conditions that require continuity of care to be maintained.
  • Nonetheless, this is not a closed list, meaning that there can be situations and conditions that require continuity of care to be maintained that are not included in the listing.

Conditions Defined as "Serious Illnesses" According to the National Health Insurance Law

Treatment in a Specialized Medical Service Center

  • A Specialized Medical Service center is a medical facility that offers a special level of medical knowledge and professional experience, usually for special and rare diseases the treatment of which requires unique skills and training on the part of the medical staff. For more information, see Ministry of Health Director Circular 22/07 from 22.11.2007.
  • Someone being treated at a specialized medical service center is entitled to continue receiving treatment there regardless of his/her health plan's arrangements or agreements with the facility.

Organ Transplants

Organ Transplants

  • Heart
  • Kidney
  • Liver
  • Pancreas
  • Lung

Other Medical Conditions

  • Current or previous malignant disease requiring continual monitoring and follow-up
  • Genetic diseases (such as Pompe disease, Fabry disease and Hunter syndrome
  • Patients who have undergone an operation and who require monitoring and follow-up due to chronic complications, the possibility of complications or a follow-up surgical procedure (such as closing a stoma)
  • Patients with a complex medical condition requiring monitoring in a hospital (including outpatient clinics and facilities)
  • Repeat or additional hospitalization/surgery due to the same illness or medical condition
  • Dialysis treatments including resumption of dialysis treatment after a discontinuation of less than a year, not including dialysis treatment performed during hospitalization
  • Child development services
  • Physical therapy
  • First clinical visit after surgery in the hospital in which the surgery was performed
  • Oncological treatments
  • Monitoring and specialized treatments related to transplants

How to Claim It?

  • Continued provision of a medical treatment/service or medication due to the Principle of Treatment Continuity should occur automatically.

Appealing a Health Plan Decision Not to Continue Provision of a Medical Treatment/Service or Medication

  • The issues related to application of the Principle of Treatment Continuity are complicated, and there are cases where the health plan will refuse to continue funding a a medical treatment/service or medication.
  • In cases where the health plan refuses to continue funding a medical treatment/service or medication that was previously provided (i.e. by refusing to issue a payment voucher (Form 17) or paying for a medication), the policyholder may do the following:
Example
A case in which the National Health Insurance Law Ombudsman required a health plan to issue a payment voucher (Form 17) due to the Principle of Treatment Continuity, despite the fact that the health plan did not have any arrangements with the service provider: A 70 year old policyholder underwent a right hip implant in Ichilov Hospital before choice of service provider arrangements were publicized, and required on-going monitoring after recovering from the implant. She later required a left hip replacement, but was then told by her health plan that she may only have the procedure performed in Tel Hashomer Hospital due to the fact that the health plan did not have choice of service provider arrangements with Ichilov Hospital. Her son submitted a complaint that as a result of these circumstances, she would have to have the examination of her right hip performed at Ichilov Hospital, and the examination of her left hip performed at Tel Hashomer Hospital. After the health plan was contacted repeatedly by the ombudsman and the attending physician, the health plan provided the policyholder with a payment voucher (Form 17) for Ichilov Hospital. For more information, see The National Health Insurance Law Ombudsman Report for 1998-1999 - Section 4.

Please Note

  • Even if the Principle of Treatment Continuity does not keep the health plan from transferring policyholders' care from one facility to another due to a change in service provider arrangements, the health plan must still inform policyholders of any such changes enough time in advance so that they are able to ensure that their continuity of care is not negatively impacted.
  • Policyholders whose health plan has refused to continue providing a medical service they received previously may claim that they are entitled to continue receiving such services from the health plan due to the Principle of Treatment Continuity.
  • In rare cases, a decision may be made to deviate from the Principle of Treatment Continuity due to professional considerations given to the improvement of treatment or preference given to one treatment policy over that which had been provided previously. In such cases, a health plan administrator/manager must consider the decision and defend it in writing. Moreover, the administrator/manager must provide this decision to the patient.

Aid Organizations

  • For a comprehensive categorized listing of healthcare organizations offering assistance and support, click here.

Government Agencies

Laws and Regulations

Additional Publications

Sources