(Created page with " {{זכות/תחילת טור ימני}} {{דגשים | מידע = According to the Principle of Treatment Continuity, no policyholder may be forced to switch treatment facil...")
 
Line 3: Line 3:
 
{{דגשים  
 
{{דגשים  
 
| מידע = 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
 
| מידע = 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
| חשוב = Health plans are required to maintain continuity of medical services (treatment continuity) regardless of any changes with regard to service provider agreements that may impact their policyholders
+
| חשוב = 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 their policyholders
 
| איסור = <!-- דוגמה: אסור לעשות -->
 
| איסור = <!-- דוגמה: אסור לעשות -->
 
| חשוב2 = The Principle of Treatment Continuity is also applicable with regard to medications
 
| חשוב2 = The Principle of Treatment Continuity is also applicable with regard to medications
Line 12: Line 12:
 
}}<!-- פרמטרים סטנדרטיים: מידע/איסור/חשוב/פיצוי/שאלה/ממשל. ראו [[תבנית:דגשים]] למידע על אפשרויות הפרמטרים בתבנית -->
 
}}<!-- פרמטרים סטנדרטיים: מידע/איסור/חשוב/פיצוי/שאלה/ממשל. ראו [[תבנית:דגשים]] למידע על אפשרויות הפרמטרים בתבנית -->
  
עקרון הרצף הטיפולי מטיל על קופות החולים את החובה לשמור על רצף בשירות הרפואי הניתן למבוטח במהלכם של אותם מחלה או מצב רפואי, על-אף שינויים בהסכמים או ב[[בחירת נותני שירותים רפואיים#הסדרי הבחירה של הקופות השונות |הסדרי הבחירה]] של קופת החולים עם נותני השירותים. ביסוד עקרון זה עומד הרעיון ששמירה על איכות הטיפול ומתן טיפול רפואי ברמה סבירה מחייבים, במקרים מסוימים, שמירה על רציפות בטיפול הרפואי לו זקוק המבוטח.
+
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 the same illness or medical condition, regardless of any changes with regard to [[:he:בחירת נותני שירותים רפואיים|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.
  
{{ דוגמה | מבוטח בעל בעיות כאב כרוניות חמורות ונמשכות, שבמשך שנה טופל בהצלחה במרפאת כאב מסוימת, וזאת לאחר שהטיפול בו במוסדות רפואיים קודמים אחרים לא הביא להטבה במצבו, לא יועבר למרפאת כאב אחרת גם אם קופת החולים הפסיקה את ההתקשרות עם מרפאת הכאב האמורה. }}
+
{{ דוגמה | 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 moved to different pain clinic even if his health plan changes its arrangements with the aforementioned clinic.}}
  
עקרון הרצף הטיפולי חל גם באשר לתרופות. לכן, אם קופת החולים הפסיקה את הספקתה של תרופה מסוימת למבוטחיה (למשל, מאחר שתרופת מקור הוחלפה בתרופה גנרית או תרופה גנרית אחת בתרופה גנרית אחרת), והרופא המטפל בחולה סבור שמצבו הרפואי של זה מחייב המשך טיפול בתרופה הקודמת שנטל (למשל- מדובר בחולה סוכרת והשימוש בתרופה הקודמת השיג איזון במצבו) על הקופה תחול חובה להמשיך ולספק למבוטח תרופה זו.  
+
The Principle of Treatment Continuity is also applicable with regard to medications. Accordingly, if a health plan stops providing a specific medication to its policyholders (i.e. if a brand-name drug is replaced with a generic drug or one generic drug is replaced with another), and a patient's doctor indicates that the patient's conditions requires provision of the medication s/he was already taking (i.e. if the medication a diabetes patient was taking was more successfully at stabilizing his/her condition), the health plan is obligated to continue providing the medication.
  
 
{{זכות/סיום הקדמה}} <!-- תבנית זו דואגת לכך שהכותרת הבאה בתור תתחיל רק מתחת לתוכן העניינים -->
 
{{זכות/סיום הקדמה}} <!-- תבנית זו דואגת לכך שהכותרת הבאה בתור תתחיל רק מתחת לתוכן העניינים -->
  
 
== Who is Eligible? == <!--מי זכאי-->
 
== Who is Eligible? == <!--מי זכאי-->
<!-- כאן יש להכניס פירוט לגבי הזכאים לקבלת הזכות. -->
+
* 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 required continuity of care to be maintained that are not included in the listing.
 +
 
 +
=== '''Conditions Defined as "Serious Illnesses" According to the [[:he:חוק ביטוח בריאות ממלכתי|National Health Insurance Law]]'''===
 +
# Kidney failure being treated by [[Dialysis|dialysis]]
 +
# [[:he:איידס (תסמונת הכשל החיסוני הנרכש)|AIDS]]
 +
# [[Gaucher's Disease]]
 +
# Thalassemia
 +
# [[:he:המופיליה|Hemophilia]]
 +
 
 +
=== 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 the [http://www.health.gov.il/hozer/mk21_2007.pdf Ministry of Health Director Circular 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]] ===
 +
# Heart
 +
# Kidney
 +
# Liver
 +
# Pancreas
 +
# Lung
 +
 
 +
=== Other Medical Conditions ===
 +
* '''Patients with any of the following conditions:'''
 +
:# Current or previous malignant disease requiring continual monitoring and follow-up
 +
:# Orphan diseases
 +
:# Patients who have undergone an operation and who require monitoring and follow-up due to chronic complications, the possibility of complications or 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? == <!--תהליך מימוש הזכות-->
 
== How to Claim It? == <!--תהליך מימוש הזכות-->
<!-- איך ניתן לממש את הזכות? נא להכניס כאן הסבר מפורט, כולל שלבים ופרטי קשר במידת הצורך. -->
+
*The issues related to application of the Principle of Treatment Continuity are complicated. Policyholders whose health plan has refused to continue providing a medical service they received previously (i.e. by refusing to issue a payment voucher (Form 17) or paying for a medication) is entitled to do the following:
 +
:* [[Submitting a Complaint to the Health Plan|Submit a complaint to the health plan]]
 +
:* [[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
 +
 
 +
{{דוגמה | 1= 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 [http://www.old.health.gov.il/pages/default.asp?maincat=21&catid=60&pageid=318#4 The National Health Insurance Law Ombudsman Report for 1998-1999 - Section 4].}}
  
 
== Please Note == <!--חשוב לדעת-->
 
== Please Note == <!--חשוב לדעת-->
<!-- במידת הצורך, ניתן להכניס כאן הבהרות חשובות. ניתן למחוק סעיף זה אם אינו נחוץ. -->
+
*
 +
גם אם עיקרון הרצף הטיפולי אינו שולל מהקופה , במקרה מסוים, את האפשרות להעביר את מבוטחיה למוסד רפואי אחר בשל שינוי שחל בהסדרי הבחירה, הרי שעליה להודיע
 +
להם על כך זמן סביר מראש, באופן שיאפשר להם להתארגן כך שרציפות הטיפול הרפואי לא תפגע.
 +
*במקרה שבו הקופה מסרבת להמשיך ולממן למבוטח שירות רפואי שספקה לו בעבר,  עומדת למבוטח האפשרות לטעון כי הוא זכאי להמשיך ולקבל את השירות הרפואי  מטעם הקופה מכוח עיקרון הרצף הטיפולי.
 +
* סטיה מעקרון הרצף הטיפולי בניגוד לעמדתו של המטופל יכולה להיעשות במקרים חריגים בלבד, ובתנאי שהדבר נעשה משיקולים של שיפור הטיפול בחולה או משיקולים של העדפת מדיניות טיפול שונה מזו שהעניקו לחולה עד כה. במקרים אלה על מנהל קופת החלים לשקול את ההחלטה ולנמק אותה בכתב. כמו כן עליו למסור את החלטתו המנומת לידי החולה.
  
 
== Legal Precedents == <!--תקדימים משפטיים-->
 
== Legal Precedents == <!--תקדימים משפטיים-->

Revision as of 13:11, 6 November 2013

Template:זכות/תחילת טור ימני

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 their 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

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 the same illness or medical condition, regardless of any changes with regard to 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 moved to 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. Accordingly, if a health plan stops providing a specific medication to its policyholders (i.e. if a brand-name drug is replaced with a generic drug or one generic drug is replaced with another), and a patient's doctor indicates that the patient's conditions requires provision of the medication s/he was already taking (i.e. if the medication a diabetes patient was taking was more successfully at stabilizing his/her condition), the health plan is obligated to continue providing the medication.

Template:זכות/סיום הקדמה

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 required 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

  1. Kidney failure being treated by dialysis
  2. AIDS
  3. Gaucher's Disease
  4. Thalassemia
  5. Hemophilia

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 the Ministry of Health Director Circular 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

  1. Heart
  2. Kidney
  3. Liver
  4. Pancreas
  5. Lung

Other Medical Conditions

  • Patients with any of the following conditions:
  1. Current or previous malignant disease requiring continual monitoring and follow-up
  2. Orphan diseases
  3. Patients who have undergone an operation and who require monitoring and follow-up due to chronic complications, the possibility of complications or follow-up surgical procedure (such as closing a stoma)
  4. Patients with a complex medical condition requiring monitoring in a hospital (including outpatient clinics and facilities)
  5. Repeat or additional hospitalization/surgery due to the same illness or medical condition
  6. Dialysis treatments including resumption of dialysis treatment after a discontinuation of less than a year, not including dialysis treatment performed during hospitalization
  7. Child development services
  8. Physical therapy
  9. First clinical visit after surgery in the hospital in which the surgery was performed
  10. Oncological treatments
  11. Monitoring and specialized treatments related to transplants

How to Claim It?

  • The issues related to application of the Principle of Treatment Continuity are complicated. Policyholders whose health plan has refused to continue providing a medical service they received previously (i.e. by refusing to issue a payment voucher (Form 17) or paying for a medication) is entitled to 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

גם אם עיקרון הרצף הטיפולי אינו שולל מהקופה , במקרה מסוים, את האפשרות להעביר את מבוטחיה למוסד רפואי אחר בשל שינוי שחל בהסדרי הבחירה, הרי שעליה להודיע

להם על כך זמן סביר מראש, באופן שיאפשר להם להתארגן כך שרציפות הטיפול הרפואי לא תפגע. 
  • במקרה שבו הקופה מסרבת להמשיך ולממן למבוטח שירות רפואי שספקה לו בעבר, עומדת למבוטח האפשרות לטעון כי הוא זכאי להמשיך ולקבל את השירות הרפואי מטעם הקופה מכוח עיקרון הרצף הטיפולי.
  • סטיה מעקרון הרצף הטיפולי בניגוד לעמדתו של המטופל יכולה להיעשות במקרים חריגים בלבד, ובתנאי שהדבר נעשה משיקולים של שיפור הטיפול בחולה או משיקולים של העדפת מדיניות טיפול שונה מזו שהעניקו לחולה עד כה. במקרים אלה על מנהל קופת החלים לשקול את ההחלטה ולנמק אותה בכתב. כמו כן עליו למסור את החלטתו המנומת לידי החולה.

Legal Precedents

Aid Organizations

Government Agencies

Laws and Regulations

Additional Publications

Sources

Template:זכות/סיום טור ימני

Template:זכות/תחילת טור שמאלי Template:סטטוס Template:זכות/ראו גם

Template:זכות/טפסים

Template:זכות/סיום טור שמאלי