The law requires that basket of health services be provided to the insured at a reasonable distance from his place of residence, but does not define the term “reasonable distance”. There have been conditions for which the Ministry of Health has ruled that the Kupat Cholim must reach an arrangement with an institute near the insured’s place of residence or, alternatively, it must arrange transportation for the insured to and from the institute to which he was referred. Additionally, if there is no nearby medical facility which can provide a required service within a reasonable wait time, the health plan must provide the required service at a different facility, even if it does not have an agreement or arrangements with that facility. Though, again, the law does not define what “reasonable wait time” is, so it is also open to interpretation.
In localities with a population of less than 5,000 residents, not more than one health-fund clinic may operate; in localities with a population of less than 10,000 residents, not more than two health-fund clinics may operate. A health fund that operates a clinic in a locality with a population of less than 10,000 people is obligated to provide medical services, within the framework of the clinic, to members of another health fund that does not operate a clinic in the same locality, upon the same conditions at which it provides them to its own members. There is no need to receive the approval of the health fund that does not have a clinic in the locality and a member of that fund may apply directly to the clinic for services.
A health fund provides health services through its own service providers or by arrangement with other providers. The Kupat Cholim may establish guidelines for members choosing between its service providers, and is obligated to publish its guidelines for selecting service providers and to provide them free of charge at its branches at the request of any insured individual.
However, where there is medical justification for providing the service at a specific location, the health fund must fund the treatment at that location. For example: when a disease or medical condition warrants treatment at a medical institution that possesses a special degree of knowledge and professional experience, the insured will be given the option to receive the medical service he requires in connection with that disease or medical condition at such an institution.
Continuity in treatment must be maintained and the insured must be allowed, when possible, to receive the entire treatment for a disease or for a defined medical condition at the same institution where the treatment was begun . Thus, even if a health fund decided to provide a certain treatment that is not included in the mandatory basket of services, once it was begun and as long as it is suitable and medically indicated, the health fund is obligated to continue providing it.
A health fund is forbidden to discriminate between patients suffering from a particular disease. Thus, all members of a health fund who apply for treatment/hospitalization in a certain department/institute and meet the same conditions are entitled to receive the fund’s approval for that service.
This information was translated and adapted from content provided by The Society for Patients’ Rights in Israel and Kol-Zchut.
For more information on this and related topics, see Health Plan Choice of Service Provider Arrangements and the Health Plan Portal, both of which we translated as part of our collaboration with Kol-Zchut.
To your health ! לבריאות