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Payment and Choice in the Kupah [Basics Review]

As I read through Leumit’s Passport to Healthcare in Israel brochure from 2010 (available for download here) I thought it was a good opportunity to highlight some points that they felt were essential information about what a Kupat Cholim has to offer its clientele. I will not be referring to anything unique to Leumit, so members of Meuhedet, Maccabi and Clalit can also follow along to learn or recall just what you are entitled to receive, and what options you have in the Israeli public health system.

You Do Not Pay The Kupah for the Basic Basket

We’ve summarized the Basket of Health Services here, but these points bear repeating:

  • The Kupot Cholim provide the government’s package of basic healthcare services, which include: doctor visits, laboratory services, imaging, hospitalization, rehabilitation, paramedical (speech, occupational and other therapies), prescriptions and medical equipment.
  • You do not pay your Kupat Cholim for this insurance coverage (except for co-pays). The basic coverage is automatic when you sign up as a member to any kupat cholim. The funding comes out of your payments to Bituach Leumi (National Insurance Institute), not the kupot.

You Do Pay for Supplementary Health Insurance (Shaban)

Kupat Cholim Level 1 Level 2
Clalit Mushlam Zahav Mushlam Platinum
Maccabi Gold Sheli
Meuhedet Adif
Leumit Kessef Zahav

 

Your monthly fees to the kupah are for additional policies that add benefits on top of the basic basket entitlements. Since you are paying extra for additional coverage, you should be familiar with the added benefits and how to use them. Some supplemental benefits:

  • Private doctors, or private medical procedures at hospitals or other facilities. These options can be limited in the expense covered, the number of times used in a year, or to whom or where you can go. Explore the arrangements directly with your kupah to find out how to exercise these private options, or get reimbursements. 
  • Additional or expanded categories of services, such as genetic testing, dental treatment discounts, orthopedic products and travel vaccinations.
  • Extending coverage on treatments included in the basic basket, such as additional paramedical treatments in child development services.
  • Some surgery, transplant or treatment abroad options.
  • Additional pre- and post-natal services and tests, such as fertility treatments, genetic testing, scans, private obstetrician, preparation classes and convalescence.
  • Additional pediatric services, such as testing for learning disabilities and bedwetting treatments.
  • Discounts on drugs not included in the basic basket.
  • More preventative care.
  • Expansion of mental health coverage.
  • Discounted alternative medicine options.

Your Kupah Has Doctor and Facility Choices Without Going Private

  • Your Kupah has a directory of physicians that are considered “within the kupah”. This directory is on the kupah website (in Hebrew) and is accessible through the 24-hour hotline representative, or your local branch secretary. Occasionally you may even be able to get a print version that looks like a small phone book.

  • You can use this directory to find a primary care physician, the center of your galaxy in the Kupah system, and to find specialists. 

  • Many primary care physicians can see you on the same day you call, or the next. 

  • Specialists can have longer wait times, but if you find multiple options from the kupah directory, you can “shop” for the best appointment.

  • Finding a facility or clinic that is not “within the Kupah” is still an option even without using your private appointment supplemental benefits, especially if the Kupah does not have a good alternative (within a reasonable time and distance). Request a hitchayvut from the kupah, and see what happens.

Further Reading

Kupat Cholim Discounts on Glasses

woman-glasses

You may be eligible to receive discounts on purchasing glasses from your kupat cholim if you are a member of their additional health service plans. All of the kupot cholim have agreements with specific stores, or their own stores, where the discounts they offer are available. Be sure to ask the secretary at your local clinic, or the information hotline to locate a participating store. You will also have to fulfill the eligibility requirements to get your discount. We have summarized the discounts and conditions below, but be sure to check your eligibility directly with the kupat cholim.

Maccabi

Gold Members

Adults with the following diagnosed vision problems are entitled to partial coverage for the cost of plastic glasses lenses or contact lenses. Children are eligible for these same benefits, or a blanket discount of up to 600 NIS for one pair of frames and lenses per year without specific diagnosis requirements.

  • Shortsightedness or farsightedness of 7 or higher (5 up to age 10): 83% discount up to a ceiling of 510 NIS on one pair of glasses lenses or one pair of contact lenses per year, or a discount of 83% up to a ceiling 225 NIS on the purchase of a single contact lens 
  • Astigmatism or a cylinder of number 7 or higher: 83% discount up to a ceiling of 1,995 NIS on one pair of glasses lenses per year
  • Keratoconus: 83% discount up to a ceiling of 1,995 NIS on one pair of glasses lenses per year, or 998 NIS off the purchase of a single lens or 1,995 NIS off the purchase of one pair of contact lenses per year
  • After a corneal transplant or corneal therapy: 83% discount up to a ceiling of 1,995 NIS on the purchase of one pair of contact lenses or an 83% discount up to a ceiling of 998 NIS on the purchase of a single lens per year

Sheli Members

Members are eligible for any discounts available to gold members. In addition, Sheli members who need glasses are entitled to a 50% discount on the purchase of eyeglasses, sunglasses and contact lenses at participating stores. This discount can be used on multiple purchases over 3 years until reaching a ceiling of 1,002 NIS discounted (total purchase cost of  2,004 NIS). The full discount credit is renewed every 3 years. This discount cannot be combined with the discount on plastic glasses lenses available for the specific conditions listed above, but the member may choose which benefit to receive. 

Click here for full details in Hebrew on the Maccabi website.

Meuhedet

Si Members

Children up to age 18 are entitled to purchase prescription glasses once a year costing up to NIS 700 with a co-payment of 10%. When the glasses cost more than NIS 700, members pay the difference plus 70 shekels.

Adults 70 years and older are eligible for the same discount as children for regular glasses or a discount on multifocal or bifocal glasses up to a ceiling of 1,200 NIS with a co-payment of 10% once every two years. When the multifocals or bifocals cost more than 1,200 NIS, members pay the difference plus 120 NIS. 

Click here for full details in Hebrew on the Meuhedet website.

Leumit

Gold and Silver Members

Adults are are eligible for up to 70% total discounts on frames and lenses on purchases made at participating stores. Prices are determined based on the specific frame and lens choice. Children are eligible for free glasses ((frame, optical lenses and anti-reflex coating) up to 650 NIS ceiling with a 21 NIS co-payment. 

Click here for full details in Hebrew on the Meuhedet website.

Clalit

Mushlam Platinum members

Children up to age 18 are entitled to a discount on glasses up to 600 NIS once per calendar year. If the cost exceeds 600 NIS the member pays the difference. The benefit includes checking eyesight and glasses (frame, optical lenses and anti-reflex coating). Alternatively, you can use this benefit for the purchase of contact lenses.

Click here for full details in Hebrew on the Clalit website.

See Also:

 

Choosing Your Kupah’s “Higher Level” Plans

Is it worth it to pay my kupat cholim for their additional “levels”? What am I getting? Which level should I choose? Is there a straightforward comparison of each kupah’s offering?

These are very common questions for anyone who makes Aliyah, and unfortunately, they often remain questions years and decades after their Aliyah. The answers are too subjective, and too many personal researchers have tried and failed to compile an objective comparison.

However, let’s review some important decision criteria and examples of benefits offered by these plans (known as Supplemental Plans, Additional Health Services or Shaban) to assist anyone taking the time to think about these choices. The following information cannot be comprehensive or account for all the variation between plans!

 First, Some Important Caveats

  • Most benefits offered still have associated costs, like requiring partial payment by the member, partial reimbursement for private services after the member pays in full, and/or enumerated limits to how much the kupah will pay.
  • Private services offered may depend on specific agreement with specific providers, not any provider that you choose.
  • There are rules and regulations that you will have to fulfill for entitlement to many benefits, so claiming them may take further effort.
  • Besides variation in benefits offered by each kupah, within the kupah there are multiple “levels” with distinct offerings.
  • When a person first joins a supplemental plan, the specified benefits can have various waiting periods before they are available to them. Qualification periods can range up to 2 years from sign-up. (When switching kupat cholim, you retain the time you have waited with your previous kupah  if you sign up for an equivalent plan within three months.)

Examples of offerings (remember, not comprehensive or universal!):

More personal choice of advanced medical care:

  • Additional private diagnostic consultations (second opinions) with medical specialists in Israel and abroad
  • Choice of specific surgeons and/or private healthcare facilities
  • Treatment, transplants and surgery abroad (Expanding the reimbursements and instances already established by the Health Insurance Law)

Services in fields not covered by the basic Health Basket:

  • Genetic testing
  • Kupah dental clinics
  • Kupah complementary medicine clinics
  • Orthopedic devices
  • Vaccinations for traveling abroad
  • Cosmetic treatments

Fields covered by the basic Health Basket, but expanded with additional treatments/benefits

  • Additional child development treatments in physical therapy, occupational therapy, speech therapy, psychotherapy
  • Educational or psycho-educational assessments
  • More fertility treatment benefits
  • Additional testing during pregnancy
  • Discounts on hundreds of medications not included in the “Drug Basket” or medication in the basket for indications not included in the list (Note: this benefit is commonly used by people particular about their medications and/or options in treatment, and it has the potential to cover the cost of a premium plan in savings to the consumer)

Miscelaneous bonus benefits

  • Laboratory services at home (like blood tests)
  • Private nurse during hospital stay
  • Discounted prescription glasses for children
  • Fittness and nutrition benefits
  • Subscription to Private Emergency Cardiac Services
  • All kinds of other hard-to-categorize boons.

Conclusion

Your choice about which plan is good for you will come down to a new set of personal questions. How much do you value increased, though still limited, choices? Do you consider the “Basic Health Basket” inadequate coverage of your needs? Do you feel confident that you will make sure to know and claim your benefits? Answer those questions and the choice about your kupah plans may not be obvious, but it will be more informed.

Also See:

What is the Kupat Cholim Selling Me?

We’re often asked what are the differences between the various types of insurance offered by the kupot cholim. We decided to put together the following to help make it a bit clearer what your kupat cholim is actually selling (or trying to sell you):

What_is_the_kupat_cholim_selling_me

Feel free to print it out and pass it along!

 

If this information is helpful to you, please enable us to help others: 

Medication Look-Up: Basic Basket and Supplemental Plans

pillbottle

Have you ever wondered if/to what extent your medications are covered by national health insurance or your supplemental plan?

Use the links listed below to search listings of  the medications covered by the basic Healthcare Basket or by the supplemental insurance plans from each kupat cholim.

co-payment is often required for all medications, and coverage may be dependent on meeting diagnostic criteria and/or other clinical factors specified in the listings (in Hebrew). 

 

Medications in the Healthcare Basket

Medications included in the Healthcare Basket are provided to anyone covered by national insurance (anyone entitled to national insurance/paying Bituach Leumi contributions).

 

Medications Covered by Supplemental Health Plans

Those who have a supplemental health plan are entitled to full or partial coverage of some medications which are not included in the Healthcare Basket.

  • Clalit (Mushlam Platinum, Mushlam Zahav) – PDF document – as of January 2016
  • Leumit (Silver, Gold) – Database search – click the letter or enter the English first letters into the search box
  • Meuhedet (Adif, C) – Database search – enter the English first letters into the search box
  • Maccabi (Sheli, Magen Kesef, Magen Zahav) – Database search – click the letter or enter the English first letters into the search box

 

Please note: Websites and listings may change or be updated over time so please leave a comment below if a link doesn’t work or is outdated.

 

If this information was helpful to you, please enable us to help others by supporting the project:
 www.shirapranskyproject.org/donate/ 

Long-Term Care Benefit

https://www.flickr.com/photos/papalars/1425443134/

Information about the Long-Term Care Benefit in English! 

A Long-Term Care Benefit is given to people who have reached retirement age, live at home in the community, and need help with daily activities (such as getting dressed, getting bathed, eating, mobility in the home, etc.), as well as elderly people who need supervision in order to prevent them from endangering themselves, or their surroundings (such as people with decreased mental faculties like Alzheimer’s disease patients who are liable to endanger themselves or their surroundings if left home alone).

The benefit is generally provided in the form of services, and is usually not monetary in nature!

As part of our on-going collaboration with Kol-Zchut, we are proud to have translated and published a Rights Guide for the Mentally Ill and Their Families. While a number of the links in the guide still lead to Hebrew content, it is an easy-to-read, critical and unique resource of information that was not previously available in English. You can either view the guide below or click here to follow an external link. 

Related information:

 

Not familiar with AACI’s Shira Pransky Project?

AACI’s Shira Pransky Project was founded to help English speakers in Israel better navigate the Israeli healthcare system and make use of the rights and services that are out there.

 

If this information was helpful to you, please enable us to help others by supporting the project:
Donate Now!

 

 

To your health ! לבריאות

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Long Term Care Insurance

What is Long-term Care Insurance?

Long-term care insurance is meant to cover financial support and/or assistance services for a person who cannot carry out Activities of Daily Living (ADL) and needs continual care. ADLs are six basic daily activities: 

  • standing up and lying down
  • dressing and undressing
  • bathing
  • eating and drinking
  • walking
  • continence

The inability to perform several of these activities usually constitutes a long-term care insurance event. 

These policies are most commonly associated with fulfilling the needs of the elderly, but it is important to remember that they can be just as applicable to a younger person that encounters disabling conditions. 

Through the Kupat Cholim

Long-term care insurance offered through the Kupat Cholim is a group insurance plan provided by the health fund in association with a private insurance company.

The policy is not like the other supplemental insurance plans offered by the Kupah in the following ways:

  • There is no obligation to accept every applicant to this plan.
  • The group insurance is for a limited period, and the insurance company is entitled not to renew it at the end of the period.
  • This insurance has no connection to the Health Basket and should be regarded the same as any group health insurance policy.

Comparison

Since Long Term Care Insurance is a private insurance policy, you can compare the terms of the proposed policy from the Kupat Cholim to any other policy offered by a private insurance company. A registered insurance agent can help you determine which policy is suitable and purchase it directly from the insurance company.

One who considers buying long-term care insurance should look into the following details:

Claims and Benefits
  • How is the insurance event defined?
    • How many ADLs does it take to define the insurance event? (In most cases, the qualifying situation is the inability to perform three or four ADLs)
    • Are mental frailty and Alzheimer’s included in the definition of the insurance event?
  • How long can benefits be paid? (Possible periods are three years, five years, and unlimited. The duration has an effect on the level of premium.)
  • What is the level of the monthly benefit? 
    • Can the monthly benefit be enlarged?
    • Does the level of insurance benefits depend on the insured’s age?
  • Are the insurance benefits given in the form of indemnification (against actual expenses) or of compensation?
  • Does the policy cover nursing care in the insured’s home?
    • Are receipts required in the case of at-home care?
  • Does the policy have a nonforfeiture benefit, i.e., an entitlement to partial benefits even if the insurance is terminated? 
Costs
  • Is the insurer allowed to change the premium for insureds at large (in contrast to a declared change in premium that is adjusted to the age of each insured), and under what conditions?
  • Is it possible to buy a policy in which the premium does not change as the insured ages?
  • What rights does the insured have in the event of an increase in premiums? (According to some policies, if the premium scale is raised the insured may pay the old price for reduced benefits and/or become eligible for a nonforfeiture benefit.)
  • Is the insured excused from paying premiums while receiving monthly benefits?
  • Are the premiums for at-home care different from those upon admission to a nursing institution?

 

Related pages:

Private Insurance Consumer Guide

Unlike national health insurance  delivered by the health funds and Misrad Habriut, insurance companies sell policies expanding the basic package of services, offering additional layers, and providing a level of service that the basic package omits, including private health services such as long-term care. These policies can be examined independently via registered insurance agents, as well as compared to the supplemental plans offered by your Kupat Cholim.

The private insurance companies are regulated by the Finance Ministry, and in the year 2000 they released the following aid to the consumer, explaining the types of policies available and offering advice and tools for comparison:

Supplemental Insurance

The Kupat Cholim is permitted to offer supplemental health service plans (“Shaban” – Sherutei Briut Nosafim, which literally means “Additional Health Services”) that offer additional medical services beyond those included in the Health Basket. These plans are optional and require additional payment to the Kupat Cholim beyond the basic health insurance contributions that all residents pay to Bituach Leumi.

A health fund is forbidden to make the provision of services included in the basket of services conditional on enrollment or membership in its supplementary health services plan, and they are not permitted to include components related to those that are in the basic healthcare basket, such as a discount on co-payments for medications included in the healthcare basket, or shortened waiting periods for specific services.

The price for joining an additional health services plan is the same for all policyholders in the same age group in the same plan. 

Differences between Kupot

There are differences in the supplementary plans offered by the different health funds. Each fund is free to choose which services it will offer its members under its supplementary plan, providing that these services are not included in the basic “basket of services.”  All policyholders are entitled to receive a copy of the additional health services plan offered by the health plan to which they belong. For information in English on your specific plan, check out English Websites and Publications for Each Kupat Cholim and Form and Files.

Waiting period

The health fund may set a reasonable “qualification period” (waiting period), i.e. a certain period between the date when the member joined the supplementary plan and the date when he will be entitled to rights under the plan. When switching health plans, the rights provided by an additional health services plan, including waiting period requirements, are retained in the new health plan and at the same level.

Comparison to Private Insurance Policies

The supplemental plans can be compared to private insurance policies that also cover additional medical services beyond those included in the Health Basket, but with some important differences, including:

  • The health fund is obligated to accept any member requesting to join the plan, regardless of his state of health, and the rights of an enrolling member may not be made conditional or restricted in any way.
  • The price of the plan must be uniform for each age group, regardless of the number of years of membership in the plan or the member’s state of health or finances.

 

In addition, a health fund may introduce changes in its supplementary plan (e.g. payments, addition or removal of medical services, etc.) only after it received the approval of the Ministry of Health. Private insurance policies, on the other hand, are regulated by the Finance Ministry. It is important to understand that the only truly private insurance options offered by the kupot (meaning those in which pre-existing conditions and other personal and medical information may impact premiums) are travel insurance and long-term care insurance.

Click here for more information on the “Additional Health Services (Supplementary Insurance)” page we translated as part of our collaboration with Kol-Zchut.