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):

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Feel free to print it out and pass it along!

 

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In Vitro Fertilization (IVF) – Informational Videos

Women are entitled to have up to four IVF treatment cycles included in the healthcare basket for their first and second children and up to eight treatment cycles over the course of two years with district committee approval. For more information on rights related to IVF and fertility treatment in general, check out our All Rights Index (which is searchable and browseable), especially the Fertility Treatments Portal and the In Vitro Fertilization (IVF) page.

Not sure what to expect in terms of the IVF treatment process? The Ministry of Health has produced the following informational videos with English subtitles to explain how the process works and what steps are involved in terms of preparation, treatment and follow-up: 

The first step: receiving the couple for treatment

A detailed review given by a doctor and a nurse regarding the entire in-vitro fertilization process, including chances for success and possible risks.

 

Hormone treatment procedure

A detailed explanation given by a doctor and a nurse regarding the hormone treatment procedure, the treatment protocol, and the method of hormone injection.

 

Ovum retrieval procedure

A detailed description of the ovum (egg) retrieval procedure, performed under general anesthesia, and the procedure of obtaining sperm until the egg and sperm are transferred to the lab.

 

The fertilization process in the lab

Fertilization of the egg and the sperm in the lab using the appropriate method, while ensuring correct identification, sterilization, and strict work procedures.

 

Embryo transfer procedure

A description of the embryo transfer procedure. This movie includes a discussion regarding the number of the transferred embryos and details of the continued hormonal treatment.

 

Summary of treatment results

The pregnancy test performed after embryo transfer, description of the continued hormonal support in cases with a resulting pregnancy, and possible courses of action in unsuccessful cases.

 

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

Medication Look-Up: Basic Basket and Supplemental Plans

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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:
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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.

Health Ministry Responsibilities Under the Health Basket

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Personal Preventive Medicine

The basket includes such services as:

  • Checkups and guidance for pregnant women
  • Tests for early detection of congenital diseases and birth defects
  • Immunization and developmental testing for infants and children
  • Health services for schoolchildren

 

These services are usually provided at family health stations (Tipat Chalav) or within the school framework. Some of the services entail a copayment.

Nursing Home Stay

This applies to patients who meet any of the following criteria:

  • health condition and functioning are poor due to a chronic disease or permanent disability
  • require hospitalization in a nursing home for skilled nursing care 24 hours a day
  • bedridden or confined to a wheelchair
  • need full or partial help in activities of daily living and cannot control their bodily functions

 

Patients are entitled to hospitalization in a nursing home with financial assistance from the Ministry of Health.

Eligibility for this service is conditional on the recognition of the person’s condition by the local health office of the Ministry of Health and on the availability of space based on the quota of nursing home beds determined in the Ministry of Health budget for that year. The service entails a co-payment by the hospitalized person and his family, based on income and financial capacity tests. The services are provided through the district/sub-district health office after determining eligibility for the service and according to the waiting list.

A nursing care patient who requires additional medical treatment – such as feeding by nasogastric tube; prolonged intravenous infusions; dialysis; treatment for severe pressure wounds; or chemotherapy for cancer patients – is defined as a “complex nursing patient.” This service is the responsibility of the health funds and entails a co-payment.

Recovery from Drug and Alcohol Addiction

Hospitalization and clinic services for recovery from drug and alcohol addiction.

Rehabilitation, walking and mobility accessories

The Ministry of Health assists with the funding of rehabilitation (e.g. various prostheses as well as vision or hearing accessories), walking and mobility accessories according to the criteria specified in the ministry’s procedures. The service is provided to the public via the district health offices.

Disabled persons who are workplace accident disabled, victims of hostilities, victims of the Nazis and Nazi persecution, or traffic accident disabled (from 1976 on), receive their assistance from other sources, and are therefore not eligible for assistance from the Ministry of Health.

For the list of devices and information on the funding policy, see Rehabilitation, Walking and Mobility Devices.

Mental Health Services

These services include emergency treatment and emergency room treatment, psychiatric hospitalization and outpatient care at general and psychiatric hospitals, ambulatory services at government mental health clinics, services at kindergartens for special needs populations and psychiatric rehabilitation services for patients referred by a regional rehabilitation board. Hospitalization services and clinic services are also provided for drug and alcohol rehabilitation.

For more information on mental health care and the ongoing transition of many responsibilities to the Kupat Cholim, see Mental Health Care Rights.

Kupat Cholim Responsibilities Under the Health Basket

Services Provided by the Kupat Cholim

  • Diagnosis, consultation and medical treatment.
  • Medications according to a list, some of which are provided only for a particular indication.
  • Hospitalization in a general hospital.
  • Rehabilitation, including hospitalization.
  • Accessories and medical supplies.
  • Medical services in the work place. 

Copayments

The health plans (kupot) are permitted to charge Copayments for a portion of the medical services in the healthcare basket, dependent on approval from the Knesset Finance Committee. The following is a partial list of the services for which a Copayment may be charged:

  • medicine included in the basket; doctor visits;
  • visits to an external clinic in the general hospital framework;
  • visits to institutions outside the hospital framework (x-ray, ultrasound, CT, MRI, EEG, EMG, gastroenterology, etc.);
  • emergency room services;
  • transport in an ambulance;
  • emergency services (medical center);
  • comprehensive hospice care;
  • fetal protein tests;
  • child development treatments;
  • dental treatments for oncological patients;
  • use of medical devices,
  • appliances and equipment;
  • doctor home visits;
  • fertility treatments;
  • psychiatric treatments.

Discounts and Exemptions from Payment

According to the law, certain population groups are exempt from payment. The list of those who are entitled to exemptions and discounts based on socio-economic status is sent to the health plan from the National Insurance Institute (Bituach Leumi).

In order to claim exemptions or discounts, inquire at your closest health plan branch.

Distance, Choice and Continuity

Reasonable distance

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.

Service in small localities

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.

Choice of health service provider

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.

Maintaining treatment continuity

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.

Prohibition on discrimination

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.

Health services abroad

In principle, the obligation imposed by the law for the Kupat Cholim to provide health services to Israeli residents is limited exclusively to the territory of Israel. However, there is a defined set of cases where the insured is entitled to participation in the costs of medical treatment abroad, subject to the fulfillment of all the following conditions:

  1. The treatment is in one of the following fields: organ transplants, congenital defects, tumors, cardiovascular diseases and neurocerebral diseases.
  2. The insured is unable to receive the required treatment or an equivalent treatment in Israel (if a little experience does exist in Israel, it is considered as if the insured is able to receive the treatment in Israel).
  3. The insured is in danger of losing his life if he does not receive the specific health service.

 

In addition, if in the opinion of the health fund a case presents exceptional medical circumstances, it may fund the treatment abroad.
Note: If a health fund rejects the insured’s request to receive health services outside Israel, the decision may be appealed before a special appeals committee in the Ministry of Health.

The Scope of Treatment

Indications for treatments

For some medications, the basket of health services explicitly determines “indications” – that is, provisions that limit the insured’s right to receive the medication or the medical service to specific medical conditions. A health fund is not obligated to fund the cost of a medication for indications other than those included in the basket.

Treatment alternatives

The choice between treatment alternatives which are included in the basket of health services, such as different medications, is subject to the discretion of the health fund, which may determine that an insured individual will receive the cheaper of two medications that have the same medical effect. Nevertheless, when there is an indication that a certain alternative is preferable for treating the insured’s problem, the health fund is obligated to provide the preferred alternative.

Limits on the scope of treatment

The fact that a certain service or medication is included in the basket of health services does not mean that that service or medication will be provided free of charge and without any limit. For example: physiotherapy for chronic patients may be limited to 12 treatments per year, and may require reasonable co-payment.

Receiving Services Not Included in the Basket

The basket of health services describes a minimum, and the health fund is authorized to provide additional medical services or medications determined by a committee that considers exceptional cases. The committee’s approval will apply to all patients who meet the criteria that were set. The committee must conduct an orderly proceeding, including the hearing of arguments, keeping of minutes, etc. and an insured is entitled to receive a copy of the minutes and any information on the hearing in his case.

*This information was translated and adapted from content provided by The Society for Patients’ Rights in Israel.