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Info for Those Injured in an Automobile Accident

Automobile accidents can occur in an instant and can make life difficult physically, emotionally, and financially. In order to ease your hardship and ensure your rights as a victim, it is important to know to your rights.

 

Payment for Evacuation from the Accident Site and Transportation to the Hospital

The kupat cholim is responsible to pay the related bills for anyone evacuated from an accident who is hospitalized, or for anyone that is not hospitalized, but was evacuated via an intensive care ambulance (Natan/Atan). You must go to a branch with hospital release papers and a report from Magen David Adom.

The liable insurance company pays when someone is evacuated to the emergency room in a regular ambulance but is not hospitalized in the end  (some companies pay directly to Magen David Adom and some reimburse the victim for expenses).

Assistance to Families of Automobile Accident Victims

During the difficult period following the accident, The Ministry of Welfare operates assistance centers for the affected families. More information (in Hebrew) and phone numbers for centers around the country can be found on the program’s web page.

Medical Treatment after the Injury

Someone who is injured in an automobile accident is eligible to receive the medical treatment included in the healthcare basket, covered by his/her Kupat Cholim.

Someone who is injured in an automobile accident is eligible for exemption from payment of copayments for the medical treatment included in the healthcare basket, for treatment stemming from the accident, regardless of the date of the accident.

See a health plan branch for details about receiving reimbursement for these payments.

The insurance company liable for the accident is responsible for payment of medical treatment that is not included in the healthcare basket (hospital nursing care, nursing assistance at home, purchasing of wheelchairs and appliances, dental treatments, etc.).

For more information on rights for Victims of Road Accidents see the Kol Zchut page.

Mental Health Care Rights

Different Populations

In discussing mental health care rights it is important to distinguish between several populations that these rights address. First, there is the general population in Israel that may encounter acute or ongoing psychological issues, and have rights addressed in the National Health Insurance Law. Another sub-population is considered the “mentally disabled” (nachei nefesh) who have particular rehabilitation rights due to their disorder. The “mentally ill” is another limited group defined by law as suffering from impaired judgment and sense of reality, with particular arrangements regarding treatment and protection of rights.

The following is an overview of rights regarding these three populations with links to sections with more information on the latter two. Some specific psychology related conditions are discussed in other sections.

Universal Rights to Mental Health Care

According to the National Health Insurance Law, all of the rights given to someone who is ill with a non-psychiatric illness are also given to someone afflicted with a psychiatric illness. 

Dispute over responsibility

Originally, mental health services were under the responsibility of the Ministry of Health. However, the law has been reformed to pass this responsibility on to the health funds. This transition has been under dispute for many years, and as a result, responsibility for mental illness treatments has not yet been arranged between the health funds and the Ministry of Health. 

The health basket specifies entitlement to 60 psychological treatments  (30 treatments per year for two years)  from psychologists, psychiatrists, trained social workers, and other treatment professionals, subject to medical necessity. Currently, fulfillment of this obligation by the health funds varies in the number, type, and co-payment of treatments, as well as the benefits added to supplemental plans. Contact your Kupat Cholim to determine your rights. The Ministry of Health may also be contacted for help.

Rehabilitation for the Mentally Disabled

The Rehabilitation of the Mentally Disabled in the Community Law refers to the rehabilitation and integration of the mentally disabled in the community while maintaining their dignity. The law defines “rehabilitation” as a process aimed at developing the abilities and skills of the mentally disabled in a community framework in order to guarantee the achievement of the greatest possible level of functional independence and quality of life accompanied by medical oversight, including the receipt of rights in the fields of housing, employment, education and professional training, as well as training in the development of social skills and use of leisure time.

For more information see: Community Rehabilitation of the Mentally Disabled

Treatment of the Mentally Ill

A mentally ill individual is one who suffers from impaired judgment and sense of reality. The Law for Treatment of the Mentally Ill defines the rights of the mentally ill, as well as the measures that can be taken for them, including voluntary or involuntary commitment to a psychiatric hospital or clinical treatment, and how this applies to minors. This law does not refer to mental disturbances that do not fit this definition of mental illnesses (i.e. personality disorders, delinquency, etc.). 

For more information see: Rights and Treatment of the Mentally Ill

Related information

Rights of Patients After a Cardiac Event

After a heart attack or surgery, patients feel vulnerable and anxious and are sometimes afraid of losing their ability to function; they do not always know what action is required in their situation. To alleviate these problems, heart rehabilitation programs have been developed, which are designed for those who suffer from one of the following:

  • Patients who have had a heart attack
  • Patients who have undergone coronary artery bypass surgery
  • Patients with Class II-III heart failure and/or LVEF < 35% decrease in left ventricular functionality with intermediate severity and above
  • Patients who have undergone pacemaker/defibrillator implantation

Before Implantation or Open Heart Surgery

The Ministry of Health requires that before a transplant or open heart surgery, the patient must undergo a comprehensive dental examination and treatment of all of the infections found in the patient, as well as preventive action against infections in the patient.

Recovery and Rehabilitation in a Convalescent Home

Included in the health basket is eligibility for five days of recovery in a convalescent home that has an agreement with the kupat cholim, without any co-payment. In order to obtain the service contact a kupat cholim representative in the hospital before being released or in a kupat cholim branch within 24 hours of being released from the hospital and present a medical recommendation from a cardiologist. As part of a stay in the convalescent home, the patient is entitled to medical oversight, instruction and follow-up, nutritional lectures and supervised exercise.

Also note that every kupat cholim offers an extended stay in the convalescent home in their supplemental health services plan (Shaban). Contact a representative for the details of your plan.

Rehabilitative Exercise

Anyone is who is insured is eligible to receive rehabilitative exercise services for a period of 4 months, with a co-payment. The program includes supervised physical activity with monitoring and follow-up by a cardiologist, a Holter stress test, relaxation and anxiety reduction, plus lectures on proper nutrition and risk factors.

Also note that every kupat cholim offers  an extended program for an additional period in their supplemental health services plan (Shaban). Contact a representative for the details of your plan.

Heart Rate Monitoring/Follow-up

Included  in the health basket is eligibility for receiving a personal monitoring device (cardiobeeper)  for 6 weeks, allowing the E.K.G to be broadcast directly to the medical center which is manned at all times.

Also note that every kupat cholim offers an extension of the service for an additional period of approximately one year  in their supplemental health services plan (Shaban). Contact a representative for the details of your plan.

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

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Hearing Devices – Kupat Cholim and Misrad Habriut Funding

Kupat Cholim

Eligibility for anyone who is insured

Anyone who is insured by a Kupat Cholim is eligible for a Kupat Cholim contribution towards the purchase of a hearing device.

Accurate as of August 2010, the Kupat Cholim contribution is a total of 851 NIS per year per ear.

Eligibility for those who are age 65 and above

The Kupat Cholim contribution is a total of 3,000 NIS towards a device for each ear, once every three years.

Eligibility for Additional Health Services (Shaban)

The Kupat Cholim’s Supplementary Health Services (Shaban) include an additional contribution towards the purchase of hearing devices and it is recommended to clarify this eligibility with the Kupat Cholim.

Misrad Habriut

Children under the age of 18

Children with hearing impairments are entitled to a contribution from the Misrad Habriut towards the purchase of a hearing device.

Cochlear Implant

Cochlear implant surgery is included in the health basket for children and adults.

Additionally, maintenance and care of wear to the cochlear implant, including the battery, is included in the basket.

Assistance in the educational system for students with hearing impairments

Student with hearing impairments are entitled to receive assistance in the educational system.

The following services are included:

  • Training and instruction for the school integrating the student, as well as instruction for the classmates, if required.
  • Preparing the school classroom acoustically.
  • Integration plan according to the integration committee decision.
  • Additional tutoring / speech therapy sessions.
  • Different diagnostic testing.
  • Unique programs suited for students with hearing impairments.
  • Accommodation in school examinations and matriculation examinations.
  • Borrowing of amplifier devices.
  • Training and advising for parents; individual support.

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

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Speech Therapy

The following describes eligibility for speech therapy under specific conditions as defined on the Clalit health plan website (valid as of January 1, 2011). The health basket also requires the Kupat Cholim to provide speech therapy as part of child development services. The best way to clarify the services available, and any additional entitlements included in the supplemental plans, is to ask the Kupat Cholim.

Voice disorders as the result of surgery

Up to 20 treatments in one treatment sequence, one-time diagnosis according to a speech therapist’s opinion up to two years from the day of the incident.

Language and speech disorders as the result of CVA or MS

Up to 20 treatments in one treatment sequence, one-time diagnosis according to a speech therapist’s opinion up to two years from the day of the incident.

Listening and lip reading exercises for the hard of hearing after hearing device adjustment

Up to 4 treatments only.

Cleft palate and lip

The extent of the treatment is determined by a professional certified by the health plan and is approved by a health plan speech therapist.

Teacher and kindergarten teacher hoarseness in the public education system

With occupational physician approval- Up to 15 treatments only. Treatment may be discontinued before exhausting all eligibility in the absence of a response or if treatments are no longer required.

Hoarseness lasting at least 6 months

Eligibility

Hoarseness lasting at least 6 months since the initial E.N.T. doctor examination and caused by a problem in the vocal chords after all other treatments and after changing the required habits (smoking), when it is not possible to treat using surgery to correct the problem according to the detailed findings.

Extent of treatments

Only up to 20 treatments may be approved according to the medical guidelines and with approval of a professional certified by Clalit (the health plan).

Eligible Conditions
  • Warts (papillomas) on the vocal chords (subject to changing of habits)
  • Swelling of the vocal cords (subject to changing of habits)
  • Sound chord paralysis
  • Lack of chord closure due to weakness
  • Swelling of the vocal cords due to reflux (after exhausting previous treatment)
  • Thickening of the vocal cords – according to etiology
  • Chronic laryngitis – according to etiology

 

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

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Kupat Cholim Services for Diabetes Patients

As detailed on the Clalit health plan health services website (January 1, 2010)

Insulin Pump

Clalit customers are entitled to receive an insulin pump free of charge under the following conditions with a referral from the treating doctor:

  1. Children and adults with diabetes who suffer from hypoglycemic attacks marked by spontaneous loss of consciousness, confusion and change in behavior without prior warning.
  2. Those who suffer from repeated attacks of ketosis, acidosis and hypoglycemia requiring hospitalization.
  3. Diabetes patients whose HgA1c level is 7.5 and more.
  4. Diabetes patients who received intensive treatment including three or more injections of insulin throughout the day; however, did not achieve the balance goals.
  5. Women who suffered from diabetes in the period before pregnancy and during pregnancy.
  6. Type 2 diabetes patients in cases of severe resistance to insulin and those treated with high doses of insulin who do not reach the recommended sugar level balance.
  7. For those who suffer from pulmonary hypertension, the service is given with a recommendation from a hospital lung disease specialist. In cases of preliminary pulmonary hypertension, please get approval from the district medical administration.

Reimbursement for a sugar level measuring device

Clalit customers who require a sugar level measuring device may purchase it in a Clalit pharmacy and receive a reimbursement. In order to receive the reimbursement, please obtain a letter from a doctor specializing in diabetes or a family health specialist. The recommendation must be approved by the clinic manager. Additionally, a tax invoice or original receipt indicating the name of the device and the customer for whom the device was purchased must be attached. Such a reimbursement may be given once every three years.

The health plans are responsible for providing device supplies

The Ministry of Health has made it obligatory for the health plans to provide patients with the supplies required to operate an appliance or device which is included in the basket without a co-payment. Click here to download the Ministry of Health notice regarding such supplies.

Syringes for personal use – Diabetes patients who require syringes for personal use may obtain them from Clalit free of charge.

Needles for diabetes patient self-examinations – Diabetes patients who require needles for self-examinations are entitled to a 90% discount in Clalit pharmacies.

Strips for checking blood sugar – Diabetes patients who require strips for checking their own blood sugar are entitled to a 90% discount in Clalit pharmacies.

Nocturnal erection testing, such as RigiScan

The service is provided to the patient in his home using a designated device in the following cases:

  1. The patient suffers from impotence and is a prosthesis transplant candidate.
  2. The patient suffers from impotence due to diabetes and/or high blood pressure.

Laparoscopic surgery without a band

The service is provided in the following cases according to a referral from the treating doctor:

  • BMI above 40.
  • BMI above 35 with one of the following risk factors
  • Moderate to severe sleep apnea.
  • Right heart failure.
  • Diabetes which is unbalanced under insulin treatment of 100 units per day and more.
  • High blood pressure that cannot be balanced using the best pharmaceutical treatment (make sure to obtain approval from a district-certified doctor).
  • Gallbladder stones (when operating on the gallbladder).
  • Joint replacement due to obesity.
  • Cicatricial hernia or major hiatal hernia.

General Rights for the Chronically Ill and/or Disabled

Medication Co-Payment Ceiling

Diabetes patients are chronically ill and it is their responsibility to ensure that they are considered as such by their health plan. Being defined as chronically ill is primarily important because it entitles the insured to pay less for medications, up to the ceiling which changes every year. 

Please note: When calculating the cumulative cost of co-payments, purchases of supplies (syringes, bandages, etc.) must also be included.

Bituach Leumi Rights

General Disability

Anyone who is ill and above the age of 18 is entitled to submit a disability claim to the National Insurance Institute.

The disability rating is defined in proportion to the medical problem, its severity or complications connected to it. Attention must be paid to the existence of complications which raise the disability rating, even if they are not treated on a daily basis.

If the claimant has been defined as at least 40% medically disabled and he/she lost the ability to earn a living, either fully or partially, he/she will be eligible for a disability allowance from the National Insurance Institute.

Click here to see more information about general National Insurance and disability rights.

Income Tax and Municipal Tax Benefits

Income Tax

Parents of children with diabetes are entitled to income tax and municipal tax benefits. Diabetes patients do not generally receive income tax benefits. Those whose disability has been defined as above 90% are entitled to an income tax exemption.

Municipal Tax

The discounts depend on the municipal authority and should be checked on a case by case basis.

Other Rights

Insurance companies – Additional rights to which diabetes patients are entitled are rooted in claims against insurance companies for those with policies including coverage for loss of work capacity if their earning was damaged as the result of diabetes or the detection of serious illness.

Click here to visit the Juvenile Diabetes Research Foundation website.

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

 

 

 

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Sharap 101

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Note: This post is specifically about Hadassah Hospital’s Sharap service. Other private and non-profit hospitals in Israel offer similar services.

If you are dealing with specialists or procedures in the Jerusalem area, you should know about Sharap.

Sharap is the private health services associated with Hadassah Hospitals that enables patients to select the senior physician who will treat them, both for the outpatient clinics and for surgery and hospitalization at Hadassah. Sharap can also be arranged to obtain more timely clinic appointments or procedure scheduling as well as access to preferred laboratories, imaging equipment, and operating theaters.

According to Hadassah’s website, Sharap services also make accessible medical treatment in all medical fields, “second opinion” consulting, and legal medical opinions for use in court or for the medical committees of the National Insurance Institute, Ministry of Defense, Ministry of Health, etc.

Sharap is a private, paid service, however your Kupat Cholim’s supplemental plan may include reimbursement, sometimes as much as 90%. Speak to your kupah first to find out what the policy is for your plan.

Sharap Hadassah Ein Kerem
Location: Hospital entrance level.
Hours of operation: Sunday – Thursday, 8:00 AM to 7:00 PM
Fridays, 8:00 AM to 12:00 noon.
Telephone: 02-6778899
Fax: 02-6776600

Sharap Hadassah Mt. Scopus
Location: Hospital entrance level.
Hours of operation: Sunday – Thursday, 12:30 PM to 8:00 PM
Telephone: 02-5844044
Fax: 02-5323307

Sharap Tel Aviv – 10 Dubnov St.
Location: 10 Dubnov St., Tel Aviv.
Hours of operation: Sunday – Thursday, 12:00 noon to 8:00 PM
Fridays, 8:00 AM to 12 noon
Telephone: 03-6955333
Fax: 03-6954433

English Websites and Publications for Each Kupat Cholim

It’s important to understand your kupat cholim. Getting familiar with your kupat cholim’s services and how to use them can save you time and money, or possibly make a difference in more important ways. Below are the links to the English sites for each Kupat Cholim, and you can also see our “Forms and Files” page to browse and download the English brochures and regulations that they have produced. Take a few moments to browse, and don’t stop until you’ve found out something you didn’t know:

Meuhedet- lang.meuhedet.co.il

Very simple sidebar navigation for English descriptions of all Meuhedet’s services, including PDF versions of their English pamphlets on supplemental insurance services and regulations.

Maccabi- maccabi4u.co.il/1781-he/Maccabi.aspx

Also simple navigation for good English descriptions, and downloadable PDFs. Plus, a handy summary of major points in the National Health Law.

Clalit- clalit-global.co.il/en/

Top navigation bar with drop down menus so it’s easy to navigate to very specific descriptions of services.

Leumit- leumit.co.il/eng/homepage.asp

Definitely the weakest English portal of the pack. Short lackluster descriptions and summaries of services. Tip- If you don’t see the sidebar navigation, try a different browser.

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Where to Turn: Social Workers

 

When you are struggling to navigate the system, just remember that Israel’s medical social workers serve the number one guidance function in the healthcare system here.


Guidance

Have you ever had a sit-down meeting with your Kupat Cholim social worker? Hospital social worker? Medical social workers are trained assistance professionals there to offer guidance when you need it. What kind of guidance?

  • Information about rights and services that relate specifically to a person’s circumstances, and practical guidance on acquiring them.
  • Practical insight, and some hand holding, on navigating the medical system, whether it be within the Kupat Cholim network,  in the hospital, or where the two overlap.
  • More practical insight and assistance with other bureaucratic institutions, like Bituach Leumi.
  • Help finding and connecting with organizations dedicated to particular conditions, where there may be even more resources of specific interest to you.
  • Help with emotional coping in difficult situations.

 

When to see a social worker

Make an appointment when you …

Feel like you’ve hit a brick wall. You’re trying to get a particular service from the Kupah and it’s not working out well. A decision was made and you need help appealing it.

Have an ongoing medical issue. There may be medical or social services you are unaware of, or specific organizations or government programs specifically dedicated to your circumstances.

 

Make sure the interaction is productive

A Few Tips:

  • Schedule a sit-down meeting and make sure there is enough time blocked out to discuss what you need.
  • Delegate tasks to accomplish your goals. Note the things you need to do (e.g. call this office, obtain these documents, etc.) and the things the social worker is committing to doing (e.g. calling that office, finding out about that service, getting ahold of those forms, etc.).
  • Schedule the next contact. e.g. The social worker will call you in two days with some more information on something, or you will meet again in a week to fill out forms together, etc.
  • Show your appreciation. Everyone in the healthcare sector chose to go into a profession dedicated to helping others. The social workers especially, did not do it for the glamour.

 

Okay, it’s not always peachy

Plenty of people have met with a social worker without productive results, or perhaps even had an unpleasant experience (I’m treading lightly here), but the thing is, guidance is a necessity in many circumstances. It shouldn’t be an option to resign oneself to fumbling around in the dark because the first match was a little soggy. Just like finding the right doctor, you can’t give up until you’ve found the social worker that you can communicate with and find the guidance you need. So just look for…

 

More Options

The first interaction with the kupah or hospital social worker may not have satisfied,  so try:

  • Another kupah or hospital social worker. Speak to a branch or department secretary and ask how you can arrange a meeting with another social worker, perhaps with better English…
  • Hadassah Kivunim. This is an admirable initiative in Hadassah Hospital, Ein Karem, where anyone, not just Hadassah patients, can access trained personnel for assessment of needs, assistance filling out forms and advice regarding benefits and services. Visit their offices, call 02-6777011 or email kivunim@hadassah.org.il.
  • The Shira Pransky Project has absolutely no pretensions of actually performing the functions of medical social workers, but we will try to help you find one if you’re having some trouble. Send us an email.

 

And remember

There are times when guidance in healthcare is absolutely necessary, and the medical social workers of Israel are at your service.

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5 Things To Know About Your Kupat Cholim

 

Leumit Logo

 

1. Your Branch Secretary is the Center of the Universe

If you need anything the Kupat Cholim offers and you want to know how to get it, ask the branch secretary. In practically every publication from the Kupah you are told to contact your local branch for clarifications about rights, permissions, required documents, payment authorizations, etc.
 
There are surrogates, of course. While away from home you can call the closest branch, and you can always call the Kupah’s 24 hour number. You can even directly access most of the information you need straight from the Directory of Services (Madrich Sherutim) or online. But really, learning the local secretary’s name and establishing some sort of rapport might be the most valuable investment in your wellbeing that you could make.
 
Also, remember you can just call to ask questions, or fax to transfer documents. You may get a small charge if the Kupah has to fax some document to or for you, but the hours saved in making the trip are probably worth it.
 

Finally, it’s usually not worth it to ‘sort of get’ crucial information, so if you need to, speak English. Most professionals know it, or can pass you on to someone who does. Besides, you’re about to learn the most essential vocabulary-

2. Two Words: Hafnaya and Hitchayvut

 

Always ask if you need either or both of these to get the service you need.

A Hafnaya (הפנייה) is a referral to a specialist or other medical  services, sometimes necessary for internal Kupah services, and very often necessary for services from other institutions.

A Hitchayvut (התחייבות) is a payment voucher from the Kupah, usually necessary for services, including tests and hospitalization, from other institutions. This payment voucher is also referred to as Form 17 (“Tofes Shva Esrei”), or a letter of financial obligation (“Tofes Hitchayvut”).  Click here to learn more about this important concept from a page we translated as part of our collaboration with Kol-Zchut.

3. Your Primary Doctor is the Center of your Galaxy

 
doctor-145198_1280

Your primary doctor is the Kupah’s point man for your physical wellbeing. He/she should be the fount from which flows all (or most) referrals, prescriptions, and communiqués.

Got a prescription from a private specialist? Ask your doctor to reissue it as a Kupah prescription. Looking for lab results from blood work? They get sent to your doctor. Need to see a physical therapist? Ask for a referral from your doctor,  etc.

It’s true that you can find your own specialists and services in the Directory of Services, and many will not require a referral. Perhaps you don’t need to check with your primary care physician every time you want to see a dermatologist, but it’s important to keep in mind the Kupah’s point-man perspective when deciding a course of action.

You might even want to consider adopting the philosophy yourself. In many health related situations it’s important to have a professional to rely on with an eye on the big picture.

Not sure if the doctor you’ve got actually fits the bill for your ideal point-man? The Kupah won’t fuss if you change doctors after one calendar quarter. If you need a more immediate change, consult the branch secretary for advice.

Finally, keep in mind that if your doctor is not available, or you just want to see someone else for some reason, there are other options-

4. Round the Clock Service

Any time you’re in need when the Kupah is closed, or the timing is simply inconvenient, call the Kupah’s 24 hour number to check if the service can be sent to your door, or  where the closest emergency medical center is that you can walk into any time.

Despite the operating hours of local branches, the Kupot have admirably committed themselves to round the clock basic medical services like diagnosis and prescriptions, and sometimes even lab tests and imaging.
The Kupah has arrangements with emergency medical centers, like Terem, as well as house-call services, though the services offered by these institutions will vary, as well as the expected co-payment.

It’s worthwhile to know the capabilities of the closest emergency medical center for times when your need is not just a matter of convenience. In certain urgent situations you should go straight to the hospital or call an ambulance. Click here for information about coverage of ambulance costs from a page we translated as part of our collaboration with Kol-Zchut.

5. Knowing Your Insurance Plan is Totally Worth it


In the USA  “good health insurance” is so elusive (read: expensive) and coveted it’s almost mythical. Here it’s really quite cheap.

By law, the Kupot cover doctor visits, diagnostic and laboratory services, some paramedical services, medical equipment, rehabilitation, hospitalizations and many prescription medications. Still, what’s left out, and how these services are provided can sometimes feel restrictive.

Supplementary Insurance (Bituach Mashlim) plans cost an extra monthly membership fee but offer a much wider selection of medications, more opportunity for using private doctors and specialists, and more options and benefits in general. If you already have it, review your additional benefits, and remember to check with the Kupah before paying for any medical service out of pocket.

If you don’t already have a supplementary insurance plan but want to join, do it immediately. There may be a waiting period before all the extra benefits kick in, though the Kupah must accept you to their supplementary health insurance plans regardless of age or medical history. Different benefits also may have different waiting (qualification) periods. Click here for more information about supplementary health insurance on a page we translated as part of our collaboration with Kol-Zchut.

Bonus: Long term care insurance may also be worth it, though it’s a different beast all together. Worthy of a separate post found here.

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Kupat Cholim Second Opinion/Private Consultation Benefit

Further Reference:
Meuhedet
Maccabi
Clalit
Leumit

The supplemental plans of the Kupot Cholim offer second opinion or private consultation benefits that include a refund of a significant percentage of a private doctor’s fees. Details differ between the Kupot Cholim and are available in each one’s guide to supplemental services.

This benefit may also be useful for a member who wishes to visit an in-network specialist with whom it was not possible to arrange consultation via the kupat cholim directly because of limits on seeing different doctors within the same specialty without officially changing doctors, or for other reasons.

Consultation

The benefit is only intended to include consultation, and not treatment. Diagnoses, treatment recommendations, referrals and prescriptions are normal services- though the latter two often must be rewritten by in-network doctors. The supplemental plans have separate regulations for reimbursing some private treatments (especially if the fees are different from a regular consultation/visit). Refer to a branch secretary or phone representative to find out coverage for different treatments via private arrangements. 

The List

The Kupat cholim retains a list of out of network doctors for every medical specialty that are eligible for this benefit. Before making an appointment with a private doctor, ask the branch secretary to check the name against the list.

Payment

The benefit is often fulfilled by providing receipts and documentation of the visit to the branch secretary for reimbursement of the appropriate percentage. In other cases, a Hitchayvut can be provided in advance. Check with the branch secretary, or Kupat Cholim information services in advance of using this benefit for instructions on the best way to implement it.

On the other hand, people who have already paid out of pocket for private doctor visits should check with their Kupat Cholim to see if they can receive a reimbursement from this benefit.

Restrictions

There are certain conditions specified by the Kupat Cholim that are not eligible for consultation under this benefit. These generally correspond to services that the Kupat Cholim does not cover. For example, dental.

Second Opinion Abroad

The additional insurance plans of the Kupat Cholim also include a benefit to consult with senior specialists in contracted medical centers abroad for certain serious conditions. Consultation for these purposes means sending relevant medical material abroad and receiving the specialist’s opinion on treatment, not sending the patient abroad.

 

 

Note: This information is intended to aid interactions with qualified social workers and other assistance professionals.

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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.

For more information of Health Services Abroad click here

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Health Services: Distance, Wait, Choice and Continuity

Reasonable distance and wait time

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.

 

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.

 

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

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Limits and Exceptions in the Scope of Treatment from the Kupat Cholim

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.

 

Receipt of Services Not Included in the Basket From a Health Fund

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.