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.
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 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.
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.
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.