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 workplace.

Co-Payments

The health plans (kupot) are permitted to charge co-payments 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 co-payment 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.

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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, speak to your branch secretary.

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Distance, Choice and Continuity

Reasonable Distance

The law requires that 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.

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Service in Small Localities

In localities with a population of less than 5,000 residents, not more than one health fund (Kupat Cholim) clinic may operate; in localities with a population of less than 10,000 residents, not more than two health-fund clinics may operate. A Kupat Cholim 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 Kupat Cholim 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 kupah that does not have a clinic in the locality and a member of that fund may apply directly to the clinic for services.

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Choice of Health Service Provider

A Kupat Cholim 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 Kupat Cholim 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.

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Maintaining Treatment Continuity (Continuity of Care)

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 Kupat Cholim 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 kupah is obligated to continue providing it.

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Prohibition on Discrimination

The Kupat Cholim is forbidden to discriminate between patients suffering from a particular disease. Thus, all members of a kupah 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.

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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 or 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.

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In addition, if in the opinion of the kupah, a case presents exceptional medical circumstances, it may fund the treatment abroad.

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Note: If the kupah 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.

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The Scope of Treatment

Indications for Treatments

For some medications, the health basket (sal briut) explicitly determines "indications" - that is, provisions that limit the insured's right to receive the medication or the medical service to specific medical conditions. The kupah is not obligated to fund the cost of medication for indications other than those included in the basket.

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Treatment Alternatives

The choice between treatment alternatives that are included in the sal briut, such as different medications, is subject to the discretion of the Kupat Cholim, 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 kupah is obligated to provide the preferred alternative.

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Limits on the scope of treatment

The fact that a certain service or medication is included in the sal briut 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.

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Receiving Services Not Included in the Basket

The sal describes a minimum, and the kupah 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.