Healthcare basket details

 
General

What is the healthcare
basket ?  
The healthcare
basket includes all of the services, medications, supplies and medical equipment that the insured is entitled to receive. The things included in the basket are provided to the insured according  medical discretion, at reasonable quality, within a reasonable amount of time and at a reasonable distance from the patient's place of residence, subject to the conditions set forth in the law and its regulations.

How is the healthcare basket determined?
The healthcare basket is anchored in the National Health Insurance Law and is determined on the basis of the health services that were provided by the Clalit health plan as of January 1, 1994 and on the basis of the health services that were provided by the Ministry of Health as of December 31, 1994. Since the National Health Insurance Law became effective, medications and medical technologies have been added to the basket, with the approval of the Ministry of Health, according to additions to the budget allocated in accordance with recommendations by a public committee.
 
Health Services for Which the Health Plans are Responsible
 
Which services included in the healthcare basket are the health plans responsible for providing?
The healthcare basket for which the health plans are responsible is detailed in the Second Schedule to the National Health Insurance Law, 5754-1994, in its regulations and in the National Health Insurance Law (Medications in the Basket of Health Services). The schedule lists the medical services provided as part of the basket, without specifying diseases and medical conditions for which treatment is required, as a general rule . Below is the definition of the fields of service:
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.
 
Limitation of the scope of treatment
The fact that a certain service or medication is included in the healthcare basket does not mean that that service or medication will be provided free of charge and without limitations. In the Medzini Case, which dealt with the scope of the physiotherapy services included in the basket, it was ruled that there is a limit to the extent of the service to which an insured individual is entitled, even if the service is included in the basket, according to the limitations that were in force in the Clalit health plan on the law's "determining date" (January 1, 1994). Thus, for example, regarding physiotherapy for chronic patients , it was held that the limit is 12 treatments per year, according to the limitation on this service that was in force in the Clalit health plan on January 1, 1994.
 

Indications for treatments
For some medications, the basket explicitly determines "indications" - that is, more detailed provisions that limit the insured individual's right to receive the medication or the medical service to specific medical conditions. For example, an insured individual may be eligible to receive a particular medication for the treatment of a specific disease but not for the treatment of other diseases. The court ruled explicitly that a health plan is not obligated to fund the cost of a medication for a different indication than the one for which the medication is included in the basket (Lilly Carmel Case).

Generic versus proprietary (patented) medications

  • The choice between different treatment alternatives which are included in the healthcare basket (i.e.: different medications), is subject to the discretion of the health plan, 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 individual 's problem, the health plan is obligated to provide the preferred alternative.


Choosing between service providers – This subject is dealt with in several sections of the law, as follows:

  • Main legal authority – Section 23: Section 23 of the National Health Insurance Law states that a health plan may establish arrangements for choosing between its service providers, and that it is obligated to inform the Minister of Health of these arrangements and to publish them to its members. On December 1, 2005, regulations were issued setting conditions and limitations for the health plans in this regard.
  • Arrangements for selecting service providers: Every health plan is required to publish its arrangements for selecting service providers and to provide them free of charge at its branches at the request of any insured individual. Where there is medical justification for providing the service at a specific location, the health plan must fund the treatment at that location.
  • 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.
  • Treatment at a specialized medical institution: 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/she requires in connection with that disease or medical condition at such an institution (irrespective of the selection arrangements).
  • Prohibition of discrimination: A health plan is forbidden to discriminate between patients suffering from a particular disease. Thus, all members of a health plan who apply for treatment/hospitalization in a certain department/institution, and meet the same conditions are entitled to receive the plan's approval for that service.
  • Reasonable distance: Section 3 of the Law relates to provision of the service at a reasonable distance from the insured's place of residence. The Law does not define the term "reasonable distance," but with regard to a disease that requires ongoing treatment (such as dialysis, child development, etc.), there were cases in which the Ministry of Health ombudsman ruled that the health plan 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/she was referred.

   See additional details in Appendix D.

Discontinuation of a treatment not included in the healthcare basket
If a health plan decides to provide a certain treatment that is not included in the mandatory basket of services, it is then subject to supplementary normative duties, based on the principles of justice, fairness and equality established in Section 1 of the National Health Insurance Law, 5754-1994, which stem from the plan's standing as a public body. Thus, once a certain treatment was begun, and as long as it is suitable and medically indicated, the health plan is obligated to continue providing it.


Health Services for Which the Ministry of Health is Responsible
There are several health services that, as of now, have not been transferred to the health plans, and remain the responsibility of the State:

  • Preventative medicine – well-baby clinics and inoculations.

 

  • Certain general rehabilitation devices, walking and other mobility devices, for which the Ministry of Health contributes towards the cost.

 

  • Health services for schoolchildren.

 

  • Nursing home stays.

 

  • Mental health services – Following a reform, these are meant to come under the responsibility of the health plans.

Note: For additional details on the healthcare basket , see The Ministry of Health's English website by clicking here.

Receiving Services Not Included in the Basket
From a Health Plan

  • The medical services that a health plan is obligated to provide constitute a "minimum," and the health plan is permitted and authorized to provide additional medical services or medications beyond those included in the basket (Medzini Case).

 

  • Every health plan has an Exceptions Committee that considers exceptional cases.

 

  • The Exceptions Committee 's approval will apply to all patients who meet the criteria that were determined.

 

  • The Exceptions Committee must conduct an orderly proceeding, including the hearing of arguments, keeping of minutes, etc. (Medzini Case).

 

  • An insured individual is entitled to receive a copy of the minutes of meetings and any information on the hearing for his/her case.


Health Services in Foreign Countries

  • In principle, a health plan's duty to provide health services to an Israeli resident is limited exclusively to the territory of Israel.

 

  • A health plan is not obligated to provide medical services or to contribute towards the cost of services for a person going abroad on a trip or on business.

 

  • A person who elects to receive medical treatment abroad is not entitled to a contribution towards the costs of the treatment from his/her health plan, apart from a defined and limited list of cases and subject to the fulfillment of all the conditions set out below:

            - The treatment is in one of the following fields: organ transplants, congenital defects, tumors,                     cardiovascular diseases and neurocerebral diseases.
            - The insured is unable to receive the required treatment or an equivalent treatment in Israel (if some               experience does exist in Israel, it is considered as if the insured is able to receive the treatment in               Israel).

            - The insured is in danger of losing his/her life if he/she does not receive the specific health service.

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

 

Service in Small Localities

  • In localities with a population of less than 5,000 residents, no more than one health plan clinic may operate; in localities with a population of less than 10,000 residents, no more than two health plan clinics may operate. For the purposes of this matter , the Minister of Health may also determine that several neighboring localities will be considered a single locality .
  • A health plan 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 plan 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 plan that does not have a clinic in the locality and a member of that plan may apply directly to the clinic for services.