Social security international standards and best practices Medical

Social security international standards and best practices Medical Care

Medical Care What should be covered? What is the Social Risk covered? 1) Any morbid condition (=sickness), whatever its cause, and 2) pregnancy and confinement and their consequences. (≠sickness)

Medical Care Who should be covered? Typeofofprogramme Type Source of financing Persons protected Compulsory social insurance Contributions Employees & Spouses and Children OR OR Compulsory social insurance & Voluntary schemes OR OR Contributions & Taxes OR Economically active population & Spouses and Children OR Rightsbasedsocial Rights assistance & & Universal schemes OR Taxes OR All residents

Good example n Example of provision of coverage of dependents: Thailand n National Health Security Act, B. E. 2545. 2002 Section 9 Limits of the right of Health service of the following persons shall be pursuant to such laws, rules, regulations, notifications, resolutions of Cabinet or other orders as prescribed for the public sector, local government, organization, state enterprises or other state agencies. The said right shall be enjoyed pursuant to this Act. (1) Government Official or employee of the public sector (2) Official or employee of local government organizations (3) Official or employee of state enterprises, persons working for other government agencies, or persons entitled to medical care service from the government budget (4) Parent, spouse, child or anyone entitled to medical care service under the right of persons pursuant to (1), (2) or (3).

Medical Care What types of medical care that should be covered? Ø General practitioner care, including home visits; Ø Specialist care in hospitals or outside; Ø The essential pharmaceutical supplies; Preventive care and Curative care Ø Hospitalization where necessary; Ø Prenatal, confinement and postnatal care either by medical practitioners or by qualified midwives, and hospitalization where necessary. At a minimum Ø Dental care Ø Medical Rehabilitation (incl. Prosthetic and orthopaedic applicances) Ø Medical aids Recommended Ø Services for convalescents

Good example n Example of provision of medical care package: South Korea: National Health Insurance Act, 1999 Article 39 (Health Care Benefits) (1) Health care benefits referred to in the following subparagraphs shall be provided for the treatment of diseases and injuries, and childbirths, etc. of the insured and his dependent: 1. Diagnosis, medical examinations; 2. Supply of medicine, materials for medical treatment; 3. Emergency aid, operation or other types of medical treatments; 4. Prevention, rehabilitation; 5. Hospitalization; 6. Nursing; and 7. Transfers. (…)

Medical Care Cost sharing of medical care n The beneficiary can participate in the cost of medical care BUT n Cost-sharing should not involve hardship

Good example n Example of provision of medical care cost-sharing/hardship: Vietnam: Law on Health Insurance, 2008 (amendments 2014) Article 22. Benefit levels of health insurance 1. The benefit levels of the insured receiving medical examination and treatment in accordance with the regulations in Articles 26, 27 and 28 of this Law whose medical examination and treatment expenditures are covered by the health insurance fund shall be: a) Total medical examination and treatment expenditures with regard to the insured prescribed in points a, d, e, g, h and i Clause 3 Article 12 of this Law. The costs of the non-covered medical services of the insured prescribed in point a Clause 3 Article 12 of this Law shall be paid by the health insurance budget used for medical examination and treatment of these insured persons; if this budget is insufficient, the State budget shall be in charge. b) Total medical examination and treatment expenditures with regard to any medical examination and treatment at commune hospitals whose cost is lower than the cost prescribed by the Government. c) Total medical examination and treatment expenditures with regard to the at least 5 -year-insured whose medical examination and treatment expenditures exceed the total amount of the base salaries in 6 months, except for the insured who go to the hospitals different from the registered hospitals; d) 95% of the medial examination and treatment expenditures with regard to the insured prescribed in point a Clause 2, point k Clause 3 and point a Clause 4 Article 12 of this Law; e) 80 % of the medial examination and treatment expenditures with regard to other insured persons; (…)

Medical Care What conditions can be prescribed for entitlement to medical care? ØPossibility of setting a qualifying period as may be considered necessary to preclude abuse (from 1 to 3 months)

Good example Example of qualifying period for medical care Thailand : Social Security Act, B. E. 2533 (1990)11 August) Section 62 The insurer shall be entitled to the danger or sickness benefits for any danger or sickness caused by any reason other than working if the insurer has, within the period of fifteen months before receiving medical service, remitted the counterpart fund for not less than three months.

Medical Care How long should medical care be provided? Ø Minimum of 26 weeks in each case of sickness Ø Duration of medical care is to be prolonged as long as beneficiary is entitled to sickness benefit and in case of diseases recognized as entailing prolonged care Ø Maternity medical benefits should be provided throughout the contingency