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What is covered?

  • Australia

    Services: The federal government defines and funds Medicare benefits, which include hospital care, medical services, and pharmaceuticals, to name a few. States provide further funding and are responsible for the delivery of free public hospital services, including subsidies and incentive payments in the areas of prevention, chronic disease management, and mental health care. The Medicare Benefits Scheme (MBS) provides for limited optometry and children’s dental care.

    Pharmaceutical subsidies are provided through the Pharmaceutical Benefits Scheme (PBS). To be listed, pharmaceuticals need to be approved for cost-effectiveness by the independent Pharmaceutical Benefits Advisory Committee (PBAC). War veterans, the widowed, and their dependents may be eligible for the Repatriation PBS.

    Nearly half (49%) of federal support for mental health is for payments to people with a disability; the remaining support goes toward payments to states, payments and allowances for caregivers, and subsidies provided through the MBS and PBS. State governments are responsible for specialist and acute mental care services.

    Home care for the elderly and hospice care coverage are described below in the section “How is the delivery system organized and financed?”

    Cost-sharing and out-of-pocket spending: Out-of-pocket payments accounted for 18 percent of total health expenditures in 2013–2014. The largest share (38%) was for medications, followed by dental care (20%), medical services (e.g., referred and unreferred private health insurance), medical aids and equipment, and other health practitioner services.

    There are no deductibles or out-of-pocket costs for public patients receiving public hospital services. General practitioner (GP) visits are subsidized at 100 percent of the Medicare Benefits Scheme (MBS) fee, and specialist visits at 85 percent. GPs and specialists can choose whether to charge above the MBS fee. About 83 percent of GP visits were provided without charge to the patient in 2014–2015. Patients who were charged paid an average of AUD31 (USD20).

    Out-of-pocket pharmaceutical expenditures are capped. In 2016, the maximum cost per prescription for low-income earners was set at AUD6.20 (USD4.00), with an annual cap of AUD372.00 (USD242.00). For the general population, the cap per prescription is AUD38.30 (USD25.00), which reverts to the low-income cost cap if a patient incurs more than AUD1,476.00 (USD958.00) in out-of-pocket expenditure within a year. Consumers pay the full price of medicines not listed on the Pharmaceutical Benefits Scheme (PBS). Pharmaceuticals provided to inpatients in public hospitals are generally free.

    Safety nets: There are three safety nets. The Original Medicare Safety Net covers the cost of all Medicare services out of hospital above an annual out-of-pocket threshold of AUD447 (USD290). The Extended Medicare Safety Net covers 80 percent of out-of-pocket costs over an annual threshold of AUD648 (USD420) for those with government-issued concession cards (e.g., low-income, seniors, caregivers) and AUD2,030 (USD1,318) for others. The “Greatest Permissible Gap” sets the maximum out-of-pocket fee per out-of-hospital service at AUD79.50 (USD52.00). The government is seeking to replace these with a single Medicare Safety Net that would reimburse 80 percent of out-of-pocket costs (up to a cap of 150 percent of the MBS fee) for the remainder of the calendar year once annual thresholds are met: AUD638 (USD414) for concessional patients (including low-income adults, children under 16, and certain veterans); AUD648 (USD420) for parents of school children; and AUD2,030 (USD1,318) for singles and all other families.

  • Canada

    Services: To qualify for federal financial contributions under the Canada Health Transfer, provincial and territorial insurance plans must provide first-dollar coverage of medically necessary physician, diagnostic, and hospital services (including inpatient prescription drugs) for all eligible residents. There is no nationally defined statutory benefit package; most public coverage decisions are made by provincial and territorial governments in conjunction with the medical profession. Provincial and territorial governments’ insurance plans provide varying levels of additional benefits, such as outpatient prescription drugs, nonphysician mental health care, vision care, dental care, home care, and hospice care. They also provide public health and prevention services (including immunizations) as part of their public programs.

    Cost-sharing and out-of-pocket spending: There is no cost-sharing for publicly insured physician, diagnostic, and hospital services. User fees for ambulance services vary considerably across provinces. All prescription drugs provided in hospitals are covered publicly, with outpatient coverage varying by province or territory. Physicians are not allowed to charge patients prices above the negotiated fee schedule. In 2014, out-of-pocket payments represented about 14 percent of total health spending, going mainly toward prescription drugs (21%), nonhospital institutions, mainly long-term care homes (22%), dental care (16%), vision care (9%), and over-the-counter medications (10%).

    Safety nets: Cost-sharing exemptions for noninsured services such as prescription drugs vary among provinces and territories, and there are no caps on out-of-pocket spending. For example, Ontario administers a universal prescription drug program for seniors and social assistance recipients that includes copayments and deductibles. There are no caps on out-of-pocket spending. However, the federal Medical Expense Tax Credit supports tax credits for individuals whose medical expenses, for themselves or their dependents, are significant.

  • Switzerland

    Services: The Federal Department of Home Affairs (FDHA) defines the mandatory health insurance (MHI) benefit basket by evaluating whether services are effective, appropriate, and cost-effective. It is supported in this task by the Federal Office of Public Health (FOPH) and by Swissmedic, the agency for authorization and supervision of therapeutic products.

    MHI covers most general practitioner (GP) and specialist services, as well as an extensive list of pharmaceuticals and medical devices; home care services (called Spitex); physiotherapy (if prescribed); and some preventive measures, including the costs of selected vaccinations, selected general health examinations, and screenings for early detection of disease among certain risk groups (e.g., one mammogram per year for women with a family history of breast cancer).

    Hospital services are also covered by MHI, but are highly subsidized by the cantons. Care for mental illness is covered if provided by certified physicians. The services of nonphysician professionals (e.g., psychotherapy by psychologists) are covered only if prescribed by a qualified medical doctor and provided in his or her practice. MHI covers only “medically necessary” services in long-term care. The FOPH and Swiss Conference of Cantonal Health Ministers aim to eliminate gaps that exist in the financing of hospice care. Dental care is largely excluded from MHI, as are glasses and contact lenses for adults (unless medically necessary), but these are covered for children up to age 18.

    Cost-sharing and out-of-pocket spending: Under MHI, insurers are required to offer a minimum annual deductible of CHF300 (USD235) for adults and a zero deductible for children up to the age of 18, although insured persons may opt for a higher deductible (up to CHF2,500 [USD1,960] for adults and CHF600 [USD470] for children) and a lower premium. In 2014, 22.3 percent of all insured persons opted for the standard CHF300/0 deductible, 14.7 percent had a higher deductible, and 63.0 percent chose another model with a gatekeeping element.

    Insured persons pay 10 percent coinsurance above deductibles for all services (including GP consultations), but it is capped at CHF700 (USD549) for adults and CHF350 (USD274) for children up to 18 in a given year. For brand-name drugs with a generic alternative, 20 percent instead of 10 percent coinsurance is charged. For hospital stays, there is an additional charge of CHF15 (USD12) per inpatient day. Cost-sharing in MHI and voluntary health insurance (VHI) accounted for 5.6 percent and 0.1 percent of total health expenditure in 2014.

    Out-of-pocket payments for services not covered by insurance (and in addition to cost-sharing) accounted for 18.6 percent of total health expenditure. Most of these direct out-of-pocket payments were spent on dentistry and long-term care. Providers under MHI are not allowed to charge above the fee schedule.

    Safety net: Maternity care and some preventive services are fully covered and thus exempt from deductibles, coinsurance, and copayments. Children or young adults in school (up to the age of 25) do not pay copayments for inpatient care. Federal government and the cantons provide income-based subsidies to individuals or households to cover MHI premiums; income thresholds vary widely by canton. Overall, 26.9 percent of residents in 2014 benefited from individual premium subsidies. Municipalities or cantons cover the health insurance expenses of social assistance beneficiaries and recipients of supplementary old age and disability benefits.

  • China

    Services: Publicly financed insurance covers primary, specialist, emergency department, hospital, and mental health care, as well as prescription drugs and traditional medicine. A few dental services (e.g., tooth extraction, but not cleaning) and optometry services are covered, but mostly such services are paid for completely out-of-pocket. Home care and hospice care are often not included either. Local health authorities define the benefit packages. Preventive services such as immunization and disease screening are included in a separate public-health benefit package funded by central and local governments; every resident is entitled to these without copayments or deductibles. Coverage is person-specific; there are no family or household benefit arrangements.

    Cost-sharing and out-of-pocket spending: Inpatient and outpatient care, including prescription drugs, are subject to different deductibles, copayments, and reimbursement ceilings. There are no annual caps on out-of-pocket spending. In 2014, out-of-pocket spending per capita was CNY1,306 (USD367) and CNY754 (USD212) in urban and rural areas, respectively—representing about 32 percent of total health expenditures.

    Most out-of-pocket spending is for prescription drugs. Reimbursement ceilings are significantly lower for outpatient care than for inpatient care. For example, in 2016, ceilings were CNY3,000 (USD843) for outpatient care in primary care facilities, CNY10,000 (USD2,809) for outpatient care in secondary/tertiary hospitals, and CNY180,000 (USD50,562) for outpatient care in the rural new cooperative medical scheme in Beijing.

    Provider networks are specific to the insurance scheme, normally at the prefecture level for urban employment-based basic health insurance and urban resident basic health insurance (which may share the same network, but with different benefits) and at the county level for the new cooperative medical scheme. People can use out-of-network health services (even across provinces), but these have higher copayments. There are no universal cost-sharing arrangements, and each risk-pooling unit (network) has its own policies. Cost-sharing in primary care facilities (village clinics, rural township hospitals, and urban community hospitals) is also different from that in secondary or tertiary hospitals, with the lowest copayments in the former. Secondary and tertiary hospitals are accredited by the local health authorities based on their qualifications, and both provide primary care, outpatient specialists, and inpatient hospital care. Migrant populations face much higher cost-sharing and out-of-pocket spending, since they often use out-of-network care. Fee schedules for primary and secondary care are regulated by the local health authorities and the Bureaus of Commodity Prices, and it is unlawful for public clinics and hospitals to charge patients above the fee schedules. To encourage nongovernmental investment in health care, in 2014 China began allowing private clinics and hospitals to charge more.

    Safety net: For individuals who are not able to afford individual premiums for publicly financed health insurance or who cannot cover out-of-pocket spending (which is not capped), a medical financial assistance program, funded by local governments and social donations, serves as a safety net in both urban and rural areas. In Beijing, individual poverty-level income in 2016 was defined as CNY800 (USD225) per month in both rural and urban areas; poverty levels for other provinces may be lower than in Beijing. Medical financial assistance programs prioritize inpatient care expenses. Funds are used mainly to pay for individual deductibles, copayments, and medical spending exceeding annual caps, as well as individual premiums for publicly financed health insurance. In 2014, 67.2 million people (approximately 5% of the Chinese population) received such assistance for health insurance enrollment, and 24.0 million people (1.8% of the population) received funds for direct health expenses.

    There are other financial assistance programs to help with unreimbursed emergency department and other health expenses. These are funded mostly by local governments.

  • Denmark

    Services: Publicly financed health care covers all primary, specialist, hospital, and preventive care, as well as mental health and long-term care services. Dental services are fully covered for children under age 18. Outpatient prescription drugs, adult dental care, physiotherapy, and optometry services are subsidized. Home care and hospice care are organized and financed by the regions, as described below.

    Decisions about levels of service and new medical treatments are made by the regions, within a framework of national laws, agreements, guidelines, and standards. Municipalities decide on the service level for most other welfare services, within a framework of national regulation. There is no defined benefit package for health care, but very few restrictions exist for treatments that are evidence-based and clinically proven.

    Cost-sharing and out-of-pocket spending: There is no cost-sharing for hospital and primary care services. Cost-sharing is applied to dental care for those age 18 and older (coinsurance of 35% to 60% of total cost), outpatient prescriptions, and corrective lenses. Out-of-pocket payments represented 12.4 percent of total health expenditures in 2013, covering mostly outpatient drugs, corrective lenses, hearing aids, and doctor and dental care. Patients with outpatient drug expenses of more than DKK3,045 (USD406) per year receive the highest reimbursement rate—85 percent. Private specialists, hospitals, and dentists are free to set their own fees for patients not covered by public funding.

    Safety net: There are cost-sharing caps of DKK22,115 (USD2,949) for children and DKK17,975 (USD2,397) for adults, and the municipalities provide means-tested social assistance to older people. Chronically ill people with high drug usage and costs can apply for full reimbursement above an annual out-of-pocket ceiling of DKK3,775 (USD503). The terminally ill also can apply for full coverage of prescriptions. Municipalities may grant financial assistance to individuals certified as otherwise unable to pay for needed medicine.

  • Germany

    Services: Statutory health insurance (SHI) covers preventive services, inpatient and outpatient hospital care, physician services, mental health care, dental care, optometry, physical therapy, prescription drugs, medical aids, rehabilitation, hospice and palliative care, and sick leave compensation. Home care is covered by long-term care insurance (LTCI). Preventive services under SHI include regular dental checkups, child checkups, basic immunizations, checkups for chronic diseases, and cancer screening at certain ages. All prescription drugs are covered except for those explicitly excluded by law (mainly so-called lifestyle drugs) and those excluded following benefits assessment. While the broader framework of the benefit package is legally defined, specifics are determined by the Federal Joint Committee (see below). Long-term care services are covered separately by the LTCI scheme (see below).

    Cost-sharing and out-of-pocket spending: Out-of-pocket spending accounted for 13.2 percent of total health spending in 2014, mostly on nursing homes, pharmaceuticals, and medical aids.

    Copayments include EUR5.00 to EUR10.00 (USD6.36 to USD12.72) per outpatient prescription, EUR10.00 per inpatient day for hospital and rehabilitation stays (for the first 28 days per year), and EUR5.00 to EUR10.00 for prescribed medical devices. Sickness funds offer selectable tariffs with a range of deductibles and no-claims bonuses. Preventive services do not count toward the deductible. Statutory health insurance (SHI)-contracted physicians are not allowed to charge above the fee schedule for services in the SHI benefit catalogue. However, a list of “individual health services” outside the comprehensive range of SHI coverage may be offered to patients paying out of pocket.

    Safety nets: Children under 18 years of age are exempt from cost-sharing. For adults, there is an annual cap on cost-sharing equal to 2 percent of household income; part of a household’s income is excluded from this calculation for additional family members. About 0.3 million of those insured under statutory health insurance (SHI) exceeded the 2 percent cap in 2014 and were exempted from further cost-sharing. The cap is lowered to 1 percent of annual gross income for qualifying chronically ill people; to qualify, those people have to demonstrate that they attended recommended counseling or screening procedures prior to becoming ill. Nearly 6.3 million people, or around 9 percent of all the SHI-insured, benefited from this regulation in 2014. Unemployed people contribute to SHI in proportion to their unemployment entitlements. For the long-term unemployed, government contributes on their behalf.

  • France

    Services: Lists of procedures, drugs, and medical devices covered under statutory health insurance (SHI) are defined at the national level and apply to all regions of the country. The health ministry, a pricing committee within the ministry, and SHI funds set these lists, rates of coverage, and prices.

    SHI covers hospital care and treatment in public or private rehabilitation or physiotherapy institutions; outpatient care provided by general practitioners, specialists, dentists, and midwives; diagnostic services prescribed by doctors and carried out by laboratories and paramedical professionals; prescription drugs, medical appliances, and prostheses that have been approved for reimbursement; and prescribed health care–related transportation and home care. It also partially covers long-term hospice and mental health care and provides only minimal coverage of outpatient vision and dental care.

    While preventive services in general receive limited coverage, there is full reimbursement for targeted services, such as immunization, mammography, and colorectal cancer screening, as well as targeted populations. A measure of the “Touraine law,” adopted on April 14, 2015, mandated the legalization of drug-use centers over a subsequent six-year period. These centers will be used exclusively for treatment of especially vulnerable drug addicts, under the supervision of health professionals.

    Cost-sharing and out-of-pocket spending: Cost-sharing takes three forms: coinsurance; copayments (the portion of fees not covered by statutory health insurance [SHI]); and balance billing in primary and specialist care. In 2014, total out-of-pocket spending made up 8.5 percent of total health expenditures (excluding the portion covered by supplementary insurance), a lower percentage than in previous years—possibly because of the agreement signed between physicians’ unions and government to limit balance billing in exchange for its voluntary capping at twice the official fee. This contract offers patients partial reimbursement of balance billing by SHI and reduced social charges for physicians.

    Most out-of-pocket spending is for dental and vision services, for which official fees are very low, not more than a few euros for glasses or hearing aids and a maximum of EUR200 (USD241) for dentures, but all of these are commonly balance-billed at more than 10 times the official fee. The share of out-of-pocket spending on dental and optical services is decreasing, however. At the same time, out-of-pocket expenditures on drugs are increasing, owing to increased VHI coverage of dental and optical care and increasing numbers of delisted drugs, as well as a rise in self-medication.

    Coinsurance rates are applied to all health services and drugs listed in the benefit package and vary by:

    • type of care (inpatient, 20%; doctor visits, 30%; and dental, 30%)
    • the effectiveness of prescription drugs (highly effective drugs, like insulin, carry no coinsurance; rates for all other drugs are 15% to 100%, depending on therapeutic value)
    • compliance with the recently implemented gatekeeping system

    The table below lists nonreimbursable copayments for various services. These apply up to an annual ceiling of EUR50 (USD60). There are no deductibles.

    ServiceCopayment
    EurosU.S. Dollars
    Inpatient hospital day18.0022.00
    Doctor visit1.001.20
    Prescription drug0.500.60
    Ambulance2.002.40
    Hospital18.0022.00

    Safety net: People with low incomes are entitled to free or state-sponsored voluntary health insurance (VHI), free vision care, and free dental care, with the total number of such beneficiaries estimated at around 10 percent of the population. Exemptions from coinsurance apply to individuals with any of 32 specified chronic illnesses (13% of the population, with exemption limited to treatment for those conditions); individuals who benefit from either complete state-sponsored medical coverage (3%) or means-tested vouchers for complementary health insurance (6%); and individuals receiving invalidity and work-injury benefits (2%). Hospital coinsurance applies only to the first 31 days in hospital, and some surgical interventions are exempt. Children and people with low incomes are exempt from paying nonreimbursable copayments.

  • England

    Services: The precise scope of the National Health Service (NHS) is not defined in statute or by legislation, and there is no absolute right for patients to receive a particular treatment. However, the statutory duty of the Secretary for Health is to ensure comprehensive coverage. In practice, the NHS provides or pays for preventive services, including screening, immunization, and vaccination programs; inpatient and outpatient hospital care; physician services; inpatient and outpatient drugs; clinically necessary dental care; some eye care; mental health care, including some care for those with learning disabilities; palliative care; some long-term care; rehabilitation, including physiotherapy (e.g., after-stroke care); and home visits by community-based nurses.

    The volume and scope of these services are generally a matter for local decision-making, but the NHS Constitution also states that patients have a right to drugs or treatment approved in technology appraisals carried out by the National Institute of Health and Clinical Excellence (NICE), if recommended by their clinician. For drugs or treatments that have not been appraised by NICE, the NHS Constitution states that Clinical Commissioning Groups (CCGs) shall make rational, evidence-based decisions.

    Cost-sharing and out-of-pocket spending: There are limited cost-sharing arrangements for publicly covered services. Out-of-pocket payments for general practice are limited to some services, such as examinations for employment or insurance purposes and the provision of certificates for travel or insurance.

    Outpatient prescription drugs are subject to a copayment (currently GBP8.40, or USD12.14, per prescription item in England); drugs prescribed in National Health Service (NHS) hospitals are free. NHS dentistry services are subject to copayments of up to GBP233.70 (USD338.00) per course of treatment. These charges are set nationally by the Department of Health. Out-of-pocket expenditure on health by households accounted for 14.8 percent of total expenditures in the U.K. in 2014. Also in 2014, the largest portion of out-of-pocket spending (42.4%) was for medical goods (including pharmaceuticals), followed by 35.9 percent on long-term care services, including residential care.

    Safety net: People who are exempt from prescription drug copayments include children age 15 and under and those ages 16 to 18 in school full-time; people age 60 or older; people with low income; pregnant women and those who have given birth in the past 12 months; and people with cancer, certain other long-term conditions, or certain disabilities. Patients who need large amounts of prescription drugs can buy prepayment certificates costing GBP29.10 (USD42.00) for three months and GBP104.00 (USD150.00) for 12 months. Users incur no further charges for the duration of the certificate, regardless of how many prescriptions they need. In 2015, 89.7 percent of prescriptions in England were dispensed free of charge. Young people, students, pregnant and recently pregnant women, prisoners, and those with low incomes are not liable for dental copayments. Vision tests are free for young people, those over 60, and people with low incomes, and financial support to meet the cost of corrective lenses is available to young people and those with low incomes. Transportation costs to and from provider sites also are covered for people who qualify for the National Health Service (NHS) Low Income Scheme.

  • India

    Services: In principle, all services at government facilities, including preventive and primary care, diagnostic services, and outpatient and inpatient hospital care, are delivered free of charge. In practice, severe shortages of staff and supplies limit access to care. Medications on the essential drug list are free (though there are often shortages), while other prescription drugs are purchased from private pharmacies. India has one of the world’s largest publicly financed HIV drug programs, and all drugs and diagnostic services for vector-borne diseases, such as dengue fever and malaria, are free, as are insecticide-treated bed nets for malaria control. Immunizations and maternal and child health services are free as well.

    Most of the services under health packages like the Central Government Health Scheme and Employees State Insurance Scheme are free. These remain the most generous of health coverage programs catering to a small section of the population, raising issues around equity. Under the RSBY insurance scheme for the poor, hospitalization services are free, up to allowable amounts.

    Cost-sharing and out-of-pocket spending: High out-of-pocket spending (69% of total health expenditures) results in part from patient fees charged by private health care providers and, to some extent, public providers. Under the National Health Mission, described below, free care in public hospitals was extended to certain services: maternity, newborn, and infant care and disease control programs. Also, despite plans to upgrade facilities to meet benchmarks laid down by Indian Public Health Standards, the availability of staff, equipment, and drugs varies significantly between and within states, forcing patients to seek care in the more expensive private sector.

    More than 63 million Indians are faced with impoverishment every year because of catastrophic health care costs.

  • Israel

    The mandated benefit package includes hospital, primary, and specialty care, prescription drugs, certain preventive services, mental health care, dental care for children, and other services. Dental care for adults, optometry, and home care are generally excluded, although the National Insurance Institute does provide some funding for home care, dependent on need. Limited palliative and hospice services are included in the national health insurance (NHI) benefit package as well.

    Israel has a well-developed system for prioritizing coverage of new technologies within an annual overall budget set by the Cabinet (which includes Parliament members from the ruling parties). Proposals for additions are solicited and received from pharmaceutical companies, medical specialty societies, and others. The Ministry of Health then assesses the costs and benefits of the proposed additions, and a public commission combines the technical input with broader considerations to prepare a set of recommendations. These are usually adopted by the Ministry and subsequently by the Cabinet.

    Cost-sharing and out-of-pocket spending: In 2014, out-of-pocket spending accounted for 23 percent of national health expenditures. Some of this was for services not part of the national health insurance (NHI) benefit package, including dental care for adults, optical care, institutional long-term care (for those not eligible for means-tested assistance), certain medications, and medical equipment. The other major component was copayments (user charges) for NHI services, such as pharmaceuticals, visits to specialists, and certain diagnostic tests. Dental care and pharmaceuticals are the two largest out-of-pocket components.

    There are no copayments for primary care visits or for hospital admissions. There are also no quarterly or annual deductibles with NHI coverage. Within the NHI system, physicians are not allowed to balance-bill.

    Safety net: There are a variety of safety-net mechanisms in place. For pharmaceuticals there is a quarterly ceiling for the chronically ill and discounts for the elderly based on age, income, and health status. Holocaust survivors are exempt from copayments for pharmaceuticals. With regard to specialist visits, there are exemptions for elderly welfare recipients, children receiving disability payments, and people afflicted with certain severe diseases. There is a quarterly ceiling per household on total copayments for these visits, which is 50 percent lower for elderly people. In addition, people earning less than 60 percent of average wages pay a reduced health tax of 3 percent of income, instead of 5 percent.

  • Italy

    Services: Primary and inpatient care are free at the point of use. Positive and negative lists are defined using criteria related to medical necessity, effectiveness, human dignity, appropriateness, and efficiency in delivery. Positive lists identify services offered to all residents; examples include pharmaceuticals, inpatient care, preventive medicine, outpatient specialist care, home care, primary care, and hospice care. Negative lists identify services not offered to patients, such as cosmetic surgery; services covered only on a case-by-case basis, such as orthodontics and laser eye surgery; and services for which hospital admissions are likely to be inappropriate, such as cataract surgery. Regions can offer services not included at the essential levels of care but must finance them themselves.

    Prescription drugs are divided into three tiers according to clinical effectiveness and, in part, cost-effectiveness. The first tier (classe A) includes lifesaving drugs and treatments for chronic conditions and is covered in all cases; the second (classe C) contains all other drugs and is not covered by the NHS. There is an additional tier (classe H) comprising drugs that can be delivered only in a hospital setting. The three tiers are updated regularly by the National Pharmaceutical Agency based on new clinical evidence. For some categories of drugs, therapeutic plans are mandated, and prescriptions must follow clinical guidelines.

    Dental care is generally not covered, except for children up to 16 years old, vulnerable populations, and people in economic and emergency need.

    Cost-sharing and out-of-pocket spending: Procedures and specialist visits can be prescribed either by a general practitioner (GP) or by a specialist. While there are no user charges for GP consultations and hospital admission stays, patients pay a copayment for each prescribed procedure or specialist visit up to a ceiling determined by law—currently at EUR36.15 (USD48.00). Therefore, a patient who receives two separate prescriptions (e.g., for an MRI scan and for a consultation with a gastroenterologist) pays EUR36.15 (USD48.00) for each prescription.

    To address rising public debt, in July 2011 the government introduced, along with other economic initiatives, an additional EUR10 (USD13) copayment for each prescription. Copayments have also been applied to outpatient drugs at the regional level, and a EUR25 (USD33) copayment has been introduced for “unnecessary” use of emergency services (although some regions have not enforced this copayment). No other forms of deductibles exist. Public and private providers under a contractual agreement with the National Health Service are not allowed to charge above the scheduled fees.

    All individuals with out-of-pocket payments over EUR129 (USD172) in a given year are eligible for a tax credit equal to roughly one-fifth of their spending, but there are no caps.

    In 2015, 22 percent of total health spending was paid out-of-pocket, mainly for drugs not covered by the public system and for dental care. Out-of-pocket payments can be used to access specialist care and, to a lesser extent, inpatient care delivered in private and public facilities to paying patients.

    Safety net: Exemptions from cost-sharing are applied to people under age 6 and over age 65 who live in households with a gross income below a nationally defined threshold (approximately EUR36,000, or USD48,000); people with severe disabilities, as well as prisoners, are exempt from any cost-sharing. People with chronic or rare diseases, people who are HIV-positive, and pregnant women are exempt from cost-sharing for treatment related to their condition. Most screening services are provided free of charge.

  • Japan

    Services: All Statutory Health Insurance System (SHIS) plans provide the same benefits package, which is determined by the national government, usually following a decision by the Central Social Insurance Medical Council, a governmental body. The package covers hospital, primary, specialty, and mental health care as well as approved prescription drugs, home care services by medical institutions, hospice care, physiotherapy, and most dental care. It does not cover corrective lenses unless recommended by physicians for children under age 9, or optometry services provided by non-physicians. Home care services by nonmedical institutions are covered by long-term care insurance. Preventive measures, including screening, health education, and counseling, are covered by health insurance plans, while cancer screenings are delivered by municipalities.

    Cost-sharing and out-of-pocket spending: All enrollees have to pay a 30 percent coinsurance for services and goods received, except for children up to around age 6 (20%), adults ages 70 to 74 with lower incomes (20%), and those age 75 and older with lower incomes (10%). There are no deductibles. Copayments for children's health care are often subsidized by local governments. Annual expenditures on health services and goods can be deducted from taxable income, including copayments and payments between JPY100,000 (USD952) and JPY2 million (USD19,000) for balance billing and over-the-counter drugs. In 2013, out-of-pocket payments for cost-sharing accounted for 13 percent of current health expenditures. Providers are prohibited from charging extra fees except for some services specified by the Ministry of Health, Labor and Welfare (MHLW), including amenity beds, experimental treatments, the outpatient services of large multispecialty hospitals, after-hours services, and hospitalizations of 180 days or more.

    Safety net: Catastrophic coverage stipulates a monthly out-of-pocket threshold, which varies according to enrollee age and income—for example, JPY80,100 (USD763) for people under age 70 with a modest income; above this threshold, a 1 percent coinsurance rate applies. There is a ceiling for low-income people, who do not pay more than JPY35,400 (USD337) a month. Subsidies (mostly restricted to low-income households) reduce the burden of cost-sharing for people with disabilities, mental illnesses, and specified chronic conditions. There is an annual household health and long-term care out-of-pocket payments ceiling, which varies between JPY340,000 (USD3,238) and JPY2.12 million (USD20,190) per enrollee according to income and age, above which such payments can be reimbursed. Enrollees with employer-based insurance who are on parental leave are exempt from payment of premiums. Enrollees in Citizens Health Insurance (for the unemployed, the self-employed, and retirees) who have low incomes, and those with moderate incomes who face sharp, unexpected income reductions, are eligible for reduced premium payments. Reduced coinsurance rates apply to patients with 306 designated long-term diseases, varying by income, when using designated health care providers. Some providers are allowed to reduce coinsurance for low-income people through the Free/Lower Medical Care Program. Means-tested public assistance covers health services for their beneficiaries.

  • Netherlands

    Services: In defining the statutory benefits package, government relies on advice from the National Health Care Institute. Health insurers are legally required to provide a standard benefits package including, among other things, care provided by general practitioners (GPs), hospitals, and specialists; dental care through age 18 (coverage after that age is confined to specialist dental care and dentures); prescription drugs; physiotherapy through age 18; home nursing care; basic ambulatory mental health care for mild-to-moderate mental disorders; and specialized outpatient and inpatient mental care for complicated and severe mental disorders. In case the duration exceeds three years, the last of these is financed under the Long-Term Care Act (see below).

    Some treatments, such as general physiotherapy and pelvic physiotherapy for urinary incontinence, are only partially covered for some people with specific chronic conditions, as are the first three attempts at in vitro fertilization. Some elective procedures, such as cosmetic plastic surgery without a medical indication, dental care above age 18, and optometry, are excluded. A limited number of effective health improvement programs (e.g., smoking cessation) are covered, and weight management advice is limited to three hours per year.

    As of 2015, home care is a shared responsibility of the national government, municipalities (day care, household services), and insurers (nursing care at home) and is financed through the Health Insurance Act. Hospice care is financed through the Long-Term Care Act. Prevention is not covered by social health insurance but falls under the responsibility of municipalities.

    Cost-sharing and out-of-pocket spending: As of 2016, every insured person over age 18 must pay an annual deductible of EUR385 (USD465) for health care costs, including costs of hospital admission and prescription drugs but excluding some services, such as GP visits. Apart from the overall deductible, patients are required to share some of the costs of selected services, such as medical transportation or medical devices, via copayments, coinsurance, or direct payments for goods or services that are reimbursed up to a limit, such as drugs in equivalent-drug groups. Providers are not allowed to balance-bill above the fee schedule. Patients with an in-kind insurance policy may be required to share costs of care from a provider that is not contracted by the insurance company. Out-of-pocket expenses represented 14.7 percent of health care spending in 2014 (authors’ calculation).

    Safety net: GP care and children’s health care are exempt from cost-sharing. Government also pays for children’s coverage up to the age of 18 and provides subsidies (health care allowances), subject to asset testing and income ceilings, to cover community-rated premiums for low-income families: singles with annual income less than EUR27,012 (USD32,662) and households with income less than EUR33,765 (USD40,828). Approximately 4.42 million people, or about a quarter of the total population, receive allowances set on a sliding scale, ranging from EUR2.00 (USD2.40) to EUR83.00 (USD 100.00) per month for singles and from EUR10.00 (USD 12.00) to EUR 158.00 (USD191.00) for households, depending on income.

  • Norway

    Services: Parliament determines what is covered, although there is no defined benefit package other than for new and costly treatments and technologies (see below). In practice, national health care covers planned and acute primary, hospital, and ambulatory care, rehabilitation, and outpatient prescription drugs on the formulary (the “blue list”). It also covers dental care services for children up to 18 years of age and other prioritized groups, such as people with some chronic diseases, patients with chronic mental disabilities, and patients in nursing homes. Dental care for 19-to-20-year-olds and dental orthopedics (braces) for children are partially covered. Regular glasses and contact lenses are not covered unless the vision is very limited. Cosmetic surgery is not covered.

    Primary, preventive, and nursing care are organized at the local level by municipalities. The municipality, often in cooperation with the county, decides on public health initiatives or campaigns to promote healthy lifestyles and reduce social health disparities. Preventive services for mental health are directed toward children and adolescents through the school system. Psychological care for children under the age of 18 is fully covered. Primary care for mental health is provided by general practitioners (GPs) and municipal psychologists. Long-term care, including palliative end-of-life care, is provided on the basis of need, either at home or in nursing homes. There are few designated hospice facilities. The substantial government funding for municipalities is generally not earmarked, and budgets are set locally, but provision of some services is statutory, particularly those related to pediatric and long-term care.

    Cost-sharing and out-of-pocket spending: GP and specialist visits, including outpatient hospital care and same-day surgery, require copayments (NOK152 [USD15.5] and NOK345 [USD35] per visit in 2015, respectively), as do physiotherapy visits (in varying amounts), covered prescription drugs (up to NOK520 [USD53] per prescription), and radiology and laboratory tests (NOK245 [USD25] and NOK50 [USD5], respectively). Public providers cannot charge patients more than these amounts, other than for bandages and other supplies. Consultations for children under 16 years, for antenatal and postnatal follow-up of mother and child, for prevention and treatment of some transmittable diseases, and for treatment of sexually transmitted diseases are also exempt from copayments. Hospital admissions and inpatient treatment are free. Out-of-pocket payments finance about 14 percent of total expenditure.

    Home-based care and institutional care for older or disabled people require means-tested, high cost-sharing of up to 85 percent of personal income.

    Safety net: The major safety net mechanisms are annual caps, set by Parliament, for out-of-pocket expenditure, above which fees are waived. For 2016, the cost-sharing ceiling for most services is NOK2,185 (USD223). A second ceiling, for services such as physiotherapy and certain dental services, is set at NOK2,670 (USD272). Long-term care and prescription drugs outside the blue list do not apply toward these ceilings.

    Residents eligible for the minimum retirement or disability pensions, which amount to about NOK162,000 (USD16,530) per year, receive free essential drugs and nursing care. Individuals with specified communicable diseases, including HIV/AIDS, and patients with work-related injuries receive free medical treatment and medication. Taxpayers with high expenses (above NOK9,180, or USD937) as a result of permanent illness receive a tax deduction. “Basic benefits” (NOK670–NOK3,346, or USD68–USD341 per month) may be provided, upon application, to patients who regularly incur additional expenses because of permanent illness, injury, or disability.

  • New Zealand

    Services: The publicly funded system covers preventive care; inpatient and outpatient hospital services; primary care via private providers (excluding services such as optometry, adult dental services, orthodontics, and physiotherapy); inpatient and outpatient prescription drugs included in the national formulary (see below); mental health care; dental care for schoolchildren; long-term care; home help; hospice care; and disability support services. Government sets an annual overall budget and benefit package, based largely on political priorities and health need. It also sets national requirements for publicly funded services, to be implemented by the 20 district health boards (DHBs). Rationing and prioritization are applied largely to nonurgent services and vary by DHB.

    Cost-sharing and out-of-pocket spending: Out-of-pocket payments, including both cost-sharing and other costs paid directly by private households, accounted for approximately 12.6 percent of total health expenditures in 2014, with the largest portion going to outpatient services. There are no deductibles in the public sector, although copayments are required for general practitioner (GP) services and many nursing services provided in GP clinics. The average adult copayment for a GP consultation ranges from NZD15 to NZD45 (USD10–USD31), but GP copayments vary significantly, as they have no limits. An exception applies to the one-third of New Zealanders residing in low-income areas, where a higher annual per-patient capitation rate is paid and, in return, patient copayments are capped at NZD17.50 (USD12.00) per visit. GP copayments fell during the period 2002–2008, when there were significant increases in government funding for primary care, but copayments have been increasing since then.

    For drugs prescribed by GPs and private specialists, copayments are required for the first 20 prescriptions per family per year (NZD5.00, or USD3.40, per item), after which there are none. Residents receive treatment free of charge in public hospitals, although there are some user charges, such as for crutches and other aids supplied upon discharge. There are various means-tested subsidies, resulting in some copayments for long-term care (discussed below).

    Safety net: Primary care is mostly free for children age 13 and under and is subsidized for the 98 percent of the population enrolled in the networks of self-employed providers known as primary health organizations (PHOs). PHOs include general practitioners, practice nurses, and allied practitioners. Additional PHO funding and services are available for treating people with chronic conditions and for improving access to care for groups with greater health needs. A “high-use health card” is also available, upon application, to patients who have had more than 12 GP visits in a year. Subsequent capitation payments for those patients are set at a higher level to reflect this high-utilization pattern, although patients continue to make copayments.

  • Singapore

    Services: Subsidies are available in public hospitals and polyclinics, as well as from government-funded intermediate and long-term care providers. MediShield provides low-cost insurance coverage for treatments in the subsidized wards of public hospitals and for certain outpatient care, including kidney dialysis and cancer treatment. As a catastrophic insurance program, MediShield generally does not cover primary care, prescription drugs, preventive services, mental health care, dental care, or optometry. Home hospice service is free of charge, while in-patient and day hospice services are subsidized based on means-testing. Governmental-funded home-based services, such as home medical and home nursing, home help, and senior home care, are also subsidized.

    Cost-sharing and out-of-pocket spending: The government subsidizes a portion of the cost of patient care, based on ability to pay. Copayments after subsidy can be covered by MediShield insurance or paid for using Medisave savings. After subsidy, MediShield pays between 80 percent and 90 percent of the claimable amount that exceeds the deductible for selected outpatient treatment charges claimable under MediShield; this includes, for example, kidney dialysis, chemotherapy, and erythropoietin for chronic kidney failure. Other outpatient services are fully paid from private funds or, in some cases, employer benefits. Deductibles do not apply to outpatient treatments; instead, 20 percent coinsurance is imposed. There is no annual cap on out-of-pocket spending.

    Individuals are ultimately responsible for their own health and are required to share in the cost of the health care services they use. In 2013, private spending accounted for 69 percent of total health expenditures, of which 88 percent represented out-of-pocket spending, including that covered and reimbursed by employer health insurance benefits.

    Safety net: Medifund, established in 1993, is the government-funded health care safety net for the poor. Money from the fund is disbursed each year to approved institutions, and a committee at each institution evaluates and approves financial assistance to patients. Government-funded providers can tap Medifund assistance for their patients. Medifund generally covers necessary medical treatment, including drugs, services, and tests. Medical social workers assist patients with the application process required before aid is granted. The amount of aid is determined by the patient’s and the family’s income, the social circumstances of the patient, the medical condition, and treatment costs. More than 90 percent of approved patients receive 100 percent coverage for the outstanding portion of subsidized bills they are unable to pay. MediShield premium subsidies are available for lower- and middle-income Singaporeans, with the subsidized percentage based on income and age. In 2013, Medifund’s capital endowment was more than SGD4 billion (USD4.7 billion).

    In 2013, the government set up Medifund Junior for needy children and extended Medifund to primary care, dental services, prenatal care, and delivery services.

    The ElderCare fund subsidizes care for low- and middle-income patients in intermediate and long-term care facilities. The fund’s endowment stands at SGD3 billion (USD3.5 billion).

  • Sweden

    Services: There is no defined benefit package. The publicly financed health system covers public health and preventive services; primary care; inpatient and outpatient specialized care; emergency care; inpatient and outpatient prescription drugs; mental health care; rehabilitation services; disability support services; patient transport support services; home care and long-term care, including nursing home care and hospice care; dental care and optometry for children and young people; and, with limited subsidies, adult dental care. As the responsibility for organizing and financing health care rests with the county councils and municipalities, services vary throughout the country.

    Cost-sharing and out-of-pocket spending: In 2014, about 16 percent of all health expenditures were private; of these, 97 percent were out of pocket. Most out-of-pocket spending is for drugs.

    The county councils set copayment rates, leading to variation across the country (see table below). Providers cannot charge above the scheduled fee.

    ServiceFee Range (2016)
    Swedish KronerU.S. Dollars
    Primary care physician visit150–30017–33
    Hospital physician consultation200–35022–38
    Hospitalization per day50–1005.5–11
    Source: Swedish Association of Local Authorities and Regions (SALAR), 2016.

    Nationally, annual out-of-pocket payments for health care visits are capped at SEK1,100 (USD120) per individual. In all county councils, people under age 18—and in most county councils, people under 20—are exempt from user charges for visits.

    Dental care: Dental and pharmaceutical benefits are determined at the national level. People under 20 have free access to all dental care. People 20 or older receive a fixed annual subsidy of SEK150–SEK300 (USD17–USD34), depending on age, for preventive dental care. For other dental services, within a 12-month period patients 20 or older pay the full cost of services up to SEK3,000 (USD330), 50 percent of the cost for services between SEK3,000 and SEK15,000 (USD330 and USD1,643), and 15 percent of costs above SEK15,000 (USD1,643). There is no cap on user charges for dental care.

    Prescription drugs: Individuals pay the full cost of prescribed medications up to SEK1,100 (USD120) annually, after which the subsidy gradually increases to 100 percent. The annual ceiling for out-of-pocket payments for prescriptions is SEK2,200 (USD240) for adults. A separate annual out-of-pocket maximum of SEK2,200 (USD 240) applies collectively to all children belonging to the same family. For certain prescription drugs not on the National Drug Benefits Scheme and not subject to reimbursement, patients must pay the full price.

    Safety net: In general, all social groups are entitled to the same benefits. The ceilings on out-of-pocket spending apply to everyone, and the overall cap on user charges is not adjusted for income. Some targeted groups, such as children, adolescents, pregnant women, and the elderly, are exempt from user charges or receive subsidies for certain services, like maternity care or vaccinations.

  • Taiwan

    Services: National Health Insurance (NHI) benefits are uniform and comprehensive. They include inpatient and outpatient care (both primary and specialist care), prescription drugs, dental care (excluding orthodontics and prosthodontics), traditional Chinese medicine, child birth care, physical rehabilitation, home care, chronic mental health care, and end-of-life care.

    The National Health Insurance Administration (NHIA) determines which services are covered in consultation with a broad spectrum of stakeholders. Coverage decisions are subject to considerations of their budget impact (see below).

    Cost-sharing and out-of-pocket spending: The NHIA mandates copayments for physician visits and prescription drugs, and coinsurance for inpatient care, subject to limits and exemptions (discussed below). Copayments for care obtained without referral are higher. Copayments range from NTD80 (USD2.58) to NTD360 (USD12), depending on the level of the hospital visited.

    Coinsurance for inpatient care varies by length of stay and type of bed (acute or chronic). For example, the coinsurance rate for an inpatient stay shorter than 30 days is 5 percent for chronic beds and 10 percent for acute beds. In 2015, the coinsurance limit for an episode of care was USD1,063 (NTD33,000) and USD1,803 (NTD56,000) for an inpatient stay for the same illness or condition.

    In 2014, out-of-pocket health care spending, as officially reported, accounted for 34.7 percent of total national health expenditures. However, this overstates what the Organisation for Economic Co-operation and Development (OECD) counts as out-of-pocket spending, as Taiwan includes spending on items not included in OECD data, such as infant formula, baby diapers, dietary supplements, health foods, Chinese herbal medicine, private hospital rooms, cosmetic surgery, and high-tech surgical procedures. According to a former NHIA administrator, out-of-pocket spending associated with necessary health care, including medical care, dental care, and prescription drugs, amounted to 12.1 percent of Taiwan’s national health expenditures in 2012, a figure more in line with the OECD norm.

    Safety nets: The NHI provides a generous safety net for disadvantaged populations, including the very sick, that ensures access to needed services. Outpatient copayments for people with physical or mental disability are limited to NTD50 (USD1.61). Copayments are also reduced for elderly adults with chronic disease who are enrolled in the Hospital Patient-Centered Integrated Care Plan. In addition, copayment exemptions apply to childbirth and 30 catastrophic diseases and conditions, as well as to residents of remote and mountainous areas and offshore islands, veterans, families of diseased veterans, low-income households, children under age 3, tuberculosis patients, and others. Since 2013, for residents of underresourced areas, copayments were reduced by 20 percent, and copayments for home care were halved, from 10 percent to 5 percent for residents of underserved areas and for those who have difficulty traveling to providers for care.

    Those living in remote and mountainous areas and off-shore islands also have access to needed services through the Integrated Delivery System.

    The NHIA also provides insurance premium subsidies. For example, it pays 100 percent of premiums for low-income households, military personnel, veterans, civil servants (including public school teachers), and convicts; 70 percent for dependents of veterans and members of farmer, fishermen, and irrigation associations; and 35 percent for private school teachers.

    Finally, to protect the right to care of people with Ministry of Health and Welfare (MoHW)–recognized rare diseases, the NHIA waives copayments for all drugs necessary to keep them alive.

  • United States

    Services: The Affordable Care Act (ACA) requires all health plans offered in the individual insurance market and small-group market (for firms with 50 or fewer employees) to cover services in 10 essential health benefit categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health services and substance use disorder treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including dental and vision care. Each state determines the range and extent of specific services covered in each category by selecting a benchmark plan that covers all 10 categories; most states choose one of the largest small-group plans as the benchmark. Specific covered services vary somewhat by state.

    Private insurance plans sometimes use narrow networks of providers, with limited or no coverage if patients receive out-of-network care. Private coverage for dental care and optometry is also available—sometimes through separate policies—as is long-term care insurance. Private health insurance is required to cover certain preventive services (with no cost-sharing if provided in-network).

    Medicare provides coverage for hospitalization, physician services, and, through a voluntary supplementary program, prescription drugs. The program also has eliminated cost-sharing for a number of preventive services. Medicare offers a choice between “traditional” Medicare, which is open-network and pays predominately on a fee-for-service basis, and Medicare Advantage, under which the federal government pays a private insurer for a network-based plan. Medicare covers post-acute care but not long-term care, while Medicaid offers more extensive long-term care coverage (see below). In addition, Medicaid covers a broad range of core services, including hospitalization and physician services, with certain optional benefits varying by state.

    Cost-sharing and out-of-pocket spending: Cost-sharing provisions in private health insurance plans vary widely, with most requiring copayments for physician visits, hospital services, and prescription drugs. High-deductible health plans—those with a minimum annual deductible of USD1,250 per individual or USD2,500 per family—can be paired with tax-advantaged health savings accounts (i.e., deposited funds are not subject to federal income tax). The ACA includes cost-sharing subsidies for the purchase of plans through the insurance exchanges, with the largest subsidies aimed at people with incomes between 100 percent and 250 percent of the federal poverty level (USD20,090 for a family of three, as of 2015). In the last open-enrollment season, 57 percent of people who selected plans in the federally facilitated marketplaces had cost-sharing subsidies.

    Medicare requires deductibles for hospital stays and ambulatory care and copayments for physician visits and other services, while Medicaid requires minimal cost-sharing. Most public and private insurers prohibit providers from balance billing—charging patients more than the copayment required by their insurance plan—if they have an agreement with the payer to accept their set or negotiated payment amounts. Out-of-pocket spending accounts for 11 percent of total health expenditures in the United States. Cost-sharing for most private insurance plans is capped at USD6,850 for individuals and USD13,700 for families per year for 2016 and USD7,150 for individuals and USD14,300 for families for 2017.

    Safety nets: A variable and patchwork mix of organizations and programs deliver care for uninsured, low-income, and vulnerable patients in the United States, including public hospitals, local health departments, free clinics, Medicaid, and the Children’s Health Insurance Program (CHIP). Under the ACA, 32 states and the District of Columbia expanded Medicaid coverage to cover individuals with incomes up to 138 percent of the poverty level. Premium and cost-sharing subsidies are also available to low- and middle-income individuals through the insurance exchanges or marketplaces, with health plan premium subsidies offered to those at 133 percent to 400 percent of the poverty level and cost-sharing subsidies offered to those at 100 percent to 250 percent of poverty. Hospitals that provide care to a high percentage of low-income and uninsured patients receive disproportionate share hospital payments from Medicare and Medicaid to partially offset their uncompensated care. The federal government also funds community health centers, which are a major source of primary care for underserved and uninsured populations. In addition, private providers are a significant source of charity and uncompensated care.