Co-payment of expenses
Example of the rate of co-payment- For hospitalized treatment
· The patient will bear 50/100 ofthe expenses of his/her meals [meal expenses during the patient’shospitalization period (including extra costs spent on additional elementsinfluencing the quality and service of meals provided to the hospitalizedpatient (hereinafter referred to as “Additional Meal Expenses”)] added to 20/100of the total expenses of health care benefits (excluding the expenses of mealsand dental treatment for the disabled as determined and announced by theMinister of Health and Welfare) [Article 44(1) of the National Health InsuranceAct and Article 19(1) and subparagraph 1(a)1 of the Attached Table 2 of the Enforcement Decree of theNational Health Insurance Act].
· However, suppose the insuredreceives medical treatment in a hospital ward in the department of psychiatryfor two, three, or four patients, or a hospital ward in a general hospital fortwo, three, or four patients reported by a high-ranking general hospitalaccording to Article 43 of the National Health Insurance Act. In this case, theinsured shall pay 50%, 40%, 30% of the hospital bill, respectively. Or, theinsured may receive medical treatment in a general hospital ward for two orthree patients, or a hospital ward in the department of psychiatry for two orthree patients reported by a general hospital, hospital, oriental medicinehospital, or nursing hospital (limited to nursing hospitals defined as amedical rehabilitation facility under subparagraph 4 ofArticle 58(1) of the Act on Welfare of persons With Disabilities andmeet the qualifications under Article 3-2 of the Medical Service Act) and psychiatric hospitals. In this case, theinsured shall pay 40% or 30% of the hospital bill, respectively, and 10% whenstaying at an isolation hospital ward determined and notified by the Ministerof Health and Welfare (Article 44(1) of theNational Health Insurance Act and Article 19(1) andsubparagraph 1(a)1 of the Attached Table 2 ofthe Enforcement Decree of the National Health Insurance Act).
- If a patient is fit to be admitted to medical facilities or outpatient treatment
· Among those receiving inpatient treatment at a care hospital under the “Medical Act”, if the patient falls under the group of patients determined and announced by the Minister of Health and Welfare as a person suitable for admission to a care hospital or for outpatient treatment, rather than inpatient treatment, he/she will be required to pay 1/2 of the meal expenses during his/her hospitalization added to 4/10 of the total cost of health care benefits [Article 44 (1) of the “National Health Insurance Act”, Article 19 (1) of the “Enforcement Decree of the National Health Insurance Act” and attached Table 2, Subparagraph 1 A Item 2 ].
- For the preparation of medicine under a prescription
· In the case of dispensing medicines according to a prescription issued by a doctor or dentist who provided treatment, the person will bear 30/100 of the total cost of health care benefits [Article 44 (1) of the “National Health Insurance Act” and Article 19 (1) and attached Table 2, Item 1 (c) 1 of the “Enforcement Decree of the National Health Insurance Act”].
√ At this time, if a self-employed insured aged 65 or older has medication dispensed according to a prescription, the co-payment payable by that person is as follows [Article 19 (1) and attached Table 2, Subparagraph 1 C item 1 of the “Enforcement Decree of the National Health Insurance Act” and Article 13 and attached Table 4 No. 1 of the “Enforcement Rule of the National Health Insurance Act”]:
① If the total cost of health care benefits does not exceed 10,000 won: 1,000 won
② If the total cost of health care benefits exceeds 10,000 won, but does not exceed 12,000 won: Total cost of health care benefits X 20/100
Q. I did not feel well, so I went to a hospital nearby my house, and I was told that I should receive a detailed diagnosis at a tertiary general hospital. What kind of hospital does the tertiary general hospital mean?
A. A tertiary general hospital is a general hospital that specializes in highly difficult medical treatment for serious diseases among general hospitals that satisfy certain requirements.
A tertiary general hospital has more than 20 medical departments as set out in the Rules on Designation and Evaluation of Tertiary General Hospitals, has exclusive specialists at each department, and has workforce, facilities, equipment, etc., as prescribed under the Medical Act (Article 3-4 (1) of the “Medical Act”).
Payment mode- The co-payment is paid by the person receiving health care benefits at the request of the health care institution (the former part of Article 19 (2) of the “Enforcement Decree of the National Health Insurance Act”).
※ What is the diagnosis-related group payment system?
The diagnosis-related group payment system (DRG) refers to a medical cost payment method which groups inpatients undergoing similar treatment processes together and sets a single price for the entirety of treatments. Under the DRG, a patient is only required to pay a pre-determined amount of medical cost depending on which disease he/she was hospitalized for, regardless of the type or amount of medical services.
The DRG includes inpatient treatment for lens surgery (cataract surgery), tonsil and adenoid surgery, anal and perianal surgery (hemorrhoid surgery), inguinal and femoral hernia surgery (excluding newborns), appendectomy (appendicitis surgery), uterine and appendage surgery (excluding malignant tumor) and cesarean delivery.
Payment of the excess amount by the National Health Insurance Service- If the total amount of co-payments annually exceeds the upper limit of co-payment according to the attached Table 3 of the “Enforcement Decree of the National Health Insurance Act”, the National Health Insurance Service will pay the excess amount (Article 44 (2) of the “National Health Insurance Act” and Article 19 (4) of the “Enforcement Decree of the National Health Insurance Act”).