What is Covered and How You Pay for Medical Expenses
This section provides information on your benefits under the National Health Insurance Plan and explains the payment system. Please read the other sections on this topic to ensure that you are fully informed.
What Is Covered and How Much is Covered?
Patients are given almost unconstrained freedom in choosing providers and can choose both western and oriental medicine. The third-party payment system has been adopted for reimbursing health care institutions for their medical services and providers are paid mainly by fee-for-service. With regards to administration of the NHI program, NHIC, the unique insurer, is responsible for operating the program, the Health Insurance Review Agency (HIRA) is in charge of reviewing claims of providers, and the Ministry of Health and Welfare supervises the operation of the NHI program as a whole. You have the freedom to choose your Health Care Provider. An Employer cannot dictate which Health Care Provider you use and if the Employer does so then it is time to review your Health Insurance Plan. If the Employer is insisting that you go to specific Health Care Providers you are not enrolled in the National Health Insurance Program and you have further limitations that you should be made aware of.
Restrictions and Suspension of Benefits
For the purpose of maintaining financial stability and appropriate standardization of benefits, the NHI program has some limiting conditions.
Restrictions of Benefits
The insured cannot get insurance benefits if coming under one of the following cases: when injury was caused due to deliberate or criminal actions; when the insured person intentionally violates the instructions for health care of medical institutions or the NHIC ; when the insured person intentionally avoids answering a question or getting a diagnosis; or when the insured person has already been compensated for the injuries or diseases that happened at work by other insurance programs like Industrial Accidents Compensation Insurance. Industrial Accidents Compensation Insurance is automatically required by every Employer and does not require a contribution by the Employee. It covers accidents that happen at work or diseases that are caused by the work environment.
Suspension of Benefits
During travel or work abroad, or when in the care of correctional institutions, health care benefits are suspended. If you are traveling outside of Korea make sure you get travel insurance due to the fact that NHIC will not cover any medical costs outside of the Republic of Korea.
The National Health Insurance Program is a Co-Payment Program with a Maximum Co-Payment ceiling of 3 Million WON over a period of 6 months. The Co-Payment rate for Inpatient care is 20%, the Co-Payment for Outpatient care is 40% at Hospitals and 50% at General Hospitals. Dental Hospitals and Clinics have a Co-Payment rate of 30%. The procedures covered are basic healthcare, cosmetic procedures are not covered. Private Insurance companies offer additional coverage that reduces the Co-Payment and some procedures not covered by the National Health Insurance Program.
Persons who receive health care treatments pay certain portions of the health care costs as co-payments pursuant to Article 41 of the National Health Insurance Act. In order to curtail overuses of health care services, and lessen the concentration of medical services in large urban hospitals, the co-payment for outpatient and in-patient services have been set differently according to the level and type of medical care institutions.
In-patient Medical Services
When a patient is admitted to a clinic, a hospital or a general hospital, the patient is required to pay 20% of the total medical charges for the in-patient care.
Outpatient Medical Services
Co-payments for out-patient cares vary depending on the level of health care facilities or the total amount of service charges. For outpatient services provided at a clinic, a patient must pay 3,000 WON when the total charges do not exceed 15,000 WON (at a dental clinic; 3,500 WON). An elderly patient, however, pays only 1,500 WON in this case. When exceeding 15,000WON, a patient has to pay 30% of the total charges including the diagnosis fee regardless of ages. For outpatient services provided at a hospital or a general hospital, 40% or 50%, respectively, of the total charges is paid for co-payments. In case of visiting hospitals or general hospitals in remote and rural areas, patients pay 4,100 WON or 4,600 WON, respectively if not exceeding 15,000 WON. If exceeding 15,000 WON, 35% or 45% of total costs, respectively has to be paid. However, at a specialized general hospital a patient has to pay 50% of the total charges, excluding the diagnosis and consultation fee.
The following table is from The National Health Insurance Program of Korea, 2007 available at the English NHI website.
Type of Medical Institution
|Specialized General Hospital||All Areas||Total Amount of Consultation Fee + 50% of Total Health Care Costs|
|General Hospital||Urban Areas||50% of Total Health Care Costs|
|Rural Areas||Exceeding 15,000 won: 50% of Total Health Care Costs Not Exceeding 15,000 won: 4,600 Won|
|Hospital Dental Hospital Oriental Hospital||Urban Areas||40% of Total Health Care Costs|
|Rural Areas||Exceeding 15,000 won: 35% of Total Health Care Costs|
|Not Exceeding 15,000 won: 4,100 Won|
|Exceeding 15,000 won: 30% of Total Health Care Costs|
|Clinic Oriental Clinic Public Health Center||All Areas||Not Exceeding 15,000 won: 3,000 won(aged less 65 years) 1,500 won(aged 65 years and over)|
|Dental Clinic Public Health Center (Dental)||All Areas||Exceeding 15,000 won: 30% of Total Health Care Costs Not Exceeding 15,000 won: 3,000 won(aged less 65 years) 1,500 won(aged 65 years and over)|
|Exceeding 10,000 Won: 30% of Total Health Care Costs|
|Pharmacy||With Prescription||Not Exceeding 10,000 won: 3,000 won(aged less 65 years) 1,500 won(aged 65 years and over)|
|Exceeding 4,000 won: 40% of Total Health Care Costs|
|Without Prescription||Not Exceeding 4,000 won: 1,400 won(Medicine for 1 Day) 1,600 won(Medicine for 2 Days) 2,000 won(Medicine more than 3 Days)|
Note: The rates are adjusted each Spring to reflect any changes in salary, bonuses, etc. since they are based on a percentage of earnings. This adjustment will be reflected in the April contribution. The April increase (should there be one) is not part of the annual contribution rise; it is a reflection of a rise in the contributor's income. The increase also occurs if the employer declared a lower salary over the past year than what was actually paid and is based on each employee's year-end tax settlement (end March). Should the salary be lower than what was declare, the contributor's rate will decrease in April.
For more information and additional details on the health insurance plan and how it may affect you, scroll down and click on the various topics listed.
Contact NHIC: English helpline 02-390-2000 or NHIC website.
K4E Editor: We try to make the information on Korea4Expats.com as complete and accurate as possible, so if you notice any errors or omissions in the content above, please let us know at firstname.lastname@example.org.
Last Updated on 2017-01-10
|In the same header|
|Apply for National Health Insurance||Health Insurance for Foreign Residents|
|How You Get Korean Medical Coverage||Intro to Korean Health Insurance|
|What is Covered and How You Pay for Medical Expenses|
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