h-well National Health Insurance Service

Health Insurance System

1. Objectives
   • Resolve the medical expense problem. → Protect public health and household budgets.
   • Redistribute income and disperse risk. → Strengthen social solidarity and promote social integration.
2. Function and Role
   • Social solidarity
   • Sharing health care expenses reasonably and providing insurance benefits equally.
   • Risk dispersion and income redistribution
3. Features
   • Compulsory Insurance: Compulsory subscription by the law
   • Short-term insurance: Increase in annual financial balance and short-term payment
   • Contribution payment according to the level of household’s income and property
   • Equal Insurance Benefits
   • Compulsory collection of contribution

The Governance of Korean Health Care System

The Ministry of Health and Welfare supervises the operation of the NHI program through making and implementing policies.
As a non-profit institution, the National Health Insurance Service is a single insurer that provides health insurance to all citizens living in Korea. The NHIS is responsible for operating a health insurance program including

• Managing the eligibility of the insured
• Collecting Insurance Contribution
• Making the medical service (insurance benefit) fee contract with representatives of health care providers
• Providing health Insurance Benefits

The Health Insurance Review & Assessment Service (HIRA) evaluates the medical service fee, quality of health care, and adequacy of medical service.
All Koreans except those belonging to the lower-income group enroll to the compulsory health insurance. Healthcare providers may not refuse to treat NHI patients, and all enrollees should pay the contributions monthly.

Governance of NHI

Health Care Delivery System

Care Benefit Process

1. The health care delivery system is introduced to utilize medical resources efficiently(to limit patients’ herd behavior to seek tertiary hospital services), establish the roles of medical institutions, and help curb the rise in national medical expenditures and to secure financial sustainability.
2. Health care benefits are delivered by 2 phases.
3. 1st phase of care benefit means the benefit from health care institutions(such as a clinic, a hospital, and a general hospital) except tertiary hospitals (specialized general hospitals).
   2nd phase of care benefit means the benefit from tertiary hospitals.

   Tertiary general hospital

   Tertiary general hospital table

   Area	Total	Upper-level general hospital
   Seoul	14	Catholic university of Korea Seoul St. Mary’s hospital, Gangbuk Samsung Medical Center, Konkuk university Medical Center, Kyunghee univ Medical Center, Korea university Guro Hospital, Korea university Medical Center, Samsung Medical Center, Seoul National University Hospital, Asan Medical Center, Gangnam Severance Hospital, Yonsei University Severance Hospital, Ewha Women’s University Mokdong Hospital, Chung Ang University Hospital, Hanyang University Hospital
   Gyeonggi North western area	4	Catholic University of Korea Incheon St. Mary’s Hospital, Gil Hospital, Soon Chunhyang University Hospital Bucheon, Inha University Hospital
   Gyeonggi southern area	4	Korea University Ansan Hospital, Seoul National University Bundang Hospital, Ajou University Medical Center, Hallym University Sacred Heart Hospital
   Gangwon	1	Yonsei University Wonju Christial Hospital
   Chungbuk	1	Chungbuk National University Hospital
   Chungnam	3	Dankook University Hospital, Chungnam National University Hospital, Soonchun hyang University Hospital Cheonan
   Cheonbuk	2	Wonkwang University Hospital, Chonbuk National University Hospital
   Cheonnam	3	Cheonnam National Uinversity Hospital, Chosun University Hospital, Cheonnam National Uinversity Hwasun Hospital
   Gyeongbuk	4	Gyeongbuk National University Hospital, Keimyung University Dongsan Medical Center, Daegu Catholic University Medical Center, Yeongnam University Medical Center
   Gyeongnam	7	Gyeongsan National University Hospital, Kosin University Gospel Hospital, Dong-A University Hospital, Busan University Hospital, Yangsan Busan University Hospital, Ulsan University Hospital, Inje University Busan Paik Hospital

4. The Exceptions of the Referral system (Care Delivery Process)
   1. When patients with severe conditions under the ‘Emergency medical treatment Article 2-1’, can get the health care benefit in the tertiary hospital
   2. When a patient gives birth to in the tertiary hospital
   3. When a patient get a dental health care benefit
   4. When the following persons receive health care benefit at the department of rehabilitation and medical treatment:
      • Disabled persons under article 32 of ‘the disabled’s welfare law’ or
      • Persons who acknowledged to need rehabilitation treatments such as, vocational treatment or kinesiatrics, etc (not simple physical therapy)
   5. When receives health care benefit at the department of the family medicine.
   6. When a patient is an employee of the tertiary hospital
   7. When a hemophiliac patient receives health care benefits in the tertiary hospital.
5. For the 2nd phase of care benefit, the patient must present a referral slip issued by the doctor who saw the patient first. The referral slip must include the fact that the benefit beneficiary needs the 2nd phase of care benefit from a tertiary general hospital. Issuing a doctor’s referral slip based on a health care delivery system enables appropriate treatment according to the doctor’s decision at the 1st primary care institution; thus aiding in the effective management of medical resources. Issuing a doctor’s referral slip at a patient’s request is never allowed because it is against the primary purpose of the health care delivery system.
6. When receiving medical treatment against the care delivery process the health care delivery system, the patient must pay the entire care benefit expense (co-payment: 100% of total expenses) pursuant to Article 10 of the enforcement regulations of the National Health Insurance Act.