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National health insurance service

National Health Insurance System

National Health Insurance Corporation

Medical Treatment Delivery System

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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
    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
    North western area
    4 Catholic University of Korea Incheon St. Mary’s Hospital, Gil Hospital,
    Soon Chunhyang University Hospital Bucheon, Inha University Hospita
    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 Hospita
    Kyungbuk 4 Kyungbuk National University Hospital,
    Keimyung University Dongsan Medical Center,
    Daegu Catholic University Medical Center,
    Yeongnam University Medical Center
    Kyungnam 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.