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The NHI copayment system was designed to avoid waste, without affecting access to medical care for those truly in need. Since the NHI inception, the copayments for outpatient and emergency care have been adjusted multiple times. The NHIA has used copayments as a means to guide medical resource utilization to ensure that hospitals and clinics at different levels focus on their respective duties.

Adjusting Copayments and Realizing Two-way Referrals

To encourage persons with minor illnesses to seek care at local clinics, and obtain referral to regional hospitals, medical centers, and other larger hospitals only when further examination or more advanced treatment is needed. On July 15, 2005, the NHIA modified the copayment and referral system whereby basic outpatient copayments were revised and copayments will not increase if patients conform to referrals. Under these measures, the basic copayment for attending a western medicine outpatient clinic at a hospital depends on whether or not an individual has a referral. If people seek care directly at a medical center, regional hospital, or district hospital without a referral, they will be subject to higher copayments.

However, such copayments are waived in cases of major illness and injury, child delivery, those who seek care in mountain and offshore island areas, and other cases complying with NHIA regulations.

Starting in June 2016, the NHIA has reinforced referral system in an effort to encourage the public to first seek care at primary care level hospitals and clinics, and if needed, they would be referred to an appropriate specialist hospital department or clinic for further care. This approach will enable large hospitals to devote their full attention to treatment of serious illnesses and medical research, while making primary level hospitals and clinics the frontline of primary care. The revised basic copayment schedule for Western medicine outpatient care announced by the NHIA on April 15, 2017 reduced copayments for referrals to medical centers and regional hospitals by NT$40, and increased copayments for medical care at a medical center without a referral by NT$60. Furthermore, copayments for emergency care are now charged depending on triage grade. These measures ensure the realization of two-way referrals.

In order to benefit areas with limited medical resources, where it may be difficult to seek care outside, people living in such areas enjoy 20% reduction in copayments, and the copayment rate for home health care has been reduced to 5% from the original 10%.

Family Doctors and Community Pharmacies

To ensure that the insured can obtain comprehensive and continuing medical care near their homes, the NHIA introduced the “NHI Family Doctor Plan” in March 2003. Under this plan, five or more NHI-contracted western medicine clinics in the same area can join with a community hospital to form a community health care group. As long as they take a doctor at a primary-level clinic near their home as their family doctor, people can obtain front-line healthcare. Family doctors should ordinarily serve as preventive healthcare consultants, and should bear responsibility for gathering medical data and providing 24-hour health consulting service hotlines. If patients’ conditions warrant surgery, further examination, or hospitalization, their family doctors can provide referrals. The family doctor system is intended to save the time and money involved in the process of seeking healthcare.

As of the end of June 2021, 623 community healthcare groups were operating, with 5,587 primary level clinics participating, which represented a participation rate of 53.1%, 7,637 doctors were participating, for a participation rate of 46%, and more than 6.01 million persons benefited from community healthcare groups.

With regard to pharmacy services, individuals can obtain medication from a contracted pharmacy upon presentation of a prescription from a contracted hospital or clinic. If patients have any questions about their prescription, they can ask their pharmacist or assistant pharmacist at a pharmacy to provide usage and health consulting services. Pharmacies not only keep tabs on the public’s medication safety, but also provide the public with correct medication usage knowledge.