To ensure that the insured persons are able to access NHI benefits when they suffer from unexpected injuries or illness overseas, the insurer has set up maximum limits for the Reimbursement of Self-Advanced Medical Expenses Occurred Overseas. The limits are determined based on the average expenses incurred in NHI contracted medical centers in Taiwan during the previous quarter from emergency treatments (per person/instance), outpatient services (per person/visit), and in-patient hospitalizations (per person/day), and shall be announced by the Bureau of National Health Insurance(BNHI) on a quarterly basis. Utilizing the actual amounts declared by the domestic NHI contracted medical centers for the third quarter of 2010, the Bureau of National Health Insurance has announced the maximum limits for the reimbursement of self-advanced medical expenses for the first quarter of 2011: NT$1,619 for outpatient services (per visit), NT$2,928 for emergency treatment (per instance) and NT$7,118 for hospitalizations (per day), NT$3,525 for routine blood dialysis (per instance) and NT$3,598 for blood dialysis for acute or severe diseases (per instance). If the reimbursement amount claimed by the beneficiary is lower than the maximum limit, the reimbursement shall be made according to the actual amount advanced. The relevant regulations and application forms for reimbursement can be accessed/downloaded by visiting the Bureau of National Health Insurance regional divisions' website and looking under “Download Areas” for ” Instructions for NHI Prepaid Medical Expense Refund Application Form ”.
According to Article 6 of the “Regulations for National Health Insurance Reimbursement for Self-Advanced Medical Expenses”, if the medical services are received at places outside of the NHI coverage area, the BNHI shall reimburse the medical expenses based on the actual insurance payment. The BNHI, however, shall not reimburse the part in excess of the average expenses (i.e., emergency care per person/instance, outpatient services per person/visit, and hospitalizations per person/day) declared by the NHI contracted medical centers for the quarter preceding to the date when the emergency care or outpatient service takes place, or when the patient checks out from the hospital. The maximum limits for the reimbursement shall be announced by the Bureau of National Health Insurance on a quarterly basis.
The BNHI has calculated the average expenses (i.e., emergency care per person/instance, outpatient services per person/visit, and hospitalizations per person/day) paid to the NHI contracted medical centers and announced the maximum limits for the reimbursement of self-advanced medical expenses for the first quarter (January to March) of 2011: NT$1,619 for outpatient services (per visit), NT$2,928 for emergency treatment (per instance), NT$7,118 for hospitalizations (per day), NT$3,525 for routine blood dialysis (per instance) and NT$3,598 for blood dialysis for acute or severe diseases (per instance). Except for blood dialysis, all maximum limits have been raised in the first quarter of 2011 when compared with the previous quarter, i.e., increases of NT$29 in the limit for outpatient services (per visit); NT$174 for hospitalizations (per day); and NT$58 for emergency treatment (per instance).
Furthermore, the NHI has incorporated copayment design with the aim of providing the most effective and highest quality medical services to all insured while simultaneously preventing waste of limited resources. To avoid creating excessive financial burdens on the insured due to frequent hospitalizations, there are also a ceiling for both one-time copayment and the copayment for a period of one year. The goal is to offer the most adequate medical care to all insured.
The coinsurance ceiling is determined according to regulations based on the average national income per capita of the most recent year, which is reviewed annually. The coinsurance ceiling for the following year is normally announced at the end of the year. The new ceiling to take effect on January 1, 2011, as announced recently, is NT$28,000 for one instance of hospitalization (for the same disease) and NT$47,000 for a period of one year. Both amounts have been lowered by NT$1,000.
Pursuant to Article 35 of the National Health Insurance Act regarding the copayments standards, the co-insurance rate is 10% for hospitalization within 30 days which is caused by acute disease and 5% for hospitalization within 180 days for chronic disease, respectively. The co-insurance rate shall be increased when additional days of hospitalization are required. The coinsurance ceiling is 30%. Furthermore, in accordance with Article 64 of the Enforcement Rules of the National Health Insurance Act, the maximum expense for the beneficiary for coinsurance of hospitalization shall be six percent of the average national income per capita for one instance of hospitalization or ten percent of the average national income per capita for a period of one year regardless of whether it is the same illness.
According to the data published on November 18, 2010 by the Directorate General of Budgeting, Accounting and Statistics, the Executive Yuan, the average national income per capita for the most recent year (2009) was NT$471,797. The coinsurance ceiling of hospitalization is therefore NT$28,308 for one instance (i.e., 6% of NT$471,797) and NT$47,180 for a period of one year (i.e., 10% of NT$471,797). The ceilings for both have been lowered by NT$1,000 to reduce the financial load of insurance participants in response to the slight decrease in national income in 2009 compared with 2008. As a result, the coinsurance ceiling for hospitalization is NT$28,000 for one instance (for the same disease), and NT$47,000 for a period of one year, respectively.