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Table 3 Key Out-of-Pocket Payment Requirements in the most Recent Year, by Country. This annex contains a table presenting a full description of all out-of-pocket payment requirements in the ten high-income countries studied in this paper

From: Revisiting out-of-pocket requirements: trends in spending, financial access barriers, and policy in ten high-income countries

  Depth Scope Breadth
  Deductibles Co-insurance and co-payments Extra-billing and reference prices Protection mechanisms   
Australiaa none - specialist ambulatory care: 15% co-insurance
- prescriptions: co-payment: AUD38.30
- hospital care: 25% co-insurance at private hospitals
- physicians may bill above fee schedule
- private hospitals may bill above fee schedule
- prescriptions: reduced co-payment for low-income and children: AUD6.20 + cap at AUD372; others: cap at AUD1,476 after which low-income co-payment applies.
- ambulatory care: co-insurance cap AUD447; cap on OOP for extra billing at AUD648 for low income and children and AUD2,030 for others (80% of costs are covered after reaching the cap)
excluded services: adult dental care, OTC drugs
VHI exists for excluded services and private hospital care
universal coverage,
+ VHI held by about 50%
Canada - for prescriptions (depending on province) - prescriptions (depending on province): co-payment or co-insurance - not allowed - prescriptions: provincial regulations determine OOP caps and exemptions
- low income: various provincial programs cover OOP costs
- tax credits for individuals whose medical expenses exceed 3% of annual income
Excluded services (depending on province): prescriptions, vision, dental care, home care, rehabilitation, medical devices/aids
VHI exists for many of the excluded services
universal coverage,
+ two thirds with VHI
Englandb none - prescriptions: co-payment GBP8.40
- dental care: GBP19.70, 53.90, or 233.70, depending on type of service
- none -exemptions: children, low income, certain diseases, + for prescriptions and eye tests also aged 60+
- annual cap on prescriptions co-payment (prepayment certificate): GBP104
Excluded services:
- private services
- vision aids, eye tests
universal coverage
France none - physician visits: 30% co-insurance + €1 co-payment per visit and lab test/x-ray
- prescriptions: 15–100% co-insurance + €0.5 co-payment/pack
- inpatient care: co-insurance: 20% + co-payment €18/day
- dental care: co-insurance (30%) + co-payment €1
- additional co-payment for expensive care (>€120): €18 (once per visit or stay)
- 20% of physicians bill above fee schedule
- reference prices exist for dental care, glasses, dentures, hearing aids (covering as little as 10% of costs)
- children exempted from co-payments
- patients with one of 32 severe chronic diseases exempted from co-insurance
- low income (10% of population) receive free VHI, free vision care, free dental care
- complementary VHI covers co-insurance
- hospital co-payment limited to 31 days
- €50 caps on co-payments each for physician visits, prescriptions, and dental care
none universal coverage,
+  95% with complementary VHI
Germanyc None - prescriptions and medical aids: 10% co-insurance (min €5, max €10) per prescription
- Hospital co-payment: €10 per day
- Home nursing, physiotherapy, etc.: 10% co-insurance + €10 per prescription
- Reference prices exist for crowns and dentures (covering about 50% of normal treatment), prescriptions, and medical aids. Exemption: Children under age 18;
Maximum cost-sharing (does not apply to OOP above reference prices): 2% of annual income (1% for patients with chronic conditions)
excluded services: OTC drugs, certain services of uncertain benefit or unfavourable cost-effectiveness. universal coverage; 10% covered by substitutive VHI
Netherlands - €385 for all services except primary care - 20-25% co-insurance for non-contracted care (only for benefits in-kind insurance policies) - prescriptions: OOP above reference price
- medical devices and aids: OOP above reference prices
deductible exemption: children < 18, maternal care, integrated care programs excluded services: adult dental care, certain prescriptions (statins, ASS, benzos), physiotherapy universal coverage
Norwayd None co-payments:
- primary care: NOK 152/201
- specialist care: NOK 345
- physiotherapists: NOK 98–300
- psychologist: NOK 345–1035
- dental care for 19–20 years: 25% in co-payment if services are provided by public providers
- prescriptions: 39% of full price if on the “blue list” (max NOK 520/prescription)
- radiology: NOK 245/exam
- lab test: NOK 54
- extra billing of services/materials used that are excluded from statutory coverage (this is not included in cap 1 or 2) such as bandage, consumables - children under age 16 exempted from co-payments, up to 18 years for dental care
- Cap 1: max 2205 NOK during a calendar year covering primary and specialist care, radiology and “blue list” prescriptions
- Cap 2: max 1990 NOK during a calendar year covering physiotherapists, some dental care for adults (predefined conditions), some rehab, and treatment abroad when referred by Oslo university hospital
- tax deductions for patients with medical expenses above NOK 5880
excluded services: adult dental care (with some exceptions for a few predefined conditions), prescription drugs not covered by the “blue list”, services provided by non-contracted providers, services provided or devices/materials used that are excluded from statutory coverage (e.g. bandages, consumables) universal coverage
Swedene - prescriptions: 1100 SEK (for adults> 18)
- dental care: 3000 SEK (for adults > 22)
co-payments (varying across the 21 county councils):
- primary care: 120–200 SEK per physician visit
- specialist care: 200–350 SEK per physician visit (reduced if referred from primary care)
- hospitalization: 100 SEK/day for adults> 19
- medical devices/aids: co-payment for different types of devices/aids
co-insurance (determined at national level):
- prescriptions: 50% between 1100 and 2100 SEK, 25% between 2100 and 3900 SEK, 10% between 3900 and 5400 SEK (max 2200 in co-payments for each 12 month period)
- dental care: 50% between reference prices of 3000 and 15,000 SEK, 15% for reference prices above 15,000 SEK (applies for each 12 month period)
- dental care: OOP above reference prices
- medical devices/aids: OOP above reference prices; extra billing for medical devices/aids not covered in some county councils (e.g. multifocal lenses in cataract surgery, advanced hearing aids)
General exemptions:
- children and young adults < 22 for dental care, < 18 for prescription drugs, < 20 for health services
Two separate co-payment caps for each 12 month period:
- visits to primary and outpatient specialist care combined: 1100 SEK
- prescription drugs: 2200 SEK
excluded services:
certain medicines, dental services and aids with uncertain benefits and/or poor cost-effectiveness; services provided by non-contracted private providers; vision aids including eye test
universal coverage
Switzerland all services: min. CHF300 – max CHF2500 - Co-insurance 10% of all costs above deductible;
- Hospital co-payment: CHF 15 / day
- medical aids: patients pay OOP above reference price - Children (< 19 y): no deductible (or voluntary between CHF 100 and CHF 600);- Maximum for co-insurance: CHF700/year (Children: CHF350/year)
- exemptions for preventive and maternal care
excluded services: adult dental care, OTC drugs, psychotherapy performed by independent psychologists, vision aids Universal coverage
US Employer plans
- average: US$1318
Medicare:
- hospital care: US$1288
- physician services: US$166
- drugs: varies by plan
Employer plans:
- average co-insurance: 18–19% primary, specialist and hospital care
- average co-payment: US$24 (primary), US$37 (specialist), US$308 (hospital)
- prescriptions: co-insurance 17–32%, co-payment: US$11–93
Medicare:
- hospital care: no co-payment for first 60 days, US$322/day until day 90
- physician services: 20% co-insurance
- drugs: varies by plan
- usually not allowed Employer plans:
- median cap on user charges: US$3000–3999
Usually excluded: dental care and vision care 8.6% uninsured
  1. aAUD amounts refer to 2016 values; refs: https://www.humanservices.gov.au/customer/enablers/2016-medicare-safety-net-thresholds; http://www.pbs.gov.au/info/healthpro/explanatory-notes/front/fee; http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf
  2. bValues refer to 2016
  3. cOOP requirements refer to SHI system; requirements for substitute VHI differ
  4. dValues refer to 2015, ref.: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf
  5. eValues refer to 2011