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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