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Bureau of National Health Insurance--Management Measures for Out-of-Pocket Payments by NHI

1. NHI contracted hospitals and clinics are required to observe the following three principles when providing medical services, even if such services are not included within the scope of NHI benefits:
(1) Public Disclosure of Information: The Bureau of National Health Insurance (BNHI) shall provide guidance to contracted hospitals and clinics to publicize detailed information about the out-of-pocket payment items in the outpatient service area, counter areas, or on bulletin boards. This disclosure requirement shall be incorporated into the regular audit checklist by the local health bureaus when executing audits on medical institutions.
(2) Advice in Advance: With the exception of urgent or unexpected situations, medical institutions are not allowed to inquire about the willingness of a patient to use Non-NHI covered items when a surgery, medical check-up, or treatment is in progress.
(3) Issuance of Official Receipts: The receipts should clearly record the respective amounts of the NHI copayment, NHI out-of-pocket payment items, and non-medical items.

2. Items Not Included within the Scope of NHI Benefits:
(1) Items stipulated in Article 39 of the National Health Insurance Act, which are not covered by NHI, e.g., registration fees, cosmetic surgery expenses, indicator drugs, dentures, and ocular prostheses.
(2) Items included within the scope of NHI benefits, but for which the patient does not meet the eligibility requirements for the indication.
(3) The items are partially covered by the NHI as announced by the Department of Health, Executive Yuan. The patient is required to pay the difference out-of-pocket.

3. Channels for Accessing to the NHI-Related Consulting Services:
(1) Free Consulting Services Line: 0800-030-598
(2) The BNHI Global Website (www.nhi.gov.tw) -Public suggestion box (Contact us)
Following are the service area of NHI Regional Divisions:

The service area of NHI Regional Divisions
Regional Division Service Area Phone Number
Taipei Division Taipei City, New Taipei City, Keelung City, Yilan County, Kinmen County, Lienjiang County (02) 2348-6753
Northern Division Taoyuan County, Hsinchu City, Hsinchu County, Miaoli County (03) 433-9111
Central Division Taichung City, Changhwa County, Nantou County (04) 2258-3988
Southern Division Yunlin County, Jiayi City, Jiayi County, Tainan City (06) 224-5678
Kaoping Division Kaohsiung City, Pingtung County, Penghu County (07) 323-3123
Eastern Division Hualien County, Taitung County (03) 833-2111

4. Disciplinary Actions for Hospitals/Clinics Violating the Regulations
(1) If a contracted hospital/clinic requests out-of-pocket payments from NHI beneficiaries for items already covered by NHI, the behavior shall constitute a violation of Article 58 of the National Health Insurance Act., i.e., “Creating items to charge to the beneficiaries.” The violating hospital/clinic shall reimburse the collected funds to the beneficiary and be subject to a penalty equivalent to five times of the amount of money collected.
(2) Where the medical care service is covered by NHI, the contracted medical service providers shall not request the insured to purchase drugs or medical materials, or pay for health check-ups out-of-pocket. The contracted medical service providers are also prohibited from claiming NHI payments against any services not required for curing the disease, if a request for such services is made by the insured party. Any violation of the regulation shall be subject to penalty points stipulated in the relevant NHI regulations.

5. Other
(1) If considered necessary, the insurer shall continuously provide explanations on the out-of-pocket payment items frequently required in contracted hospitals/clinics, for example, large-volume infusion, general medical materials, patient-controlled Analgesia, Hyperbaric Oxygen Therapy, PET Scan, etc. Such information will be publicized for review by the general public and the contracted hospitals/clinics.
(2)“Are out-of-pocket payment items more effective and of better quality?” The NHI system enforces a dual-control mechanism on pharmaceutical products. First of all, a drug license from the Department of Health, Executive Yuan is required to ensure the legitimate marketing of a pharmaceutical product. Secondly, the supplier of the pharmaceutical product shall submit an application for incorporating the product into the NHI benefit system and for price evaluation. The quality of the pharmaceutical products is thereby fully guaranteed.
(3) When receiving medical care, the patient is, in fact, receiving a highly-personalized service. Apart from the diagnosis and prescription process, it is also important to consider the facilities of the hospital as well as the competency and mindset of the physicians. It is therefore recommended that before selecting an out-of-pocket payment item, the NHI beneficiary should first ask five questions: (1) Is it covered by NHI? (2) What is the out-of-pocket expense? (3) What are the benefits of choosing the out-of-pocket payment item when compared with the NHI covered item? (4) Are there any alternatives? (5) Are there any potential complications or after-effects?

Source: National Health Insurance Administration, Ministry of Health and Welfare
(formerly known as Bureau of National Health Insurance, Department of Health, R.O.C.(Taiwan))