2014 National Health Insurance System of KoreaLifelong health with the NHIS Welcome to National Health Insurance Service National Health Insurance Service(NHIS), as a single insurer, is in charge of operating and managing national health insurance (NHI. The Korean health insurance scheme officially started from 197 for the companies with 500 employees or more, After gradual expansion of healthcare coverage, Korea achieved universal healthcare coverage(UHC) in 1989, It took only 12 years, the shortest period in the world, As the result, Korean NHI Scheme has played an important role in improvement of the quality of life, Medical resources have been remarkably expanded comparing to the initial period of health insurance scheme, The NHIS was launched by integration of Medical Insurance Societies in 2000, The NHIS has made progress in the administrative effectiveness and the equity to healthcare, The NHI Scheme has especially received internationally good evaluation in cost effectiveness and accessibility to healthcare Despite these achievements, The NHIS has faced various challenges due to the changes of the socioeconomic structure such as super low ferlility rate and rapidly agingpopulation, Since these changes threaten the sustainability of NHI, the NHIS should take the precautionary measures for financial stability as far as possible, For these reasons, the NHIS should reform the imposition and levy system, and secure additional resources for the healthcare finance such as objective tax. In addition, The NHIS should prepare countermeasures against skyrocketing healthcare costs for the elderly and chronic diseases, modify provider payment system, and utilize the limited medical resources effectively. Therefore, the NHIS has adopted a new management model of healthcare service leaving the previous paradigm behind since 2012. First of all, the NHIS has tried to devise imposition system based on income for the contribution equity. The NHIS will lower healthcare costs by early detecting of diseases and health promotion. Finally, the NHIS will continuously improve healthcare expense reimbursement and drug pricing system. The NHIS is ready to be the best customer-centered organization, and put more efforts into providing high-quality services and promoting the quality of life, Furthermore, the NHIS keeps cooperating with the developing countries for introducing and improving the Health Insurance Scheme, This booklet is primarily prepared for foreign visitors, overseas healthcare organizations and foreigners residing in Korea, | hope that NHI Scheme of Korea can be helpful for universal heath coverage of the world, and that you could gain appropriate and reliable information of NHI of Korea in this booklet, Thank you, May, 2014 74 Ae Jong Dae, Kim National Health Insurance:Service Korea National Heath Insurance Service1) wD2014 National Health Insurance System of KoreaEse eS Cu} The social security system of Korea has three components such as social insurance programs, public assistance programs, and social wellare service programs, Social Security System Social Insurance Public Assistance Social Welfare Service + Health Insurance + Basic Livelhood + Wellare for the Elderly + Long-term Protection + Wettare for the Care Insurance Disabled “Welfare for Children “+ Weltare for Women + Pension Insurance + Medical Aid + Employment Insurance + Industrial Accident Compensation + Medical or Psychiatric Insurance Social Work ‘4 Universal Heath Coverage forthe WorldCueto iC) GW National Health Insurance scheme @ The NHI scheme of Korea covers the whole population residing within the territory of Korea. The major source of financing is contributions from the insured and government subsidies, » Function and Roles + Social solidarity and integration, + Fair sharing of healthcare expenses and reasonable benefit in kind, + Risk pooling and income redistribution, » Features + Compulsory insurance by law ~~ exception for beneficiaries of medical aid, * Short-term insurance : annually balanced finance and short-term payment * Contributions according to the income level. + Equal benefit in kind, * Coercive collection of contributions, G Medical Aid program ® Medical Aid program by the government is a public assistance scheme to secure the minimum living standard of low-income households and to assist with the self-help by providing medical services. GD Long-term Care Insurance program (LTC!) ® The LTC! program was first introduced in July 2008 to alleviate financial burden on nursing and to encourage health promotion and living stabilization, The program aims at the elderly with difficulties in activities of daily living due to geriatric disease or old age by supporting physical activities and household chores,National Health Insurance (NHI) Scheme % History of NHI © National Health Insurance # NHIS Governance program for Foreigners ‘ © Healthcare Delivery System See eee ete ‘& Reimbursement System ‘© Financial Resources © Benefit in Kind and Co- payments % Imposition and Collection © Health Checkups of Contributions ‘© Health PromotionHistory of NHI program 1963. 12. Legislation of Medical Insurance Act 1977. 7. Introduction of Medical insurance program for companies over 500 employees 1979. 1. Coverage expansion to companies over 300 employees, public officials and private school employees 1981. 1. Pilot project for the self-employed medical insurance in three rural areas 1988, 1. Implementation of medical insurance program for rural area 1989. 7. Achievement of universal coverage by expanding to urban area 2000, 7. Integration into a single insurer, National Health Insurance Service Implementation of separation of prescribing and dispensing drugs 2004, 7. Introduction of co-payments ceiling system for alleviation of financial burden on households which may suffer from disastrous and high-costs disease 2006, 1. Provision of insurance benefits for meals during hospitalization 2008, 7. Introduction of the Long-term Care Insurance program 2011, 1, Implementation of integrated collection for 4 social insurance contributions 2013, 10. Strengthening coverage of increase in major diseases such as colorectal cancer(5% co-payments) Integration reform for coverage increase and effective operation Health insurance societies for the employees(139) Since 1977 Health insurance corporation for public officials & private ened school employees(KMIC) 1" integration rpareaees Since 1979 Nene Sed Insurance = —> Corporation Oct, 1998, Health insurance societies for the self-employed(227) ih rural area Since 1988 In urban areas Since 1989GD Effects of integration Reform ® + Improved management efficiency : reduction of administrative expenditure. + Enhanced financial stability : nationwide risk pooling. + Simplified system of claim and reimbursement of healthcare expenses, » The ministry of Health and Welfare determines health insurance policy and supervises general operation of NHI scheme, » NHIS, a single insurer, takes responsibility for operation of NHI scheme, Eligibility review of the insured, imposition and collection of contributions, insurance benefits, and negotiation of medical fee schedule with healthcare service providers. » Health Insurance Review and Assessment Service (HIRA) reviews appropriateness of medical fee claims, assesses the service quality of healthcare institutions, and evaluates medical necessity of healthcare services by providers » Healthcare institutions are designated by law. Healthcare providers are not allowed to deny treatment of NHI patients, " yy. Results of review Contribution Health Insurance Review and Assessment = Service(HiRA) x Ministry of Health claim TRSURRRED and Welfare — A benefits (Planning, supervising) ver > Copayment i a Provider Healthcare service 8 Universal Heath Coverage for the WordPopulation Coverage » NHIS provides universal coverage to all nation in Korea except for lower-income group supported by the Medical Aid program. + Overseas Koreans and foreigners, residing in Korea, can join the NHI program by the registration procedure, » The insured are classified into two groups: the employee insured and the self- employed insured. Population coverage, 2013 51,448 Subtotal 49,990 Employee insured 36,006 Self-employed insured 14,984 *The number of the foreign insured are 616 thousand —_ (Source: NHIS Statistical Yearbook, 2013) ColegoryanEna neared Whole Population , Employees in Persons exclu Employees it public from the pa pri empl Dependants +The insured’ s spouse + Direct lineal + Direct lineal + UnmarriedG Financial Revenue ® » Financial resources of the NHI scheme consist of contributions collected by the insured and government subsidy. + Contributions account for 82.7% and government subsidy is 17.3% + Government subsidy is comprised of general tax and surcharge on tobacco errr oan Pare) +The employee insured (67.5%) +The selt-employed insured (15.2%) + General lax (10.2%) + Surcharge on tobacco), Otners6 08) Source: NHIS Statistical Yearbook, 2013) forerae on oheos02"%8) Oe O%) » Government subsidy +Under Medical insurance act, general tax is spent on insurance benefits, operation costs and contributions reduction, Surcharge on tobacco is used for heath checkups and public health promotion, The status of Government Subsidy (unit: bition) Total 3,014 3,424 3,483 3,695 3,836 3,672 4,026 4,683 4856 5,029 5,343 5,799 iE 2779 2857 2,770 2870 2,704 3,002 3,657 3,793 4,072 4,336 4,800 surcharge iy 439 645 626 925 966 968 1,024 1,026 1,063 957 1,007 999 (Source: NHIS Statistical Yearbook, 2013) 10. Universal Heath Coverage for the WordG Financial Expenditure ® » The 94.5% of NHI revenue is spent on insurance benefits while administrative expenditure is 4.4% ~~ Management efficiency Expenditure, 2018 1 tnsurarce Genet aministaion Cots I omer (Source: NHIS Statistical Yearbook, 2013) Expenditure details on insurance benefits Service Utilisation type lies 2.48% (Source: NHIS Statistical Yearbook, 2013) Korea National Heath Insurance Service 11 |Pa CMEC Mera Neral oel » Contribution taking the insured's abilities of payment such as incomes into account is monthly imposed and billed. + Biling unit is @ workplace(employee insured) or a household{self-employed insured), + Coercive collection can be made by NHIS when the contributions are in arrears, Types of the insured Responsibility of Payment Collection : Monthly Billing Self-employed Insured Householder: 100% ance fest ren Employee Insured . Employer : 50%, Private Company Employes : 50% « 1 50% Deducted from . jovernment : Salary Government Organisation Coo ant Employee : 50% Government : 20% Baie) Employer : 30% Employee : 50% GD Contributions Imposition © » The employee insured + The contribution of the employee insured is calculated based on gross salary of the employees, and equally shared by both employees and employers. Monthly Contribution = Average Monthly Salary x Contributions Rate + In case of incomelapart from salary) exceeding 72 million won per year, the employee insured is charged additional contribution. ‘Additional contribution = Monthly extra income X Contribution rate x 0.5lemployee charge) Additional contribution has been collected from September 2012 » The Self-employed Insured +The contribution of the sell-employed insured is calculated considering annual average income, properties, vehicles, age and gender. Monthly Contribution = contribution scores X value per score 12. Universal Heath Coverage for the WordContribution Score id Property & Car Score i (A) Household @ Estimated @Household — @ Household with taxable income _ Income(30Grades) with properties with cars cl Srl KRW o ess (50 grades) (15 grades) «Living standard *Slandard Value + Standard Value (Property, Car Level by Tax Autorities by Tax Authorities {B) Household @ Taxable wilh taxable income | income exceeding § milARW (75 Grades) — NOTE: I (A), contribution score = DHA and It (B), contribution score = @HI+@ %*5 mil KRW = approx 3,100 USD Contribution Rate (Unit: %, Won) Classification 2005 2008 2007 2008 2009 2010 2011 2012 2013 2014 Employee insured 4.94 448 4.77 5.08 5.08 533 564 580 589 599 {contribution rate) Self-employed insured (Gaus per pon) 1265 1314 139.9 1489 1489 1562 165.4 170.0 1727 1756 G contributions Reduction ® Employee Insured Self-employed Insured Reduction Reduction Reduction Case Rae Reduction Case Rae The insured working or living in qq, ‘The insured living in an island 59 an island or remote rural areas or remote rural areas Registered Handicapped persons 10~30% The insured working overseas and who have dependents in 50% ‘The insured who work on farms pa, Keres or on the sea The insured living rural area 22% Career Soldier 20% The insured with low incomes 10~30% ‘* Contributions reduction takes medical sccessibilly and income level into account and total reduction rate ‘must not exceed 50% of the monthly contributions Korea National Heatth Insurance Service 13 |G@ Exemption for Contributions @ +The insured travelling abroad, +The insured working abroad and not having any dependents in Korea, +The insured serving in military duty & military cadets. +The insured detained in a correctional institute, GD Integrated Collection of Contributions & » From January 2011, NHIS manages the integrated collection system of four social insurance contributions (National Health Insurance, National Pension, Employment Insurance, Industrial Accident Compensation insurance), + Social contributions should be paid by the 10th of every month, DEG UML alae » Foreign employees in the company, covered by NHI, have NHI eligibility. Foreigners, residing in Korea over 3 months, can join the NHI program as the self- employed insured according to the application procedure. +The number of foreign insured: 640,823(including the employee insured and the self— employed insured) © Foreigners : 616,361, Overseas Koreans : 24,462 Collection of Contributions Integrated collection systern for all social insurance contributions a 1 wom yEme, ‘Donel 1 evar) | i 1 Ervotment } yargcasent Insurance = a * In January 2011, NHIS implemented the integrated collection of four sourced of social insurance Contributions to improve administrative etficiency and enhance convenience ol the insured, 14. Universal Heath Coverage for the Word+The contribution of the foreign employee is calculated by the same formula as the Korean employee insured, Monthly contribution = Average Monthly Salary x Contributions Rate +The contribution of foreign self-employed insured, © With salary statements, Monthly contribution = contributions scores x value per score (© Without salary statements, Monthly contribution = average contributions of the self-employed insured at the end of last year. Cae ee) ) » The NHI Healthcare delivery system is comprised of 2-levels. + Ist level medical institution: all medical institutions except for tertiary hospitals. + 2nd level medical institution: 44 tertiary medical institutions designated by government for effective use of medical resources, » A patient who wants to receive healthcare services in a tertiary hospital, the patient referral slip, issued by tst or 2nd level hospital, is necessarily required. + Exception: childbirth, emergency medical care, dental care, rehabilitation, family medicine and heallheare services for a hemophiliac, @ Insurance Benefits and Co-payments » Insurance Benefits + Insurance benefits are provided for childbirth, health promotion, rehabiltation as well as prevention and treatment of sickness and injury in daily life ‘*Two types of insurance benefits : benefit in kind, benef in cash, Korea National Heatth Insurance Service 15 |Types of Insurance Benefits +Health Care Benefits Benelits in Kind Health Checkups Insurance + Refunding Allowance for Health Care ce + Copayment Ceiling System Benelils in Cash acpliance Expenses for the Disabled +Pregnancy & Childbirth Examination Expenses » Benefit in Kind +Healthcare benefits: diagnosis, tests, drugs, medical materials, treatments, surgery, preventive care, rehabilitation, hospitalization, nursing, and transportation. *NHI health checkups are divided into regular health checkups and cancer screening. The cancer screening program includes stomach, colon, breast, cervical and liver cancer screening, » Benefit in Cash + Refunding allowance for healthcare: healthcare expenses spent on home oxygen therapy for patients with chronic obstructive pulmonary disease, peritoneal dialysis purchases for chronic renal failure and childbirth at a place other than a healthcare institution. +Refunding for co-payments exceeding 1.2~5 million won per year(differentiated according to the level of monthly contributions), *Provide 80% of the standard price for the registered disabled when purchasing appliances (e.g. canes, wheelchairs and hearing aids). Non-benefit items Any healthcare services, drugs or materials used for illness which do not cause serious problems in daily life or business, e.g, simple snoring, fatigue “Any healthcare services, drugs or materials used for care not aiming for improving physically essential functions. e.g, plastic surgery, freckles + Any healthcare services, drugs or materials used for care not aiming for medical treatment of disease and injury. e.g. removal bad breath, tooth correction 116 Universal Heath Coverage for the World» Co-payments +A patient who receives healthcare treatment should pay co-payments that are part of total healthcare expenses. In order to curtail overuse of healthcare services and to lessen concentration of healthcare services into large hospitals, co-payments are differentiated according to the level of healthcare institutions and oulpatient/inpatient service. Service Healthcare Institution Diseases Copayment rate of total healthcare cost = General 20% Inpatient - Rare” 40% - Serious” 5% Tertiary hospital - 60% General hospital - 50% Outpatient Hospital S 40% Clinic 5 30% Pharmaceuticals - 30% 1) Rare diseases: hemophilia, chronic renal failure, etc, 2) Serious diseases: cancer, cardiovascular disease, cerebrovascular disease, tuberculosis, and severe bun» Co-payments Ceiling System +For alleviation of financial burden, co-payments exceeding 1.2 ~ 5 million won(depending on income levels) per year are reimbursed by the amount of surplus for medical treatment. Co-payments ceiling based on income levels (Unit: milion) grade grade grade Income grade grade! ON? Me a grade 8 grade 9 grade 10 Amount of — 1.2Million 1,5Million 2Million 2,5Million 3Million 4Million SMilion co-payments won won = won = won, = won won won. *Co-payments include expenses for hospitalization and outpatient clinic, and drug price. Reimbursement Mechanism » The healthcare expenses are calculated based on fee-for-service for all services and referral levels. + Fee-for-service = Resource-Based Relative Value X unit price per score. +The Resource-Based Relative Value is calculated by considering the amount of work and resources such as manpower, facilities, equipments, and risks of insurance benefits. The Ministry of Health & Weltare(MOHW) determines the score. +The unit price per score is annually determined by the mutual agreement between NHIS president and representatives of the healthcare provider groups. » Diagnosis Related Group(DRG) + In order to redeem problems of fee-for-service, the DRG system started from Jan 2002 and covers the seven disease groups for inpatients, © The seven disease groups : Lens procedures, Tonsillectomy and Adenoidectomy, Anal and Stomal procedures, Inguinal and Femoral Hernia procedures, Appendectomy, Uterine and Adnexa procedures, and Caesarean section. +2012. 7. 1. Obligatory applicable for clinics and hospitals. +2013, 7, 1, Obligatorily applicable for general hospitals. » Per Diem *Applied to healthcare expenses of inpatients in geriatric LTC care hospital and psychiatric hospital, 18. Universal Heath Coverage for the WordCustomized total healthcare TI) services with every stage of the life cycle % Health Checkups © Health Promotion * Anew Approach to Health Checkups and Promotions with NHI big data(NHIS) 20. Universal Heath Coverage for the Wordheckups G General Health Checkups ® » Subject + For adults in Korea aged 40 and older, » Cycle + Once every two years (every year for the employee insured who are not office workers) » Cost sharing: NHIS(100%) G Examinations for Specific Cancers © » Periodical examinations targeting high incident cancers according to age groups. + Stomach cancer and breast cancer: adults aged 40 and older, once every two years. Liver cancer: adults aged 40 and older in the high-risk group based on the insurance benefit details, every year, + Colon cancer: adults aged 50 and older, every year. + Cervical cancer: all women aged 30 and older, once every two years, » Cost sharing + NHIS (80%), Examinee (20%) -- Pap-test : NHIS (100%) G Health Checkups according to Life-cycle Stage ® » For early detecting diseases and providing appropriate benefit in kind, health checkups according to life-cycle stages are implemented +Health checkups for infants and adults are conducted by NHIS, and health checkups for the youth are conducted by schools and local governments. Korea National Heath Insurance Service 21 |‘Student Screening Students in elementary, middle and high school Juvenile Screening Non student juvenile (15~19 yrs) G Health checkups for Infants © » Implementation of developmental screening, diagnosis and dental inspections for infants under the age of 6 » Cost sharing : NHIS (100%) 22. Universal Heath Coverage forthe World+ Implementation of health promotion and campaigns such as daily exercises support, follow-up alter checkups and health management for chroni¢ patients. Customized Health Service based on Health Condition _, _Heatin promotion for whole nationals Primary Nogtal (by NHIS oF local government) (oe Unconsenting 7 . case to Resta voup information use having (by NHIS) Checkups = » metabolic Fotowpjol Secondary > the result of 4 syndrome chee Consenting case prevention risky to information use faciors “= “Thy connected pulole heath center) Patients having Mana ging those Benet diseases Tertiary Records (hypertensi a | eer on and uy diabetes) Korea National Health Insurance Service 23G Follow-up after Checkups and Management of chronic patients © » Provision of personalized health education and consultation for patients diagnosed with hypertension, diabetes and metabolic syndrome risk factors. GD ‘support for Appropriate Healthcare Use » Encouraging appropriate use for over-users of healthcare services by providing information about the proper use of services. GD operation of 17 Health Promotion Centers ® » The health promotion programs by healthcare professionals such as personalized exercises, nutrition guidance and consultation based on follow-up after health checkups. GD operation of Health Class for the Elderly ® » The healthcare programs for the elderly pursuing healthy golden years. @ Health campaigns © » Supporting health campaigns with community resources contact, promoting public health by raising awareness of the need of health self-management. GD Provision of Healthcare Information ® » Provision of personalized healthcare information through the web site (http://hi.nhis.or.kr) based on the NHIS health data analysis. » Provision of health information including healthcare news, professionals’ opinion, QnA and medical encyclopedia 26. Universal Heath Coverage for the WoreDOE een n ety Cree PO UC an MCE iel hs) Paradigm shift from disease treatment to prevention ® » Growing needs and expectation about health checkups and promotion » Increasing chronic diseases and insufficient management system GD contents of NHID ® » NHID includes 1.3034 trillion data as below. Ne eg — <—— Utilization of NHID » Purpose + Developing heath disease alarm model + Developing health - disease index and surveillance system + Providing regional and customized services + Building sample cohort DB Korea National Health Insurance Service 25GD Procedure for an alarm model Publ structured veaincae | jAtabang cay | y Proecn by | y _Povidra aia DaleDete, Healrcare dal, Disease trend & (NHI Big Data Disease, patent Disease trend ‘Alern systern information) analyzing stuctured oaia @ Procedure for Health + disease index and surveillance system © onal i | i rt aa di GD Developing nationwide servicelAlarm Screen) » Warning the risk of disease occurrence by region, age and severity. (D Providing customized health services and producing evidence-based health policies based onNHID » Health risk appraisal. » Management of metabolic syndrome. » Prediction and appraisal for stroke risk factors. » Appraisal and prescription for obesity program. » Providing personalized information based on health risk factors. » Others.GB Building sample cohort DB ® Sample Cohort DB nena Sampling 2% + The insured DB ——P Metical treatment DB. * Heat checups 08 G@ Effects of NHID ® » Providing useful evidence for good decision making » Effective predicting risks & preventing diseases. » Supporting research & development. » Reducing procedure and time for researches using sample cohort DB. Korea National Heath Insurance Sevice 27Long-term Care Insurance (LTCl) Scheme © Financial Resources © Background © Application for Benefits and % History of LTC! Assessment Procedure © Operational Structure Insurance Benefits © Eligibility and Beneficiaries %® Reimbursement System © Current Status © Future Tasks With rapid aging, increasing nuclear family and growing women participation in labour market, care for the elderly is no longer the burden of an individual or household but social responsibility. Accordingly, LTC! program is implemented from July 2008 in order to support physical activities and household chores for the elderly having difficulties in the daily life on the basis of the social solidarity, 28. Universal Heath Coverage fr the WordGB Demographic Changes & » Rapid population aging : 10% in 2007, 24.7% in 2030 » Decrease in fertility rate: 4.53% in 1970, 1.28% in 2030 Population Aging Total Fertility Rate (Unit: 96) an (Unit: person) 56 li lis 2007 2010 2020 2030 2050 4970 1990 2000 2010 ‘The population proportio of the ‘The number of live births per woman aged over 65 (Source: Korea National Statistical Office, 2013) » Increase in burden for the elderly care Cc ed Dee x. ‘The burden of support for seniors(over aged 65) by productive proportion(between aged 15 and 64) Korea National Health Insurance Service 29 |GD increase in financial burden caused by rise in medical expenses for the elderly ® » Soaring costs for the elderly aged over 65 out of total health insurance expenditure. 9.3% in 1990, 19.2% in 2000, 33.3% in 2011, 35.4% in 2013 » 86.7% of the elderly have chronic diseases. Number ofDemeRio tne 000 psa 2008 2020 2030) 2050) by productive proportionibelween aged 15 and 64) GD The elderly care as a social issue according to the change of social structure @ » Increase in nuclear family. » Growing women participation in labour market. » Weakened social solidarity. 30. Universal Heath Coverage for the WordHistory of LTC! 2001. 8. Proposal to launch "LTC Security System for the Elderly, at President congratulatory address 2003. 3. Establishment & operation of the ‘Public LTC Security Planning & Promotion Team, 2004, 3. Establishment & operation of the ‘Public LTC Security Executive Committee, 2007, 4 Enaciment of the ‘Act of the LTC Security for the Elderly, 2008. 7. Introduction of the ‘Long-Term Care Insurance program, 2013, 5. Expansion of LTC! benefits (criterion score from 55 to 51) Korea National Heath Insurance Service 31 |@ Effects of LTCI Introduction » Provision of physical and social assists to the elderly. » Lessening financial burden for caring the elderly. » Contributing to government intention to create jobs. Operational Structure Operational Structure ofthe TCI pot installment and registration Ministry of Heath ity, County and Weltare Proviges and District J ’ © Authorization Providing government subsidy Suversion Request cash NE Sota? request ca op saes, MRSS = = Domiciliary service Provide services + Horne visit care + Horne visit bathing + Hore vist nursing Day or night care Respite care + Weltare equiornent service Provide cash Benelis Analy for LG assessment and Y bay contribution DETER “Provide ho standardised LTC uanereneonice utilisation plan + Grout Some «Monitor services. ° *Manage qualtication and charge Request benefit cost contribution } Manage Grading Committee Pay benefit cost » The minister of the Health and Social Welfare administers LTC! program. » NHIS takes responsibility for operation of LTCI program and carries out to review and reimburse LTCI benefit costs. *Enable to reduce additional administrative expenditure based on experience and skilled manpower of NHI operation, » The president of local government authorizes service providers by application. 32. Universal Health Coverage fr the WordGD Etgibitity ® » Eligibility for LTCI program: the elderly aged over 65 or under 65 having geriatric disease, G Beneficiaries ® » Beneficiaries: persons who have difficulties in performing Activities of Daily Living(ADL) for over six months are assessed as beneficiaries by LTC Grading Committee, Elles & BeetidaresLune 2013) » Beneficiaries of LTC (Unit: person) Subscribers + National Health Insurance(49,805,974) + Medical Aid(127,099) Eligibles + Basic Livelyhood Protectiont{,365,708) + Over aged 65(6,07,994) + + (Under aged 65 with geriatric diseases(38,777) + Limited in ADI by the (Source : NHIS statistical yearbook, 2013) aGD The Number of Beneficiaries ® The NumbereFBenefiares un 1000 pune 280 (Source : NHIS stalistcal yearbook, 2013) Year 2008.07 2009.08 = 2010.06 201.06 §=— 201206 2018.06 ‘Beneficiaries, 146,643 268.980 312,138 320,261 327,766 355,727 ** Note : Abou! 57% of the elderly applied for LTC, among which 52% have been approved as a beneficiary, EU a tl es G Revenue and Expenditure ® The government supports about 20% of LTC! contributions within its annual budget. » 93.1% of total LTCI finance is spent on insurance benefits. 5.6% is spent on administrative expenses. 49.3% of total expenditure is for the costs of domiciliary benefits, 43.8% of total expenditure is for the costs of facility benefits. sours of evens and Exped for the TC Revenue, 2013 Expenditure, 2013, pemninstatie Expenses ase ‘omers 08% (Source : NHS statistical yearbook, 2013) 34. Universal Heath Coverage for the WordG imposition and Collection ® » LTCI contributions are calculated on the basis of NHI contributions. + LTC! contributions = NHI contributions x LTC! contributions rate(6,55%) » LTCI contributions are monthly billed with NHI contributions, but LTCI contributions cannot be paid separately. Application for Insurance Benefits aac » Step 1: Applying for LTCI services * Submission of the application form by an applicant to the LTC Operation Center of NHIS, » Step 2: Home visit assessment (52 items) + Visit of healthcare professionals from NHIS and assessment of physical and special needs, » Step 3: Care category decision +TC Grading Committee decides the level of care category by assessing the necessily of support whether the beneficiary has difficulty in performing ADL over six months, » Step 4: Issue Certificate “The LTC cerlificate and the standardized LTC utilization plan are issued to the applicants approved by the LTC Grading Committee, » Step 5: Use of LTC services + Beneficiaries can receive LTC services either at LTC facilities or at home according to the level of care category determined by the Committee, Korea National Heatth Insurance Service 35 |Category 2 + Nearly bedridden Requires substantial “Incapable of eating, dressing, chewing without assistance assistance in daily activities + Suffering from dementia and needs LTC C Insurance Benefits and Co-payments GD types of Services ® » Domiciliary Service «Home Visit Care: Staff visit beneficiaries’ home to support activities of the daily life and household chores, +Home Bathing: Staff visit beneficiaries’ home to provide bathing with appliances for bathing. +Home Nursing: A nurse provides nursing, medical treatment, consultation and dental hygiene according to doctors’ instruction(including oriental doctor and dentist), *Day or night care: Provision of education and training in LTC institutions for the improvement of physical and psychological activities for hours per day. Respite Care: Provision of support in LTC institutions for the improvement of physical and psychological activities during short period. *Weltare Equipment Service: Lending wheelchair, movable bathtub, movable it for bath, movable benches and mattress for prevention of bedsore when the beneficiaries who are not in LTC institutions pay co-payments. ‘36 Universal Heath Coverage forthe World» Facility Benefits *Provision of education and training for supporting, maintaining and improving activities of daily life in an institution for a long time, » Special Benefit in Cash +Family care cash benefits: reimbursement of family care cash benefits when the beneficiaries receive family care instead of domiciliary service, + Special care cash benefits: partial reimbursement of LTC benefit costs, in case the beneficiaries receive visit care or facility care in the undesignated facility, + Nursing benefits in the LTC hospital: Part payment of LTC costs in the LTC hospital in case of hospitalization, Non-covered Services + Costs for meal and medical materials, + Additional charge caused by using private bed: + Costs for haircut and cosmetics, etc. G@ co-payments ® + 15% of domiciliary costs, 20% of facility costs. + Exemption of co-payments for the vulnerable applied to National Basic Living Security Act, + 50% exemption of co-payments for those having low income, PT uu aut liu G Costs payment per hour ® » Home visit care » Home visit nursing GD Costs payment per day @ » Day or night care(per hour) » Home nursing » Respite care » Institutional benefits GD costs payment per visit ® » Home bathing Korea National Heatth Insurance Sevice 37 |GB Monthly Maximum Amount of Long-term Care Benefits ® » Long-term care benefits are available within monthly maximum amount that is calculated according to LTC category and types of LTC benefits. » Monthly maximum amount for facility benefits + Monthly maximum amount = tday(relevant category) x days per month Institutions: Category 1 52,640 Category 2 48,850 Category 3 45,050 Cohabiting house for the elderly Category 1 50,190 Category 2 46,570 Category 3 42,930, » Domiciliary Benefits + Monthly maximum amount per month 1,140,600 Won 1,003,700 Won 878,900 Won 38. Universal Heath Coverage for the Word» Expansion the coverage(beneticiaries) » Lack of the qualified care workers » Shortage of LTC facilities + Centralization of LTC facilies in urban area (causing imbalance between supply and demand). » Increase in the needs of improvement of the service quality Korea National Health Insurance Service 39 |National Health Insurance Service Vision and Mission Major Activities Organization NHIS Ilsan Hospital NHIS Call Center 8 sc ee le = wey oto! OF 08.0% as . ay % 0Improvement in quality of life through enhancing public health Mission and social security The world best health security organization for the public's lifelong Vision health Continuous Enriching improvement Long-term Increasing _—_Strengthening Targets of health Care beneficiaries’ organizational insurance insurance Satisfaction competencies system system eeectring simproving *Bulcing + Developing sustainability benefits ang customer professional of insurance quality of friendly human nance rel service ‘Management resources system + Expanding - Developing + Strengthening ens Tecra ye Reforming for organization coverage a fair levy capacity i system through Tasks + Establishing competition lifetime Sean “Strengthening based system health care sustainability Pe"sonal te otal information + Advancing a security the labor— health + Balancing system management insurance Cole Et reecene ae policy ee social + Improving support responsibilty IT capacity Core value Humanism Harmony Passion Professionalism Korea National Heath Insurance Service 41B Core Valuest2H2P) » Humanism ~ NHIS's attitude towards customers. * NHIS devotes with love and service for customers’ trust, » Harmony - Partnership with coworkers. “ NHIS sincerely serves with harmony and cooperation. » Passion - NHIS's powerful competitiveness. * NHIS develops for the better future with passion and challenging mind, » Professionalism ~ NHIS's pride and self-esteem, *NHIS aims for the best professional in healthcare filed with continuous self- improvement. DB) Meaning of NHIS Logo ® The red circle embracing the heart represents trust and love, suggesting the role of the Nalional Health Insurance Service: it also symbolizes the happiness of people as derived from a healthy high-quality life. The circle stroke that appears to be drawn with a finger represents the new look of the National Health Insurance Service, which shows greater efforts to build close relationship between people through warm ‘communication as a public friendly institution, BB} Meaning of NHIS Characters © ‘The characters are created from the motif of Haelae (mythical unicorn lion), which symbolizes good health and long life, Geoni(left blue character) protects public health, whereas Gangiright pink character) is the health fairy, Symbolism of Haetae represents an envoy of heaven, a patron saint, the descendent prosperity, world peace, and longer life, 42_ Universal Heath Coverage for the WordMajor Act (3 +Management of the eligibility of the insured + Imposition of contributions + Collection of 4 integrated social insurance contributions + Management of insurance benefits Health checkups and health promotions + Operation of hospitals + Research activities on health insurance + International cooperation with international organizations G Research of Health Security Policy ® NHIS operates NHI Policy Research Institute(HIPRI), conducting activities which support strategic and evidence-based decision making in the management of the NHI program, Nain activities of HIPRI are not only researches on insurance policy, insurance benefits, prevention, health promotion, medical costs, pharmacy costs and long-term care related to health security field but also policy support for countries which are making efforts to achieve sustainable and universal health security In addition, HIPRI endeavors to do its own best for the development of world healthcare services through sharing the results of researches and actively cooperating with other countries conducting health security system, GD International Cooperation Program + Introduction of NHI and LTC! scheme to the international society. *Maintaining close relationship with international organizations such as ISSA, OECD, WHO, UNESCAP, ILO and relevant research institutes. Dispatch staff to ISSA and operation liaison office for East Asia * Operation of NHI training course annually(total 670 participants and 75 countries by 2013) + Official Development Assistance(ODA) business. © Instructing the operation method of NHIS system including IT to developing countries Hosting annual international symposium *Management of foreign correspondents in 12 countries to collect and investigate international healthcare information Korea National Heatth Insurance Service 43NHI Training Course From 2004, NHIS has implemented NHI Traing Course with cooperation of WHO, UNESCAP and MOHW for persons in healthcare field to provide relevant lectures and knowledge Organization +The NHIS president is appointed by the president of Republic of Korea upon recommendation of the Minister of MOHW, + Headquarters, 6 regional headquarters, 178 branch offices, 227 LTC operation centers and 7 call centers, + Current employees: total 12,677 (10,157 for NHI & 2,520 for LTCI excluding ILsan Hospital Board of Directors. Headquarters en x planing Cy + Planning + Organisation + Cooreination Management + Legal atars + Financial Management + Personnel Management 4d Universal Heath Coverage forthe World Current slafi12.667 “Not including isan hospital sta or stn Health In -—————__ Fi Eatery Bete Cer Director (oe CESS *Elgibilty + Benefits + Imposton +Disease + Collection prevention ur and Heath ppromation +N Big Dla + git + Benelits “Claim Review + Insgection ManagementB Board of Directors ® » 15 Members (chairperson, 5 standing executive directors, and 9 non— standing directors) » Decision making for NHIS major policies Planning annual business programs. + Preparation of the budget draft and closing accounts. + Amending articles of NHIS, +Enactment, amendment and abolition of NHIS regulations, *Contributions, collection and insurance benefits + Debt and repayment. + Decision to purchase, manage and dispose of property + Other important matters concerning operation of NHIS, B Financial Committee ® » 30 members(Chairperson is elected by the committee among its members representing public interests) +10 members representing the employee insured, +10 members representing the self-employed insured. +10 members representing public interests » Deliberation and Decision. + Contract for the costs of insurance benefits, + Deticit disposal of contributions(inecluding LTC! contributions). + The calculation method for the employee insured contributions. + Other matters concerning insurance finance, t I Korea Nalional/Health Insurance Service 45NHIS Ilsan Hospital lisan Hospotal is the sole nation's hospital operated by NHIS, To enhance public health and serve as the representative example of The health insurance hospital based on the high quality healthcare services, llsan hospital started on March 2000 with 745 beds, in the building with five basement levels and 13 stories high. G Background ® *With increase in the elderly population and the needs of healthcare services, and change of disease pattern, the development of healthcare services and the example of hospital operation are necessarily required in accordance with public needs. GD Aim of Establishment & +llsan hospital, the insurer-operated hospital, aims to provide convenient use of healthcare services, to meet the needs of services in local society and to develop the level of public health and NHI scheme through clinical medical research, survey and research on national health environment. = = = ere mel NRRL MRL UL ACEC ele eer fitter eric) + Evaluation + Compliance with medical foe standard ol medical schedules care + Participation in government s public medical care! + Provision * Development of of appropriate level standardized medical of medical care care guidelines + Conduct + Operation of of government s patients-centered policies hospital programs + Promotion of medical support for vulnerable group + Cultivation of medical cooperation system 46 Universal Heath Coverage forthe WorldGD Major Features ® By introducing automatic systems for building, inventory, tests and pharmacy, and establishing the comprehensive information system, the waiting time of patients is reduced and the benefits of medical care are improved *With cooperation with Yonsei University of human resources and technical, retention of the ‘competent medical professionals, ‘Initial introduction of the 4-patient ward system in Korea to provide a comfortable and pleasant atmosphere for patients. + By operating the non-profit facilities including a directly operated funeral hall, the enhancement of the positive NHIS image, Pleasant surroundings equipped with advanced architectural structure + Aim at the patient-oriented healthcare with reasonable medical expenses. alegre tg The Call Center seeks to provide the highest-quality consultation services to meet customer satisfaction, The main call center was established in 2006, and four regional call centers (Busan, Gwangju, Daegu, Daejeon) were launched in 2008, and the Kyeangin center opened in 2009. The Center, where 1,277 consultants receive complaints, service requests, and questions from the insured, handles about on average, 100,000 telephone calls per day. For the hearing- impaired or foreigners, the video call consultation (sign language) and consultation in English are provided » English Speakers Only + 1577-1000 (press “8") or 02390-2000 (Outside Korea : 82-2-390-2000) » Korean Speakers Overseas + 82-2-3270-9114 » Visual(Sign Language) Phone Consultation + 02-2289-0404 » Operating Hours and Service Areas + Available times : Monday to Friday from 9 am, to 6 p.m, (except for statutory holidays) + Service areas : All Areas in Korea Korea National Heatth Insurance Sevice 47Current Issues and Future Directions © Equity and fairness of * Reform of unfair benefits structure contiibat ons rapa tn © Expansion of insurance coverage % Measures for financial Pen ec ee sustainability y # Activation of prevention and ‘© Provision of the customer-centered health promotion with big data LTC services 48. Universal Heath Coverage forthe Worldeuler) G Too many customer complaints by unfair calculation of contribution levy system +The different contribution levy system depending on the respective insured types, + Lack of equity between the employee insured and the selt-employed insured Weak financial condition threatened by rapid aging and low fertility rate + Decrease in contributions payers due to increase in the elderly and low fertility rate + Soaring elderly medical expenses caused by rapid aging, G Cure-focused healthcare services ® + Increase in benefit costs due to lale detection and non-activated prevention, Preference for general hospitals rather than clinics. + High co-payments causing the time delay of treatment GD Unmet needs of LTCI beneficiaries ® * Complaints of mild dementia patients and excluded beneficiaries. + Low satisfactions of co-paymenis and the service quality. Korea National Heat Insurance Service 49Efforts of improveme! GD Raising equity and fairness of imposition system © + Unified income-centered imposition system regardless of the insured types. * Contributions including various incomes such as financial income etc. GD Improvement in operation and reimbursement system for securing financial sustainal ity +Improvement in claim-review-reimbursement system according to NHIS operation principles, + Expansion of DRGs. GD Activation of prevention and health promotions with medical treatment using big data + Reinforcing the comprehensive management of risky groups(e.g. metabolic syndrome) and chronic diseases. GD Improvement of unfair benefits structure such as the concentration toward large hospitals © sIntension of tst level medical institutions on minor symptoms rather than tertiary hospital GD Expansion of insurance coverage ® + Expansion of insurance coverage to the extent of the developed countries! level, by covering partial expenses for upper class ward, optional care and nursing that are not currently covered by NH Average coverage of 29 OECD countries is 72.4% in 2012, GD Provision of customer-centered LTC| services ® + Support for minor dementia and improvement of the qualily of services, 550. Universal Heath Coverage fr the Word311, Dongmak-+o, Mapo-gu, Seoul, 121-749, Korea Tel : 82-2-390-2000, 82-1577-1000 Homepage : wwwnhis.orkr/engishh-well oO h National Health Insurance Service 311, Dongmak-r0, Mapo-gu, Seoul, 121-749, Korea Tel : 82-2-390-2000, 82-1577-1000 Homepage : www.nhis.orkr/english