Supplemental Insurance Plans Offered by the Health Plans: Analysis and Comparison of Baskets of Services in 2006

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1 Myers-JDC-Brookdale Institute Smokler Center for Health Policy Research Knesset Research and Information Center Supplemental Insurance Plans Offered by the Health Plans: Analysis and Comparison of Baskets of Services in 2006 Shuli Brammli-Greenberg Revital Gross Ronit Matzliach The study was funded by the Knesset Research and Information Center RR

2 Researchers Shuli Brammli-Greenberg, Revital Gross, Ronit Matzliach Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute Study Steering Committee Shirley Avrami, Director of the Knesset Research and Information Center Sharon Soffer, Head of Staff, Knesset Research and Information Center Bruce Rosen, Director, Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute

3 Related Myers-JDC-Brookdale Institute Publications Gross, R.; Brammli-Greenberg, S.; and Matzliach, R Public Opinion on the Level of Service and Performance of the Health System in 2003, in Comparison to Previous Years. RR (Hebrew) Brammli-Greenberg, S.: and Gross, R The Private Health Insurance Market in Israel, RR (Hebrew) Gross, R.; and Brammli-Greenberg. S Public Opinion of the Level of Service and Performance of the Health System in 2001, Compared to Previous Years, RR Gross, R.; and Brammli-Greenberg. S Israel's Health System as Perceived by the Public 1995, 1997, and RR (Hebrew) Kaye, R.; and Roter. R Complementary Health Insurance in Europe and the West: Dilemmas and Directions. RR (Hebrew) Brammli-Greenberg, S.: and Gross, R Supplemental and Commercial Health Insurance, 1998: Changes in Policy, Financing, and Consumer Behavior. RR (Hebrew) Gross, R.; and Brammli-Greenberg, S Supplemental and Commercial Health Insurance in Israel 1996: A Comparative Survey, Analysis of Changes in the Market and Examination of Policy Alternatives. RR (Hebrew) To order these publications, please contact the Myers-JDC-Brookdale Institute, P.O.B. 3886, Jerusalem, 91037; Tel: (02) ; Fax: (02) ; brook@jdc.org.il

4 Executive Summary Since the National Health Insurance Law came into effect in 1995, the health plans have been marketing supplemental health insurance plans. Over the years, there has been a considerable increase in the proportion of supplemental insurance policyholders among the public, the plans have become more complex, and there have been changes in the coverage. In view of these trends, the Myers-JDC-Brookdale Institute was asked by the Knesset Research and Information Center to examine the supplemental insurance plans offered by the health plans in Israel and the changes that have been made to these plans over the course of time. Two goals were set for the study: 1. To analyze and compare the supplemental health insurance plans offered by Israel's four health plans in To compare the main services offered by the supplemental insurance plans during the preliminary period, when the plans were constructed in their new format (1996), with those currently offered. This report, which relates to the first stage of the study, presents a comparative analysis of all seven supplemental health plans offered by the health plans in The comparative analysis was conducted using uniform measures: type of services offered, terms and restrictions, price, registration process, and the exercising of eligibility. In the second stage of the study, we described how the services offered by each of the health plans had developed over time. We classified the services added since 1996 according to the effect they are likely to have had on an individual's medical condition. This was done in consultation with the members and observers of the Ministry of Health committee responsible for the introduction of new technologies into the basic basket of services using the Delphi Method. The findings of the second stage of the study will be published separately. The importance of the study lies in the fact that it provides complete and objective information about the terms and rights regarding the health plans' supplemental insurance plans. It makes it possible to identify clauses where the eligibility terms are unclear or are unfair to the insured member. The study also identifies areas where state intervention is needed in order to regulate the conditions. Furthermore, the study sheds light on the connection between the supplemental basket and the basic basket, making it possible to raise for public discussion the health plan's use of the supplemental basket as a way of providing additional services to some members of the public. It is difficult for people in need to clarify and understand for themselves the terms and areas of coverage to which they are entitled through their supplemental insurance. This is due to the legal jargon, the unfamiliar use of concepts, and the overwhelming quantity of details. Members can get answers to specific questions from the health plans' information services but they need to know what to ask, which many of them probably do not. So the situation may arise where i

5 members do not take full advantage of what they are entitled to. The study proposes a range of ways that could, if implemented, help members of the public to exercise their eligibility and compare the plans. Study Method The comparison was based on the detailed regulations of each of the health plans as of late 2006, information sheets and publications disseminated by the health plans, and documents setting out rights and obligations. The comparison is presented by category of service: medication, paramedical treatment, surgery, life-saving services, etc. * The analysis was given to the officials responsible for supplemental insurance at each of the health plans. Representatives of all the health plans have confirmed the accuracy of the analysis with regard to the insurance plans offered by their own health plans and answered key questions and queries that we referred to them. Their answers helped provide a deep understanding of the comparison of the plans and to expound issues arising from the findings. The report does not include Clalit Health Services' Platinum plan, which has not, at the time of writing, been made available to the public. The plan is similar in character to the Meuhedet Sie (Summit) plan. Plans Currently Available Main Findings of the Comparison Altogether seven different supplemental plans (additional health services) are currently offered to members of the health plans: Clalit Health Services (hereinafter, Clalit) offers Clalit Mushlam (Perfect) Maccabi Healthcare Services (hereinafter, Maccabi) offers Maccabi Magen Kessef (Silver Shield) as first layer supplemental insurance and Maccabi Magen Zahav (Gold Shield) as second layer insurance Meuhedet Health Plan (hereinafter, Meuhedet) offers Meuhedet Adif (Preferred) as first layer supplemental insurance and Meuhedet Sie (Summit) as second layer insurance Leumit Health Fund (hereinafter, Leumit) offers Leumit Kessef (Silver) as first layer supplemental insurance and Leumit Zahav (Gold) as second layer insurance. In order to purchase a supplemental insurance package, it is necessary to be a member of the particular health plan that offers it. Members wishing to acquire second-layer supplemental coverage, if it exists, have to purchase the basic supplemental layer offered by the health plan. Altogether, all of the supplemental insurance plans offer 55 areas of coverage (e.g., surgical operations at private hospitals, second opinions, and medication). Members purchase all areas of coverage in the plan en bloc. * A detailed comparison of the components of the supplemental insurance plans is presented in Appendix E of this report (Hebrew).

6 Services Covered by the Plans We classified the 55 different areas of coverage into 15 main areas ("catastrophe" or major medical coverage, high-use routine coverage, and medication) and 40 other areas (relatively low-use routine coverage or inexpensive costs to the health plan). The main areas of coverage are those that constitute the core of the plan (which account for the bulk of the premium in actuarial costing) and the health plans' main expenditure on the plan. The classification was made in consultation with insurance experts and representatives of the health plans. All the plans cover the 15 main areas of coverage. The plans are similar in their terms of coverage regarding the qualifying period, terms of eligibility, ceiling, and co-payments. The differences among all areas of the plans lie mainly in the lists of service providers and the specific service covered. The lists include operations covered, hospitals in the agreement, surgeons in the agreement, medical implants, convalescence homes in the agreement, medical centers abroad, and the medications included in the plan. The lists are meant to be appended to the regulations and they constitute essential information for members wishing to exercise their rights or compare the plans on an informed basis. However, it is very difficult to obtain these lists, which are not usually published for members together with the regulations. Some of them are available at the health plan clinics, but it is not always clear to the average member where they can be obtained. With regard to the nature of the services (welfare as opposed to medical services), the comparison reveals that of the 15 main areas of coverage, twelve may be defined as medical services, e.g., surgery at a private hospital, and three as welfare services, such as convalescence following surgery. In other areas of coverage, the majority are welfare services. With regard to the correspondence between the services and the basic basket of services, the comparison reveals that most of the coverage in the main areas is for extended coverage (more than is given in the basic basket). Only in a few cases is it for improved coverage (given under better terms than in the basic basket). Only a few items covered are supplemental and are not covered by the basic basket. With regard to the target population by area of coverage, the comparison shows that six of the 15 main areas are aimed at the entire population or at the elderly and five of them are for young families and children. Four services are intended for the gravely ill and for heart patients. In other areas of coverage, the target populations for most of the services are children and youth, young people, and young families. Only four of the other services are for older populations. The Meuhedet Sie plan includes the greatest number of services for the elderly population. There is similarity among the plans in the ceiling and co-payments according to the respective layers.

7 Medication There are substantial differences among the health plans in the number of medications covered by the supplemental plans, the type of medication (emphasis on prescription medication rather than non-prescription medication), and the amount of co-payment for the medications. Following the intervention of the Ministry of Health, medications covered by the basic basket have recently been withdrawn from some of the supplemental plans. Note that it is hard for the average person to compare the lists of medications in the various plans because they are lengthy and medical knowledge is required (concerning the names and function of medications). Eligibility Restrictions The "qualifying period" is the continuous period of membership from the time of joining the supplemental plan, during which the members' rights are limited. In the case of commercial health insurance policies, it has been determined that a person already in need of services covered by the policy during the qualifying period will not be granted the services when the qualifying period is over. Ministry of Health directives for the implementation of supplemental insurance stipulate that the health plans are entitled to determine qualifying periods for additional health services. However, at the end of the qualifying period, members are entitled to all the services provided by the plan without exceptions or limitations. The fact that the term "qualifying period" has a different meaning from that used in commercial insurance is likely to confuse members. An analysis of the supplemental insurance plans reveals that three of the health plans (Leumit, Meuhedet, and Clalit) have a general exclusion clause stipulating that members are not entitled to medical services that they needed during the period of limited eligibility, even after the limited eligibility period is over. The way it is written does not make it clear whether this refers to the type of service in general or to retroactive reimbursement of payment for a specific service provided before the eligibility period. For example, if a person has been taking a certain medication that is included in the supplemental insurance plan, it is unclear whether he is disqualified from the entitlement to receive a discount on the medication even after the limited eligibility period or whether he simply cannot obtain a retroactive refund of the sums he paid during that period. If the meaning of the clause is that the member is disqualified from receiving a specific service after the qualifying period, the clause is in contravention of the Ministry of Health directives on supplemental insurance. Note that, according to the representatives of the health plans and the deputy director-general for health plans and additional health services at the Ministry of Health, the disqualification for specific services after the end of the qualifying period is in fact not actually put into effect.

8 However, the existence of such a clause may cause problems from the perspective of the consumer, who may, for example, refrain from submitting claims. Premiums and Co-payments The most complex aspect of the comparison is that of tariffs (i.e., premiums and co-payment rates). The difficulty of comparing premiums derives from the fact that each plan has a different payment rating based on age groups, bonuses for children and discharged soldiers, and some offer family discounts. Note that the basic rate and membership is individual rather than family-based. The premiums are linked to the cost-of-living index and in addition they are periodically adjusted according to the composition of the basket of services and the real costs of the range of services they offer. In our comparison, we did not take the family discounts and the various bonuses into account. The comparison reveals that the lowest rates are for Maccabi Magen Kessef and Leumit Kessef (the first layer plans of Maccabi and Leumit) and these are followed by Clalit Mushlam, Maccabi Magen Zahav, and Meuhedet Adif. The most expensive plans are Leumit Zahav and, way out in front, Meuhedet Sie. Note that we did not perform a financial analysis of the fairness of the premium with regard to the bonuses offered by the plan. In all the plans, there is a salient increase in the premiums until the age of 64, from which time the premium stabilizes at the same high rate for the remainder of the member's life. All the plans collect a co-payment for the services covered. Some of the plans pay the suppliers in the agreement directly and the members pay the difference. In other cases, the plans reimburse the members for a certain percentage of the expenses when receipts are submitted. The main difficulty in comparing the plans derives from the fact that each plan fixes the co-payments in a different way. With regard to catastrophe (or major medical) coverage (surgery, transplants, treatment abroad, and fertility treatment), the co-payments are thousands of shekels. With regard to routine coverage, while the co-payments constitute a high percentage of the actual cost, in absolute terms they are relatively low. Payment Methods According to data from studies conducted by the Myers-JDC-Brookdale Institute in 2005, 31% of the population has supplemental insurance and commercial insurance (so-called duplicate insurance). Commercial insurance either reimburses insured persons or compensates them. By law, the health plans either reimburse members on submission of original receipts or they make direct payment

9 to the service providers with whom they have an agreement without compensating the members financially. It is therefore feared that despite the fact that members who have both supplemental insurance and commercial insurance have been paying premiums for two insurance plans for some time, they will only be able to obtain payment from one of the plans in time of need. Possible Ways to Improve the Plans for the Consumer Several steps could be taken to simplify the exercising of one's eligibility - Advanced data technology could be used to provide automatic eligibility for certain coverage (chiefly areas that are extensions of the basic basket, such as medications and childhood development). - Advanced data technology could be used to provide individuals with relevant lists of coverage for their own particular medical condition. For example, when a patient is to be hospitalized, the health plan could provide him/her with a comprehensible information sheet that includes a list of the relevant items covered (second opinion, private nurse, convalescence, rehabilitation, etc.); or, when a child is referred to childhood development services, the plan could provide a list of services that he/she is eligible for (occupational therapist, speech therapist, etc.). - Members could be informed by mail of every substantial change to the plan or additional services provided. Apparently the changes made frequently are to the medications and transplant lists. It is clear to us that it is not possible to provide ongoing updated information about all the services, but the combination of automatic eligibility and information sheets could make it easier for members to exercise their rights. Steps could be taken to make it easier to compare the plans and encourage competition among the health plans (extended coverage, increased refunds, reduction in co-payments, reduced premiums, etc.). It is difficult for members in need of a certain service to clarify and understand for themselves what the supplemental insurance entitles them to. All the plans currently provide summary tables, but they are not formulated in a uniform manner and there is variance in the emphases. In addition, aspects that are important to consumers are not always emphasized. - It is proposed that, as is the case for commercial insurance plans, the health plans be required, for the main areas, to provide their members with tables giving details based on uniform parameters to be decided by objective professionals. - Professionals could also clearly classify the main items covered, which would be classified according to welfare or medical coverage and to the correspondence with the basic basket. It is also important that the medications be classified on the basis of the parameters that will be chosen. We consider the following to be among the parameters that could be included: - Qualifying period: the qualifying period for key services could be published. - Premiums: A uniform definition could be made of the age cohorts in all the plans, including family payments, so that it is possible to compare them. To help people decide whether to

10 join a higher layer plan, the total payments for all layers by age and by family arrangement could be included - The extent of co-payments and refunds: With regard to the main items covered, the amount of co-payments and the refunds (reimbursement) could also be noted The considerable variance among the plans regarding the premiums paid and the amount of copayments raises the question about the fairness of the premium and the co-payments vis-à-vis the coverage. It is worth considering having the Ministry of Health examine the question and publishing a loss ratio index to clarify the fairness of the plan. In view of the lack of clarity regarding the term "qualifying period," we suggest introducing the standard term "limited eligibility period," which would correspond with the terms of the Ministry of Health directives, i.e., the continuous period of membership from the day of joining the plan, during which time the member is included in the plan and is required to pay membership dues, but is not eligible for the rights set out in the plan. At the end of the limited eligibility period, the member would be entitled to all the services covered by the plan. Furthermore, we suggest deleting the eligibility-exclusion clauses that appear in the regulations of some of the health plans in cases where a person is in need of the medical service during the limited eligibility period, so as to prevent uncertainty as to how to interpret the eligibilityexclusion clause. About a third of the population has supplemental insurance as well as commercial insurance. It may be that members who have been paying premiums for two insurance plans for some time will only be able to obtain coverage from one of the plans in time of need. It is therefore proposed that members' attention be drawn to the inherent problems of duplicate insurance and to the possibility that they may not be able to receive full compensation from all their insurance plans. In addition, it is possible that allowing the health plans to give financial compensation instead of reimbursement in exchange for receipts could help the individual exercise his rights in the case of duplicate insurance (when he has both supplemental and commercial insurance). The loss ratio is the ratio between the gross claims (claims paid and changes in pending claims) and the insurance payments made by the members.

11 Acknowledgments We would like to thank the Knesset Research and Information Center for approving the funding of this study and for giving us a distinguished platform on which to present the findings. Special thanks to Dr. Shirley Avrami, director of the Knesset Research and Information Center, to Sharon Soffer, head of staff at the Knesset Research and Information Center, and Dr. Bruce Rosen, director of the Smokler Center for Health Policy Research at the Myers-JDC-Brookdale Institute, for their role on the study steering committee and for their useful comments and support throughout the study and during the drafting of the report and the presentation of the findings. We are also grateful to the managers responsible for the supplemental insurance plans at all the health plans, who gave their blessing to the study before we began and whom we interviewed: Dr. Toviya Horev, Meuhedet Health Plan; Yitzhak Ganor, Maccabi Healthcare Services; Kobi Shuqri and Adv. Irit Shnizik Coleman, Leumit Health Fund; and Peretz Goza, Clalit Health Services. We thank the health plan representatives who devoted hours to checking and approving the analysis of the plans offered by their respective organizations: Meir Ben Meir, Clalit Health Services; Yael Navon, Leumit Health Fund; and Haniella Vilner, Maccabi Healthcare Services. We express gratitude to MK Shaul Yahalom, who chaired the Knesset Labor, Welfare, and Health Committee in 2005, and who initiated the study, and to his deputy, MK Haim Katz. Our thanks to Yoel Lipschitz and Gabi Ben Nun from the Ministry of Health for their useful comments. Special thanks are due to Dorit Ganot-Levinger for designing the table comparing the supplemental insurance plans offered by the health plans and making it clear and easy to read. Finally, we thank Prof. Jack Habib and other members of the Institute who gave helpful advice in the course of our work. Thanks to Mati Moyal, who edited the report, Leslie Klineman, who prepared it for printing, and Elana Friedman, who helped with the typing.

12 Table of Contents 1. Introduction Structure of the Health Insurance System in Israel Services in the Supplemental Basket 3 2. Study Design and Goals Sources of Information for the Comparisons of Plans in Parameters for Analyzing the Plans 5 3. Comparison of Supplemental Health Plans in Methods of Payment Terms and Information Qualifying/waiting Period Services Covered in the Plans Nature of the Services: Welfare Services as Opposed to Medical Services Differences in the Fifteen Main Areas of Coverage (excluding medication) Premiums and Co-payments 20 Bibliography 23 Appendix A: General Stipulations of the National Health Insurance Law, 1994, that Affect the Additional Health Services Section 10 of the National Health Insurance Law Section 21 of the National Health Insurance Law 25 Appendix B: Supplemental Insurance Policyholders in the General Population, Appendix C: Knowledge about Rights and Public Information about Supplemental Insurance Knowledge about Rights and Public Information about Supplemental Insurance Obtaining Information from the Health Plans Knowledge about Legal Rights and Interest in Receiving Additional Information from the Health Plans 31 Appendix D: Supplemental Insurance from the Health-Plan Representative's Perspective What are the advantages or the unique features of the plan offered by your health plan compared with other plans? Why has your health plan chosen to emphasize and develop the areas where you believe you have an advantage? In the medications clause, what criteria does your health plan apply for including a medication in the plan? 35

13 4. Are there coverages that other health plans provide in their additional health service basket and that your health plan provides in the basic basket? If so, which? A comparison we made appears to show salient differences in the premiums paid for the various plans. Can you help us understand this? Which coverages make the plan of your health plan more expensive than others? 37 Appendix E: Detailed Comparison of Supplemental Health Plans, List of Tables and Figures Table 1: Differences by Terms and Information (excluding Qualifying Period) 9 Table 2: Differences Pertaining to the Qualifying/Waiting Period 10 Table 3: Comparison of Premiums for Supplemental Health Plans 2006, by Uniform Age Cohort 21 Table B1: Characteristics of Supplemental Insurance Policyholders in the Population, Table B2: Supplemental Insurance Policies Held: Multivariate Logistic Regression Analysis, Table C1: Background of Members who Reported Receiving Information about Supplemental Insurance from the Health Plans during the Year Preceding the Survey, Table C2: Additional Information that Members would Like to Receive about Supplemental Insurance, by Health Fund, Table E1: Comparison of the Additional Health Service Plans of the Various Health Plans, Figure 1: Scale of Supplemental and Commercial Insurance Policies Held,