The National Health Insurance Law, 1994 obliges the HMOs to make a reasonable alternative available for service to their members at all hours of the day and night.
A circular by the Deputy Director for Supervision of the HMOs and Additional Health Services, “
Medical Service to HMO Members during the Hours of Operation of the Clinics“ (Circular Number 08/2007), determines: “The National Health Insurance Law obliges the HMOs to make a reasonable alternative available for service to their members at all hours of the day and night. It is understood that the question of reasonableness is judged differently at different times of the day and night. Subject to this basic obligation being fulfilled, the operation of different clinics (including independent physician clinics) is possible at different hours of operation.”
The Circular defines routine operating hours of the HMO clinics as: Weekdays - from 08:00 to 19:00, Fridays and holiday eves - from 08:00 to 12:00. During these hours of operation, the HMO must provide its members with available clinic services, either on its own, or through a party acting on its behalf, under the accepted rules of co-payment that appear in the member payment program for visits to a primary physician or a secondary physician. During routine operating hours, one should present to HMO clinics or other clinics that appear in the list of the HMO’s direct service providers.
As stated in the above-mentioned Circular, the HMO’s responsibility is not limited to routine operating hours. However, it is natural that during operating hours that are outside of the routine operating hours, the system of services will be different, and will be mainly based on night medical service system provided by or on behalf of the HMO, as well as, when appropriate, on emergency medicine systems of the general hospitals.
According to the Director General’s Circular
Medical Services during Hours when the HMO Clinics are Inactive (Circular 14/2008), the HMO must make a
manned telephone center available to its members, with the role of referring members who require medical service outside of the HMO clinics’ routine operating hours to an appropriate service provider.
The HMOs’ telephone information centers are:
- Clalit Health Services - *2700
- Maccabi Healthcare Services - *3555
- Meuhedet Health Fund - *3833
- Leumit Health Fund - 1-700-507-507
Additional information about medical services outside of the hours of regular operation of clinics can be obtained in the clinics at at the HMO’s website.
The operator will refer a member who so requires to the following services:
- Night Medical Center - Referral to a clinic center operated by or on behalf of the HMO shall be made in any case where this provides an appropriate response for the case at hand, provided that the night center is no more than a 30 minute journey from the member’s residence for an urban residence (for a non-urban place of residence, provided that the distance from the residence to the closest town in which there is a night center enables reasonable availability considering the member’s medical condition).
- Home Visit by a Physician - Response by means of a house call by a physician shall be done in cases that necessitate a house call due to the patient’s condition, and in any case where the HMO has no alternative service, provided that the time till the arrival of the physician at the member’s home does not exceed 90 minutes.
- Emergency Medicine Department (Emergency Room) - Referral to an emergency room shall be done in cases that necessitate an emergency room visit, as well as in cases where the HMO has no alternative of a night center or of a house call by a physician. The referral shall have the force of a “medical letter” or a “Form 17” as regards emergency room service, and the HMO will bear the full cost of the service, with no co-payment from the member. In such a case, the patient shall be issued with a Reference Number, which will constitute proof of approval given by the HMO to the member, and its undertaking to bear the full cost of the emergency room visit.
It is the member’s right to independently turn to the night centers operated by or on behalf of the HMO, or to the house call service operated by or on behalf of the HMO. A visit to a night center or the ordering of a house call by a physician, whether by operator’s referral or independently,
involves the standard co-payment for that type of service as per the circular by the Deputy Director for Supervision of the HMOs and Additional Health Services “
Updated Payments for Health Services and Medications for the Year 2012“ (Circular Number 09/2012), which is updated from time to time.
Also, the possibility to contact the telephone center does not replace the member’s right to independently present to an Emergency Medicine Department (Emergency Room).
Funding of the service in this case will be subject to the provisions of the Second Addendum to the National Health Insurance Law, 1994.
