The Differences between out of Pocket Payment without Authorization and Partial out of Pocket Payment with Authorization under the National Health Insurance
Whether National Health Insurance (NHI) contracted health care services providers can request the NHI insured to pay for services out of their own pockets or purchase drugs or medical devices out of their own pockets has always been a contentious issue. In terms of legal control framework, year 2011 is water shed. Before 2011, the National Health Insurance Act (NHI Act) explicitly prohibits out of pocket payment without authorization. After 2011, the provision prohibiting out of pocket payment without authorization still exists but the new provision allowing partial out of pocket payment with authorization has been amended to the NHI Act. The health care market in Taiwan is a nearly single buyer market. Due to the reality that the power and authority is highly vested in the National Health Insurance Administration (NHIA), the insurer and the health care services providers are not based on equal footings. As such, the NHI reimbursement policies have always been criticized to be unjust. In light of the recent pricing fuss of medical devices, one of the possible solutions is to separate the pricing function from the insurer. The values of health care services, drugs and medical devices are determined by an independent third party. The NHIA as a buyer can then negotiate payment schedule with health care services providers and manufacturers. Under this mechanism, the insured will not worry about being over charged when they need to pay out of their own pocket.