Table 3.
Key Out-of-Pocket Payment Requirements in the most Recent Year, by Country. This annex contains a table presenting a full description of all out-of-pocket payment requirements in the ten high-income countries studied in this paper
| Depth | Scope | Breadth | ||||
|---|---|---|---|---|---|---|
| Deductibles | Co-insurance and co-payments | Extra-billing and reference prices | Protection mechanisms | |||
| Australiaa | none | - specialist ambulatory care: 15% co-insurance - prescriptions: co-payment: AUD38.30 - hospital care: 25% co-insurance at private hospitals |
- physicians may bill above fee schedule - private hospitals may bill above fee schedule |
- prescriptions: reduced co-payment for low-income and children: AUD6.20 + cap at AUD372; others: cap at AUD1,476 after which low-income co-payment applies. - ambulatory care: co-insurance cap AUD447; cap on OOP for extra billing at AUD648 for low income and children and AUD2,030 for others (80% of costs are covered after reaching the cap) |
excluded services: adult dental care, OTC drugs VHI exists for excluded services and private hospital care |
universal coverage, + VHI held by about 50% |
| Canada | - for prescriptions (depending on province) | - prescriptions (depending on province): co-payment or co-insurance | - not allowed | - prescriptions: provincial regulations determine OOP caps and exemptions - low income: various provincial programs cover OOP costs - tax credits for individuals whose medical expenses exceed 3% of annual income |
Excluded services (depending on province): prescriptions, vision, dental care, home care, rehabilitation, medical devices/aids VHI exists for many of the excluded services |
universal coverage, + two thirds with VHI |
| Englandb | none | - prescriptions: co-payment GBP8.40 - dental care: GBP19.70, 53.90, or 233.70, depending on type of service |
- none | -exemptions: children, low income, certain diseases, + for prescriptions and eye tests also aged 60+ - annual cap on prescriptions co-payment (prepayment certificate): GBP104 |
Excluded services: - private services - vision aids, eye tests |
universal coverage |
| France | none | - physician visits: 30% co-insurance + €1 co-payment per visit and lab test/x-ray - prescriptions: 15–100% co-insurance + €0.5 co-payment/pack - inpatient care: co-insurance: 20% + co-payment €18/day - dental care: co-insurance (30%) + co-payment €1 - additional co-payment for expensive care (>€120): €18 (once per visit or stay) |
- 20% of physicians bill above fee schedule - reference prices exist for dental care, glasses, dentures, hearing aids (covering as little as 10% of costs) |
- children exempted from co-payments - patients with one of 32 severe chronic diseases exempted from co-insurance - low income (10% of population) receive free VHI, free vision care, free dental care - complementary VHI covers co-insurance - hospital co-payment limited to 31 days - €50 caps on co-payments each for physician visits, prescriptions, and dental care |
none | universal coverage, + 95% with complementary VHI |
| Germanyc | None | - prescriptions and medical aids: 10% co-insurance (min €5, max €10) per prescription - Hospital co-payment: €10 per day - Home nursing, physiotherapy, etc.: 10% co-insurance + €10 per prescription |
- Reference prices exist for crowns and dentures (covering about 50% of normal treatment), prescriptions, and medical aids. | Exemption: Children under age 18; Maximum cost-sharing (does not apply to OOP above reference prices): 2% of annual income (1% for patients with chronic conditions) |
excluded services: OTC drugs, certain services of uncertain benefit or unfavourable cost-effectiveness. | universal coverage; 10% covered by substitutive VHI |
| Netherlands | - €385 for all services except primary care | - 20-25% co-insurance for non-contracted care (only for benefits in-kind insurance policies) | - prescriptions: OOP above reference price - medical devices and aids: OOP above reference prices |
deductible exemption: children < 18, maternal care, integrated care programs | excluded services: adult dental care, certain prescriptions (statins, ASS, benzos), physiotherapy | universal coverage |
| Norwayd | None | co-payments: - primary care: NOK 152/201 - specialist care: NOK 345 - physiotherapists: NOK 98–300 - psychologist: NOK 345–1035 - dental care for 19–20 years: 25% in co-payment if services are provided by public providers - prescriptions: 39% of full price if on the “blue list” (max NOK 520/prescription) - radiology: NOK 245/exam - lab test: NOK 54 |
- extra billing of services/materials used that are excluded from statutory coverage (this is not included in cap 1 or 2) such as bandage, consumables | - children under age 16 exempted from co-payments, up to 18 years for dental care - Cap 1: max 2205 NOK during a calendar year covering primary and specialist care, radiology and “blue list” prescriptions - Cap 2: max 1990 NOK during a calendar year covering physiotherapists, some dental care for adults (predefined conditions), some rehab, and treatment abroad when referred by Oslo university hospital - tax deductions for patients with medical expenses above NOK 5880 |
excluded services: adult dental care (with some exceptions for a few predefined conditions), prescription drugs not covered by the “blue list”, services provided by non-contracted providers, services provided or devices/materials used that are excluded from statutory coverage (e.g. bandages, consumables) | universal coverage |
| Swedene | - prescriptions: 1100 SEK (for adults> 18) - dental care: 3000 SEK (for adults > 22) |
co-payments (varying across the 21 county councils): - primary care: 120–200 SEK per physician visit - specialist care: 200–350 SEK per physician visit (reduced if referred from primary care) - hospitalization: 100 SEK/day for adults> 19 - medical devices/aids: co-payment for different types of devices/aids co-insurance (determined at national level): - prescriptions: 50% between 1100 and 2100 SEK, 25% between 2100 and 3900 SEK, 10% between 3900 and 5400 SEK (max 2200 in co-payments for each 12 month period) - dental care: 50% between reference prices of 3000 and 15,000 SEK, 15% for reference prices above 15,000 SEK (applies for each 12 month period) |
- dental care: OOP above reference prices - medical devices/aids: OOP above reference prices; extra billing for medical devices/aids not covered in some county councils (e.g. multifocal lenses in cataract surgery, advanced hearing aids) |
General exemptions: - children and young adults < 22 for dental care, < 18 for prescription drugs, < 20 for health services Two separate co-payment caps for each 12 month period: - visits to primary and outpatient specialist care combined: 1100 SEK - prescription drugs: 2200 SEK |
excluded services: certain medicines, dental services and aids with uncertain benefits and/or poor cost-effectiveness; services provided by non-contracted private providers; vision aids including eye test |
universal coverage |
| Switzerland | all services: min. CHF300 – max CHF2500 | - Co-insurance 10% of all costs above deductible; - Hospital co-payment: CHF 15 / day |
- medical aids: patients pay OOP above reference price | - Children (< 19 y): no deductible (or voluntary between CHF 100 and CHF 600);- Maximum for co-insurance: CHF700/year (Children: CHF350/year) - exemptions for preventive and maternal care |
excluded services: adult dental care, OTC drugs, psychotherapy performed by independent psychologists, vision aids | Universal coverage |
| US | Employer plans - average: US$1318 Medicare: - hospital care: US$1288 - physician services: US$166 - drugs: varies by plan |
Employer plans: - average co-insurance: 18–19% primary, specialist and hospital care - average co-payment: US$24 (primary), US$37 (specialist), US$308 (hospital) - prescriptions: co-insurance 17–32%, co-payment: US$11–93 Medicare: - hospital care: no co-payment for first 60 days, US$322/day until day 90 - physician services: 20% co-insurance - drugs: varies by plan |
- usually not allowed | Employer plans: - median cap on user charges: US$3000–3999 |
Usually excluded: dental care and vision care | 8.6% uninsured |
aAUD amounts refer to 2016 values; refs: https://www.humanservices.gov.au/customer/enablers/2016-medicare-safety-net-thresholds; http://www.pbs.gov.au/info/healthpro/explanatory-notes/front/fee; http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf
bValues refer to 2016
cOOP requirements refer to SHI system; requirements for substitute VHI differ
dValues refer to 2015, ref.: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf
eValues refer to 2011