National Health Insurance (NHI)

The National Health Insurance (NHI) is one of two components that make up the Healthcare Fund program.

NHI was designed to complement the medical savings accounts, since MSA funds are usually insufficient to cover the costs of catastrophic illnesses or injuries. It is a social health insurance that pools contributions of many people - in this case, employers' 2.5% matching contributions - and is used to cover the costs of catastrophic illnesses or prolonged injuries.

The concept behind the National Health Insurance is based on Social Security: People coming together to help one another.

Coverage for Inpatient Care at Belau National Hospital

A patient with NHI coverage pays 20% of his total cost, up to a ceiling of $200 - $400 depending on household income. The following table shows the co-payment ceiling for individuals, depending on household income:

Annual Household Income
$ 0 - $ 5,599
$ 5,600 - $ 11,199
$ 11,200 - $ 16,799
$ 16,800 +
Ceiling for Inpatient
$ 200
$ 300
$ 400
$ 400
Example:
Total Bill: $ 4,000
20% of Total Bill: $ 800
Copayment Ceiling: $ 300
Patient must pay: $ 300
 

If an NHI-covered patient also has access to a medical savings account, he may use his MSA funds to pay for his 20% copayment.

Coverage for Off-Island Referrals

A patient with NHI coverage pays 20% of his total cost, up to a ceiling of $1,000 - $4,000 depending on household income. The following table shows the co-payment ceiling for individuals, depending on household income:

Annual Household Income
$ 0 - $ 5,599
$ 5,600 - $ 11,199
$ 11,200 - $ 16,799
$ 16,800 +
Ceiling for Referrals
$ 1,000
$ 2,000
$ 3,000
$ 4,000
Example:
Total Bill: $ 35,000
20% of Total Bill: $ 7,000
Copayment Ceiling: $ 1,000
Patient must pay: $ 1,000
 

If an NHI-covered patient also has access to a medical savings account, he may use his MSA funds to pay for his 20% copayment.

Currently, the maximum coverage by NHI is $35,000 per case. Any referral costs over $35,000 becomes the responsibility of the patient. Payment arrangements may be coordinated with the Ministry of Health's Medical Referral Program.

Procedure for Approval and Coverage of Off-Island Referrals

To be covered under the HCF program for an off-island referral, the first step a patient must take is to consult his doctor. If a doctor recommends that his patient be referred for off-island treatment, then he can present his patient's case to the Ministry of Health's Medical Referral Committee.

Most practicing physicians in Palau - including doctors from the private clinics and the Belau National Hospital - are familiar with the process of presenting their patient's case to the Medical Referral Committee. Doctors from private clinics are not excluded from this process, and they are able to present a patient's case at their discretion.

Once a doctor presents his patient's case, the Medical Referral Committee will discuss and review the patient's case against a specific set of guidelines. If the patient is approved, the Medical Referral Coordinator will confirm the patient's NHI coverage with the HCF office.

Once the approved patient's NHI coverage is confirmed by the HCF office, he is required to pay 20% of the estimated cost of his treatment to the Billing and Collection Department at the Belau National Hospital. Once the copayment has been paid, the HCF will begin processing the forms to purchase the patient's round-trip ticket.

If the amount paid by the patient has not yet reached the 20% copayment ceiling, he may be required to pay additional fees upon return to Palau if the actual treatment cost is higher than the previously estimated cost.

Round-trip airline fare for Approved Off-Island Referrals

If the NHI-covered patient is approved for off-island referral, then HCF will purchase a round-trip economy class airline ticket for the patient.

If a stretcher is medically necessary, the HCF office will purchase the cost of a round-trip airline ticket that will meet the number of seat required to accommodate a stretcher.

If a medical escort is medically necessary, the HCF office will also purchase the round-trip economy class airline ticket for the medical escort.

If the NHI-covered patient is a minor, the HCF office will purchase the round-trip economy class airline ticket for the parent or guardian.

At this time, inter-island medical evacuation costs within Palau are not reimbursable by the HCF office.

Limitations & Exclusions for Inpatient and Off-Island Referrals

LIMITATIONS & EXCLUSIONS FOR INPATIENT SERVICES
  • Cost related to hemodialysis
  • Co-payments for in-patient care at BNH
  • Personnel costs at the Ministry of Health
  • In-patient psychiatric care
  • Treatment for drug, alcohol, or other addictions
  • Cosmetic surgery
  • Fertility, conception, or contraceptive care
  • Dental (except due to accident or injury)
  • Care that is rehabilitative, palliative, or supportive rather than usual, reasonable and customary curative care
  • In-patient care solely for an advisory opinion
LIMITATIONS & EXCLUSIONS FOR REFERRALS
  • Co-payments for approved off-island referrals
  • Services that can be provided at BNH or elsewhere on Palau
  • Services where the costs of care are covered by a foreign government or other donor or grantor
  • Costs related to hemodialysis
  • Psychiatric care
  • Treatment for drug, alcohol, or other addictions
  • Cosmetic surgery
  • Sex change operations
  • Fertility, conception, or contraceptive care
  • Dental, hearing and vision care (except due to accident or injury)
  • Organ transplants, except as specifically covered by Section 552 of the HCF regulations
  • Cancer where prognosis is poor
  • Care that is rehabilitative, palliative, or supportive rather than usual, reasonable and customary curative care
  • Care solely for an advisory opinion
  • Care for diagnostic purposes, except as specifically covered by Section 553 of the HCF regulations
  • Care not approved by the Medical Referral Committee