When you are diagnosed with cancer, the first thing you learn about is the National Health Insurance Service's special calculation exemption system. You may feel relieved to hear that your co-payment rate drops to 51%, but many people are surprised when they actually receive their billing statement from the hospital because it differs from their expectations.
The problem is the special calculation exception Only in salary items The point is that it applies. Medical expenses classified as non-covered, such as the latest anticancer drugs, expensive tests, and premium ward fees, are not protected by the Special Calculation Exception and must be borne by the individual. There is also a set application deadline, so you will suffer a loss if you do not check in advance. In this article, I have summarized the scope of non-covered items you need to check before applying for the Special Calculation Exception and the actual amount of out-of-pocket expenses.
The special calculation exception guarantees only benefit items.
The Special Calculation Exemption is a system that lowers the co-payment rate to 51 TP3T for medical treatments covered by health insurance for patients diagnosed with cancer. This is much lighter compared to general patients who have to pay 201 TP3T for hospitalization or 30 to 601 TP3T for outpatient treatment.
but Non-covered, fully self-paid, and selective benefit items are excluded from this benefit.Yes, it does. Even if you receive the same anticancer treatment, you only pay 5% for drugs covered by health insurance standards, but for new drugs awaiting insurance approval or not yet recognized, you have to pay the full amount yourself. Furthermore, if you choose a higher-class room instead of a standard room when hospitalized, you have to bear the entire difference yourself.
Special Calculation Exception 5% operates only within the scope of benefits recognized by health insurance.
The reason why non-covered expenses account for the majority of actual costs
Let's assume a stage 4 lung cancer patient is being treated with the latest immunotherapy drug. The total medical cost is approximately 20 million won, but if the special medical expense exemption is applied, the patient's co-payment is about 1 million won (5%). At first glance, this seems reasonable, but this Applies only to medical expenses within the scope of “coverage” defined by health insurance.It's a calculation.
The problem lies in the accompanying costs. Even for the same cancer treatment, covered and non-covered items vary depending on the Pharmaceutical Separation Act or insurance standards. For example, a single dose of the immunotherapy drug Tiscentrix costs approximately 1.93 million won, but if administered repeatedly for a year and a half, the total cost reaches tens of millions of won. If health insurance only covers a portion, the patient must pay the rest out of pocket.
Nursing care costs during hospitalization also account for a significant portion. It is set at around 100,000 to 150,000 won per day, and this It is not within the scope of special calculation exceptions, so the patient bears the full cost.That is the case. If the hospitalization period is prolonged, the nursing care costs alone amount to millions of won.
Who is eligible for public health center support?
Apart from the special medical expense exemption, there is a system at public health centers that provides medical expense support to cancer patients. However, you must check the eligibility requirements first.
New support for adult health insurance subscribers was discontinued as of July 1, 2021. Currently, support is focused on Medical Aid recipients and the near-poverty group.We are currently doing so. If you were an existing selected recipient who was already receiving support from the public health center, you can continue to receive it, but general adults applying for the first time must meet the income and asset criteria.
The support amount is also up to 2 million won per year for adults. Children (under 18) receive more: 20 million won per year for other types of cancer, and up to 30 million won for leukemia or hematopoietic stem cell transplantation.
| Target | Income criteria | Annual support limit | Support period |
|---|---|---|---|
| adult health insurance subscribers | Suspension of new support (existing selected recipients only) | 2 million won | – |
| Medical assistance recipients and those nearing the bottom | Median income 1201 TP3T or less | 2 million won | – |
| Pediatric (other cancers) | Median income 1201 TP3T or less | 20 million won | Until the year one turns 18 |
| Pediatrics (leukemia, hematopoietic stem cell transplantation) | Median income 1201 TP3T or less | 30 million won | Until the year one turns 18 |
If you miss the 30-day application deadline, it is not retroactive.
One of the most important conditions for special calculation exceptions is Application periodIf you apply within 30 days of being diagnosed with cancer, the special medical expense exemption is applied retroactively from the date of diagnosis. If you apply after 30 days, it applies only from the date of application.
For example, if you were diagnosed with cancer on July 1st and applied on August 5th, it means that all medical expenses paid from July 1st to August 5th will be settled at the general co-payment rate, and the 5% co-payment will apply only from August 5th, the date of application. You must cover all medical expenses incurred during that period yourself.
There is a deadline for applying for medical expense support at public health centers, and for catastrophic medical expense support, you must apply within 180 days from the day after your last treatment or discharge date. If you do not know this in advance, you will not be able to receive the benefits of the system.
Things to check in advance when applying for special calculation exceptions
It will be hectic right after being diagnosed with cancer, but, Things to do as soon as possibleThere is this.
First, ask the medical institution what treatments and tests you plan to undergo, and clearly identify which items are non-covered. This is because classifications can vary from hospital to hospital even for the same treatment. Since cancer treatment involves a combination of various medications and tests, simply knowing whether each item is covered or not makes future cost predictions much more accurate.
Next, check if you are eligible for medical expense support from the public health center. It is best to contact the health center first to inquire whether you were selected before 2021 and whether you meet the income and asset criteria. If you are not eligible, you may need to consider supplementing your coverage through catastrophic medical expense support or private cancer insurance (with riders for diagnosis and treatment costs).
And most importantly, Apply for special medical expense exemption within 30 days of receiving the confirmed diagnosis certificateYou must do it. This is a deadline you cannot miss. There are various methods available, such as contacting the National Health Insurance Service Customer Center, visiting a branch office, or applying by mail, so please choose the method that is most convenient for you. Even if everything is confusing, please do not put this one thing off.