CHAPTER I GENERAL PROVISIONS
The purpose of this Act is to promote social security and contribute to protecting national health, by increasing health care access by partially subsidizing health care costs for the citizens of the Republic of Korea who suffers economic difficulty arising from excessive health care costs compared with income levels.
The terms used in this Act are defined as follows:
| 1. | The term "health expenditure" means expenses falling within the scope prescribed by Presidential Decree, among the following expenses incurred in treating or rehabilitating from a disease, injury, etc.: |
| 2. | The term "catastrophic medical circumstances" means circumstances where a person suffers economic difficulty arising from excessive health expenditure, based upon income and property levels, etc., in treating or rehabilitating from a disease, injury, etc.; |
| 3. | The term "catastrophic health expenditure" means expenses calculated based upon the criteria prescribed by Presidential Decree, as excessive health expenditure to be borne by a person eligible for support prescribed in this Act, based upon the income and property levels of the household to which the person belongs. |
| Article 3 (Responsibilities of the State) |
| (1) | The State shall strive to provide appropriate support to persons in catastrophic medical circumstances; and shall proactively provide guidance on the program that partially subsidizes catastrophic health expenditure (hereinafter referred to as "catastrophic health expenditure support program"), including persons eligible for the catastrophic health expenditure; criteria for income and property; details of and procedures for providing support; and other necessary matters. |
| (2) | The medical personnel and the heads of medical institutions under the Medical Service Act, shall proactively cooperate in the catastrophic health expenditure support program. |
| Article 4 (Relationship to Other Statutes) |
Except as otherwise specifically provided for in other statutes, matters relating to subsidizing catastrophic health expenditure shall be governed by this Act.
| (1) | The catastrophic health expenditure support program shall be supervised by the Minister of Health and Welfare. |
| (2) | The National Health Insurance Service established under the National Health Insurance Act (hereinafter referred to as the "NHIS"), shall be the institution that manages and operates the catastrophic health expenditure support program. |
| (3) | The NHIS shall perform the following duties to manage and operate the catastrophic health expenditure support program: |
| 1. | Receiving applications for funding for catastrophic health expenditure under Article 10; |
| 2. | Determining as to funding prescribed in Article 12; and paying support money under Articles 13 and 14; |
| 3. | Collecting an unjust enrichment under Article 17; |
| 4. | Investigating to determine payment of support money and verify appropriateness of payment under Article 22; |
| 5. | Other matters prescribed as duties of the NHIS, in this Act. |
| Article 6 (Formulation of Plans) |
| (1) | For soundly operating the catastrophic health expenditure support program, the Minister of Health and Welfare shall formulate the comprehensive national health insurance plan referred to in Article 3-2 (1) of the National Health Insurance Act and the annual implementation plan referred to in paragraph (3) of said Article, including a plan for the catastrophic health expenditure support program; and shall evaluate results of performing said plans pursuant to paragraph (4) of said Article. |
| Article 7 (Committee for Deliberation on Catastrophic Health Expenditure Support Policy) |
| (1) | The Committee for Deliberation on Catastrophic Health Expenditure Support Policy (hereinafter referred to as the "Deliberation Committee"), shall be established under the jurisdiction of the Minister of Health and Welfare to deliberate and pass resolutions on the following: |
| 1. | Matters relating to plans for operating the catastrophic health expenditure support program; |
| 2. | Matters relating to selecting persons eligible for support under Article 9 and setting the criteria therefor; |
| 3. | Matters relating to the scope of funding and determining the maximum of amount under Article 13; |
| 4. | Matters relating to writing off as deficits prescribed in Article 19; |
| 5. | Other matters prescribed by Ordinance of the Ministry of Health and Welfare regarding operating the catastrophic health expenditure support program. |
| (2) | The Deliberation Committee shall be comprised of not more than 20 members, including a chairperson. |
| (3) | The Vice Minister of Health and Welfare shall be the chairperson of the Deliberation Committee; and the Minister of Health and Welfare shall appoint or commission the following persons as such committee members: |
| 1. | Not more than four experts in health and medical services, recommended by organizations representing the medical field; |
| 2. | Not more than four persons recommended by organizations representing patients; |
| 3. | Not more than four experts in social welfare; |
| 4. | One public official belonging to the Ministry of Health and Welfare; |
| 5. | One full-time director of the NHIS; |
| 6. | One person from among persons recommended by the managing entity of a fund referred to in Article 20 (1) 4 (referring to the fund managing entity under the National Finance Act); |
| 7. | One person from among persons recommended by the corporations and organizations referred to in Article 20 (1) 5; |
| 8. | Not more than three persons representing public interests. |
| (4) | A working committee for the catastrophic health expenditure support program by region (hereinafter referred to as "working committee"), may be established to provide working-level support in operating the catastrophic health expenditure support program; and to address matters delegated by the Deliberation Committee as prescribed by Presidential Decree. |
| (5) | Other necessary matters for the composition, operation, etc., of the Deliberation Committee and working committees, shall be prescribed by Presidential Decree. |
CHAPTER II SUPPORT FOR CATASTROPHIC HEALTH EXPENDITURE
| Article 8 (Principle of Support) |
In principle, support for catastrophic health expenditure under this Act shall be provided for medical expenses unsubsidized or unpaid under other statutes or regulations or contracts.
| Article 9 (Persons Eligible for Support) |
| (1) | Support for catastrophic health expenditure shall be provided to the citizens of the Republic of Korea who live in the country and meet the criteria prescribed by Presidential Decree based upon their income, level of bearing medical expenses, etc., (hereinafter referred to as "persons eligible for support"). |
| (2) | Notwithstanding the criteria referred to in paragraph (1), where deemed necessary by the Deliberation Committee to provide support based upon the characteristics of the disease, household conditions, necessity of support, etc., of a person bearing catastrophic health expenditure, such person shall be deemed eligible for support. |
| (3) | Notwithstanding paragraph (1), any of the following foreigners staying in the Republic of Korea shall be eligible for support: |
| 1. | A person prescribed by Presidential Decree, who or whose spouse is pregnant or is raising a child or minor child of Korean nationality or shares livelihood or residence with the spouse's lineal ascendant who is a Korean nationality, after having been married to a Korean national; |
| 2. | Any other person determined and publicly notified by the Minister of Health and Welfare, as a person who is necessary to be included among persons eligible for support based upon whether he or she is covered by the National Health Insurance, of his or her qualifications therefor, period being covered, duration of stay in the Republic of Korea, qualifications for stay, etc.. |
| (4) | Matters relating to the detailed scope, etc., of persons eligible for support under paragraphs (1) through (3), shall be prescribed by Presidential Decree. |
| Article 10 (Application for Funding) |
| (1) | Where catastrophic health expenditure occurs due to any of the following grounds, a person eligible for support who intends to receive funding for catastrophic health expenditure, shall submit an application for such funding to the NHIS, as prescribed by Ordinance of the Ministry of Health and Welfare: |
| 1. | Where he or she is hospitalized and undergoes medical treatment at any of the following medical institutions, etc., (hereinafter referred to as "medical institutions, etc."): |
| (c) | A public health clinic established under the Act on the Special Measures for Public Health and Medical Services in Agricultural and Fishing Villages; |
| 2. | Where he or she undergoes medical treatment at a medical institution, etc., as an outpatient to treat a serious disease prescribed by the Presidential Decree; |
| 3. | Cases prescribed by Presidential Decree, where he or she purchases drugs at a pharmacy registered under the Pharmaceutical Affairs Act; or at the Korea Orphan and Essential Drug Center established under Article 91 of said Act (hereinafter referred to as the "Korea Orphan and Essential Drug Center") according to a prescription issued by a medical institution, etc., in medical treatment prescribed in subparagraph 1 or 2. |
| (2) | Notwithstanding paragraph (1), if any ground exists where it is impractical for a person eligible for support to personally submit an application for funding for catastrophic health expenditure, a family member of the person eligible for support or an employee, etc., of a medical institution, etc., may submit an application for funding for catastrophic health expenditure to the NHIS, after obtaining consent from the person eligible for support on his or her behalf. In such cases, the procedures and methods, etc., for submitting an application by an agent shall be prescribed by Ordinance of the Ministry of Health and Welfare. |
| (3) | When submitting an application for funding for catastrophic health expenditure pursuant to paragraph (1) or (2), a written consent to providing the following data or information shall also be submitted, from a person eligible for support and his or her household members: |
| 2. | Whether the applicant holds a policy for any insurance prescribed in subparagraphs of Article 4 (1) of the Insurance Business Act; or the coverage scope of such insurance; the commencement date and expiry date of such coverage; such insurance amount receivable; the status of such insurance contract; and other data or information prescribed by Presidential Decree (hereinafter referred to as "insurance information"). |
| (4) | A corporation, organization, facility, institution, etc. designated by the Minister of Health and Welfare at the request of a person eligible for support may assisting in filing an application for catastrophic health expenditure under paragraph (1) or (2). <Newly Inserted on Jun. 8, 2021> |
| Article 11 (Provision of Financial Information) |
| (5) | A person currently or formerly engaged in duties referred to in paragraph (1) or (2) or a person entrusted with duties pursuant to Article 27, shall neither use financial information, etc., acquired in the course of performing duties for purposes other than those provided for in this Act nor provide or divulge such information, etc., to any third person or institution. |
| (6) | Necessary matters for requesting, providing, etc., financial information, etc., under paragraphs (1), (2), and (4), shall be prescribed by Presidential Decree. |
| Article 12 (Determination on Funding) |
| (1) | Upon receipt of an application for funding under Article 10, the NHIS shall verify whether the applicant for such funding is eligible for support under Article 9; shall determine whether the applicant can be funded for catastrophic health expenditure; and shall notify the applicant of such determination. |
| (2) | The notification prescribed in paragraph (1) shall be given within 30 days from the date the application for funding is submitted: Provided, That in any of the following cases, such notification may be given within 60 days from the date the application for funding is submitted: |
| 1. | Where the examination is delayed due to any grounds prescribed by the Minister of Health and Welfare, including incompleteness of documents submitted for the application for funding; |
| 2. | In cases of persons deemed eligible for support pursuant to Article 9 (2). |
| (3) | Matters relating to determining funding, procedures and methods for notification, etc., under paragraph (1), shall be prescribed by Ordinance of the Ministry of Health and Welfare. |
| Article 13 (Scope of Funding) |
| (1) | The NHIS shall pay a person eligible for support the partial amount of catastrophic health expenditure according to the criteria prescribed by Presidential Decree. In such cases, the maximum of the support money may be set based upon the income level of such person eligible for support, funds provided under Article 20, and other relevant matters. |
| (2) | In cases prescribed by Presidential Decree, where a person eligible for support has received or is eligible to receive any benefit, money, valuables, etc., from the State or a local government for catastrophic health expenditure according to other statutes or regulations or contracts; or has received or is eligible to receive insurance proceeds, money, valuables, etc., from an insurance company under the Insurance Business Act, he or she shall be paid catastrophic health expenditure excluding the equivalent to the relevant benefit, insurance proceeds, money, valuables, etc.. |
| Article 14 (Methods for Funding) |
| (1) | For a person eligible for support for whom it is determined to be funded for catastrophic health expenditure pursuant to Article 12, the NHIS shall deposit an amount falling within the scope of funding prescribed in Article 13 (hereinafter referred to as "support money") into a designated account opened in the name of the person eligible for support (hereinafter referred to as "designated account"): Provided, That where support money cannot be transferred to a designated account due to extenuating circumstances, including an information and communications network malfunction, the person eligible for support may be paid in cash or by other means, as prescribed by Presidential Decree. |
| (2) | Notwithstanding paragraph (1), in cases prescribed by Ordinance of the Ministry of Health and Welfare, where a person eligible for support has submitted an application for payment of support money directly to a medical institution, etc., the support money prescribed in paragraph (1) may be paid directly to the medical institution, etc.. |
| (3) | Detailed procedures, methods, etc., for depositing support money under paragraph (1) and paying support money under paragraph (2), shall be prescribed by Ordinance of the Ministry of Health and Welfare. |
| Article 15 (Restriction on Payment) |
In any of the following cases, the NHIS shall not pay support money:
| 1. | Where it is intended to receive support for catastrophic health expenditure by fraud or other improper means; |
| 2. | Where the catastrophic health expenditure results from a crime caused intentionally or by grave negligence of a person eligible for support; or due to a deliberate accident thereof; |
| 3. | Other cases where any grounds prescribed by Ordinance of the Ministry of Health and Welfare exist, as it is necessary to restrict funding for catastrophic health expenditure. |
| Article 16 (Prohibition of Seizure) |
| (1) | No entitlement to receive support money under this Act shall be transferred or seized. |
| (2) | No receivables relating to support money deposited into a designated account pursuant to Article 14 (1), shall be seized. |
| (3) | Where a person eligible for support is a deceased person, the entitlement of the relevant person eligible for support to submit an application for funding or to receive support money under this Act as at the time of his or her death, shall be transferred to his or her inheritor. |
| Article 17 (Collection of Unjust Enrichment) |
| (1) | If a recipient of support money (including any medical institution, etc., which has directly received support money pursuant to Article 14 (2)) falls under any of the following cases, the NHIS shall collect all or part of the support money, as unjust enrichment: |
| 1. | Where the support money is paid, even though a ground for restricting payment prescribed in subparagraphs of Article 15 exists; |
| 2. | Any other case where the support money has been paid erroneously. |
| (2) | Where a healthcare institution (referring to a healthcare institution prescribed in Article 42 of the National Health Insurance Act; hereinafter the same shall apply) or an institution providing medical benefits (referring to an institution providing medical benefits prescribed in subparagraph 2 of Article 2 of the Medical Care Assistance Act; hereinafter the same shall apply) which has received support money fraudulently or otherwise wrongfully pursuant to subparagraph 1 of Article 15 falls under any of the following cases, the NHIS may collect unjust enrichment from the relevant healthcare institution or institution providing medical benefits. In such cases, the NHIS may require the founder or operator of the healthcare institution or institution providing medical benefits to pay unjust enrichment, jointly and severally with the healthcare institution or institution providing medical benefits: |
| (3) | Where any act referred to in any subparagraph of Article 15 or paragraph (2) is conducted deceptively, including a false report, statement, or certification and submitting a false report, the NHIS may require a person who has conducted such act to pay unjust enrichment, jointly and severally with a recipient of support money. |
| (4) | In order to collect unjust enrichment pursuant to paragraphs (1) through (3), the NHIS shall notify the person liable to pay such enrichment in writing of the amount, payment deadline, etc., as prescribed by Ordinance of the Ministry of Health and Welfare. |
| (5) | If a person liable to pay unjust enrichment fails to pay it by the payment deadline referred to in paragraph (4), the NHIS may demand payment by a due date. |
| (6) | If a person in receipt of demand under paragraph (5) fails to pay unjust enrichment by a fixed due date, the NHIS may collect arrears in addition to unjust enrichment, as prescribed by Presidential Decree, from the date following the fixed due date. |
| (7) | If a person in receipt of demand under paragraph (5) fails to pay unjust enrichment by a fixed due date, the NHIS may collect the enrichment in the same manner as national taxes in arrears are collected, after obtaining approval from the Minister of Health and Welfare. |
| (8) | Other necessary matters for the method of collecting etc., unjust enrichment shall be prescribed by Ordinance of the Ministry of Health and Welfare. |
| Article 18 (Right to Demand Reimbursement) |
| (1) | Where the NHIS has paid support money to a person eligible for support under Article 9, since a ground for supporting a catastrophic health expenditure arose from action conducted by a third party, the NHIS can claim an indemnity from the third party in the range of up to the amount of support. |
| (2) | Where a person entitled to support money pursuant to paragraph (1) has already received an indemnity from a third party, the NHIS shall not pay support money up to the amount of such indemnity. |
| Article 19 (Write-off as Deficits) |
| (1) | Where any of the following grounds arises, the NHIS may write off unjust enrichment, overdue amount, and amount in arrears prescribed in Article 17 (7) (hereinafter referred to as "amount unpaid"), as a deficit after obtaining a resolution passed by the Deliberation Committee: |
| 1. | Where a measure regarding an amount in arrears is ceased and the portion to be appropriated for the amount in arrears falls short of the amount unpaid; |
| 2. | Cases prescribed by Presidential Decree, where it is impossible to collect the amount unpaid. |
| (2) | When identifying the existence of other property seizable after writing off amounts under paragraph (1), the NHIS shall cancel such write-off without delay; and shall take a measure regarding an amount in arrears. |
| (1) | Expenses incurred in the catastrophic health expenditure support program shall be appropriated from the following funds: <Amended on Jun. 8, 2021> |
| 1. | Contributions or subsidies made from the State and local governments; |
| 2. | Unjust enrichment, collected pursuant to Article 17; |
| 4. | Contributions or amount allocated from a fund; |
| 5. | Contributions or support money from related corporations and organizations; |
| 6. | Other income prescribed by Presidential Decree. |
| (2) | The NHIS shall keep an account for the catastrophic health expenditure support program; and an account opened under the National Health Insurance Act, separately. |
CHAPTER III SUPPLEMENTARY PROVISIONS
| Article 21 (Cooperation in Providing Materials) |
| (1) | Where necessary for the catastrophic health expenditure support program, the NHIS may request health care institutions or institutions providing medical benefits; the heads of related central administrative agencies; the heads of local governments; the heads of public institutions; and other related corporations, organizations, etc., to provide necessary materials, as prescribed by Presidential Decree. |
| (2) | Those in receipt of request to provide materials under paragraph (1) shall conscientiously comply therewith. |
| Article 22 (Investigation) |
| (1) | Where necessary to verify the appropriateness of determination to pay support money or of payment thereof, the Minister of Health and Welfare or the NHIS may order a person prescribed by Ordinance of the Ministry of Health and Welfare, such as a person eligible for support; a member of the household to which a person eligible for support belongs; a health care institution; or an institution providing medical benefits, to submit necessary materials as prescribed by Presidential Decree; and may require the competent public officials or employees to investigate related materials or ask necessary questions. |
| (2) | Public officials who investigate and ask questions under paragraph (1) shall carry identification as to their authority and produce it to related persons. |
| (3) | No person currently or formerly engaged in duties referred to in paragraph (1) shall use or divulge materials and other facts obtained and learned in the course of performing duties for purposes other than those prescribed by this Act. |
| Article 23 (Filing Objections) |
| (1) | If a person who has submitted an application for funding for catastrophic health expenditure is not satisfied with a measure taken by the NHIS for determination on funding, etc., he or she may file an objection with the NHIS. |
| (2) | Each objection prescribed in paragraph (1) (hereinafter referred to as "filing an objection"), shall be filed in writing (including electronically) within 90 days from the date the relevant person becomes aware of the measure taken; but shall not be filed after 180 days from the date the measure is taken: Provided, That this shall not apply where explained that an objection could not be filed within such period due to a justifiable ground. |
| (3) | Except as provided in paragraphs (1) and (2), necessary matters for the methods for filing an objection, determining thereon, notifying such determination, etc., shall be prescribed by Presidential Decree. |
| Article 24 (Statute of Limitation Period) |
| (1) | The statute of limitation period of the right to receive support money determined to be paid pursuant to Article 12, shall completely terminate if such right is not exercised within one year. |
| (2) | The statute of limitation period of the right to collect unjust enrichment pursuant to Article 17, shall completely terminate if such right is not exercised within three years. |
| (3) | The statute of limitation period prescribed in paragraph (2) shall be interrupted by demand made pursuant to Article 17 (5). |
| (4) | In addition to matters expressly prescribed in this Act, matters relating to the statute of limitation periods prescribed in paragraphs (1) and (2), the interruption of the statute of limitation period prescribed in paragraph (3), etc., shall be governed by the Civil Act. |
| Article 25 (Processing of Sensitive Information and Personally Identifiable Information) |
| (1) | The Minister of Health and Welfare; the NHIS (including persons who perform duties entrusted under Article 27); health care institutions; or institutions providing medical benefits, etc., may process data which contains information on health under Article 23 of the Personal Information Protection Act and personally identifiable information under Article 24 of said Act, in connection with the catastrophic health expenditure support program prescribed in this Act. |
| (2) | When the Minister of Health and Welfare, the NHIS, health care institutions, or institutions providing medical benefits, etc., process data containing information referred to in paragraph (1), they shall protect the relevant information according to the Personal Information Protection Act. |
| Article 26 (Preservation of Documents) |
Each health care institution, institution providing medical benefits, etc., shall preserve documents relating to the catastrophic health expenditure support program prescribed in this Act, as prescribed by Ordinance of the Ministry of Health and Welfare.
| Article 27 (Delegation and Entrustment of Authority) |
| (1) | The Minister of Health and Welfare may partially delegate or entrust his or her authority under this Act to the Special Metropolitan City Mayor; Metropolitan City Mayors; the Special Self-Governing City Mayors; Do Governors; the Special Self-Governing Province Governor; the heads of Sis/Guns/Gus (referring to the heads of autonomous Gus; hereinafter the same shall apply); or related institutions and organization, etc., as prescribed by Presidential Decree. |
| (2) | In relation to the catastrophic health expenditure support program, the NHIS may partially entrust its authority under this Act to the Special Metropolitan City Mayor; Metropolitan City Mayors; the Special Self-Governing City Mayors; Do Governors; the Special Self-Governing Province Governor; the heads of Sis/Guns/Gus; or related institutions and organization, etc., as prescribed by Presidential Decree. |
CHAPTER IV PENALTY PROVISIONS
| Article 28 (Penalty Provisions) |
| (1) | A person who uses financial information, etc., for any other purpose or provides or divulges it to any third person or institution, in violation of Article 11 (5), shall be punished by imprisonment with prison labor for not more than five years or by a fine not exceeding 50 million won. |
| (2) | Any of the following persons shall be punished by imprisonment with labor for not more than three years or by a fine not exceeding 30 million won: |
| 1. | A person who uses or divulges any information, etc., in violation of Article 22 (3); |
| 2. | A person who receives support for catastrophic health expenditure under this Act or causes a third party to receive catastrophic health expenditure, fraudulently or otherwise wrongfully. |
| Article 29 (Joint Penalty Provisions) |
Where the representative of a corporation, or an agent, employee or any other person working for a corporation or individual commits any violations of Article 28, in connection with the business of the corporation or individual, not only shall such violator be punished accordingly, but the corporation or individual shall be punished by a fine prescribed in the relevant paragraph of said Article: Provided, That this shall not apply where the corporation or individual has not been negligent in paying due attention and supervision to the relevant business in order to prevent such violation.
| Article 30 (Administrative Fines) |
| (1) | A person who fails to submit information referred to in Article 22 (1) without good cause; or submits false materials; or a person who refuses or evades an investigation, shall be punished by an administrative fine not exceeding five million won. |
| (2) | Administrative fines under paragraph (1) shall be imposed and collected by the Minister of Health and Welfare, as prescribed by Presidential Decree. |
ADDENDA <Act No. 15349, Jan. 16, 2018>
Article 1 (Enforcement Date)
This Act shall enter into force on July 1, 2018.
Article 2 (Preparatory Activities for Enforcement of This Act)
| (1) | Where deemed necessary to enforce this Act, the Minister of Health and Welfare and the NHIS may request the provision of materials under Article 21; may establish a related information system; and may conduct other preparatory activities to enforce this Act, before this Act enters into force. |
Article 3 (Applicability concerning Support for Catastrophic Health Expenditure)
Support for catastrophic health expenditure prescribed in this Act shall begin to apply from the first person who is hospitalized and undergoes medical treatment at a medical institution, etc., pursuant to Article 10 (1) 1; and/or the first person undergoes medical treatment at a medical institution, etc., as an outpatient to treat a serious disease pursuant to Article 10 (1) 2.
ADDENDUM <Act No. 18223, Jun. 8, 2021>
This Act shall enter into force on the date of its promulgation: Provided, That the amended provisions of Article 10 (4) shall enter into force on January 1, 2022.