Rare, incurable disease patients to see out-of-pocket costs cut in half

Copayment rate to be lowered in stages; reregistration for special disease benefits simplified

Phase 1 health insurance coverage innovation plan to support 1.97 million patients with 800 billion won annually

The government will reduce the copayment rate for rare disease and severe incurable disease patients from the current 10 percent to 5 percent by the first half of next year, as part of efforts to strengthen national health insurance coverage.

Support for insulin pumps and continuous glucose monitors, currently limited to Type 1 diabetes patients under national health insurance, will be expanded to cover all severe diabetes patients, including those with Type 2.

The Ministry of Health and Welfare said Tuesday that its 15th Health Insurance Policy Deliberation Committee meeting had voted to approve the Phase 1 Health Insurance Coverage Innovation Plan, which includes these measures.

With this expanded coverage, the ministry expects about 1.97 million patients with severe or rare incurable diseases to receive 800 billion won ($596 million) in support annually.

Copayment rates for rare, severe incurable disease patients to fall in stages; reregistration tests eased

The government will gradually lower the health insurance copayment rate for patients with rare diseases and severe incurable diseases from the current 10 percent to 5 percent.

The rate will first drop to 7 percent starting in December, then decrease further to 5 percent in the first half of next year.

As a result, average annual out-of-pocket health insurance costs for about 1.36 million patients with rare or severe incurable diseases are expected to fall from 750,000 won to between 530,000 won in 2027 and 390,000 won in 2028 — a reduction of about 220,000 to 360,000 won.

The testing procedures required when patients with rare or severe incurable diseases reregister for special calculation benefits every five years will also be simplified.

Currently, about 340,000 patients with 312 of the 1,389 recognized rare diseases and 234 severe or incurable diseases must submit separate test results in addition to a clinical diagnosis when reregistering.

Going forward, patients will be able to reregister based on their clinical diagnosis and treatment history even without test results.

Since January, reregistration testing has been eliminated for nine diseases, including Charcot-Marie-Tooth disease, and starting this month the ministry will further ease reregistration criteria for 95 diseases, including Guillain-Barre syndrome.

It plans to improve reregistration criteria for 62 more diseases by the end of this year and for 146 more by next year.

The government is also running a pilot project to dramatically simplify the process of listing rare disease treatments under national health insurance.

Pre-listing cost-effectiveness assessments will be replaced with post-listing evaluations based on actual clinical outcomes, and negotiations over drug prices and total drug spending will be replaced by preset contract conditions.

Through these changes, the government aims to cut the time required to list rare disease treatments under national health insurance from the current 240 days to no more than 100 days.

Insulin pump support for severe diabetes patients regardless of type

The government will expand support for severe diabetes patients starting in December, in line with the newly added pancreatic disorder disability category.

Currently, national health insurance covers insulin pumps and continuous glucose monitors for home treatment and management only for Type 1 diabetes patients, and provides additional reimbursement when doctors conduct home monitoring for Type 1 patients.

These benefits have not applied to Type 2 diabetes patients with the same level of severity, forcing them to pay the full cost of insulin pumps and continuous glucose monitors out of pocket.

Going forward, support will be provided regardless of diabetes type, covering both severe diabetes patients at the level of pancreatic disorder disability and those with pancreatic insufficiency-level diabetes whose pancreatic function has significantly declined, even if it does not reach the threshold of a pancreatic disorder.

Under the expanded criteria, about 11,000 patients with severe Type 2 diabetes are expected to newly qualify for national health insurance support.

Insulin pump support currently covers 90 percent of costs for patients under 19 and 70 percent for those 19 and older. Going forward, patients with a pancreatic disorder will receive 90 percent support regardless of age.

For Type 2 diabetes patients with severe diabetes at the pancreatic insufficiency level, who previously paid the full cost themselves, their share will drop to 30 percent, with health insurance covering the remaining 70 percent.

For young people ages 19 to 34, the support base amount will be raised to 4.5 million won, the same level as for children.

The out-of-pocket rate for continuous glucose monitors will be lowered by 10 to 20 percentage points from current levels.

Currently, the out-of-pocket rate for continuous glucose monitors is 10 percent for Type 1 diabetes patients under 19 and 30 percent for those 19 and older, while Type 2 diabetes patients receive no health insurance support except in cases of gestational diabetes.

Going forward, the copayment rate for Type 1 and severe Type 2 diabetes patients with pancreatic disorder will be set uniformly at 10 percent, while patients with pancreatic insufficiency will have a copayment rate of 20 percent.

The home management program will also expand from Type 1 diabetes to severe Type 2 diabetes patients.

With expanded device and home management service support, the ministry expects Type 1 patients to save 360,000 won annually and severe Type 2 diabetes patients to save 4.18 million won annually.

For about 344 patients with glycogen storage disease, coverage will expand for diabetic supplies and continuous glucose monitor electrodes needed for blood sugar management.

For about 10,978 patients with neurogenic bladder who have difficulty urinating on their own, support for self-catheterization catheters will rise from 9,000 won per day to 18,000 won for those under 19 and 13,500 won for those 19 and older.

Dental implant support for toothless seniors 65 and older

Starting next year, national health insurance will cover two dental implants for toothless seniors aged 65 and older. Currently, implant support is available only to those who still have some teeth, leaving those with none to bear the full cost.

The expanded implant support is expected to provide about 70,000 seniors with 2.28 million won each in medical cost coverage.

However, patients with complete edentulism who have already received full denture support under national health insurance will become eligible for implant support only seven years after receiving the dentures.

For children and adolescents, the age range for coverage of light-cured composite resin used in cavity treatment will expand from ages 5 to 12 to ages 5 to 13.

By extending light-cured composite resin coverage to age 13, when permanent teeth are fully formed, about 140,000 13-year-olds will receive 220,000 won in annual medical cost support.

Plan to strengthen dental coverage [Ministry of Health and Welfare data]

The ministry also said it is considering ways to expand support for hospitals specializing in severe muscular rare diseases such as amyotrophic lateral sclerosis, commonly known as Lou Gehrig's disease.

Given that such hospitals carry out many additional treatment procedures for the most critically ill patients and face a heavy caregiving burden, the ministry plans to discuss separate additional compensation measures for them.

"We will continue to identify various support measures to ease the burden of medical costs for patients with severe and rare diseases as our top priority, while also working to reduce caregiving burdens and improve public health," the ministry said. "We will push to bring essential treatment-related non-covered items under insurance coverage, while restricting new entries and strengthening management of non-covered items with a high risk of medical overuse."

thlee@heraldcorp.com