3.4 Out of pocket payments
3.4.1 Cost sharing (user charges)
Cost-sharing has been a long-standing feature of the Norwegian health care system and has been in place since the early 1980s. The main aim has been to reduce the growth in public spending and to free up resources for high-priority areas. Another aim has been to curb the demand from people with minor health issues.
Most publicly funded health services, including primary care, require cost-sharing (Table3.3). The exemptions are for inpatient care and long-term home-based nursing care, where no cost-sharing is required (see section 3.3). Cost-sharing usually takes the form of co-payments and their level is set nationally. Exceptions are applied for certain diseases and groups of people and Helfo provides subsidies for prioritized patients (see Table3.3). General dental care for adults is one area where the share of OOP payments is very high (approximately 70% of total spending on dental care) (Statistics Norway, 2016). Most adult patients bear the full cost of dental care. In 2016, 12.1% of the adult population received reimbursements for dental treatment/care. Between 2014 and 2016 this proportion increased, but the average amount of reimbursement decreased (Ekornrud, Skjøstad & Texmon, 2017). However, children under 18 years old are entitled to free publicly provided dental care. LTC in institutional dwellings is another type of care that is subject to high co-payments.
Two annual cost-sharing ceilings are set by the parliament each year. Ceiling 1, amounting to NKr 2369 (€227) in 2019, applies to treatment by physicians and psychologists, medicines on the “blue list”, diagnostic tests and transportation expenses related to examination and treatment. Once the ceiling is reached, an exemption card for health care services is issued, which entitles the holder to free treatment and benefits for the remainder of the calendar year. Ceiling 2, amounting to NKr 2085 (€200) in 2019, applies to physiotherapy, several forms of dental treatment subject to reimbursement, accommodation at rehabilitation centres and treatment abroad. Ceiling 1 and ceiling 2 are not related to individual income – everybody pays the same amount before an exemption card is granted. Municipal services, such as home care (except for nursing home care) for the elderly and disabled, and institutional nursing care for the elderly, are among the services that are not included in the ceiling for cost-sharing. These services are usually subject to considerable OOP expenses. Residents in nursing homes typically pay between 75% and 85% of their income to the municipalities.
Taxpayers who incur extra expenses due to long-term illness, which amount to at least NKr 9180 per year (€881), were until 2013 entitled to deduct the amount of these expenses from their before-tax income (there is no maximum limit for the deduction). Due to concerns about its redistributive effects and high administrative costs, the tax deduction scheme was meant to be discontinued from the 2015 tax year. However, the scheme is still in place in 2019.
Most publicly funded health services and goods, with the exception of hospital care, require some out-of-pocket (OOP) payments in Norway. Patients are required to make these payments until an annual threshold (ceiling), which is set by the parliament each year, is reached. Afterwards, services and benefits are free for the user for the reminder of the year. Patient co-payments have been collected within two different systems, with two different ceilings: one is applied to medical treatment by physicians and psychologists (ceiling 1) and the other one to physiotherapy, some dental treatment, accommodation at rehabilitation centres and treatment abroad (ceiling 2).
From 1 January 2021, the two ceilings will be merged. There will only be one OOP ceiling that will apply to all services that were previously covered by the separate ceilings. The stated purpose of the reform is to reduce the burden of co-payments for the patients who use the services the most. The annual threshold for co-payments for 2021 was set at NKr 2460 (€ 246), which mirrors ceiling 1. This means that patients who previously exhausted both annual thresholds - an estimated 188,000 patients - will benefit from reduced annual expenses of NKr 2170 (€ 217) (which is equivalent to ceiling 2).
Changes to the National Insurance Act were approved by the parliament on December 10, 2020 and are enacted from the 1 January 2021. The Ministry of Health and Care Services is responsible for regulating co-payments and can decide which expenses are to be included in the system.
3.4.2 Direct payments
Full fees have to be paid for health care services provided by non-contracted private providers and for goods and services excluded from the statutory coverage. No information on the extent of these payments is available.
3.4.3 Informal payments
There is no evidence of the existence of informal payments in the health sector in Norway.