In case the beneficiaries encounter illness, injury, or maternity, the contracted medical care institutions shall provide medical services, drafting fee schedules, drug dispensing items, and regulations governing fee schedule pursuant to Paragraph 2 of the Medical Benefit Regulations, as well as Paragraphs 1 and 2 of Article 41.
The Competent Authority shall determine the procedure of medical visit, medical visit advice, provision of insurance medical services, and other regulations concerning medical services of the preceding paragraph. If the insured is in a correctional facility, the restrictions on treatment schedule and venue, as well as matters relating to guarding, transferring, and method of providing insurance medical services shall be determined jointly by the Competent Authority and the Ministry of Justice

The Fee Schedule and Reference List for Medical Services shall be established jointly by the Insurer and the relevant agencies, experts, beneficiaries, employers, and contracted medical care institutions, and reported to the Competent Authority for approval.
Drug dispensing and fee schedule should be established jointly by the Insurer and the relevant agencies, experts, beneficiaries, employers, and contracted medical care institutions; drug providers and relevant experts as well as patients, should also be invited to voice their opinions and reported to the Competent Authority for approval.
The drafting of the two-abovementioned standards should be in accordance with the medical needs of the insured as well as the quality of medicine. The meeting should be accurately recorded; self-disclosure of the representatives’ interests and other relevant information should be made public. The results of the Insurer’s medical technology evaluation should be made public before the drafting process begins.
The joint drafting of the procedures in Paragraphs 1 and 2 as well as the drawing up of the list of representatives, its selection process, term of office, disclosure of interests, and other relevant information should be determined by the Competent Authority.

The fee schedule and reference list of medical services described in the preceding paragraph shall follow the principle of "equal payment for same nature of illness" and the relative points shall reflect the cost of each medical service. It should be drafted taking into account volume, cases, quality, individuals, and number of days.
The Insurer may first conduct a medical technology evaluation before drafting the medical service items and fee schedule in the preceding paragraph and consider human health, medical ethics, cost-effectiveness of the treatment, and the finances of the Insurance. The same applies for the drafting of the drug dispensing items and fee schedule.
Medical services and drugs are expensive and pose great danger to inappropriate users, which must be presented to the Insurer for review and approval before use, except in emergency situations.
The review items before use as well as the definition and review of emergency situations, standards, and other relevant fee schedules should be drafted in the medical service items and fee schedule and in the drug dispensing items and fee schedule.

The beneficiaries are required to pay 20 percent of the expenses of either ambulatory or emergency care and 5 percent of home nursing care expenses; 30 percent, 40 percent, and 50 percent of the expenses if they visit outpatient departments of district hospitals, regional hospitals, and medical centers respectively directly without referral.
The insured in areas with inadequate medical resources will be exempted from paying self-bearing expenses.
The Competent Authority may, when necessary, sanction the collection of a fixed amount of expenses, which the beneficiaries mentioned in Paragraph 1 shall pay for and promulgate such amount every year; such amount is to be determined in accordance with the average ambulatory care expense of the preceding year and the ratio prescribed in the Paragraph 1.
The implementation of the referral procedure and regulations in Paragraph 1, as well as the conditions for areas with inadequate medical resources in Paragraph 2, shall be regulated by the Competent Authority.

To promote preventive medicine, implement the referral system, and to improve the quality of medicine and treatment, the Insurer should draft the family physicians system.
The benefits of the family physicians system should be paid out on a per person basis; annual benefit payment should be based on the patient’s age, gender, illness, and other individual expenses after correction.
The Competent Authority shall determine the implementation regulations and schedule of the family physicians system in Paragraph 1.

The Insurer shall fix a maximum amount for special materials as well as the maximum amount charged by contracted medical care institutions as difference. The Insurer should pay the same amount for special materials with the same functional type.
The Insured should choose the special material designated by the Insurer as the maximum benefit when deemed necessary by the doctor from the contracted medical care institution and pay for the difference.
For the special material items, in which the Insured pays the difference, the permit holder should apply to the Insurer, and upon agreement of the Insurer, present jointly with implementation date to the NHIC for discussion before submission to the Competent Authority for approval.

The Insurer should adjust drug prices based on prevailing market conditions; prices for drugs with patents, which have expired for a year, should start being lowered; gradual adjustment to reasonable prices should be done within five years based on prevailing market conditions.
The Competent Authority shall determine the operating procedure for the adjustment in the preceding paragraph as well as the relevant rules.

The ratio of hospitalization expenses to be borne by the beneficiaries is as follows:
1.For acute care ward, 10 percent for the first thirty days; 20 percent from the thirty-first to the sixtieth day; and 30 percent from the sixty-first day onward;
2.For chronic care ward, 5 percent for the first thirty days; 10 percent from the thirty-first to the ninetieth day; 20 percent from the ninety-first to the one hundred and eightieth day; and 30 percent from the one hundred and eighty-first day onward.
The maximum amount to be borne by the insured for hospitalization in acute care ward for not more than thirty days, or in chronic ward for not more than one hundred and eighty days for the same illness and the maximum amount for the accumulated self-bearing expenses shall be determined by the Competent Authority.

In case of the following circumstances, the beneficiaries shall be exempted from payment of the expenses prescribed in Article 43 and the previous article:
1.Major illness and injury;
2.Child delivery;
3.Receiving medical care in mountain regions and outlying islands.
The rules relating to the exemption from the payment of expenses as well as major illnesses and injuries referred to in the preceding paragraph, the procedure for applying for proof of major illness and injury, and other relevant regulations shall be determined by the Competent Authority.

In case where the low-income households eligible under the Public Assistance Act make medical visit, the central competent authority in charge of social affairs shall prepare budget to pay for that, according to Articles 43 and 47. However, those who do not abide by referral provisions may not receive subsidies except for those in special situations.

The beneficiaries shall pay to the contracted medical care institutions for the self- bearing expenses prescribed in Article 43 and 47.
The Insurer should be notified in cases where the beneficiaries fail to pay the expenses according to the preceding paragraph after being notified and duly demanded by the contracted medical care institutions; the Insurer may suspend benefits to the beneficiaries when necessary and when it has been determined, through investigation and supervision, that the Insured is capable of paying but is unwilling to pay premiums. However, this is not applicable to individuals who are under protection in accordance with the Domestic Violence Prevention Act.

Expenses arising from the following service items are not covered in this Insurance:
1.Medical service items on which the expenses shall be borne by the each level of government according to other laws or regulations;
2.Immunization and other medical services on which the expenses shall be borne by the government;
3.Treatment of drug addiction, cosmetic surgery, non-post-traumatic orthodontic treatment, preventative surgery, artificial reproduction, and sex conversion surgery;
4.Over-the-counter drugs and non-prescription drugs which should be used under the guidance of a physician or pharmacist;
5.Services provided by specially designated doctors, specially registered nurses and senior registered nurses;
6.Blood, except for blood transfusion necessary for emergent injury or illness according to the diagnosis by the doctor;
7.Human-subject clinical trials;
8.Hospital day care, except for psychiatric care;
9.Food other than those which are to be tube feeding and balance billing for wards;
10.Transportation, registration fee, and certificate for the patient;
11.Dentures, artificial eyes, spectacles, hearing aids, wheelchairs, canes, and other treatment equipment not required for positive therapy;
12.Other treatments and drugs as stipulated by the Insurer, reviewed by the NHIC, and promulgated by the Competent Authority.

This Insurance shall not apply to a contingency incurred by war, riot, or major plague and act of God, such as severe earthquake, wind storm, flood, fire, that has been identified by the Executive Yuan and provided by all levels of the government with special aids.

No insurance benefits shall be paid by the Insurer for any one of the following events:
1.Excessive hospitalization after being notified of discharge from the hospital but refused to do so;
2.Expenses incurred from inappropriate repetitive medical visits or other improper use of medical resources; undergo treatment in medical care institutions not designated by the Insurer. This restriction does not apply in medical emergencies;
3.Treatment and drug which are not medically necessary according to the pre-examination;
4.Violating relevant medical procedures of this Insurance.

If medical services provided by the contracted medical care institutions to the beneficiaries were determined by the Insurer to be incompatible with the provisions of this Act, the expenses may not charged to the Insured.

The following may apply for reimbursement of self-advanced medical expenses from the Insurer:
1.Those within the Taiwan area who avail of medical visit from non-contracted medical institutions due to emergency or childbirth;
2.Those outside of the Taiwan area who are afflicted with special illness as determined by the Insurer and requiring local medical care due to unforeseen illnesses or emergency childbirth. The reimbursement amount should not be higher than the maximum amount set by the Competent Authority;
3.Those who received medical care services at contracted medical care institutions when their coverage was temporarily suspended but have already paid their premium in full. Those who get medical visits in non-contracted medical care institutions shall fall under the preceding two subparagraphs;
4.Those who receive treatment or who give birth in contracted medical institutions and have to self-advance medical expenses due it is non-attributable to the insured;
5.Those who have covered their own expenses according to Article 47, the annual accumulation of which has already exceeded the maximum amount set by the Competent Authority.

The Insured should apply for reimbursement of self-advanced medical expenses according to the preceding article in the following deadlines:
1.Insured persons under subparagraphs 1, 2, or 4 must apply for reimbursement of medical expenses within six months from the day of emergency treatment, or outpatient treatment, or discharge from the hospital. After the deadline, no application will be accepted. Sailors on an ocean-going fishing ship shall apply for reimbursement within six months from the date they come back from the sea.
2.Insured persons under subparagraph 3 should apply for reimbursement within six months from the day relevant expenses are paid in full; this is applicable for cases within the last five years.
3.Insured persons under subparagraph 5 should apply for reimbursement before June 30 of the following year.
The Competent Authority shall determine the documents required of insured persons applying for reimbursement of self-advanced medical expenses, reimbursement standards and procedure, and other relevant matters.

The Insured may not make repetitive application or receive duplicated payment in cash of benefits under this Insurance for the same incident.

From the date of withdrawal, no benefits shall be payable for the beneficiaries who withdraw from coverage according to Article 13; the Insurer should return all extra premium. If the benefits have already been received, the beneficiaries shall return them to the Insurer.

The right of the beneficiaries to receive cash reimbursement for self-advanced medical expenses should not be transferred, offset, seized or object to security interest.