Participation fee (co-payment) is defined as the amount to be paid by an insured person, a person who has acquired the right to retire, or the person(s) they are responsible for, in order to access various health services under the Social Insurance and Universal Health Insurance Law. Co-payments are applied for some conditions and waived for others. In this article we explain which illnesses and services are exempt from co-payment and how exemptions are determined.
Co-payments are commonly requested for services such as outpatient physician visits at hospitals, dental consultations, prosthetic treatments, and in vitro fertilization (IVF) procedures. Although the term “co-payment” may sound like a large expense and discourage people from seeking care, in practice the amounts required are generally modest. For insured persons treated in state hospitals or training and research hospitals, the standard co-payment is around 5 TL; for treatment in private hospitals it is typically around 12 TL. The same conditions apply at private hospitals that have agreements with the Social Security Institution (SGK).
Another related consideration is the difference fee (additional charge), which is evaluated and set by SGK according to the Health Implementation Communiqué. The additional charge cannot exceed twice the amount you would otherwise pay; charging more than double is not permitted. Emergency cases are specifically exempt from additional charges. This distinction between co-payment and additional charge is important when determining out-of-pocket costs for certain services and illnesses.
Co-payment rules also apply to prescription medications. When purchasing drugs at pharmacies, a contribution applies: for insured people who are still working and their dependents the rate is 20%, while for those who have earned the right to retire and their dependents the rate is 10%. For example, an employed insured person buying a 20 TL medication would pay 4 TL at the pharmacy, and this amount may be deducted from payroll in some cases. A person who has earned the right to retire would pay 2 TL for the same medication. These participation fees are collected to support SGK’s budget and maintain balance in the system, while keeping out-of-pocket costs reasonable for citizens.
Exemptions from co-payment also apply in family medicine (primary care) settings. Treatments provided by family physicians are generally not subject to co-payment. The primary aim of co-payments is to prevent overcrowding and clustering in certain areas of the health system and to ensure timely access to care when rapid intervention is needed. Examples of illnesses and consultations that are typically exempt from co-payment include tuberculosis, HIV (human immunodeficiency virus), leukemia, intellectual disability, personality and behavioral disorders in adults, heart failure, asthma, chronic liver failure, chronic kidney failure, chronic respiratory failure, and various cardiac diseases. In short, physician and dentist examinations in outpatient care and a number of chronic conditions are not subject to co-payment. Note that which illnesses are exempt can change from year to year as regulations are updated.
Other situations that do not require co-payment include medical care needed as a result of a workplace accident or an occupational disease for insured persons. Medical examinations, outpatient treatment and medication related to injuries from military exercises are also exempt. In addition, health services demanded due to disasters or wartime conditions are not subject to co-payment. These are the main points to know about which illnesses and situations are exempt from participation fees.