Covered versus non-covered care — what is the difference?
Covered care means national health insurance pays part of the cost; non-covered care is paid entirely by the patient. What counts as non-covered is fixed by law as a list.
Last checked: Published:
Covered care is care for which national health insurance pays part of the cost; non-covered care is paid entirely by the patient.
Coverage is defined by subtraction
Article 41 of the National Health Insurance Act lists seven categories of covered care — consultation and testing, drugs and materials, procedures and surgery, prevention and rehabilitation, hospitalization, nursing, and transport.
How the scope is drawn matters. For everything except drugs, covered care is “everything other than what has been designated non-covered” — a negative list. Drugs alone work the opposite way: only what the Minister designates is covered.
The non-covered list is in the law
What is excluded sits in Article 9 and Schedule 2 of the Rule on the Standards for Health Insurance Benefits.
| Category | Content |
|---|---|
| 1 | Conditions that do not interfere with work or daily life (fatigue, freckles, moles, warts, acne, simple snoring, phimosis without disease) |
| 2 | Care not aimed at improving essential bodily function — cosmetic and appearance-related |
| 3 | Preventive care not directly aimed at treating illness or injury |
| 4 | Items excluded as a matter of insurance policy (upgraded room charges, orthotics, hearing aids, glasses, dental implant add-on surgery, over-the-counter drugs) |
| 7 | Items impractical to cover given the system (designated Korean medicine physiotherapy, herbal decoctions) |
| 8 | Off-label drug prescription and administration |
Why cosmetic work sits in category 2 is covered separately in why cosmetic work is not covered.
Co-payment rates vary by institution type
Even covered care is not fully paid by insurance. Schedule 2 of the Enforcement Decree sets the rates.
Inpatient care is 20 percent of the total regardless of institution type (meals 50 percent), with room-grade surcharges applying to the room charge alone — 50 percent for a two-bed room at a tertiary hospital, 40 for three-bed, 30 for four-bed.
Outpatient care splits by tier.
| Institution | Location | Patient pays |
|---|---|---|
| Tertiary hospital | Everywhere | Full consultation fee + 60% of the remainder |
| General hospital | Urban | 50% |
| General hospital | Rural | 45% |
| Hospital, dental, Korean medicine, long-term care | Urban | 40% |
| Hospital tier | Rural | 35% |
| Clinic, dental clinic, Korean medicine clinic | Everywhere | 30% |
Tertiary outpatient care is often described as “60 percent”, which the law does not support. The consultation fee is paid in full, and 60 percent applies only to what remains, so the real rate runs higher.
Reductions exist. Pregnant patients pay 40 percent at tertiary hospitals, 30 at general hospitals, 20 at the hospital tier and 10 at clinics; infants under one pay 20, 15, 10 and 5 percent respectively.
Why non-covered prices vary so widely
Because each provider sets them. That freedom is not unlimited, though.
- Disclosure (Medical Service Act Article 45): prices must be available where patients can see them, and on the website if the provider has one. Designated items must be explained before treatment. Providers may not charge more than the posted amount.
- Reporting and publication (Article 45-2): providers report twice a year, and the Minister must publish the data for hospital-tier institutions.
Publication runs through HIRA’s non-covered price service (hira.or.kr/npay).
Sources: National Health Insurance Act Articles 41 and 44; Enforcement Decree Schedule 2; Rule on the Standards for Health Insurance Benefits Article 9 and Schedule 2; Medical Service Act Articles 45 and 45-2. Last checked 2026-08-30.
Frequently asked questions
Do non-covered prices differ between hospitals?
Yes. Covered care runs on a fixed fee schedule, so institutions charge nearly the same. Non-covered prices are set by each provider. Article 45 of the Medical Service Act bars them from charging more than the price they posted.
Can I check non-covered prices in advance?
HIRA publishes non-covered price information at hira.or.kr/npay. Disclosure is mandatory for hospital-tier institutions, and providers must report their prices twice a year.
Is the outpatient co-payment at a tertiary hospital 60 percent?
Not exactly. The consultation fee is paid in full by the patient, and 60 percent applies only to the remainder — so the effective rate is above 60 percent.