Original Editor - Didzis Rozenbergs
- 1 Patient Access to Physiotherapy or Physical Therapy Services / Entry Point
- 2 Therapist Preparation
- 3 Professional Associations
- 4 Information about the Patient Community
- 5 Social/Cultural Influences
- 6 Delivery of Care
- 7 Type of Health System
- 8 Payment System
- 9 Resources
- 10 References
Patient Access to Physiotherapy or Physical Therapy Services / Entry Point
The physiotherapy services in Israel are determined by the profession. The physiotherapist determines the clinical intervention of physiotherapy him/herself. Israel offers both public and private physiotherapy services. The insurance cover for physiotherapy is paid mainly through the national health care system, and additional private services are paid privately the patient.
Physical Therapists are permitted to:
- Act as first contact/autonomous practitioners
- Assess patients/clients
- Make a diagnosis
- Treat (interventions, advice and evaluation of outcome)
- Refer to other specialists/services
- Offer preventative advice/services
A person who wishes to become a physical therapist in Israel must have at least upper secondary education level. Studies last for 4 fulltime years. After studies person recievs bachelors degree which serves as base for autonomous practice.
Physiotherapists in Israel are professionally educated at the university level and since 2008 are required to be licensed to practice. Upon a completion of the requirements for a bachelor of physiotherapy (BPT) in an accredited school in Israel, the graduate can apply to many of the advanced academic programs related to health studies offered both in Israel and abroad.
Recognized institutions in Israel for teaching Physiotherapy:
- School of Health Professions, Tel Aviv University
- Faculty of Social Welfare and Health Sciences, University of Haifa
- School of Health Sciences, Ariel University Center
- Faculty of Health Sciences, Ben Gurion University, Be'er Sheva
- Zefat Academic College
A person who wishes to receive a physiotherapist certificate in Israel must hold a bachelor’s degree (at least) in physiotherapy, and successfully complete the government examination in this profession. In addition, the following minimal conditions must be fulfilled:
- Age at least 18.
- Citizen or resident of Israel.
- Has no dangerous disease.
- Not have been found guilty, in Israel or overseas, of a criminal offense or disciplinary offense that, due to its nature, seriousness or circumstances, renders him unfit to receive a certificate in a health care profession, and not have had a charge or complaint of such an offense laid against him, in respect of which a final verdict has not yet been given.
Recognised special interest groups:
- Cardiorespiratory physical therapy
- Educators in physical therapy
- Electrophysical agents
- Health promotion (includes non-communicable/chronic disease management, physical activity)
- Information management and technology
- Intellectual disability
- Management/administration (includes leadership, medico-legal, professional standards and best practice)
- Mental health
- Orthopaedics/manual therapy
- Occupational health and ergonomics
- Older people
- Oncology/palliative care
- Pain (includes pain management, pain research)
- Private practitioners
- Sports physical therapy
- Womens health
The Association for the advancement of physical therapy was founded in 1992 and aims to promote the profession and those engaged in it.
The Association for the advancement of physical therapy is administered by the Board of Directors elected every two years and is working on a voluntary basis. The Association is based entirely on volunteer work of colleagues and funded from annual membership fees and sponsorships.
The Israeli physiotherapy association has one staff employee (plus secretaries) but no managing director employed. The association holds regular executive meetings (meeting period not specified) and furthers liaisons with other health care professions and authorities. The Israeli physiotherapy association is member of a trade union.
Among the activities: organizing the national physiotherapy conference, organizing professional activities such as courses and seminars, establishment and support of interest groups, bringing foreign lecturers, research support and more.
The society publishes a quarterly journal giving professional stage for publishing studies conducted in Israel by physiotherapists.
For several years, the association engaged in promoting Physiotherapy Act, together with the Ministry of Health, Labor and Welfare Committee and the Health Committee, and other organizations.
Association for the Advancement physiotherapy working in full cooperation with a number of organizations: Ministry of Health, health organizations, funds, universities and others to promote the common goals of the profession of physical therapy.
Information about the Patient Community
At the end of 2007 etnic composition of Israel - 76% were Jewish, 17% were Muslim Arabs, and other minority groups included Christians (3.2%) and Druze (1.7%). Population density is among the highest in the Western world, with 311 people per km². More than 60% of the population is concentrated in the narrow strip along the Mediterranean Sea and the population density in this area is several times higher than the national average.
Israel recognizes Hebrew and Arabic as ofﬁcial languages, and English and Russian are the most commonly used foreign languages. The Jewish population is largely urban; less than 10% live in rural areas, principally in two types of cooperative communities: moshavim and kibbutzim. Most of the Arab population live in non-urban settings, primarily small- to medium-sized towns.
Israel is a relatively young society; 28% of the population are younger than 15 years and only 10% are older than 64 years. Israel’s general population is still signiﬁcantly younger than that of other Western countries. Its relatively high total fertility rate (2.88 per woman) has been accompanied by phenomenal growth in the absolute number of elderly people. Since 1955 the elderly population has increased eight-fold, while the general population has increased approximately four-fold. The proportion of elderly people in the population is expected to reach 12% by 2020 and 18% by 2050.
Immigration has played a critical role in the demographics of Israel. When the State was declared in 1948, its population was 873 000. In its early years the population increased as a result of large waves of Jewish immigration from eastern Europe and the Arab countries of the Middle East and North Africa in the 1950s. As a result, the population passed the 2 million mark within a decade of Israel’s founding. In the 1970s, there was another major wave of immigration, this time from the Soviet Union. Immigration rates were lower in the 1980s and surged again in the 1990s.
The years 1990–2000 saw the arrival of almost 1 million new immigrants, including almost 400 000 in 1990–1991 alone. The vast majority of these new immigrants arrived from FSU countries. From 1990 to 1995 – years of particularly high immigration rates – the Israeli population grew at an annual average rate of 3.5% per year, while from 1995 to 2000 the average annual growth was 2.5% and from 2000 to 2005 it was 2.3%.
In 2011 estimated population of Israel was 7.6 milion of which 92% lived in urban areas. Life expectancy at birth for both sexes was 82 years. Life expectancy at age of 60 for both sexes was 25 years. Probability of dying under five was 4 per 1 000 live births. Probability of dying between 15 and 60 years male/female was 75/44 per 1 000 population. Maternal mortality ratio in 2010 was 7 per 100000 per live births.
Noncommunicable diseases (NCDs) are estimated to account for 87% of all deaths. 27% are caused bu cardio-vascular diseases, 27% are caused by cancer, 7% are caused by diabetes, 6% are caused by respiratory diseases and 20% are caused by other NCDs. 5% of all deaths are caused by injuries and 8% oh all deaths are caused by communicable, maternal, perinatal and nutritional conditions.
In 2008 estimated prevalence of metabolic risk factors was 35.8% for raised blood pressure, 10% for raised blood glucose, 60.9% overweight, 26.2% for obesity and 53.6% for raised cholesterol.
Jewish Patients and Health Care:
- Some Jewish patients may strictly observe a rule not to "work" on the Sabbath (from sundown on Friday until sundown on Saturday) or on religious holidays. If so, this religious injunction against "work" -- which includes prohibitions against using certain tools or engaging in tasks such as those that initiate the flow of electricity -- would be problematic to tasks like writing, flipping a light switch, or pushing buttons to call a nurse, adjust a motorized bed, or operate a patient-controlled analgesia (PCA) pump. Also, the tearing of paper may be considered "work," so roll toilet paper should be replaced with an opened box of individual sheets.Medical procedures should not be scheduled during the Sabbath or religious holidays (unless they are life-saving), nor should hospital discharges be planned during such times without the consent of the patient. While these restrictions on "work" are generally associated with Orthodox Judaism, it is possible that they may be important for any Jewish patient.
- Jewish holidays are usually highly significant for patients, especially Passover in the spring and Rosh Hashannah and Yom Kippur in the fall. These holidays may affect the scheduling of medical procedures and may involve dietary changes (related to a need for special food or to a desire to fast). All Jewish holidays run sundown-to-sundown.
- Jewish patients often request a special "Kosher" diet, in accordance with religious laws that govern the methods of preparation of certain foods (for example, beef) and prohibit certain foods (for example, pork or gelatin) and combinations (for example, beef served with dairy products). During the holiday of Passover, an important distinction is made between food that is merely "Kosher" and that which is specifically "Kosher for Passover." Hand washing before eating may have a religious significance.
- Some Jewish patients may have culturally-based concerns about modesty, especially regarding treatment by someone of the opposite sex. However, Jewish tradition holds the expertise of medical practitioners in high regard, and this fact may assuage concerns about treatment by the opposite sex.
- Questions about the withholding or withdrawing of life-sustaining therapy are deeply debated within Judaism, and some patients or families are strongly opposed to the idea. Family members often wish to consult with a rabbi about the specific circumstances and decisions regarding end-of-life care.
- After a patient has died, Jewish tradition directs that burial happen quickly and that there be no autopsy (though there is acceptance when autopsy is deemed necessary, such as by a mandate from the Medical Examiner). Also, the family may request that a family member or representative constantly accompany the body in the hospital, even to the morgue (where the person may sit outside any restricted area yet relatively near the body), to say prayers and read psalms.
- There may be a request that amputated limbs be made available for burial. Details should be arranged through the patient’s/family’s funeral home.
- Jewish religious laws pose a complex set of restrictions that can affect medical decisions, and patients or family members may request to speak with a rabbi to determine the moral propriety of any particular decision. Exceptions are often made to the normal application of the religious laws when an action is understood in terms of "saving a life," such as with emergency surgery during the Sabbath or (potentially) in the case of organ donation. The value of "saving a life" is held in extremely high regard in Jewish tradition.
- It is common for Jewish patients to a yarmulke or kippah (skull cap), especially for prayer,, but some people may wish to keep them on at all times. Patients or family members may also wear prayer shawls and use phylacteries (two small boxes containing scriptural verses and having leather straps, worn on the forehead and forearm during prayer). There may be a request that at least ten people (a minyan) be allowed in the patient’s room for prayer.
- A Jewish person need not be religious to be "Jewish," and such non-religious patients may observe Jewish religious traditions for cultural reasons.
- The word "Jew" is commonly used within Jewish culture, but non-Jews should be mindful of its complex historical connotations by which it can sometimes carry a harsh tone when spoken by non-Jews.
Muslim Patients and Health Care:
- Muslim patients may express strong, religiously/culturally-based concerns about modesty, especially regarding treatment by someone of the opposite sex. A Muslim woman may need to cover her body completely and should always be given time and opportunity to do so before anyone enters her room. Women may also request that a family member be present during an exam and may desire to keep on her clothes during an exam if at all possible. Muslim men may find examination by a woman to be extremely challenging. Nudity is emphatically discouraged. There should be no casual physical contact by non-family members of the opposite sex (such as shaking hands). Some Muslims may avoid eye-contact as a function of modesty.
- Muslims may specifically request a diet in accordance with religious laws for "Halal" food, though many Muslims simply opt for a vegetarian diet as a quiet way to avoid religious prohibitions against such things as pork products or gelatin. ("Halal" is not the same as "Kosher" --the latter refers to Jewish tradition.) Forbidden foods are referred to as "Haraam."
- Muslim dietary regulation can affect patients' use of medications, especially drugs that have porcine origins or that contain gelatin or alcohol. The dietary prohibition against alcohol has occasionally raised questions about Muslims' use of alcohol-based handrubs in the hospital, but such handrubs should not ultimately prove problematic, because they do not have an intoxicating effect and are used for potentially life-saving hygiene --nevertheless, a patient or family member's concern about this should be addressed thoroughly and sensitively, perhaps with the input of an imam.
- The act of washing is generally conceived as requiring running water, either from a tap or (poured) from a pitcher. As a result, Muslim patients typically do not feel truly cleaned by a sponge bath. Also, it is generally important that Muslims wash--with running water--both before and after meals, and also before prayers.
- Muslim prayers are conducted five times a day. Patients may desire to pray by kneeling and bending to the floor, but Islamic tradition recognizes circumstances when this is not medically advisable. If patients are disturbed by their inability to pray on the floor, advise should be encouraged from an imam.
- Muslim patients may take suffering with emotional reserve and may hesitate to express the need for pain management. Some may even refuse pain medication if they understand the experience of their pain to be spiritually enriching.
- There may be a request that amputated limbs be made available for burial. Details should be arranged through the patient’s/family’s funeral home.
- Muslim tradition generally discourages the withholding or withdrawing of life-sustaining therapy. However since decisions on this subject turn on the particular circumstances of the patient and the complexities of medical treatments, family members who are morally conflicted may wish to bring an experienced imam into their discussion with physicians.
- A family member may request to be present with a dying person, so as to be able to whisper a proclamation of faith in the patient's ear right before death. (Similarly, a husband may request to be present at a birth in order to whisper a proclamation of faith in the ear of the newborn.)
- After a death, the family may request to wash the patient and to position his/her bed to face Mecca. The patient's head should rest on a pillow.
- Burial is usually accomplished as soon as possible. Muslim families rarely allow for autopsy apart from an order by a Medical Examiner. Some Muslims may consider organ donation, especially with a sense of "saving life," but the subject is open to a great difference of opinion within Islamic circles.
- During the thirty-day month of Ramadan, Muslims refrain from food and drink from dawn until sundown. Physicians should explore with patients whether it is medically appropriate to fast while in the hospital, and if so, investigate options for pre-dawn meals, for providing patients with dates and spring water in the late afternoon (--a traditional way to break the daily fast), and for delaying dinner until after sunset. While anyone who is ill is not obligated to fast, the Ramadan observance can be powerfully meaningful to patients if they can participate. The month of Ramadan shifts according to a lunar calendar, and when it occurs during the summertime, longer days can make the fast more physically stressful.
National identity for Israelis is to a large extent bound up with their identity as Jews. For the more devout, national identity takes on a spiritual element, in which the observance of religious ritual becomes an expression of national pride. However, there are also a large number of secular Jews in Israel, for whom Judaism is more a cultural and ethnic identity than a spiritual practice. Many Palestinians living in Israel do not identify as Israelis at all, but rather with the displaced Palestinian nation (and with the rest of the Arab world as well). Much of their national identity is also based on both religious and cultural elements of the Muslim faith.
Classes and Castes.
Israel is not highly stratified economically; most people have a similarly comfortable standard of living. However, the majority of the poor are Palestinian. Recent immigrants from Africa and Eastern Europe also tend to be at a disadvantage economically.
Symbols of Social Stratification.
Among Israeli Jews, clothing is often an indication of religious or political affiliation. Men wear yarmulkes , or skullcaps, for prayer; more observant men wear them at all times. Conservative Jewish men can be distinguished by their black hats, whereas liberal Jews wear white crocheted caps. In the strictest Orthodox communities, men dress all in black and wear peyes , long sidelocks. Women keep their heads covered; traditionally, after marriage, they shave their heads and wear wigs. Secular or less conservative Jews, who comprise the majority of the population, wear Western-style clothes. Many Arabs wear traditional Muslim dress, which for men is a turban or other headdress and long robes, and for women is a long robe that covers the head and the entire body.
Division of Labor by Gender.
Women are well represented in many fields, both traditional (teaching, nursing, child care), and nontraditional (law, politics, the military). Some strides toward equality have been reversed; while it used to be a hallmark of kibbutzim that labor was divided without respect to gender, today women are more likely to be found in the kitchen and in child care facilities. Women, like men, are required to serve in the armed forces, and during the war for independence fought in the front lines alongside men. Today women are not permitted combat. Instead they are mostly confined to adminstration and education, and usually do not achieve high-ranking positions.
The Relative Status of Women and Men.
In the Orthodox tradition, women and men live very separate lives. Women are considered inferior, and are excluded from many traditional activities. However, most of Israeli society is more progressive, and women are generally accorded equal status to men, both legally and socially. (The main exception to this is the divorce law.)
Traditionally, in both Arab and Jewish societies, marriages were often arranged, but that is uncommon nowadays. However, there are powerful social taboos against intermarriage, and it is illegal for a Jew to marry a non-Jew in Israel. Those wishing to do so must go abroad for the ceremony. Even within the Jewish community, it is unusual for a very observant Jew to marry someone secular. Divorce is legal, but Orthodox Jewish law applies. According to this statute, men have the power to prevent their ex-wives from remarrying. If the woman enters into another relationship, the courts refuse to recognize it, and any children from such a union are considered illegitimate and themselves cannot marry in the State of Israel.
The most common family unit consists of a nuclear family. In more traditional families, grandparents are sometimes included in this. In the original kibbutz system, the living arrangements were different. Husband and wife lived in separate quarters from their children, who were housed with the other young people. Some kibbutzim still operate in this way, but it is now more common for children to live with their parents, although their days are still spent separately.
Delivery of Care
Rehabilitation is included in the NHI beneﬁts package and responsibility for its provision therefore lies with the health plans. All rehabilitation services, whether provided in the hospital or in the community, incur a co-payment. The co-payment for inpatient services is approximately NIS 100 (€20) per day at the time of writing, and for community clinics it is approximately NIS 30 (€6) for each quarter. Outpatient services include clinics for child development and rehabilitation, and clinics for general rehabilitation. Ambulatory rehabilitation services are provided in special community facilities of the health plans.
At the end of 2006 there were 987 rehabilitation beds in Israel. Of these, 37% were in two rehabilitation centres, 35% in ten rehabilitation wards in general hospitals, 28% in six geriatric rehabilitation centres, and 25% for individuals who were comatose for an extended period of time.Approximately one-third (31%) of the beds were for neurological rehabilitation, 18% for general rehabilitation, 25% for people comatose for an extended period, 13% for children and 13% for orthopaedic rehabilitation.
Approximately one-third of these beds were owned by the Government and one-third by two health plans, while a few of the beds were either publicly or privately owned. Most of the beds are concentrated in the central region of the country, whereas the rate of general rehabilitation beds is low in the southern and northern regions.
The four health plans operate rehabilitation clinics within the community, offering physical, occupational and speech therapy. In order to receive care at one of these clinics, a patient must obtain a referral from a family physician or specialist, and this incurs a co-payment. The clinics provide neurological and orthopaedic rehabilitation services, as well as child development services. Most of the clinics contain the latest equipment and are operated by licensed professionals who remain abreast of the changes within their ﬁ eld. To a limited extent, the health plans also provide rehabilitation services in the home, through the medical home care units.
Critical issues facing rehabilitation
One critical issue is the constant shortage and the high turnover of skilled human resources. As in other parts of the world, this stems from the fact that the majority of these rehabilitation professionals are women: some work only part time, some leave after having children and some leave the profession altogether.
The relatively low salary of these skilled professionals is another incentive for leaving the ﬁeld and/or the public sector. Moreover, the high wages paid to rehabilitation professionals in the private sector, where compensation is awarded on a fee-for-service basis, also provide an incentive to leave public sector jobs.
Due to the shortage of human resources, poor physical conditions and other factors, most of the community rehabilitation centres have waiting times of months for treatment. Consequently, rehabilitation centres often have two parallel queues: one for acute cases, consisting primarily of younger people after a road or work accident and traumatic-orthopaedic cases, and the other for chronic patients, consisting primarily of older adults who suffer from back pain or neurological diseases such as a stroke or Parkinson’s disease. However, due to the constant pressure on rehabilitation centres, treatment of patients in the latter group is postponed for months or even longer.
Type of Health System
The defining characteristic of the health system in Israel is its governance by the National Health Insurance Law (1995).
This law ensures health coverage to every resident of Israel and defines the government's responsibility to provide health services to every person without discrimination. In other words, health insurance
is mandatory, and all residents of Israel must be insured. Every citizen or permanent resident of Israel is free to choose from among four competing, non-proﬁt-making health plans. The health plans must
provide their members with access to a beneﬁts package that is speciﬁed in the NHI Law. The system is ﬁnanced primarily via progressive taxation, and the Government distributes the NHI funds among the health plans according to a capitation formula that takes into account the number of members in each plan and their age mix.
In addition to its planning and policy-making roles, the Ministry of Health also owns and operates about half of the nation’s acute care hospital beds. The largest health plan operates another third of the beds, and the remainder are operated through a mix of non-proﬁt-making and proﬁt-making organizations.
The National Health Insurance Law
The following are the basic provisions of the National Health Insurance Law:
- Every resident of the State of Israel is entitled to health insurance. Coverage is mandatory, and every resident must be covered.
- The provisions of the Basket of Services (sal sherutei briut) are identical for each individual.
- Health services are provided through the health funds (kupot holim).
- Every resident of Israel must be a member of one of the healthfunds in order to receive health services.
- Every person is entitled to join the health fund of their choice. The funds are forbidden to reject any applicant.
- Any person is entitled to transfer from one health fund to another.
- Services included in the Basket of Services are provided according to the judgment of medical professionals. Care must be provided at a reasonable level of quality, within a reasonable period of time, and within a reasonable distance from the patient’s place of residence.
- The government of Israel is responsible for coverage of the costs of the Basket of Services, which is fixed by law.
- The National Insurance Institute manages collection of health insurance premiums. The rate of payment is fixed according to a progressive scale.
- The Law forbids places of employment to require their employees to belong to any specific health fund.
- The health funds are subject to ongoing governmental supervision and inspections.
- Health services are administered according to guidelines of respect for the patient and the patient’s right to privacy and medical confidentiality.
- Any person who feels that their rights have been violated may file a complaint. The health funds are forbidden to deny this right to any of its members.
The exceptions to this law include the following:
- Soldiers conscripted to obligatory service in the Israel Defense Forces receive medical care through the Army.
- Disabled IDF veterans receive medical care through the Ministry of Defense.
- Persons in jured inwork accidents, hospitalization of woman giving birth and their newborns, and persons injured during enemy actions receive coverage through the National Insurance Institute.
- Disabled World War II veterans and victims of the Nazis may be eligible for coverage from the Ministry of Finance.
The Basket of Health Services
The Basket of Health Services (sal sherutei briut) consists of a range of essential medical services, including treatments, medications, and equipment which each health fund is obligated to provide to its
members. Its contents are defined by law, but are subject to periodic revision. Therefore, residents may find that a treatment or medication that was covered at one point has been discontinued, or that new items have been added.
It is important to note that only those services included in the basket are provided free of charge or at a reduced cost. This means that residents may have to cover at least some of the cost of certain prescriptions and treatments, or fully finance items that are not included in the basket. Residents can also choose to acquire supplementary coverage from your health fund.
Obligatory services provided by the health funds include:
- Visitstoclinicsforconsultation,diagnosis,andtreatment(including consultations and treatments from family doctors, specialists, and para-medical professionals).
- Hospitalization and emergency room services.
- Laboratory services. Each health fund has its own laboratories. If the health fund laboratory does not handle a specific procedure, the patient is referred to an outside facility, and the fund covers the costs either partially or fully.
- Certain medical equipment
- Certain diagnostic procedures, including x-rays and scans.
Also provided in the basket are certain types of paramedical services such as physiotherapy, speech therapy, and occupational therapy
The Health Funds
There are four health funds: Kupat Holim Clalit, Kupat Holim Maccabi, Kupat Holim Meuhedet and Kupat Holim Leumit. Each fund has branches throughout the country.
As stated above, The law requires each health fund to provide its members with all of the services that it mandates. The differences between the funds lie mainly in the location and availability of their
facilities, the types of supplemental policies offered, and additional services offered within the framework of their facilities at a discount or with no charge.
In general, each fund allows its members to choose a primary-care physician and specialists from the list of doctors associated with the fund. Doctors accept patients either at the fund’s own clinics or in
their own independent offices. It is necessary to have your health fund membership card or booklet with you when visiting a doctor. In most cases, you will have to pay a fee for seeing a specialist.
In addition, each fund has arrangements for the hospitalization of its members, whether in government or private hospitals. The funds also offer laboratory services, x-rays, and pharmacies, as well as
paramedical services such as physiotherapy.
There is universal coverage via an NHI (National health insurance) system. NHI provides access to a broad beneﬁts package including physician services, hospitalizations, medications and so on; long-term care services and psychiatric services are not included at the time of writing. The NHI system is ﬁnanced primarily from public sources – a mixed system of payroll tax and general tax revenue. These public funds are distributed among the health plans according to a capitation formula, which primarily reﬂects the number of members in each plan and their age mix. Cost sharing for pharmaceuticals, physician visits and certain diagnostic tests also plays a role in ﬁnancing the NHI system.
Services outside the NHI system are ﬁnanced via VHI (Voluntary health insurance), and direct out-ofpocket payments for private sector services. In recent years, the share of public ﬁnancing has declined, while the share of private ﬁnancing has increased.
There are two forms of VHI available in Israel: supplementary VHI offered by the health plans and commercial VHI. In essence, the situation is characterized by competition between private insurers and public–private hybrids.
The overall NHI system is financed primarily by income-linked taxation. However, approximately 40% of Israel's national health expenditures are covered by households, through a mix of out-of pocket payments and supplemental insurance packages. Payments by households cover copayments for certain services included in the NHI benefits package (such as visits to specialists and pharmaceuticals) as well as services not included in that package (such as dental and optometric care).