The supplementary programs are located on the second level, which is in the middle between the public-universal level (which is the first level) and the private level (which is the third level), and there is ostensibly a fusion between these two dimensions. The private dimension is expressed in the voluntary nature of the stratum, i.e., joining it is the result of the insured's choice and he is not obligated to join it. This, in contrast to the first tier, is the universal public, where membership is mandatory (section 4 of the law). The public dimension derives mainly from the essence of health services and their connection to the constitutional right to life, and it is embodied in the various provisions of section 10 of the law, which impose increased obligations on the health plans towards their policyholders. Thus, for example, the health plan is obligated to add every member to the program, regardless of his financial or medical condition, subject to a uniform qualification period for all members of the program (section 10(c)); The membership fee is uniform for each age group, as opposed to their individual determination in accordance with personal characteristics (section 10(e)); The program is committed to equality between fellows, subject to the provisions of section 10(c) and section 10(d)); The plan constitutes an arrangement of "mutual mutual balancing only", and we will expand on this below (section 10(b)); The Ministry of Health is granted broad supervision and control powers similar to those granted to it in relation to the public-universal level (section 10(g)); It is also granted additional powers relating to the approval of the plan and any change therein (10(a)) and the aspect of financial reporting (section 10(g)). The fabric of these provisions gives expression to the public dimension that dominates this plan, which in our opinion carries considerable weight."
It was also ruled in the Kfir Sapir case that:
"In view of the special weight of the public dimension in the supplementary plans, in our opinion, there is no room to draw a full parallel between the health funds that operate the supplementary plans and commercial entities that operate for profit. The HMOs operate by virtue of a role assigned to them by law, which is to deepen the protection that can be given to life while maintaining a budgetary balance. whereas the activity of private-commercial entities, including insurance companies operating in the field of health within the framework of the third layer of the protection of the right to health, is to maximize their profits (see section 11 ofthe Companies Law, 5759-1999)."
- In the Shlomo case, this court discussed the relevant considerations for deciding whether the health plans should be regarded as a "dealer" for the purposes of Item 1 of the Second Appendix to the Class Actions Law. The court noted the status of the health plans as dual entities, and that "the relationship between them and their policyholders is on the seam line between commercial activity and public service and is clearly not suitable for any of them" (paragraph 44 of the judgment), and added in this regard:
"On the public side of the spectrum, it can be noted that although the health funds were established as Ottoman associations by virtue of private law, they operate – including with regard to their budgets – by virtue of the Health Insurance Law and the regulation that obligates them, and provide public health services in accordance with the basket of health services set out in the law, to every resident who chooses to register for them, without the possibility of deferring it. On the commercial side of the spectrum, it can be noted that each resident chooses according to his wishes the health plan to which he wishes to belong; The health plans may provide additional health services beyond the basic basket; and the deductible payments are collected by them as part of their business and out of motivation that can be defined as business-economic."