The government approved an amendment to the Public Health Insurance Act. It aims to promote prevention, access to dental care and the provision and reimbursement of cross-border care. Together with this law, a law on the categorisation of medical devices prescribed on a voucher covered by public health insurance was also approved today.
"The amendment to the Public Health Insurance Act, one of the most important health laws, is an absolutely crucial step to strengthen the promotion of prevention and also aims to increase the availability and quality of health care. This amendment brings very fundamental changes in the organisation of health care, its transfer abroad and in many other areas,"said the Minister of Health Vlastimil Válek. He added that the availability of covered services in outpatient care and the patient's own social environment will also be improved by the new institution of the network report, which will transparently show the needs within the contractual networks of health insurance companies so that it will be obvious at a glance which areas health insurance companies should focus on.
The proposal significantly strengthens the promotion of prevention and motivation of insured persons to a healthy lifestyle by extending funding for bonus programmes. The proposal creates a much wider scope for health insurers to create bonuses for those insureds who demonstrate good health care. The basic prerequisite is an adequate increase in potential allocations to prevention funds. Health insurers will be able to use up to six times more of these funds than is currently the case. Under the current system, up to CZK 15 billion could be used annually to support prevention.
Health insurers will also be able to finance the development of services from a newly established fund of public benefit activities. Furthermore, the amendment modifies and clarifies the procedures within the proceedings conducted by the State Institute for Drug Control so as to remove some administrative and economic barriers to the entry of individual commodities on the market in the Czech Republic and their retention in the public health insurance system to ensure their availability.
A new legal regulation on the provisions on the amount and conditions of reimbursement of medical devices prescribed on a voucher has also been separated from the Public Health Insurance Act. The aim of the new legislation is to reflect the needs of society and further developments in this dynamically developing group of medical technologies in an efficient and timely manner.
Amendment of legislation on public health insurance
Main benefits:
1. Support for prevention through bonuses provided to insured persons from the prevention funds of health insurance companies - the need to reduce the number of chronically ill people in the population (diabetes, cardiovascular problems), or to maintain their health status and thus gradually reduce the burden on the health system
2. Facilitating the possibility to use covered health services abroad up to the amount of the local reimbursement if they are unavailable in the Czech Republic or it is more effective for the health insurance company - permission for long-term or repeated use of care, possibility to conclude a contract with a foreign provider
3. Reimbursement of modern methods in dentistry - full reimbursement for children, and for basic methods for adults, and partial reimbursement for more complex methods for adults with an emphasis on prevention
Which laws the amendment modifies:
- Act No. 48/1997 Coll., on Public Health Insurance and on Amendments and Supplements to Certain Related Acts
- Act No. 592/1992 Coll., on public health insurance premiums
- Act No. 551/1991 Coll., on the General Health Insurance Fund of the Czech Republic
- Act No. 280/1992 Coll., on departmental, branch, company and other health insurance companies
Promoting prevention by motivating the insured:
- Significant increase the maximum possible allocation to the Prevention Fund
- As wide as possible Maybe benefits offer covered by the prevention fund - it depends on what the insurance company offers - the Ministry of Health will not issue a decree specifying what is covered by the prevention funds across the board for all health insurance companies
- Increase in contribution tied to taking proper care of your own health
- some benefits are now conditional on proper completion of prevention, e.g. allowance for convalescence (should only be provided if proper care is taken for one's own health)
- The health insurance company will be entitled to create own discount programs (can be effectively used e.g. in the field of dentistry)
Facilitating reimbursement for cross-border care:
- beyond the current arrangements, the proposal allows for the issue of permission to use health services abroad at the foreign reimbursement rate, even for repeated or long-term cases
- allows health insurers to enter into a contract with a foreign healthcare provider
Involvement of the Reserve Fund
- This is only part of the reserves of health insurance companies (about 10 % - the rest allocated to other funds)
- Long-term reserve fund not used even in cases where the legal conditions are met - it is proposed to include the reserve fund in the basic health insurance fund
Fund for charitable activities:
- to 0.5 % of total premiums per year (2.5 billion) can be used by health insurance companies (the insurance company will of course use 0.5 % of the premiums it receives after redistribution) for activities and services related to the development and improvement of the quality and availability of covered services and the public health insurance system - the possibility of using unspent resources of the operational fund
- support for the creation of scholarship programmes for doctors in pre-testing training
- Targeted at specialities and regions with reduced accessibility
- Support for patient organisations
Dentistry:
- Basic principles:
- Fully funded childcare
- Basic fully-funded option, extension of partial reimbursement to more modern costly treatment options - emphasis on prevention in adults - most dental complications can be effectively prevented by teeth cleaning and preventive check-ups
- Partial reimbursement of modern methods -> more dentists in the network, improved accessibility
- Greater flexibility for partial reimbursement of procedures and dental products
- Performance:
- Fillings
- Full payment of filler for children
- Full reimbursement for adults for unlaminated fillings made of photocomposite (thickness up to approx. 4 mm) and chemically or dually hardening materials, partial reimbursement for other fillings, especially laminated fillings made of photocomposite
- Endodontics (Root canal treatment)
- Fully covered for children for the entire dentition
- For adults, full reimbursement for incisors, canines and premolars using the central pin method, partial reimbursement for other methods in the same amount
- Pulpotomy (Dental amputation)
- Fully covered on temporary teeth, fully covered on incisors and canines for children under 18
- Fillings
- Products:
- Full and partial reimbursement subject to conciliation and to be determined by a reimbursement decree
Indications for care by non-medical health professionals:
- Psychologists with specialist competence will be able to refer for paid mental health care
- Adjustment for disciplines limited by the methodology of insurance companies - physiotherapy, occupational therapy, nursing care in own social environment
Expansion of reference networks for the collection of costs of care
- Extension of so-called reference networks providers to new segments of care - i.e. apart from hospitals, other types of providers will now also submit their cost data to the IHIS for the purpose of streamlining the reimbursement system
Cancellation of pre-contractual tenders in outpatient care
- It is proposed cancel tenders before the contract is concluded with a health insurance company in outpatient care
- The outcome of such a procedure was only recommendatory. In areas of reduced accessibility, a redundant and impractical step
- In order to increase the transparency of the contracting process and to ensure the availability of covered services, health insurance companies will submit annually network report contracted providers, identifying the regions and specialties where new contracts will be offered
Medicinal products with permanent reimbursement
- In order to prevent the unavailability of certain medicinal products that the MoH, in the public interest, lists in the pricing regulation, the method of calculating the maximum prices for such products (the average of prices from up to 7 countries in the reference basket, or the average of prices in EU countries or according to a therapeutically similar product) is changed.
- In order to ensure that reimbursement is set according to the most realistic situation, the rules for selecting the reference product on which the basic reimbursement will be set are being changed:
- the reference product must account for at least 5 % of total sales volume instead of the current 3%
- if it is proven that the medicinal product is not present on the market, it will be excluded from referencing
- similar products and medicinal products with a written agreement for 6 months will be considered automatically available for referencing purposes, instead of the current 12 months
Highly Innovative Medicinal Products - change of definition, contractual arrangements
- the possibilities to demonstrate innovation and obtain the status of a highly innovative medicinal product, and thus to apply for temporary reimbursement without examining the cost-effectiveness condition, are expanded
- cost limitation for VILP will be solved by a contract between the marketing authorization holder and the health insurance company, only one contract will be concluded for each medicinal product, it will not be necessary to conclude a contract for each indication separately
- the possibility of assessing VILPs used in combination with another VILP or orphan - both the patient and the health insurer will be assured that under the specified conditions the patient will be entitled to reimbursement for all VILPs used in combination
Medicinal products used only in the provision of inpatient care
- the health insurer will be able to request SÚKL to carry out an evaluation of the benefits and costs associated with the use of such LP (which does not have a set reimbursement in outpatient care) for the purposes of the contract on a different reporting method
- in the case of LP with conditional registration, the contract must include the MAH's obligation to reimburse the insurers in the event of termination, expiry or cancellation of this registration for the costs incurred for the treatment of such LP
Food for special medical purposes
- Exemption from Part Six - administrative simplification, determination of reimbursement will not be carried out in administrative proceedings (except in exceptional cases), faster entry of the PZLÚ into the reimbursement system
Medical devices
- adjustment of the conditions that health. resources can be provided in the circulation mode (so far only financial limit, now linked to the amount of reimbursement)
- removal of Annex 3 to a separate Act - Act on the categorisation of medical devices prescribed on a voucher covered by public health insurance
MZd/ gnews - RoZ
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