Decree of the Government of the Czech Republic No. 216 / 1992 Coll.
Decree of the Government of the Czech Republic issuing the Health Regulations and implementing certain provisions of the Czech National Council Act No. 550 / 1991 Coll., on General Health Insurance
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Effective from 22.05.1992
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216
GOVERNMENT REGULATION
Czech Republic
of 8 April 1992
laying down the Health Regulations and implementing certain provisions of the Czech National Council Act No. 550 / 1991 Coll., on General Health Insurance
The Government of the Czech Republic orders the implementation of the Act of the Czech National Council No. 550 / 1991 Coll., on General Health Insurance:
Health care coverage fully or partially covered by health insurance
(1) The general health insurance provides health care to insured persons for full or partial remuneration. Its scope and level are determined by the nature of the disability of the insured person and the amount of financial resources to cover it.
(2) Fully paid is financially the least demanding of possible healthcare methods, which is indicated for health reasons, complies with the principles of the procedure given by the current stage of knowledge and achieves an effect comparable to other methods.
(3) Partly paid is the kind of healthcare that is indicated for health reasons, meets the principles given by the current degree of knowledge, achieves an effect comparable to other methods, but is more financially demanding than that provided for in paragraph 2.
(4) In the case of partially paid care, the amount of remuneration paid by the insured person shall be the difference between the maximum price of performance and the price of performance paid by the relevant health insurance undertaking. The maximum power price shall be calculated by multiplying the maximum price of the point defined by the Ministry of Finance's price ratio by the point assessment of the relevant health performance included in the list of health performance with point values (hereinafter referred to as "the list of performance ') 1 and adding the price of the direct material, if indicated in the performance list for that performance. The amount to be paid by the competent health insurance undertaking for the performance shall be calculated by multiplying the point-to-point assessment of the health performance according to the preceding sentence by the price agreed by the health insurance undertaking in respect of which the insured person is insured with the contractual medical establishment and by the price of the direct material, if indicated in the list of benefits for that performance.
(5) The categorisation of health performance divided into performance partly covered, not covered or covered under specified conditions is set out in Annex 1 to this Regulation. Health performance not listed in Annex 1 shall be fully covered by health insurance companies, provided that they are included in the performance list (1).
(1) If the treating physician has doubts as to whether the health performance covered by health care is wholly or partly covered by health insurance (hereinafter referred to as "paid care"), or if the degree of disability of the insured person necessarily requires performance in addition to this, he / she shall request, prior to carrying out it, a consultation of the health care insurance supervisor chosen by the insured person (hereinafter referred to as "the medical examiner"). If, due to the degree of disability of his or her health condition, the insured person is subject to urgent medical care in excess of his or her paid care, he or she shall notify the medical practitioner after the performance of the medical examiner. The revised physician shall assess the justification for such medical performance. The health performance recognised by the medical examiner shall be paid by the health insurance undertaking at the level of the demonstrable costs associated with its execution. The medical performance not recognised by the medical practitioner shall not be covered by the health insurance undertaking; in such a case, the costs of the health care facility of the treating physician shall be borne.
(2) The provisions of paragraph 1 shall also apply to cases relating to the execution of the necessary and urgent performance which is not included in the list of performance but which, according to the treating physician, is in the interest of the health of the insured person. Such performance shall be borne at the level of the demonstrable costs associated with its implementation.
(3) The treating physician referred to in paragraphs 1 and 2 shall be the doctor who has custody of the insured person.
Diagnostic and curative care
Individual performance of diagnostic care, outpatient and institutional care including treatment rehabilitation and chronic care are listed in the list of performances. 1)
Prevention
(1) As part of the paid care, preventive examinations are carried out for insured persons. Preventive examinations shall be carried out by the chosen general practitioner for children and adolescents, by an adult practitioner, a female doctor and a dental practitioner, unless it is clear from the health file of the insured person that the examination has been carried out or that the insured person has been examined within the required time limits.
(2) A preventive inspection shall be carried out for insured persons:
(a) in the first year of life nine times per year, of which at least six times in the first half of the year of life, and of which at least three times in the first three months of life, unless they are provided with dispensary care under Article 6 (1) (a);
(b) at 18 months of age,
(c) at three years and thereafter every two years.
(3) A preventive examination is carried out in the field of dentistry:
(a) children and adolescents under the age of 18 twice a year;
(b) in pregnant women, twice during pregnancy,
(c) adults once a year.
(4) In the field of gyno, a preventive examination is carried out at the end of compulsory school and starting from the 15th year of age once a year.
(5) The scope of the preventive examinations referred to in the previous paragraphs in relation to age is set out in Annex 2 to this Regulation.
(1) The care covered also includes examinations and examinations carried out under measures against communicable diseases (2) Surveys of insured persons carrying out epidemiologically significant activities carried out in connection with the issue of a health certificate shall not be included in the necessary healthcare.
(2) The care covered also includes:
(a) established vaccination (3) carried out by medical care centres;
(b) the provision of rabies vaccines, tetanus vaccines in wounds and non-healing wounds, tuberculosis and tuberculosis testing using a tuberculin test;
(c) the collection of materials carried out at care facilities for microbiological, immunological and parasitological examination for clinical purposes and in relation to the occurrence of diseases;
(d) testing of the materials referred to in point (c) of the laboratories of the contractual health establishments;
(e) HIV, anti-HCV and HBsAg diagnostics in donors of blood, tissues, organs and gametes and HIV diagnostics carried out in preventive care facilities in cases of medical prevention procedures and where the insured person under investigation so requested, with the exception of:
1. anonymous examinations,
2. examination for private and work travel abroad.
(3) Paid care does not include:
(a) vaccination carried out by health service facilities;
(b) the provision of vaccines with the exception referred to in paragraph 2 (b);
(c) the collection and examination of materials carried out by sanitary services facilities;
(d) HIV diagnostics, including tests carried out in sanitary facilities at the request of the insured person, including anonymous examinations.
Dispensary care
(1) As part of the paid care, the pension is provided to insured persons who are healthy, vulnerable and ill in the following groups:
(a) children within one year;
(b) selected children from one year of age who are chronically ill and at risk of health disorders, including as a result of unfavourable family or social conditions;
(c) selected young persons,
(d) pregnant women from the date of detection of pregnancy,
(e) women who use hormonal and intrauterine contraception,
(f) insured persons at risk or suffering from serious diseases.
(2) The selection of insured persons for the disability care is carried out by treating doctors.
(3) The conditions and scope of the dispensary care are set out in Annex 3 to this Regulation.
Paid care includes a tour of the deceased insured person, autopsy, 4) transport to and from the autopsy to the place where the death occurred, or the place of burial, if the same distance or close to the place where the person died. Paid care does not include transportation to a judicial autopsy, a judicial autopsy, and transportation from a judicial autopsy.
Racing preventive care
Racing preventive care ensures, in cooperation with the employer, prevention, including protection of workers' health against occupational diseases and other damage to health from work and prevention of accidents. Paid care shall include:
(a) health performance carried out under first aid;
(b) periodic preventive examinations of staff carrying out epidemiological activities, of staff at risk centres, of staff whose activities may endanger the health of other workers or of other persons and of staff for whom special medical fitness is required, to the extent specified by the specific regulation; 5)
(c) exceptional and subsequent examinations ordered for health reasons;
(d) dispersal examinations of persons with reported occupational diseases and persons whose effects of occupational risks are still at risk after the end of exposure.
Provision of medicines and medical devices
(1) Individual medicines and medical devices (hereinafter referred to as "medicines and devices"), including the amount and method of payment by the health insurance company, are listed in the list of medicines and devices. 6)
(2) The health insurance company pays the medicines and means prescribed or provided by the contractual health establishments under specific rules. 15)
Transport and reimbursement of travel expenses
(1) The health insurance company shall cover the transport of the insured person, if indicated by the attending doctor, as well as the transport of the guide in the territory of the Czech Republic or in the territory of the Slovak Republic, where this results from an agreement between the Government of the Czech Republic and the Slovak Republic, to the contractual medical institution, to the place of permanent or temporary residence or to the social care institution, between the contractual health establishment and the contractual health establishment, where the health status of the insured person, as indicated by the medical practitioner, indicates, does not allow transport in a normal manner without the use of the transport health service. If the disease has occurred at the place of temporary residence, transport from the medical establishment to a place of permanent residence which is more distant than the place of temporary residence shall be paid only if the health status of the insured person is required by the treating doctor. Transport is carried out by vehicles of the contractual transport health service and is paid according to the performance list .1)
(2) The transport referred to in paragraph 1 shall be covered by the health insurance undertaking at an equivalent distance to the nearest contractual medical establishment capable of providing the required health care.
(3) In exceptional cases or cases where:
(a) it is economically more advantageous, the health insurance company shall, on the basis of the indication of the doctor and the approval of the medical examiner and the necessary air transport;
(b) there is a risk of delay, the health insurance company shall bear the costs of another carrier; such transport is decided by the treating physician.
(4) If the health status of the insured person so requires and if his life is immediately threatened, the health insurance company in the Czech Republic shall pay for the transport of transfusion products, special medicines, tissues and organs for transplantation, as well as the transport of a doctor or another healthcare professional to a specialised and necessary performance.
(1) Indicated transport of doctors and other health workers to the insured person is covered by the health insurance company according to the performance list.1)
(2) If an insured person who is entitled to transport pursuant to Paragraph 10 decides to transport by private vehicle and if the treating doctor approves such transport, he shall be entitled to reimbursement of travel costs according to the list of performance (1).
Emergency and rescue services
(1) Paid care also includes health performance performed within the framework of:
(a) health care provided in acute cases by practitioners and dental practitioners outside their office hours;
(b) first-aid medical services and constitutional emergency services,
(c) medical emergency services (16) in the provision of professional pre-hospital emergency care.
(2) The care covered includes urgent medical performance performed in the emergency service by the doctor and outside his expertise.
Assessment activities
Paid care also includes the assessment of temporary incapacity to work or to study the treating physician and the assessment of facts which are important personal obstacles to work under Section 127 of the Labour Code and similar performance for pupils and students.
Conditions for providing paid care
Provision of health care
(1) Health care is provided primarily in health care institutions, but also, where appropriate, in the insured person's apartment, or in another place where care needs to be provided, health care professionals, 7) or other health professionals, to the extent of their professional competence. Health care professionals other than doctors provide paid care on the basis of the doctor's office, unless otherwise specified.
(2) Paid care is usually provided to the insured person on the basis of recommendations or orders by a practical or other treating physician.
(3) Without prior advice by the chosen physician for children and adolescents, the practitioner for adults, women's doctor, dental practitioner or other treating physician, the paid care is provided
(a) those with chronic disease and those with an indicated disability under the care of the medical institution;
(b) when visiting a health care institution in the field of psychiatry, sexology, dermatetoenerology or ophthalmology, when it comes to prescription glasses;
(c) in acute cases where medical care is urgent or there is a risk of delay and is provided by a doctor or other healthcare professional, medical emergency services, first aid medical services or a clinical psychologist with regard to acute mental crises and traumas.
(4) In the absence of the cases referred to in the preceding paragraph, the insured person shall always pay for the cost of providing such care in accordance with the performance list when applying for health care without prior recommendation. 1)
Refusal of custody
The chosen doctor may refuse to receive the insured person into his or her care only if his or her acceptance would exceed the workload of the doctor in such a way that he or she would not be able to provide good health care for this or the other insured persons in his or her care. Another serious cause for which the chosen doctor may refuse to accept the insured person is also the excessive distance between the place of permanent or temporary residence of the insured person for the performance of the visiting service. The degree of workload and the severity of the cause for not taking care of the insured person shall be assessed by the chosen physician. A doctor may not refuse an insured person from a specified area of employment. 17)
Outpatient care
(1) Basic comprehensive health care is provided by their practitioner to the insured. This doctor means a doctor for adults and a doctor for children and adolescents.
(2) When taking custody, the doctor shall complete the registration form in accordance with Article 4 (1), the copy of which shall be sent to the competent health insurance undertaking. At the same time, the doctor who had custody of the insured person in the previous period will ask for the information needed to ensure the continuity of health care. This physician must submit this information in writing to the chosen physician. The chosen doctor shall inform the insured persons when taking care of the preventive inspection plan.
(3) The practitioner shall be obliged to provide care for the insured person in his custody, including the visiting service for those insured persons, at the place indicated on the registration sheet.
(1) Insurers who are repeatedly or long-term resident in a place different from the place of permanent residence are entitled to choose a practical, dental and female doctor available at that place. Insurers may choose this doctor with the warning of the need for only temporary care and the choice of doctor already made at the place of residence. In this case, the doctor providing health care at the place of permanent residence is required to provide the chosen physician with a medical report or extract from the medical file.
(2) After the completion of the transitional care, the doctor sends a statement from the medical file to the doctor for whom the basic choice is made.
(1) If the health status of the insured person requires the provision of professional care, the practitioner shall recommend to the insured the contractual medical establishment which is capable of providing professional care at the appropriate level; This is without prejudice to the right to choose a doctor and healthcare facility (9). The medical practitioner shall also send written reasons and relevant medical data, including the results of prior examinations and information on the treatment carried out, together with a recommendation for admission by a specialist.
(2) In the cases indicated, the treating physician shall arrange for the examination or treatment of the insured person in another medical institution; This also applies to the arrangement of constitutional care. The professional course also applies to cases where the insured person is sent to a medical establishment. 10)
(3) The medical practitioner or other health professional shall inform the practitioner, where appropriate, if the nature of the illness so requires, of the medical practitioner who has custody of the insured person, of the facts identified and of the course and termination of the treatment, in particular of the matters relevant to the assessment of medical fitness for work and of the epidemiological situation. The same applies to the provision of information between a general practitioner and a doctor of preventive care racing.
(1) A special form of outpatient care provided as
(a) domestic health care;
(b) health care in nursing homes (stationary staff),
(c) health care provided to persons who are located there for reasons other than health, 18)
(d) health care in social care institutions.
(2) The health care referred to in paragraph 1 shall be provided to those with acute or chronic illness, to those who are physically or mentally disabled and dependent on foreign aid, covered by health care in their own social environment.
Constitutional care
If the health of the insured person so requires, he shall be provided with paid care in the form of constitutional care. Constitutional care means care in hospitals and in professional medical institutions. In these facilities can be provided in addition to constitutional care and outpatient care.
(1) Insurers are usually admitted to institutional care on the advice of the treating physician. The treating physician shall also send written reasons and relevant health data, including the results of prior examinations and information on the treatment carried out, with a recommendation for admission to constitutional care. Insurers are admitted to professional medical institutions on the basis of a proposal from the treating physician; This condition may not be met when admitted to a psychiatric hospital.
(2) An insurer must be admitted to constitutional care if the postponement would endanger his or her life or seriously threaten his or her health and if the birth is involved. Acceptance shall also not be denied in the case of compulsory treatment. 11)
(3) Any non-admission of an insured person to constitutional care shall be duly documented. In this case the insured person shall be given a message to the treating physician. The same shall apply if the insured person himself refuses to accept.
(1) If the full day presence of a guide is required when the child is admitted to a health institution due to his or her medical condition, the guide may be admitted to institutional care. The stay of a guide to a child under 6 years of age in a hospital is considered as a constitutional treatment. According to the indication and possibility, the guide is placed with the child either directly in the bed section or in the compartment from the accommodation area which is part of this facility. In the case of a child older than 6 years of age, the stay of the guide in the hospital shall be considered as a constitutional treatment only with the consent of the revised physician.
(2) The residence of a guide in a professional children's hospital and a children's spa hospital is considered to be a constitutional treatment in cases of the adoption of a guide to a child under 6 years of age for the period when he is trained in the care and rehabilitation of a child or when the presence of a guide is necessary due to the child's medical condition. In other cases, for comprehensive spa care for children and adults [§ 27 (3) (a)] and for care in professional medical institutions (§ 22 and § 27a (2)), the health insurance company shall pay for the stay of the guide only where its necessity is confirmed by the medical examiner.
(1) An immediate care of the insured person is provided by a team of health professionals led by a nursing doctor of a hospital or medical institution, which determines the diagnostic and therapeutic procedure within the framework of the instructions of the head doctor of the department. In order to ensure professional care and synergy of experts of different disciplines, individual consiliary services for hospitalized insured persons are provided.
(2) If the insured person is required to be transferred to another department, the transfer must be consulted in advance with the head doctor of the ward or his authorised doctor.
(3) For medical reasons, the insured person can be released for home treatment on leave. For the duration of the pass, the health care institution shall not be entitled to charge the cost of institutional care to the health insurance company except for the medicines and means by which the insured person is provided with the pass.
(1) The insured person shall be released from institutional care as soon as the necessary examinations and treatments are carried out or if there is such improvement in the state of health where further care can be provided on an outpatient basis or in other health institutions, or in social care facilities, as appropriate. The insured person must be provided with medical treatment and the funds paid by the health insurance company for three days or, where justified, for another, strictly necessary period of time.
(2) The insured person will be released early from constitutional care at his own written request (reverse), unless it is possible to carry out investigative and medical procedures without the consent of the patient. 12)
(3) An insurer who consistently violates the rule of law in a gross manner and refuses to cooperate in a substantial manner may be released early from institutional care if such behaviour is not due to a serious mental disorder or other serious reasons and if the immediate interruption of care would not be jeopardised in a serious manner of his health. The insured person may not be released early in cases of compulsory treatment.
(4) A report on the release of the insured person, including a proposal for a further treatment procedure, shall be sent to treating physicians without delay.
(5) If the insured person is unable to do so without the assistance of another person due to his or her medical condition, he or she may be released from constitutional care only after prior timely notification of the family member or the person who is able to provide such care.
(6) The district office of Prague, the district office of the district office, according to the place of residence of the insured person, is informed of the release of the insured person who is not provided with further care. Similarly, children and adolescents with serious social problems in the family are treated the same way. The costs incurred by the further hospitalisation of the insured person, which cannot be discharged due to the failure to provide further care, are not borne by the health insurance company. 19)
Spa care
(1) Spa care provided as a necessary part of the treatment process is proposed by the treating physician, confirmed by the medical examiner and paid by the health insurance company. The proposal for spa care is submitted on a pre-printed form of a health insurance company. At the same time, the degree of urgency [paragraph 3 (a)] is determined.
(2) Diseases for which spa care is provided to insured persons, indications, duration of the treatment stay, type of spa care and list of spa places of the Czech Republic where the spa care is provided are set out in Annex 4 to this Regulation (hereinafter referred to as the "Indicative List").
(3) Spa care is provided and paid as:
a) comprehensive spa care - this care is based on institutional care or care in professional ambulances and is aimed at healing, preventing disability and inadequacy or minimising the extent of disability. In the case of sickness insurance participants, they shall be provided at the time of their temporary incapacity to work. The insured person is summoned to the spa care spa hospital. In the first order of urgency, the patient is summoned to the treatment no later than one month after the date of issue of the proposal, or after agreement of the nursing, revision and spa doctor, transferred to the hospital directly from the hospital bed. In the second order of urgency, the patient is summoned no later than three months, children and youth within six months of the date of issue of the proposal. The costs of complex spa care are fully covered by the health insurance company;
(b) health care allowance - this treatment is provided for diseases included in the Indicative List and where the conditions referred to in (a) are not met. The health insurance company shall cover the costs of the examination and treatment of the insured person. This care may be provided once every two years, unless the medical examiner decides otherwise.
(4) Children and adolescents under 19 years of age are granted spa care in accordance with paragraph 3 (a), unless it is provided at the request of parents in accordance with paragraph 3 (b). The transfer of an insured person under 19 years of age from the hospital to the hospital is not assessed by the medical examiner.
(5) In the case of occupational diseases and other damage to health from work, spa care shall be provided in accordance with paragraph 3 (a), where it has been designed or confirmed by the competent professional for occupational diseases.
(6) The method of providing the spa care referred to in paragraph 3 shall be proposed by the treating physician and approved by the revised physician according to the Indicative List. According to paragraph 3 (a), spa care may also be provided on the basis of a proposal from a treating physician other than those provided for in the Indicative List, provided that the indication is supported by an appropriate expert finding.
Care in professional children's hospitals and health care centres
(1) Health care provided on the recommendation of a doctor to children and adolescents under 18 years of age in children's professional hospitals and health care centres is covered by a health insurance company. Care shall be provided on the basis of a proposal from the treating physician, as certified by the health insurance company's revised doctor. A revised doctor doesn't assess the transfer of an insured person from hospital to rehab.
(2) Diseases in which children and adolescents under the age of 18 are treated in professional children's hospitals and the indicative orientation of these therapies (hereinafter referred to as the "Indicative list for treatment in children's professional hospitals") are set out in Annex 5 to this Regulation. In cases where indications of treatment in children's professional hospitals overlap with indications for treatment in spa hospitals, the physician who proposes a treatment in a spa facility or children's professional hospital decides on the suitability of treatment. The duration of the treatment stay in professional children's hospitals is governed by the condition of the patients and is decided by the head doctor of the hospital.
(3) Children from 3 to 15 years of age who are disabled due to adverse environmental effects, children with health problems associated with poor lifestyle and convalescence children whose health status does not require specialised treatment in a children's spa or children's professional hospital, are provided on the basis of a proposal from the treating physician, as certified by the health care health care insurance health care doctor. The length of the stay in the recovery centre does not normally exceed 21 days; a longer stay is only possible with the agreement of the revision physician.
If the insured person considers that he is not receiving adequate medical care, he may:
(a) submit a proposal for a review to the head of the medical institution, 14)
(b) contact the Czech Medical Chamber, the Czech Dental Chamber or the Czech Pharmacy Chamber, if they concern shortcomings in the professional or ethical procedure of a doctor or pharmacist, or any other professional organisation, if they have been established, if they relate to those deficiencies of another healthcare professional;
(c) to contact the medical examiner, in particular if there is a refusal to take care of the health performance covered by the paid care;
(d) contact the competent authority of the state administration which has registered the medical establishment under a special law. 20)
Provisions common, transitional and final
To the same extent as for contractual health care establishments, the health insurance company shall pay urgent care, in particular first aid, for therapeutic interventions in situations where there is a risk of delay, imminent life or serious harm to health, provided by a healthcare institution which is not under contract with the health insurance company.
For the purposes of this Regulation, a health insurance undertaking shall: General health insurance company of the Czech Republic or other health insurance company carrying out general health insurance, if any.
Control
(1) Revision practitioners and health professionals competent for the review activities designated by the health insurance undertaking (hereinafter referred to as "professionals") check that:
(a) the care provided corresponds to the care charged to the health insurance undertaking;
(b) only the performance, medicines and means which the health insurance undertaking is obliged to pay have been charged;
(c) the extent and type of health care corresponds to the health status of the insured person.
(2) In order to fulfil the tasks referred to in paragraph 1, medical practitioners and experts shall be entitled to enter a medical establishment. The performance of the activities of the revised physician and professional staff shall not interfere with the therapeutic performance performed.
(3) If the check shows that health care is not justified or incorrect, the health insurance company shall not pay such care.
The medical institution shall provide the health insurance undertaking with the necessary synergies in the performance of the check, in particular providing the required documents, communicating the data and providing explanations. Access to medical documentation shall be granted only to medical practitioners or professionals; such personnel shall have access to the medical file only to the extent appropriate for checking.
Emergency health care payment
(1) In exceptional cases, the health insurance undertaking shall pay as specific items:
(i) healthcare particularly expensive, identified in the performance list or in the list of medicines and devices in this way;
(b) health care, the provision of which, in terms of the health status of the insured person, is the only possibility of health care, otherwise by the health insurance company not necessarily covered.
(2) Special items are prescribed for valid forms indicating the character of the special item.
(3) Except where there is a risk of delay, prescribing a specific entry is bound to the prior approval of the revision physician. The health insurance company shall pay the special items in full or with the financial contribution of the insured person.
(1) Care provided in long-term sick hospitals, nursing care in nursing homes, children's homes and nurseries is paid from the budget of the founder. The budget of the body shall also cover the medical emergency services (16) and emergency services, with the exception of the medical care provided under Section 12.
(2) The provision of paragraph 1 shall be without prejudice to the obligation on citizens to pay medical compensation under specific rules.
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Regulation Information
| Citation | Decree of the Government of the Czech Republic No. 216 / 1992 Coll., which issues the Health Regulations and implements certain provisions of the Czech National Council Act No. 550 / 1991 Coll., on General Health Insurance |
|---|---|
| Regulation Type | - |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 22.05.1992 |
|---|---|
| Effective from | 22.05.1992 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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