Full text of Act No. 295 / 1993 Coll.
Act of the Czech National Council on General Health Insurance (full text as follows from later amendments and additions)
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295
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Announces
full version of the Act of the Czech National Council No. 550 / 1991 Coll., on General Health Insurance, with amendments and additions implemented by the Act of the Czech National Council No. 592 / 1992 Coll., by the Act of the Czech National Council No. 10 / 1993 Coll., by the Act of the Czech National Council No. 15 / 1993 Coll. and by the Act No. 161 / 1993 Coll.
THE LAW
Czech National Council
on general health insurance
The Czech National Council decided on this law:
BASIC PROVISIONS
Purpose of the law
This Act provides for general health insurance (hereinafter referred to as "health insurance ') on the basis of which health care is provided wholly or partly covered by health insurance to the extent provided for by this Act and the Health Regulations.
Full or partial care covered by health insurance
(1) All or part of the care covered by health insurance includes:
(a) diagnostic care, outpatient and institutional care, including rehabilitation and chronic care;
(b) prevention under generally binding legislation;
(c) the provision of medicines and medical devices under the conditions laid down in this Act;
(d) the transport of sick persons and the reimbursement of travel costs to the nearest contractual health establishment authorised to provide health care, if necessary required by their health status; local transport costs are not reimbursed,
(e) spa care and special medical care provided as recommended by the doctor as an essential part of the treatment process.
(2) The extent of care fully or partially covered by health insurance and the conditions for its provision are specified in the Health Regulations. The health rules are binding on all health insurance companies that carry out health insurance. The health insurance companies referred to in the previous sentence may adjust the scope of health care and the conditions for providing it only to the benefit of their insured persons outside the framework of the Health Code.
(3) The Health Code will be issued by the Government of the Czech Republic, representatives of other health insurance companies, representatives of contractual health institutions, professional organisations established by law (1) and representatives of professional scientific societies. The conciliation procedure shall be convened by the Ministry of Health ("the Ministry ') at least once a year.
(4) The care fully or partially covered by health insurance shall not include examinations, examinations and other performances carried out in the personal interest of natural persons or in the interest of legal persons who do not pursue a therapeutic purpose.
(5) Social care, provision in children's homes, nursing homes and nurseries are governed by specific regulations. (2)
Personal extent of health insurance
(1) Under this law they are insured by:
(a) persons resident in the Czech Republic;
(b) persons who are in working or similar relationship to an employer who is established in the Czech Republic, even if they are not resident in the Czech Republic.
(2) For the purposes of this Act, the registered office of the employer shall be the registered office of the legal person and the registered office of his or her organisational unit and the place of residence of the natural person, if any, of his or her place of residence and, where applicable, of his or her business.
(3) Health insurance under this Act excludes persons who are not resident in the Czech Republic and who are active in the Czech Republic for employers who enjoy diplomatic benefits and immunities, or for employers who are not established in the Czech Republic, and persons who are long-term resident abroad and who are not insured (§ 7 (4)).
Reimbursement of treatment abroad
The insurance companies referred to in Article 3 (1) shall be reimbursed for the costs of necessary and urgent treatment abroad, up to the costs associated with such treatment in the Czech Republic.
Establishment and termination of health insurance
(1) Health insurance is established by:
(a) by birth, if it is a permanent resident in the Czech Republic,
(b) the date on which the employer has his registered office in the Czech Republic takes up work or similar relationship;
(c) obtaining permanent residence in the Czech Republic.
(2) Health insurance shall cease:
(a) the death of the insured person or his declaration of death;
(b) the termination of an employment or similar relationship in the territory of the Czech Republic, except as regards the insured persons referred to in § 3 (1) (a);
(c) termination of permanent residence on the territory of the Czech Republic, except as regards insured persons referred to in § 3 (1) (b).
INSURANCE
Payment of premiums
(1) The payers of health insurance premiums (hereinafter referred to as "premiums payers") are:
(a) insured persons;
(b) employers,
(c) State.
(2) The insured person shall be the payer of insurance premiums in respect of employment or equivalent or self-employed activities or permanent residence in the Czech Republic, unless otherwise specified. The following shall be regarded as working or similar persons in addition to workers in employment:
(a) workers working in a ratio which has the content of an employment relationship but is not so marked or does not have all the formalities required for the employment relationship;
(b) workers working under an agreement on work activities;
(c) members of cooperatives, if they are not in employment relations with the cooperative but are engaged in the work for which they are remunerated;
(d) members of limited liability companies and commanditists of a limited liability company, if they are not in employment relations with that company but are engaged in the work for which they are remunerated;
(e) Members of the legislature,
(f) members of municipal councils acting as long-term vacant members of the municipal council,
(g) members of the Government and heads of the other central authorities of the Czech Republic,
(h) Judges,
(i) prosecutors,
j) President, Vice-President and members of the Presidium Board of the Supreme Audit Office of the Czech Republic,
(k) professional soldiers, members of the Police of the Czech Republic, members of the Prison Service of the Czech Republic and members of other armed security forces and security services,
(l) internal scientific aspirants,
(m) volunteer care staff,
(n) foster care in special establishments;
(o) persons in prison,
(p) persons with altered working capacity preparing for employment;
if they are involved in sickness insurance (insurance) under the sickness insurance (insurance) rules.
(3) The employer shall pay part of the insurance premiums for persons who are employed in employment or in a similar proportion, except for the recipients of the parental allowance, maternity leave and for other maternity leave and for men for the duration of their absence at work during which they are granted cash assistance under the sickness insurance legislation, and with the exception of those to whom he has granted leave without compensation of income, provided that such persons prove that another employer or other organisation for which they are active at that time is the same person and persons who proceed pursuant to Article 7 (4). The employer is a legal or natural person who employs an insured person in a working or similar proportion.
(4) The State is an insurance payer through the state budget of the Czech Republic
(a) unprovided children, 3)
(b) pensioner of pension pensions under the Special Act, 4)
(c) recipient of the parental allowance, 5)
(d) persons on maternity leave and other maternity leave and men during their absence at work for whom they are granted financial assistance under sickness insurance legislation;
(e) jobseekers (6) including jobseekers working on community service;
(f) persons receiving social security benefits for social needs, 7)
(g) persons who are primarily or completely helpless and who are caring for a person who is predominantly or completely helpless, 8) or a long-term disabled child, 9)
(h) persons engaged in basic (replacement) military or civil service and persons (soldiers in reserve) called for military training;
(i) persons in custody or in the execution of a prison sentence;
(j) persons who are dependent on pensioners and who, for this reason, have been adjusted as a single source of income, 10)
(k) persons who have reached the age required for entitlement to an old-age pension but who do not fulfil the additional conditions for his or her entitlement to an old-age pension and who do not have income from employment, self-employment, capital assets, hire, or other income under the Income Tax Act, or do not benefit from a foreign pension, or if the amount of income and income from abroad does not exceed, on a monthly basis, a minimum wage, 11)
(l) persons personally and properly caring for at least one child under the age of seven or at least two children under the age of 15, not the persons referred to in (d), and only one person shall be regarded as such, either the father or mother of the child or the person who has taken the child into permanent care of the parents; 12) The condition of full-time childcare is deemed to be fulfilled, even if the person has income from employment, business, other self-employment, capital goods, rental or other income under the Income Tax Act, which, after deduction of the expenses incurred to achieve them, reinsurance and maintenance, does not exceed a monthly amount of 77% of the minimum wage.
(5) If the persons referred to in points (a) to (j) of paragraph 4 have income from employment, from business, from other self-employed activities, from capital goods, from leasing or other income under the Income Tax Act, the insurance company shall also be the payer of the insurance company.
Obligation to pay insurance premiums
(1) The obligation to pay insurance is incurred by the insured person:
(a) on the date of taking up the employment or similar relationship; or
(b) the date on which the self-employed activity begins; or
(c) on the day following the date on which the State's obligation to pay insurance premiums under Paragraph 6 (4) has ceased; or
(d) on the day following the date on which the obligation to pay insurance against an employment or similar relationship or self-employment has ceased.
(2) The employer's obligation to pay part of the insurance premiums for the insured person arises on the date on which the staff member enters the employment or similar relationship with the exceptions provided for in Article 6 (3). This obligation shall expire on the date of termination of the employment or similar relationship.
(3) The obligation of the State to pay insurance premiums for insured persons arises on the day on which the State becomes liable under Paragraph 6 (4). This obligation shall expire on the date on which the State ceased to be a payer of insurance premiums under Paragraph 6 (4).
(4) The insured person is not obliged to pay insurance premiums for the period when he is long abroad and is insured abroad. In such a case, for the duration of insurance abroad and the non-payment of insurance premiums to the relevant health insurance undertaking, the insured person shall not be entitled to full or partial care covered by health insurance under this Act. Such a fact shall be recorded in writing with the relevant health insurance undertaking. A continuous stay of more than six months shall be considered as a long-term stay abroad. If the insured person has been granted leave of absence of income for a long-term stay abroad by the employer, neither the employer nor the employee shall be obliged to pay the insurance for that period if it is referred to in the first sentence.
(5) If the payee does not pay the premium at the specified amount and on time, the competent health insurance undertaking shall recover its payment from the debtor and shall be entitled to periodic penalty payments.
Amount and method of payment of premiums and periodic penalty payments
(1) The amount of premiums, periodic penalty payments and the manner in which they are paid are laid down in a separate law.
(2) Employees' premiums are paid from one third to an employee, from two thirds to an employer.
(3) By written contract between the employee and the employer, the employee may undertake to pay the employer, in whole or in part, the amount corresponding to the insurance premium which the employer is obliged to pay for the employee at the time when the staff member has provided leave without compensation for the income. In the absence of an employee at work, the employee shall pay the employer the amount corresponding to the insurance premiums paid by the employer for that period.
RIGHTS AND OBLIGATIONS OF INSURANCE AND INSURANCE PLANS
Reporting obligation for payers
(1) The insured person as a self-employed person is obliged to register with the competent health insurance undertaking no later than eight days after the start of the gainful activity and to cancel no later than eight days after the end of the gainful activity.
(2) An insurer who has no obligation to pay the insurance as an insured person in an employment or similar relationship or as a self-employed person shall be obliged to register with the relevant health insurance undertaking within eight days of the date on which that obligation expired or the obligation on the State to pay the insurance under Paragraph 6 (4) has ceased.
(3) An insurer whose health insurance has been incurred pursuant to Article 5 (1) (c) or the health insurance has ceased to exist pursuant to Article 5 (2) (c) shall be required to register or cancel with the relevant health insurance undertaking no later than eight days after the date on which the health insurance arose or expired.
(4) The employer shall register his staff with the relevant health insurance undertaking no later than eight days after their entry into the employment or similar relationship and shall cancel them no later than eight days after the termination of their employment or similar employment relationship. The employer shall keep records and documentation for that purpose.
(5) The staff member shall be obliged to register and check out with the relevant health insurance undertaking without delay if he or she finds that his or her employer has failed to fulfil the obligation under paragraph 4.
(6) The insured person shall notify the relevant health insurance undertaking within eight days at the latest of the facts relevant to the formation or termination of the State's obligation to pay the premiums pursuant to Article 6 (4). For underage insured persons or persons who are not fit for legal action, this obligation shall be fulfilled by their legal representative, unless the persons employed are the ones for whom the employer is responsible. The notification obligation on the birth of the child shall be fulfilled by its legal representative.
(7) The death of the insured person or his death declaration shall be notified to the competent health insurance undertaking within eight days of the registration in the matrix by the competent municipal authority responsible for the management of the matrix.
(8) On the first fulfilment of the notification obligation, the competent health insurance undertaking shall issue to the insured person, to a minor insured person or to a person who is not fit for legal action to his legal representative, a document serving in contact with the relevant health insurance undertaking and medical establishments as proof of the insurance relationship.
Rights of the insured person
(1) The insured person has the right:
(a) the choice of insurance undertakings carrying out general health insurance; that right may be exercised once every 3 months,
(b) the choice of a doctor or other professional in health and healthcare establishments, with the exception of racing health services, 13) who are in contract with the relevant health insurance company; that right may be exercised once every 3 months,
(c) the choice of transport services which are in contract with the relevant insurance undertaking;
(d) to cover the costs of health care provided to him to the extent provided for by this law and in accordance with the provisions laid down for its implementation;
(e) to cover the costs of providing medical treatment in urgent cases in medical establishments not under contract with the relevant health insurance undertaking;
(f) reimbursement of travel expenses pursuant to Article 2 (1) (d);
(g) to participate in the control of the care provided fully or partly covered by health insurance;
(h) to cover the costs associated with the necessary transport service, which is not under contract with the insurance undertaking, up to the amount of the remuneration determined by the insurance undertaking.
(2) Soldiers in active duty, with the exception of soldiers in reserve called for military training, and pupils in military schools who prepare for the service of an occupational soldier and are not in active service, are insured with the Military Health Insurance Agency. The basic health care is provided to them by the crew of the health care facility and, if not set up, by another medical facility with which the Military Health Insurance Agency has concluded a health care contract. Follow-up outpatient or constitutional care is provided by a medical facility designated by a doctor who provided basic health care. Physicians may be elected only within the medical facility referred to in sentence two and three.
(3) The selection of medical practitioner and transport services shall be limited in accordance with specific regulations for persons serving civil service and persons in custody or in the execution of prison sentences.
(4) The right of the insured person to choose a doctor and a medical institution as referred to in paragraph 1 (a) shall be exercised. (b) it is without prejudice to the right of the doctor to refuse to take custody of the insured person if this would exceed his workload or for other serious reasons, except where it is a matter of urgent treatment for more serious injury or illness. In the same way, the right of the insured person to provide the necessary care within the designated area of employment is not affected, (14) unless such care has been provided by the chosen doctor or health care institution.
Obligations of the insured person
The insured person shall:
(a) comply with the notification obligation provided for in Article 9 with the insurance undertaking if it has not complied with that notification requirement with another health insurance undertaking which it has chosen;
(b) communicate on the day of taking up employment to the employer chosen by the health insurance undertaking,
(c) to pay insurance premiums to the relevant health insurance undertaking, unless that obligation is to be fulfilled by the State;
(d) comply with the Health Regulations;
(e) provide synergies in the health performance and control of the course of the treatment process and comply with the doctor's established treatment regimen;
(f) submit to preventive inspections at the request of the applicant, where specific provisions so provide;
(g) comply with measures aimed at preventing diseases.
ORGANISATION OF HEALTH INSURANCE
Health insurance companies
(1) Health insurance is carried out by the following health insurance companies:
(a) insurance undertaking;
(b) departmental, branch, corporate or other insurance undertakings, as appropriate.
(2) The establishment and operation of the insurance undertakings referred to in paragraph 1 shall be governed by specific laws.
Tasks of health insurance companies
(1) The relevant health insurance undertaking shall bear the costs of care fully or partially covered by the health insurance provided to the insured persons by health care institutions on the basis of contracts concluded with healthcare establishments for a period of two years, with the possibility of termination of the contract in the event of breach of the terms and conditions before the expiry of that period.
(2) Contracts are concluded on the scope of those types of care fully or partially covered by the health insurance which the health care establishment is entitled to provide.
(3) The relevant health insurance company shall provide remuneration for the performance of health care activities carried out by health care establishments according to the list of performance points issued by the Ministry by the Decree following conciliation with the Insurance Company, representatives of other health insurance companies and representatives of contractual health institutions, professional organisations established by law (1) and representatives of professional scientific societies. Participants shall be convened by the Ministry at least once a year. The Ministry of Finance of the Czech Republic sets the value of the point by price measurement on the proposal of the Insurance Company.
(4) The health insurance undertaking concerned shall pay on the basis of:
(a) a medical prescription issued by a contractual health care institution, a doctor providing first aid to an insured person, a doctor providing health care in a social care institution and a doctor providing medical care to himself, his husband, his parents, his grandparents, children, grandchildren and siblings, provided that his expertise is guaranteed by the Czech Chamber of Medicine or the Czech Chamber of Dentistry, and that he concludes a special contract with the health insurance company
1. medical care facilities for medicinal products and medical devices with the exception of medical devices referred to in point 2;
2. to other contracting entities, glasses and eye optics, hair substitutes, orthopaedic prosthetic devices in series and individually manufactured, compensation aids for disabled persons, including carriages and lifting aids for immobile persons, and hearing aids, blind and weak-sighted,
3. medical care facilities and other apparatus used for therapy,
(b) the account submitted to the contractual health service
1. dental prosthetics and therapeutic rehabilitation aids,
2. orthodontic apparatus,
3. service interventions on the funds provided,
in accordance with the list of medicinal products and medical devices indicating the amount of the payments made by the relevant health insurance companies.
(5) The list of medicines and medical devices is prepared by the Ministry following a prior conciliation procedure with the Czech Pharmacy Chamber, the Insurance Office and representatives of health insurance companies; the parties to the proceedings shall be convened by the Ministry at least once a year. A list of medicines and medical devices, its changes and additions, is issued by the Ministry by a decree.
(6) If the prescriber prescribes a medicine or a medical device to which the insured person is involved according to the list of medicines and medical devices, he shall inform the insured person accordingly. However, if the medical condition of the patient is required in accordance with the recommendation of the treating physician, made in agreement with the medical examiner of the relevant health insurance undertaking, the health insurance company shall pay fully the prescribed medicines or medical devices, and, exceptionally, the medicines in the list of medicines and medical devices not listed.
Control
(1) Health insurance companies control the use and provision of care fully or partially covered by health insurance in its volume and quality, including compliance with prices for contractual health care establishments and insured persons.
(2) They carry out control activities by means of information data to the extent provided for by the law and by the activities of review doctors. Further control activities shall be carried out by health professionals who are eligible for review.
(3) Revision doctors assess the justification of the treatment process with particular regard to its course and prescription of medicines, medical devices and to the assessment of the need for a spa stay as part of medical care.
(4) Revision doctors carry out control activities mainly in the field of specialisation.
(5) Revision practitioners carry out control activities in relation to a health insurance undertaking which is negotiated by means of a selection procedure.
(1) Health insurance companies are subject to control by the state authorities of the Czech Republic.
(2) The equivalent of the care account fully or partially covered by health insurance is required to be provided to the insured.
FINES AND PREPARATIONS FOR INSURANCE
(1) For failure to comply with the notification requirement under § 9, the competent health insurance company may impose a fine on the insured up to CZK 10,000 and the employer up to CZK 200,000. In the event of failure to comply with the notification obligation, the employer shall impose a fine only on the employer.
(2) The fine may be imposed within one year of the date of the finding of non-compliance with the reporting obligation by the policyholder, but no more than three years after the notification obligation was to be fulfilled.
(3) In the event of repeated failure to comply with the notification obligation, a fine may be imposed up to twice the fine imposed.
(4) If the insured person fails to comply with the obligation to undergo a preventive examination in accordance with § 11 (f), or if the insured person seriously violates his or her obligations referred to in § 11 (d), the competent health insurance company may impose a fine on the insured person up to CZK 500. The fine may be imposed within one year of the date on which the insured person did not undergo a preventive examination, but no more than three years after the obligation to undergo such examination was to be fulfilled.
(5) The fine is the income of the health insurance company that imposed it.
(1) The relevant health insurance undertaking shall measure the premium to the insurance employer for which there have been repeated accidents at work or occupational diseases from the same sources or causes during the previous calendar year and consequently an increase in the cost of health care.
(2) The competent health insurance undertaking shall, in accordance with paragraph 1, allocate a premium to the insurance premium up to 5% of the share of the insurance premium paid by the employer to all employees.
(3) The premium for the premium for the calendar year may be calculated no later than 31 March of the following year. The premium shall be payable on a lump sum basis on behalf of the relevant health insurance undertaking, no later than one month after the date of delivery of the payment notice.
(4) Employers shall be obliged to send copies of the records of accidents at work to the competent health insurance undertaking at the latest by the fifth day of the following month. In the event of failure to fulfil this obligation, the competent health insurance company may impose a fine on the employer up to CZK 100,000.
(5) Medical establishments entitled to the recognition of occupational diseases shall be obliged to send copies of the report of occupational diseases to the competent health insurance undertaking.
PROVISIONS COMMON, TRANSITIONAL AND FINAL
Decision-making
(1) The general rules on administrative procedures shall apply to decisions of health insurance undertakings relating to the payment of premiums, fines, periodic penalty payments and premiums. Health insurance companies shall decide by means of payment, which shall be enforceable under the rules on civil proceedings. The appeal shall be decided by the arbitration body of the health insurance undertaking.
(2) The arbitration body consists of one representative of the health insurance company, two representatives of the Ministry of Labour and Social Affairs of the Czech Republic, one representative of the Ministry of Finance of the Czech Republic, three representatives to be appointed from among its members by the Management Board of the health insurance company, and three representatives to be appointed from among its members by the Supervisory Board of the health insurance company. The arbitration panel shall be able to act if more than two thirds of the members are present. An absolute majority of the members present shall be required for the validity of the decision. For the first meeting, the members of the arbitration panel shall be convened by the head of the health insurance undertaking. At this first meeting, the members of the arbitration panel shall elect a chairman from among their number who shall continue to convene and manage the deliberations of the arbitration panel.
(3) Where the arbitration body decides at first instance, the provisions of the Administrative Rules on Decomposition shall apply mutatis mutandis.
(4) The competent decisions of health insurance undertakings referred to in paragraph 1 shall be subject to review by the court under specific rules.
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Regulation Information
| Citation | Full text of Act No. 295 / 1993 Coll., on General Health Insurance (full text as resulting from subsequent amendments and additions) |
|---|---|
| Regulation Type | - |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 14.12.1993 |
|---|---|
| Effective from | - |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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