Decree No 396 / 2010 Coll.
Decree on the determination of the value of the point, the amount of health care payments payable on public health insurance and the regulatory limits on the volume of healthcare provided on public health insurance for 2011
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Effective from 01.01.2011
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396
DECLARATION
of 17 December 2010
on the determination of the value of the point, the amount of health care payments payable on public health insurance and the regulatory limits on the volume of healthcare provided on public health insurance for 2011
The Ministry of Health provides pursuant to § 17 paragraph 6 of Act No. 48 / 1997 Coll., on Public Health Insurance and on the amendment and addition of certain related laws, as amended by Act No. 117 / 2006 Coll., Act No. 245 / 2006 Coll. and Act No. 261 / 2007 Coll.:
This Decree sets out for 2011 the values of the point, the amount of medical care payments to insured persons under Section 2 (1) of the Act No. 48 / 1997 Coll., on public health insurance and amending and supplementing certain related laws, as amended ("the Act '), and health care provided to insured persons from other Member States of the European Union, the European Economic Area and Switzerland under the relevant European Union1 provisions) and to insured persons of other States with whom the Czech Republic has concluded international social security contracts (" the foreign insured'), covered by public health insurance and regulatory restrictions on the volume of such health care for remuneration provided in Sections 2 to 15,
(a) in contractual health care institutions, including professional medical institutions, treatment of long-term patients, medical establishments reporting treatment day No 00005 under the Decree issuing a list of health performance with point values (3) (hereinafter referred to as "the list of performance"), and hospital-type medical facilities pursuant to § 22a of the Act;
(b) contractual practitioners and practitioners for children and adolescents,
(c) in contractual outpatient medical institutions providing specialised outpatient health care, including outpatient medical institutions providing haemodialysis and orthoptic health care;
(d) in contract outpatient health care establishments providing health care in expertise 603 and 604 according to the performance list;
(e) contractual dental practitioners,
(f) in the contract outpatient health care establishments providing health care in expertise 222, 801, 802, 804, 805, 807, 809, 812 to 819, 822 and 823 according to the performance list (hereinafter referred to as "the listed expertise"),
(g) in the contract outpatient health care establishments providing medical care in the 911, 914, 916, 921 and 925, according to the performance list;
(h) in contract outpatient health care establishments providing medical care in a professional capacity 902 according to the performance list;
(i) medical emergency care facilities, medical emergency services and emergency medical services;
(j) contractual health care and rehabilitation facilities;
(k) in the framework of urgent health care in non-contractual medical establishments.
For the health care referred to in § 1 (k) and for the health care provided to foreign insured persons, paid according to the list of performances, the value of the point is set at CZK 0.95, unless otherwise specified.
(1) For health care provided by health care institutions, except in the case of health care provided in professional medical institutions, long-term sick hospitals, in health care institutions reporting on day of treatment no 00005 according to the list of performance and in hospital-type health institutions, the value of the point, the amount of medical care payments and the regulatory restrictions are set out in Annexes 1 and 9 to this Decree.
(2) For healthcare provided in professional medical institutions, long-term sick hospitals, in medical institutions reporting on treatment day 00005, according to the list of services and in hospital-type health institutions, paid at a flat rate per day of hospitalisation or according to the list of benefits, the value of the point, the amount of health care payments and the regulatory limit shall be as set out in Annex 1 to this Decree.
For health care provided by general practitioners and general practitioners for children and adolescents, paid by a combined capital charge, a combined capital charge with a top-up cap, or according to the performance list, the value of the point, the amount of health care payments and the regulatory limit shall be set out in Annex 2 to this Decree.
For specialised outpatient health care provided in outpatient health institutions, paid according to the performance list, the value of the point, the amount of health care payments and the regulatory limit shall be as set out in Annex 3 to this Decree.
For outpatient health care provided in outpatient medical institutions in expert areas 603 and 604 according to the performance list, paid according to the performance list, the value of the point, the amount of health care payments and the regulatory limit shall be as set out in Annex 4 to this Decree.
(1) For dental care, paid according to the performance list, the value of the point is set at CZK 0.95.
(2) The amounts of medical care payments by dental practitioners not covered by paragraph 1 and the relevant regulatory restrictions are set out in Annex 10 to this Decree.
(3) The health insurance company shall be entitled to limit the amount of remuneration to medical establishments so that the total cost of health insurance for dental care provided by dental practitioners in 2011 does not exceed the total amount of these costs set out in the health insurance plan of the health insurance undertaking. If the excess of the total amount of the health care payment provided by dental practitioners, as provided for in the health insurance plan of the health insurance undertaking for this health care, would be due to the provision of more necessary and urgent health care compared to 2009, the health insurance undertaking will take this greater amount into account in the remuneration.
For medical care provided by outpatient medical institutions in the listed expertise, paid according to the performance list, the value of the point and the amount of the medical care payments shall be as set out in Annex 5 to this Decree.
For health care provided by outpatient medical institutions in the field of expertise 911, 914, 916, 921 and 925 according to the performance list, paid according to the performance list, the value of the point and the amount of medical care payments shall be as set out in Annex 6 to this Decree.
For health care provided by outpatient health care institutions in the field of competence 902 according to the performance list, paid according to the performance list, the value of the point and the amount of the medical care payments shall be as set out in Annex 7 to this Decree.
For health care provided under the medical rescue service, paid according to the performance list, the value of the point is set at CZK 1.06.
For the performance provided by the transport health service, paid according to the performance list, the value of the point and the amount of the health care payments shall be as set out in Annex 8 to this Decree.
For medical care provided under the medical first aid service, paid according to the performance list, the value of the point of CZK 0.95 is determined.
(1) For comprehensive spa care provided by health care facilities, the payment for one day's stay is set at the amount agreed on 31 December 2009, but at least CZK 850.
(2) For the benefit of spa care provided by health care facilities, a payment for one day's stay shall be set at the amount agreed on 31 December 2009, but at least CZK 280.
(3) For health care provided in health care centres, the payment for one day's stay is fixed at the amount agreed on 31 December 2009, but at least CZK 540.
According to Articles 2 to 14, the procedure is to be followed unless the health insurance and health care establishment agree otherwise, subject to the conditions laid down in Article 17 (6) of the Act.
This Decree shall take effect on 1 January 2011.
Minister:
Doc. MUDr. Heger, CSc., v. r.
Příloha č. 1
Annex No 1 to Decree No 396 / 2010 Coll.
Value of the point, amount of health care payments and regulatory restrictions pursuant to § 3
A) Constitutional care pursuant to § 3 (1)
1. Health care shall be paid in 2011 by a flat-rate payment of 98% of the total remuneration due to the healthcare establishment during the reference period. The reference period is 2009, the evaluation period is 2011. All health care provided in 2009, medical establishments declared by 31 May 2010 and health insurance companies recognised by 30.9.2010 are included in the reference period.
(2) Reimbursement at the level laid down in point 1 shall belong to the health establishment if:
(a) the medical institution shall report and the health insurance undertaking shall recognise the number of hospitalizations included in the diagnosis groups referred to in the Classification of hospitalised patient4 (hereinafter referred to as "Classification") listed in Annex 9 (hereinafter referred to as "number of hospitalizations"), completed in the evaluation period, at least 94% of the number of hospitalizations reported and by the health insurance undertaking recognised in the reference period, and at least 94% of the number of hospitalizations reported and health insurance undertakings recognised by the number of hospitalizations multiplied by Indexy 2011, terminated in the reference period. If the medical institution fails to comply with the conditions set out in the first sentence, part of the payment for hospitalisation care will be reduced by the number of percentage points corresponding to the higher of the two values by which 94% of the relevant value has not been reached. The number of hospitalizations shall not include hospitalizations within which the healthcare establishment shall report performance in the day-care regime according to the performance list during the evaluation period.
(b) the health care institution shall report and the health insurance undertaking shall recognise the number of points for outpatient care performance during the evaluation period of at least 95% of the number of points for such performance during the reference period, calculated in accordance with the performance list as effective on 1.1.2011, and shall treat the medical institution in outpatient care at least 95% of the number of unique insured persons for all expertise in total compared to the reference period during the evaluation period. If the medical institution fails to meet the conditions set out in the first sentence, part of the payment for outpatient care will be reduced by the number of percentage points corresponding to the higher of the two values by which 95% of the relevant value has not been reached. A special insurer shall mean one insured person of the relevant health insurance undertaking treated by a medical institution in a given professional capacity in an assessment or reference period at least once, and it shall not be determined whether the treatment is self-care or requested. If the insured person has been treated more than once in the relevant half-year by the medical institution in the relevant professional, the number of individual insured persons shall include the relevant health insurance undertaking treated in that professional only once; in the case of a merger of health insurance undertakings, the number of unique treated insured persons means the sum of the unique treated insured persons for health insurance undertakings that have merged (if the insured person has been insured by more than one health insurance undertaking during the reference period, the number of unique treated insured persons shall be counted only once).
3. The health insurance undertaking shall take into account the change in the volume reported and recognised by the health insurance undertaking in the assessment period compared to the reference period. Exceptionally expensive health care is for the purposes of this decree health care provided by health care facilities to insured persons whose volume exceeds CZK 1 000 000. The volume of healthcare includes separately charged medicinal products, separately charged material, a flat-rate amount to be paid for medicinal products under Section 17 (7) of the Act, and the point value of the health performance according to the list of performances, with the value of the point in the evaluation and reference period of CZK 0,90. Health care which is paid by the health insurance company in a way other than the flat-rate payment referred to in point 1 shall not be included in extremely expensive healthcare.
4. If changes occur in the scope and structure of the care provided compared to the reference period in a healthcare institution and the health insurance company agrees to these changes, they shall be taken into account in the draft contract, including the quantification of the increase (reduction) payments. In relation to the changes mentioned in the first sentence
(a) the health insurance undertaking shall, when calculating the total remuneration referred to in point 1, take into account the change in the number of hospitalizations, the number of hospitalizations multiplied by the 2011 Index, the number of points and the number of unique insured persons;
(b) the health insurance undertaking may adjust the limit of the total remuneration for medical devices prescribed by medicinal products and medical devices in accordance with Part C of this Annex.
5. In the event that the health care facility provides 50 or less health care to the insured persons of the relevant health insurance company during the reference period, such health care shall be paid according to the list of performances with a value of CZK 0.90.
6. In addition to the flat-rate remuneration referred to in point 1, output 09563 and output 88101 are paid according to the list of performances, with the value of point 1 CZK.
7. The flat-rate remuneration referred to in point 1 shall not include the remuneration for medicinal products and food for special medical purposes marked with the symbol "S 'in accordance with § 29 (2) of Decree No 92 / 2008 Coll. and healthcare provided to foreign insured persons.
8. For health care paid according to the list of performances, including health care provided to foreign insured persons, the value of the point is set at CZK 0.90.
9. The health insurance company may grant a monthly advance payment of one twelfth of the 98% of the amount of remuneration for the corresponding reference period to the healthcare establishment. In determining the amount of the pre-payment, the health insurance undertaking shall take into account changes in the scope and structure of the care provided, including changes in the number of hospitalizations, the number of hospitalizations multiplied by Index 2011, the number of points and the number of unique insured persons. If there is a change in the extent of the care provided in the healthcare institution during the evaluation period, the health insurance undertaking shall be entitled to adjust the amount of the advance payment in a manner corresponding to the change in the extent of the care. The interim remuneration for the evaluation period shall be settled financially within the overall financial settlement, including regulatory restrictions, no later than 180 days after the end of the evaluation period.
B) Constitutional care under § 3 (2)
1. Rate per day hospitalisation
(a) The flat rate per day of hospitalisation shall be determined for each patient category and type of treatment day separately and shall include the value of the relevant treatment day, including the direction assigned to the treatment day and patient category according to the performance list, the flat-rate amount to be paid for the medicinal products referred to in Article 17 (7) of the Act and the medical performance to be reported as income and discharge tests according to the performance list.
(b) The flat rate per day of hospitalisation in the evaluation period shall be 98% of the flat rate per day of hospitalisation belonging to the medical establishment in the reference period. The reference period is 2009, the evaluation period is 2011.
(c) Where there are changes in the scope and structure of the care provided in the healthcare establishment compared to the reference period and the health insurance company agrees to these changes, it shall take them into account in the draft contract, including the quantification of the increase (reduction) of payments.
2. Reimbursement of outpatient care, special outpatient care and special constitutional care
a) For outpatient health care paid according to the performance list, the value of the point is set at CZK 0.95.
b) For special outpatient care provided under § 22 (c) of the Act, paid according to the list of performances, the value of the point of CZK 0,90 shall be set at 100% of the volume calculated as follows:
PBRO × POPOPOPOPro,
where:
PBRo the total number of health establishments declared and health insurance undertakings recognised by the recognised points, translated according to the performance list as effective on 1.1.2011, over a reference period. The reference period is 2009.
POPho number of unique insured persons treated with medical devices during the evaluation period. The evaluation period shall mean 2011.
POPro Number of individual insured persons treated by health care institutions in the relevant professional capacity in the reference period
Health care provided to medical institutions over 100% of the calculated volume is paid with a value of CZK 0.40. The financial settlement shall be made no later than 120 days after the end of the evaluation period.
c) For special institutional care provided in hospital-type medical institutions under § 22a of the Act, paid according to the list of performances, the value of the point of 0.90 CZK is determined.
(C) Regulatory restrictions
1. Where the total remuneration for medicinal products and medical devices prescribed by medical devices to health insurers of a health insurance undertaking in respect of which they are insured (hereinafter referred to as "the relevant health insurance undertaking ') in the evaluation period, with the exception of medicinal products or medical devices authorised by a medical practitioner, exceeds 98% of the remuneration for medicinal products and medical devices prescribed in the reference period, with the exception of medicinal products or medical devices authorised by a medical insurance undertaking, the overall remuneration shall be reduced by a maximum of 40% of that excess. The reference period is 2009, the evaluation period is 2011. The reduction according to the sentence of the first health insurance undertaking shall not apply if the health care establishment proves that the increased total remuneration for prescribed medicinal products and medical devices has been caused by a change in the amount or manner of their reimbursement, possibly due to changes in the structure of the insured insurance undertakings.
2. In the event that a healthcare institution has provided healthcare to the relevant health insurance undertaking 50 and less insured persons during the assessment period, the health insurance undertaking shall not apply the regulation referred to in point 1.
3. Where a healthcare institution provides healthcare in more than one professional capacity, the regulatory limit referred to in point 1 shall be calculated and applied by the health insurance undertaking for each professional activity separately, unless the health insurance undertaking agrees with the healthcare establishment otherwise.
D) Increase in remuneration
The health care facility, which exceeds the requirements for personnel equipment set out in the performance list, will provide an increase in remuneration in relation to the quality improvement of nursing care (NU2011). The amount of the increase granted shall be calculated as follows:
NU2011 = PPS2011 * 30 000 CZK * Kpp,
where:
PPS2011 the calculated number of general nurses and midwives in the evaluation period, calculated as the sum of the time periods of all general nurses and midwives in a given health care establishment in the relevant region; evaluation period means 2011
Kpp the ratio of the number of insured persons of the relevant health insurance undertaking in the county to the total number of insured persons in that region; the ratio of the number of insured persons to the total number of insured persons by region of the Czech Republic shall be as follows:
| Kraj | Všeobecná zdravotní pojišťovna | Vojenská zdravotní pojišťovna | Česká průmyslová zdravotní pojišťovna | Oborová zdravotní pojišťovna | Zdravotní pojišťovna Škoda | Zdravotní pojišťovna ministerstva vnitra | Revírní bratrská pokladna | Zdravotní pojišťovna Metal-Aliance | Zdravotní pojišťovna Média |
|---|---|---|---|---|---|---|---|---|---|
| Praha hl. m. | 0,6227 | 0,0475 | 0,0035 | 0,2278 | 0,0006 | 0,0937 | 0,0003 | 0,0023 | 0,0016 |
| Středočeský | 0,5783 | 0,0417 | 0,0142 | 0,0878 | 0,0772 | 0,0931 | 0,0001 | 0,1060 | 0,0017 |
| Jihočeský | 0,6486 | 0,1279 | 0,0427 | 0,0451 | 0,0001 | 0,1338 | 0,0001 | 0,0003 | 0,0015 |
| Plzeňský | 0,6212 | 0,0725 | 0,0449 | 0,0679 | 0,0001 | 0,1335 | 0,0001 | 0,0572 | 0,0025 |
| Karlovarský | 0,7116 | 0,0674 | 0,0800 | 0,0414 | 0,0001 | 0,0948 | 0,0001 | 0,0007 | 0,0038 |
| Ústecký | 0,7109 | 0,0598 | 0,0348 | 0,0522 | 0,0003 | 0,1133 | 0,0029 | 0,0192 | 0,0067 |
| Liberecký | 0,7656 | 0,0852 | 0,0242 | 0,0371 | 0,0121 | 0,0710 | 0,0001 | 0,0004 | 0,0044 |
| Královehradecký | 0,6213 | 0,0870 | 0,0519 | 0,0400 | 0,0568 | 0,1395 | 0,0001 | 0,0011 | 0,0023 |
| Pardubický | 0,7272 | 0,0612 | 0,0569 | 0,0366 | 0,0005 | 0,1129 | 0,0002 | 0,0012 | 0,0033 |
| Vysočina | 0,7551 | 0,0327 | 0,0424 | 0,0244 | 0,0001 | 0,0988 | 0,0002 | 0,0444 | 0,0019 |
| Jihomoravský | 0,6073 | 0,0564 | 0,0459 | 0,0437 | 0,0001 | 0,1828 | 0,0199 | 0,0413 | 0,0027 |
| Olomoucký | 0,4477 | 0,0892 | 0,0801 | 0,0293 | 0,0001 | 0,1023 | 0,0122 | 0,2371 | 0,0021 |
| Moravskoslezský | 0,3691 | 0,0159 | 0,2709 | 0,0241 | 0,0001 | 0,0640 | 0,2512 | 0,0011 | 0,0036 |
| Zlínský | 0,6618 | 0,0206 | 0,0963 | 0,0274 | 0,0000 | 0,0885 | 0,1027 | 0,0017 | 0,0010 |
E) Increase in remuneration for the activities of doctors in a hospital
The health insurance company will provide the health care facility with an increase in remuneration (NL2011). This increase will be provided by the health insurance company to the health care establishment in the form of interim monthly payments with financial settlement according to the documented recalculated number of doctors after the end of 2011. The amount of the increase granted shall be calculated as follows:
NL2011 = PPL2011 * 110 000 CZK * Kpp
where:
PPL2011 is the calculated number of doctors in the evaluation period, calculated as the average of the sum of the contributions of all doctors in a given hospital providing health care in the county on the last day of each calendar quarter.
Kpp coefficient of the proportion of the number of insured persons of the relevant health insurance undertaking in the county on the total number of insured persons in that region, as laid down in Part D.
Příloha č. 2
Annex No 2 to Decree No 396 / 2010 Coll.
Value of the point, amount of health care payments and regulatory restrictions under § 4
A) Combined Capitalisation Performance Payment
1. The amount of the surrender payment shall be calculated on the basis of the number of insured persons converted by the relevant health insurance undertaking multiplied by the basic rate fixed per registered insured person by the relevant health insurance undertaking per calendar month. The number of insured persons converted by the relevant health insurance undertaking shall be calculated by multiplying the number of insured persons registered by the relevant health insurance undertaking by age group in accordance with point 7 multiplied by the index referred to in point 7. The amount of the basic rate and, where applicable, the total amount of remuneration may be increased if the conditions laid down in the contract between the health insurance undertaking and the health care establishment are met. The basic rate referred to in the first sentence shall be fixed at:
a) 50 CZK for practitioners and practitioners for children and adolescents who provide medical care in the range of at least 30 operating hours spread out to 5 working days per week, with at least 1 day of the week being extended to 18 hours and allowing insured persons to book at least 2 days per week for a fixed hour,
b) CZK 49 for practitioners who provide medical care in the range of at least 25 operating hours spread out within 5 working days of the week, while at least 1 day of the week the hours are extended to at least 18 hours. If local conditions so require, the health insurance company may agree to extend the office hours differently.
c) 47 CZK for other practitioners,
d) 49 CZK for other practitioners for children and adolescents.
2. Performance according to the list of performance included in the capitalisation payment in competence 001 according to the list of performance:
| č. výkonu | Název |
|---|---|
| 01023 | CÍLENÉ VYŠETŘENÍ PRAKTICKÝM LÉKAŘEM |
| 01024 | KONTROLNÍ VYŠETŘENÍ PRAKTICKÝM LÉKAŘEM |
| 01025 | KONZULTACE PRAKTICKÉHO LÉKAŘE RODINNÝMI PŘÍSLUŠNÍKY PACIENTA |
| 01030 | ADMINISTRATIVNÍ ÚKONY PRAKTICKÉHO LÉKAŘE |
| 09215 | INJEKCE I. M., S. C, I. D. |
| 09216 | INJEKCE DO MĚKKÝCH TKÁNÍ NEBO INTRADERMÁLNÍ PUPENY V RÁMCI REFLEXNÍ LÉČBY |
| 09217 | INTRAVENÓZNÍ INJEKCE U KOJENCE NEBO DÍTĚTE DO 10 LET |
| 09219 | INTRAVENÓZNÍ INJEKCE U DOSPĚLÉHO ČI DÍTĚTE NAD 10 LET |
| 09220 | KANYLACE PERIFERNÍ ŽÍLY VČETNĚ INFÚZE |
| 09233 | INJEKČNÍ OKRSKOVÁ ANESTÉZIE |
| 09237 | OŠETŘENÍ A PŘEVAZ RÁNY OD 1 CM2 DO 10 CM2 |
| 09507 | PSYCHOTERAPIE PODPŮRNÁ PROVÁDĚNÁ LÉKAŘEM NEPSYCHIATREM |
| 09511 | MINIMÁLNÍ KONTAKT LÉKAŘE S PACIENTEM |
| 09513 | TELEFONICKÁ KONZULTACE OŠETŘUJÍCÍHO LÉKAŘE PACIENTEM |
| 09523 | EDUKAČNÍ POHOVOR LÉKAŘE S NEMOCNÝM ČI RODINOU |
| 09525 | ROZHOVOR LÉKAŘE S RODINOU |
| 44239 | OŠETŘENÍ A PŘEVAZ BÉRCOVÉHO VŘEDU LÉKAŘEM (1 BÉREC) |
| 71511 | VYJMUTÍ CIZÍHO TĚLESA ZE ZVUKOVODU |
| 71611 | VYNĚTÍ CIZÍHO TĚLESA Z NOSU - JEDNODUCHÉ |
3. Performance according to the list of performance included in the surrender payment in expertise 002, according to the list of performance:
| č. výkonu | Název |
|---|---|
| 01025 | KONZULTACE PRAKTICKÉHO LÉKAŘE RODINNÝMI PŘÍSLUŠNÍKY PACIENTA |
| 01030 | ADMINISTRATIVNÍ ÚKONY PRAKTICKÉHO LÉKAŘE |
| 02023 | CÍLENÉ VYŠETŘENÍ PRAKTICKÝM LÉKAŘEM PRO DĚTI A DOROST - DÍTĚ DO 6 LET |
| 02024 | KONTROLNÍ VYŠETŘENÍ PRAKTICKÝM LÉKAŘEM PRO DĚTI A DOROST - DÍTĚ DO 6 LET |
| 02033 | CÍLENÉ VYŠETŘENÍ PRAKTICKÝM LÉKAŘEM PRO DĚTI A DOROST - DÍTĚ NAD 6 LET |
| 02034 | KONTROLNÍ VYŠETŘENÍ PRAKTICKÝM LÉKAŘEM PRO DĚTI A DOROST - DÍTĚ NAD 6 LET |
| 06111 | KOMPLEX - VYŠETŘENÍ STAVU PACIENTA SESTROU VE VLASTNÍM SOCIÁLNÍM PROSTŘEDÍ |
| 06119 | KOMPLEX - ODBĚR BIOLOGICKÉHO MATERIÁLU |
| 06121 | KOMPLEX - LOKÁLNÍ OŠETŘENÍ |
| 06123 | KOMPLEX - EDUKACE, REEDUKACE, OŠETŘOVATELSKÁ REHABILITACE |
| 06125 | KOMPLEX - KLYSMA, VÝPLACHY, CÉVKOVÁNÍ, LAVÁŽE, OŠETŘENÍ PERMANENTNÍCH KATETRŮ |
| 06127 | KOMPLEX - APLIKACE INHALAČNÍ A LÉČEBNÉ TERAPIE P. O., S. C, I. M., I. V., UV, EVENT.DALŠÍ APLIKACE |
| 06129 | NÁCVIK A ZAUČOVÁNÍ APLIKACE INZULÍNU |
| 09215 | INJEKCE I. M., S. C, I. D. |
| 09216 | INJEKCE DO MĚKKÝCH TKÁNÍ NEBO INTRADERMÁLNÍ PUPENY V RÁMCI REFLEXNÍ LÉČBY |
| 09217 | INTRAVENÓZNÍ INJEKCE U KOJENCE NEBO DÍTĚTE DO 10 LET |
| 09219 | INTRAVENÓZNÍ INJEKCE U DOSPĚLÉHO ČI DÍTĚTE NAD 10 LET |
| 09220 | KANYLACE PERIFERNÍ ŽÍLY VČETNĚ INFÚZE |
| 09221 | INFÚZE U KOJENCE NEBO DÍTĚTE DO 10 LET |
| 09233 | INJEKČNÍ OKRSKOVÁ ANESTÉZIE |
| 09235 | ODSTRANĚNÍ MALÝCH LÉZÍ KŮŽE |
| 09237 | OŠETŘENÍ A PŘEVAZ RÁNY OD 1 CM2 DO 10 CM2 |
| 09253 | UVOLNĚNÍ PREPUCIA, VČETNĚ NEOPERAČNÍ REPOZICE PARAFIMOZY |
| 09507 | PSYCHOTERAPIE PODPŮRNÁ PROVÁDĚNÁ LÉKAŘEM NEPSYCHIATREM |
| 09511 | MINIMÁLNÍ KONTAKT LÉKAŘE S PACIENTEM |
| 09513 | TELEFONICKÁ KONZULTACE OŠETŘUJÍCÍHO LÉKAŘE PACIENTEM |
| 09523 | EDUKAČNÍ POHOVOR LÉKAŘE S NEMOCNÝM ČI RODINOU |
| 09525 | ROZHOVOR LÉKAŘE S RODINOU |
| 71511 | VYJMUTÍ CIZÍHO TĚLESA ZE ZVUKOVODU |
| 71611 | VYNĚTÍ CIZÍHO TĚLESA Z NOSU - JEDNODUCHÉ |
4. For the health performance not included in the capitalisation payment and the health performance for the unregistered insured persons of the relevant health insurance undertaking, declared by the health insurance company and recognised by the health insurance company, paid according to the list of benefits, the value of the point of CZK 1.08 is determined.
5. The value of the point of CZK 0.90 is determined for the traffic performance in the visitor service, paid according to the list of performances.
6. The index expresses the ratio of the cost of the insured person in the age group to that of the insured person in the age group 15 to 19 years.
7. Age groups and indices:
| Věková skupina | Index |
|---|---|
| 0 - 4 roky | 3,91 |
| 5 - 9 let | 1,70 |
| 10 - 14 let | 1,35 |
| 15 - 19 let | 1,00 |
| 20 - 24 let | 0,90 |
| 25 - 29 let | 0,95 |
| 30 - 34 let | 1,00 |
| 35 - 39 let | 1,05 |
| 40 - 44 let | 1,05 |
| 45 - 49 let | 1,10 |
| 50 - 54 let | 1,35 |
| 55 - 59 let | 1,45 |
| 60 - 64 let | 1,50 |
| 65 - 69 let | 1,70 |
| 70 - 74 let | 2,00 |
| 75 - 79 let | 2,40 |
| 80 - 84 let | 2,90 |
| 85 a více let | 3,40 |
B) Combined Capitalisation Power Payment with Capping
1. The amount of the capitalisation payment with a top-up shall be determined in accordance with point (1) of Part A of this Annex. The matching of the cap shall be provided where the practitioner or practitioner has less than 70% of the national average number of such insured persons (the national average number shall be determined for each calendar year according to the data of the Central Register of Insurers administered by the General Health Insurance Company of the Czech Republic) and the provision of such health care is necessary to fulfil the obligations of the health insurance company under § 46 (1) of the Act.
2. A cap of up to 90% of the surrender payment calculated on the national average number of insured persons registered with the relevant health insurance company may be granted. In addition, the health insurance company with which the health care establishment has a contract to provide and pay health care shall be involved in a share corresponding to the percentage of its insured persons from the counted insured persons registered by that health care establishment.
3. Points 4 to 6 of Part A of this Annex shall apply mutatis mutandis for the reimbursement of performance according to the list of performance.
C) Health care covered by the list of performances
For healthcare covered by the list of performances, the value of the point of CZK 0.95 is determined; the value of the point in the amount of CZK 0.90 is determined for transport performance in the visitor service.
(D) Regulatory restrictions
1. Regulation on prescribed medicinal products and medical devices and on requested care in the listed expertise (the required care does not include the medical performance of mammographic screening carried out by the medical institution which has a contract with the health insurance company to provide such health performance):
1.1. If the average remuneration for medicinal products and medical devices prescribed by the health care institution in respect of one recalculated insured person exceeds 120% of the national average remuneration for the prescribed medicinal products and medical devices, the health insurance undertaking shall be entitled to apply a regulatory haircut of up to 25% of the excess. The average remuneration per insured person is included in the supplement for medicinal products for which the prescriber excluded the possibility of replacement under § 32 (2) of the Act and which the health insurance company has paid. The health insurance company shall take into account cases where the health care establishment has demonstrated that the increased average remuneration for the health care establishment of the prescribed medicinal products and medical devices related to one recalculated insured person was due to a change in the amount or manner of their reimbursement, possibly due to changes in the structure of the insured persons treated.
1.2. If the average remuneration for the required care in the listed professions of one recalculated insured person exceeds 120% of the national average remuneration for the requested care in the listed professions, the health insurance undertaking shall be entitled to apply a regulatory deduction of up to 25% of the excess.
2. The regulatory restrictions referred to in points 1.1 and 1.2 shall not apply where health care establishments justify the health care provided on the basis of which the average payments referred to in points 1.1 and 1.2 have been exceeded.
3. Furthermore, the regulatory restrictions referred to in points 1.1 and 1.2 shall not apply where in 2010 or 2011, 50 or fewer insured persons have registered the relevant health insurance company or provided health care to 50 or less unregistered insured persons of the relevant health insurance company or in the case of healthcare provided to foreign insurers.
4. The regulatory restrictions referred to in point 1.1 shall not apply where the total remuneration for all medicinal products and medical devices prescribed by the medical practitioners and practitioners for children and adolescents in 2011, monitored for each expertise separately, does not exceed the expected level of remuneration for the relevant type of healthcare for 2011, based on the health insurance plan of the relevant health insurance undertaking.
5. The regulatory restrictions referred to in point 1.2 shall not apply if the total remuneration for requested care in the listed experts in 2011 does not exceed the expected amount of remuneration for this type of healthcare for 2011, based on the health insurance plan of the relevant health insurance undertaking.
6. The health insurance undertaking shall be entitled to apply the regulatory haircut referred to in points 1.1 and 1.2 up to a maximum of 15% of the amount of remuneration granted by that health insurance undertaking to the health care institution for the surrender payment and medical performance, less the amount of remuneration for the material separately charged and the medicinal products separately charged for 2011.
7. Where a healthcare institution provides healthcare in more than one professional capacity, the regulatory limit referred to in points 1.1 and 1.2 shall be calculated by the health insurance undertaking, where appropriate, for each professional activity separately, unless the health insurance undertaking agrees with the healthcare establishment otherwise.
Příloha č. 3
Annex No 3 to Decree No 396 / 2010 Coll.
Value of the point, amount of payments and regulatory restrictions pursuant to § 5
(A) Value of the point and amount of the payments
1. The amount of remuneration shall be determined on the basis of the performance list by remuneration for medical performance provided with a point value of
(a) CZK 1.08 for medical institutions in contract expertise 305, 306, 308 and 309 according to the performance list, showing performance performance 910 - psychotherapy according to the performance list together with the day-to-day treatment date of the daily stationary according to the performance list and 901 - clinical psychology according to the performance list for medical institutions;
b) CZK 1.06 for medical facilities providing haemodialysis care,
c) 1 CZK for medical institutions of contract expertise 927 - orthoptist according to the list of performance and medical institutions of contract expertise 903 - clinical loopedia according to the list of performances,
d) CZK 0.71 for performances 43311, 43313, 43315, 43613, 43617, 43627, 43629, 43633 according to the list of performance of contract expertise 403 - radiation oncology according to the list of performances,
e) CZK 0.71 for 75347 and 75348 according to the list of performance of contract expertise 705 - ophthalmology according to the list of performances,
f) 1.03 CZK for screening performances 15101 and 15105 according to the list of performance of contract expertise 105 - gastroenterology according to the list of performances,
g) 1.02 CZK for specialized outpatient care not mentioned above, up to the volume calculated for individual expertise according to the list of performances as follows:
PBRO × POPOPOPOPro,
where:
PBRO total number of health establishments declared and health insurance undertakings recognised for the reference period, converted according to the performance list as effective on 1.1.2011. Reference period refers to the relevant half-year 2009.
POPho number of unique insured persons treated by health care institutions in a given professional capacity during the evaluation period. A special insured person shall be the insured person referred to in Annex 1 (A) (2) (b). The evaluation period shall mean the relevant half-year of 2011.
POPro Number of individual insured persons treated by health care institutions in the relevant professional capacity in the reference period
Health care provided to healthcare institutions above the calculated amount in the given expertise, expressed in terms of the number of points for the performance of the healthcare establishments declared and by the health insurance company recognised for the reference period, shall be paid according to the list of performances with a value of CZK 0,30.
2. For a medical institution which did not exist during the reference period or which did not provide care in the relevant professional, the health insurance undertaking may, for the purpose of calculating the volume, use the average number of points per unique insured person treated in that professional period for the reference period of comparable medical establishments.
3. In the case of a medical institution where there is an increase in the average number of points per individual insured person compared to the reference period, the number of points referred to in point 1 (g) shall be increased by the number of points corresponding to the medical institutions declared and the health insurance undertaking recognised by the newly contracted health performance due to a change in the contractual extent of the healthcare provision provided by a medical institution.
4. The reduced value of the point in the competence referred to in point 1 (g) shall not apply:
(a) in the case of a medical establishment which has treated 50 or less unique insured persons in the reference period or in the assessment period, in the case of a contracted capacity of care provided, at least 30 working hours per week. In the case of contracted care capacity of less than 30 working hours per week, the limit of 50 special insured persons treated shall be recalculated by a coefficient of n / 30, where n is equal to the contracted care capacity of the professional.
(b) in the case of healthcare provided to foreign insured persons.
In the cases referred to in (a), all performances shall be paid with the value of CZK 1.02.
5. The health insurance undertaking may provide a monthly advance payment to the health institution of one sixth of the amount of remuneration for the corresponding reference period or of the value of health care declared and recognised for the relevant month. The chosen form of pre-payment shall be maintained by the health insurance undertaking throughout the period of assessment, unless the health establishment requests a reduction in the amount of the pre-payment during the period of assessment. Pre-payments for the evaluation period shall be settled financially within the overall financial settlement, including regulatory restrictions, no later than 120 days after the end of the evaluation period.
(B) Regulatory restrictions
1. If a medical institution reaches an average remuneration per individual insured person for a particular medicinal product (except for specially charged medicinal products paid at specialised workplaces under Section 15 (7) (b) of the Act) and separately charged material in the evaluation period above 105% of the average remuneration per individual insured person for the medicinal products specifically charged (except for specially charged medicinal products paid at specialised workplaces under Section 15 (7) (b) of the Act) and separately charged material in the reference period, the healthcare institution may, after the end of 2011, reduce the remuneration by an amount equivalent to 40% of the cost of the medicinal products separately charged and separately charged material (above 105%), in the ways contained in the medical establishment contract and health insurance.
2. If a health institution reaches an average remuneration per individual insured person for prescribed medicinal products and medical devices in the evaluation period of more than 105% of the average remuneration per individual insured person for prescribed medicinal products and medical devices in the reference period, the health insurance undertaking may, after the end of the evaluation period, reduce the remuneration to the healthcare institution by an amount equivalent to 40% of the increased costs of prescribed medicinal products and medical devices (over 105%), in the manner contained in the medical establishment contract and health insurance undertakings. The average remuneration per individual insured person shall also include drug supplements for which the prescribing physician excluded the possibility of substitution under Section 32 (2) of the Act.
3. If the health care institution reaches an average remuneration per individual insured person for the requested care in the listed experts in the evaluation period above 105% of the average remuneration per unique insured person in the reference period, the health insurance company may reduce the remuneration to the healthcare institution after the end of the period of assessment by an amount corresponding to 40% of the increased costs of the requested care (over 105%), in accordance with the methods contained in the medical institution contract and the health insurance undertaking. The medical performance of mammographic screening, cervical cancer screening and colorectal cancer screening performed by a health care institution which has a contract with the health insurance company for providing such health performance shall not be included in the requested care. For the purposes of determining both the amount of the average remuneration and, where applicable, the amount of any deduction under the first sentence, the performance of the required care in the assessed and reference periods shall be evaluated according to the list of performance as effective on 1 January 2011 by the value of the point in force in the assessment period.
4. The regulatory restrictions referred to in points 1 to 3 shall not apply if the health care establishment justifies the health care provided on the basis of which the average payments referred to in points 1, 2 and 3 have been exceeded.
5. The regulatory restrictions referred to in point 1 shall not apply where the total remuneration for all medicinal products specifically charged and the material specifically charged in outpatient medical institutions providing outpatient specialised care in the assessment period does not exceed 100% of the remuneration for this type of healthcare in the reference period for the health insurance undertaking concerned.
6. The regulatory restrictions referred to in point 2 shall not apply where the total remuneration for all medicinal products and medical devices prescribed in outpatient medical institutions providing outpatient specialised care in the assessment period does not exceed the expected level of remuneration for this type of healthcare for 2011, based on the health insurance plan of the relevant health insurance undertaking.
7. For a healthcare institution where there has been a change in the contractual scope of healthcare provided compared to the reference period (change in the number of performance carriers authorised to prescribe medicinal products and medical devices and require care in the listed professions), the health insurance undertaking shall, in agreement with the healthcare establishment, adjust the average remuneration values for these purposes proportionally over the reference period.
8. For a medical establishment which did not exist or did not have a contract with a health insurance undertaking in the reference period or part thereof, the health insurance undertaking may use the reference value of comparable medical establishments for the purposes of applying the regulatory restrictions referred to in points 1 to 3.
9. If, during a reference period or an evaluation period, 50 and less unique insured persons have treated the healthcare establishment, at least 30 working hours per week under contract, the health insurance undertaking shall not include that expertise in the calculation of the regulation referred to in points 1 to 3. In the case of contracted care capacity of less than 30 working hours per week, the limit of 50 special insured persons treated shall be recalculated by a coefficient of n / 30, where n is equal to the contracted care capacity of the professional.
10. The regulatory restrictions referred to in point 3 shall not apply where the total remuneration for the requested care in the listed experts in the evaluation period does not exceed the expected amount of the payments for this type of healthcare for 2011, based on the health insurance plan of the relevant health insurance undertaking.
11. The health insurance undertaking shall be entitled to apply the regulatory haircuts referred to in points 1 to 3 up to a maximum of 15% of the amount of remuneration granted by that health insurance company to the health care establishment for the medical performance less the amount of remuneration for the material separately charged and the medicinal products separately charged for the period of assessment.
12. If a medical institution prescribes a medical device above 15 000 CZK approved by a health insurance company's medical examiner, this amount will not be included in the regulatory restrictions.
13. Where a healthcare institution provides healthcare in more than one professional capacity, the regulatory limit referred to in points 1 to 3 shall be calculated by the health insurance undertaking and, where appropriate, applied separately for each professional activity, unless the health insurance undertaking agrees with the healthcare establishment otherwise.
Příloha č. 4
Annex No 4 to Decree No 396 / 2010 Coll.
Value of the point, amount of payments and regulatory restrictions according to § 6
(A) Value of the point and amount of the payments
1. The amount of the remuneration is determined according to the list of performances by payment for the health performance provided with the value of the point of CZK 1.06.
2. Total amount of reimbursement to the medical establishment
(a) the professional health care provider shall not exceed the amount calculated as follows:
POPzpo × Puroo
where:
POPzpo the number of unique insured persons treated in a given professional capacity by medical institutions during the evaluation period. A special insured person shall be the insured person referred to in Annex 1 (A) (2) (b). The evaluation period is 2011.
PUROo average remuneration for health performance, including separately charged material and specifically charged medicinal products, per unique insured person treated in a given professional activity by health care establishments during the reference period. The reference period is 2009.
(b) providing health care at the same time in expertise 603 and 604 shall not exceed an amount equal to the sum of the amounts per professional, where the amount per professional is calculated as follows:
POPzpo × Puroo
where:
POPzpo number of unique insured persons treated in a given professional capacity by medical institutions during the evaluation period
Puroo is calculated as follows:
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Regulation Information
| Citation | Decree No 396 / 2010 Coll., on the determination of the values of the point, the amount of health care payments paid from public health insurance and the regulatory limits on the volume of healthcare provided by public health insurance for 2011 |
|---|---|
| Regulation Type | Order |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 27.12.2010 |
|---|---|
| Effective from | 01.01.2011 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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