Decree No. 428 / 2020 Coll.
Regulation on the determination of the values of the points, the amount of payments of services paid and the regulatory restrictions for 2021
Valid
Order
Effective from 01.01.2021
Text versions:
01.01.2021
30.10.2020
Zobrazeno prvních 200 z celkem 943 ustanovení tohoto předpisu.
Zobrazit celý předpis →
Pro stažení celého znění použijte tlačítko Stáhnout výše.
428
DECLARATION
of 22 October 2020
on the determination of the values of the points, the amount of the fees paid for the services and the regulatory restrictions for 2021
According to Article 17 (5) 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., Act No. 261 / 2007 Coll., Act No. 298 / 2011 Coll., Act No. 369 / 2011 Coll. and Act No. 200 / 2015 Coll.:
(1) This Decree provides for 2021
(a) the value of the point;
(b) the amount of compensation paid to insured persons under Article 2 (1) of Act No. 48 / 1997 Coll., on Public Health Insurance and amending and supplementing certain related laws, as amended, (hereinafter referred to as "the Act");
(c) the level of reimbursement of paid services to insured persons from other Member States of the European Union, the Member States of the European Economic Area and the Swiss Confederation under the directly applicable provisions of the European Union governing the coordination of social security systems (1) and to insured persons of other States with which the Czech Republic has concluded international social security agreements covering the field covered by the services (2) (hereinafter referred to as "foreign insured persons"),
(d) the regulatory restriction on the remuneration referred to in Sections 3 to 19 provided by the contracting health service providers (hereinafter referred to as the provider).
(2) The provider is the provider
(a) bed care;
(b) in the field of general practical medicine and the provider of practical medicine for children and adolescents;
(c) specialised outpatient care, a provider of dialysis health care and a provider of expertise 905, 919 and 927 in accordance with the Decree issuing a list of health performances with points (3) (hereinafter referred to as "the list of performances"),
(d) outpatient care in expertise 603 and 604 according to the performance list;
(e) dental medicine;
(f) outpatient care in the field of expertise 222, 801, 802, 806 to 810, 812 to 819 and 823 according to the performance list (hereinafter referred to as "the listed expertise"),
(g) outpatient care in 911, 914, 916, 921 and home care provider in 925 and 926 according to the performance list;
(h) outpatient care in expertise 902 and 917 according to the performance list;
(i) emergency care services, patient transport providers, medical transport service providers, medical emergency services providers and dental emergency services providers;
(j) spa rehabilitation and rehabilitation services,
(k) pharmacy care.
(1) The reference period for the purposes of this Decree is 2019. The benchmark values of the provider shall be the values of the relevant payment indicators of the provider in the reference period.
(2) The evaluation period for the purposes of this Decree is 2021.
(3) This Regulation shall enter into force on the twentieth day following that of its publication in the Official Journal of the European Union.
(4) All services paid in 2021, the provider declared by 31 March 2022 and the health insurance undertaking recognised by 31 May 2022 shall be included in the evaluation period.
(5) If two health insurance companies are merged in the assessment period, the sum of the data for the reference period of the merged health insurance companies shall be used for the calculation of the remuneration.
(1) For the purposes of this Decree, a unique insured person shall mean an insured person of a health insurance undertaking treated by a provider in a specific professional capacity in an assessment or reference period at least once, and it shall not be determined whether it is a treatment under its own health services or health services requested unless otherwise specified.
(2) Where a unique insured person has been treated more than once by the provider in a particular professional capacity in the evaluation period or reference period, the number of unique insured persons shall include the relevant health insurance undertaking treated in that professional activity only once.
(3) In the event of a merger of health insurance undertakings, the insured person for whom more than one of the merged health insurance companies has been paid during the evaluation period or reference period shall be included only once in the number of individual insured persons.
(4) For the purposes of this decree, a global unique insurer means an insurer of a health insurance undertaking treated by a sleeper care provider in any professional capacity within the framework of his own or requested health services in an evaluation or reference period at least once, unless otherwise specified.
(5) If a global unique insured person has been treated by the provider more than once during the evaluation period or reference period, regardless of the number of specialists in which the insured person has been treated, the number of global unique insured persons shall include the relevant health insurance companies treated with that provider only once.
(6) In the event of a merger of health insurance undertakings, an insured person for which more than one of the merged health insurance companies has been paid for during the evaluation period or reference period shall be included only once in the number of global unique insured persons.
(7) If the health insurance undertaking is to use the values of the remuneration indicators of comparable providers when determining the level of remuneration or regulatory restrictions, it shall use the relevant values of all contractual providers that provide health services in a comparable overall scale and structure over the evaluation period as the provider for which the provisions on comparable providers are applied.
(8) International classification of diseases for the purposes of this Decree means the International Statistical Classification of diseases and associated health problems in its current version (MKN-10) 4.
In the case of the provision of paid services to foreign insured persons, the remuneration shall be determined in accordance with § 5 to 19.
(1) For paid services provided by bed care providers, with the exception of paid services provided by post-bed care providers, long-term bed care or special bed care providers, the value of the point, the amount of payment of paid services and the regulatory limit shall be as set out in Annexes 1, 9, 10 and 12 to this Decree.
(2) For paid services provided by providers of post-bed care, long-term bed care, special bed care or special outpatient care provided under § 22 (c) of the Act, the value of the point, the amount of payments paid by the services and the regulatory limit are set out in Annex 1 to this Decree.
(1) For paid services provided by providers of general medical practice and providers of practical medicine for children and youth covered by a combined capitalisation payment, a combined capitalisation payment with a top-up of the capitalisation or according to the list of performance, the value of the item, the amount of the payments of the services paid and the regulatory limitation shall be set out in Annex 2 to this Decree.
(2) For the purposes of Annex 2 to this Ordinance, office hours are agreed in a contract between a health insurance company and a provider where at least one doctor with specialised competence is available at the place of work of the insured person, with a period devoted to the visiting service and administrative activities not included in the operating hours.
For specialised outpatient care provided by outpatient care providers covered by the performance list, the value of the item, the amount of the payments of the services paid and the regulatory limit shall be as set out in Annex 3 to this Decree.
For outpatient care provided to outpatient care providers in expertise 603 and 604 according to the performance list paid under the performance list, the value of the point, the amount of payment of the services paid and the regulatory limitation shall be as set out in Annex 4 to this Decree.
The amount of the remuneration of the paid services provided by dental care providers and the relevant regulatory limit is set out in Annex 11 to this Decree.
For paid services provided by outpatient care providers in the listed expertise covered by the performance list, the value of the point and the amount of the payment of the services paid shall be as set out in Annex 5 to this Decree.
For paid services provided by providers of outpatient care in the 911, 914, 916, 921 and home care providers in the 925 and 926 professional area according to the performance list, the value of the point and the amount of payments of the services paid shall be as set out in Annex 6 to this Decree.
For paid services provided by outpatient care providers in expertise 902 and 917 according to the performance list covered by the performance list, the value of the point and the amount of payment of the services paid shall be as set out in Annex 7 to this Decree.
The value of the point and the amount of the payment of the services paid shall be set out in Annex 8 to this Decree for the services provided by the dialysis providers covered by the list of services.
(1) The value of a point of CZK 1.23 shall be determined for the services provided by the health rescue service providers under the performance list, with the exception of the transport performance according to the performance list, for which the value of a point of CZK 1.13 is determined and with the exception of the performance no. 06714 according to the performance list, for which the value of a point of CZK 1 is determined. The maximum remuneration to the provider for the reported performance No 06714 according to the list of performance during the evaluation period shall not exceed the limit of remuneration for those performance in 2019.
(2) For paid services provided by patient transport providers of urgent care paid according to the performance list, the value of the point of CZK 1.21 shall be determined, with the exception of the performance of the transport according to the performance list, for which the value of the point of CZK 1.13 is determined and with the exception of the performance no. 06714 according to the performance list, for which the value of the point of CZK 1 is determined. The maximum remuneration to the provider for the reported performance No 06714 according to the list of performance during the evaluation period shall not exceed the limit of remuneration for those performance in 2019.
(1) For the services provided by the health transport service provider, the amount of remuneration shall be determined on the basis of the performance list by remuneration for the services provided to the provider.
a) providing a 24-hour medical transport service with a value of CZK 1.13,
b) not providing a health transport service in continuous operation with a value of CZK 0.92.
(2) For the performance of transport No. 69 according to the list of performances, the value of the point is set at CZK 1.02.
(1) For paid services provided by providers in the framework of the medical emergency service paid according to the performance list, the value of the point is set at CZK 1 for medical and transport performance according to the performance list.
(2) Paragraph 9 shall apply in order to determine the level of remuneration of paid services provided by providers in the context of dental emergency services and to establish regulatory restrictions on such services.
(1) For comprehensive spa rehabilitation care for adults, children and adolescents provided in the health facilities of the spa rehabilitation care provider, a payment for 1 day's stay of 107,7% of the contracted remuneration for 1 day's stay for 2019 shall be fixed. If the payment for 1 day of stay for 2019 has not been agreed upon by 31 December 2019 inclusive, the remuneration shall be set at the level of the remuneration paid to comparable providers. The payment for the accommodation and food of the insured person's guide is set at the same amount as the payment for these components for insured persons who are provided with comprehensive spa rehabilitation care for adults.
(2) For the benefit of the spa rehabilitation care for adults, children and young people provided in the health facilities of the spa rehabilitation care provider, a payment for 1 day's stay of 107,7% of the contracted remuneration for 1 day's stay for 2019 shall be fixed. If the payment for 1 day of stay for 2019 has not been agreed upon by 31 December 2019 inclusive, the remuneration shall be set at the level of the remuneration paid to comparable providers.
(3) The payment of CZK 30 for the declared performance No. 09543 according to the list of performances is determined for the spa rehabilitation care. This performance may be declared to the insurance undertaking no more than three times during one medical stay of the insured person.
(4) For the services provided in the recovery rooms, the payment for 1 day's stay is set at CZK 980, which consists of an accommodation, catering and recovery programme component. The payment for the accommodation and food of the insured person's guide shall be set at the same rate as the payment for these components for the insured persons who are provided with the services paid at the health care centre.
(1) For each provider declared and the health insurance company recognised performance No. 09543 according to the list of performances, a remuneration of CZK 35 is determined.
(2) For each provider declared and the health insurance undertaking recognised performance No. 09115 according to the list of performance reported for patients diagnosed with U07.1 or U69.75 according to the international classification of diseases, the provider is increased by CZK 100, except for the performance performed in his own social environment by the insured person, for which the provider is increased by CZK 300. This increase in remuneration shall not be included in the amount of remuneration determined in accordance with Annexes 1 to 8 to this Order.
(3) The remuneration referred to in paragraphs 1 and 2 shall not be included in the maximum remuneration for the services paid.
(4) Paragraph 1 shall not apply to providers of spa rehabilitation care and to providers of general medical practice, to providers of practical medicine for children and adolescents, to providers of dental care and to providers of outpatient care in the field of expertise 603 and 604 according to the performance list.
(1) For each provider declared and the health insurance company recognised performance No. 09552 according to the list of performances, a remuneration of CZK 16 is determined.
(2) After the evaluation period, the health insurance company will pay the provider CZK 12 for each transfer of the paper recipe into electronic form.
This Decision shall enter into force on 1 January 2021.
Minister:
Prof. MUDr. Prymula, CSc., Ph.D., v. r.
Příloha č. 1
Annex No 1 to Decree No 428 / 2020 Coll.
Value of the point, amount of payments of services paid and regulatory restrictions pursuant to § 5
A) Bounded services pursuant to § 5 (1)
1. The payment to the provider in 2021 shall include the contractually agreed remuneration component referred to in point 2, the flat-rate remuneration referred to in point 3, the remuneration allocated to the flat-rate payment referred to in point 4, the case flat-rate payment referred to in point 5, the payment for acute bed-keeping for a small number of insured persons and foreign insured persons referred to in point 6, the payment for outpatient care referred to in point 7 (the "outpatient remuneration component") and the other remuneration referred to in point 8. In order to calculate the reference values, the individually contracted remuneration components, flat-rate remuneration, the remuneration earmarked for the flat-rate remuneration, the case flat-rate remuneration and the outpatient remuneration components shall be included in the calculation in all the services provided in 2019, the provider declared by 31 March 2020 and the health insurance company recognised by 31 May 2020.
2. Individual contractually agreed payment component
2.1 Where the health insurance undertaking and the provider agree on a different amount and method of payment of the services paid and for the services covered by the flat-rate payment, in the payment of the flat-rate payment or in the form of a flat-rate payment, the remuneration for those services shall not be included in the remuneration referred to in points 3 to 7.
2.2 The amount of the reimbursement of medicinal products and foodstuffs for special medical purposes (hereinafter referred to as the "medicinal product"), marked "S" in accordance with Paragraph 39 (1) of Decree No. 376 / 2011 Coll., implementing certain provisions of the Public Health Insurance Act (hereinafter referred to as "Decree No. 376 / 2011 Coll."), shall be determined according to the provider declared and the health insurance company of the recognised medicinal product in the unit price, but not more than the amount mentioned in points 2.2.1 to 2.2.3.
2.2.1. For HIV / AIDS, hereditary angioedema and prophylaxis of children at risk exposed to respiratory syncytic virus exposure, a maximum remuneration per administered medicinal product shall be set at the level of the provider declared and the health insurance company recognised remuneration in 2019.
2.2.2 For groups:
| a) | Dermatologie (Aktinická keratóza, Psoriáza těžká) |
| b) | Dýchací soustava 1 (Astma, CHOPN) |
| c) | Dýchací soustava 2 (Idiopatická plicní fibróza) |
| d) | Endokrinologie (Akromegalie, Endokrinní oftalmopatie, Toxická struma štítné žlázy, Růstové hormony) |
| e) | Hematoonkologie (Leukemie, Lymfomatózní meningitida, Lymfomy, Mnohočetný myelom, Myelo-dysplastické syndromy, Podpůrná hematoonkologie, Zhoubné imunoproliferativní nemoci, Hematologie) |
| f) | Imunitní systém (Autoinflamatorní onemocnění, Digitální ulcerace u systémové sklerodermie, Polyangiitida, Transplantace) |
| g) | Infekce (Hepatitida C) |
| h) | Metabolické vady (Fabryho choroba, Gaucherova choroba, Metabolické vady) |
| i) | Neurologie 1 (Epilepsie, Narkolepsie, Parkinsonova choroba, Substituční léčba) |
| j) | Neurologie 2 (Roztroušená skleróza) |
| k) | Neurologie 3 (Spinální svalová atrofie) |
| l) | Oběhový systém (Plicní arteriální hypertenze) |
| m) | Oftalmologie (Centrální venózní okluze, Makulární degenerace, Oftalmologie - DM, Vitreomakulární trakce, Oftalmologie - jiné) |
| n) | Onkologie – solidní nádory (Hepatocelulární karcinom, Nádory hlavy a krku, Nádory kolorekta, Nádory ledviny, Nádory močového ústrojí, Nádory mozku, Nádory ovarií, Nádory plic, Nádory prostaty, Nádory prsu, Nádory slinivky, Nádory štítné žlázy, Nádory z embryonálních buněk, Nádory žaludku, Osteosarkom, pNET, Sarkomy měkkých tkání, Jiné nádory měkkých tkání, Jiné ZN kůže, Kožní lymfomy, Maligní melanom, Mezoteliom pleury) |
| o) | Osteoporóza |
| p) | Revmatologie (Bechtěrevova choroba, Artritida, Lupus erythematosus, Psoriatická artritida) |
| q) | Trávicí soustava (Crohnova choroba, Ulcerózní kolitida) |
| r) | Cystická fibróza |
| s) | Ostatní – výše neuvedená onemocnění s výjimkou skupiny hepatologie |
| t) | Hepatologie - onemocnění jater a žlučových cest |
the maximum remuneration shall be fixed as follows:
Uhrmax, 2021 = Uhrt, 2020 + Istrii = asUhri, 2019 * INi
where:
| Uhrmax,2021 | je maximální úhrada v |
| i | nabývá hodnot a až s, kde a až s jsou diagnostické skupiny uvedené v bodě 2.2.2. |
| Uhri,2019 | je celková úhrada v |
| Uhrt,2020 | je celková úhrada v roce 2020 za léčbu onemocnění hepatologie. |
| INi | je index navýšení úhrady pro skupinu i, uvedený v bodě 2.2.3. |
The maximum payment is set for all groups of diseases together.
2.2.3 The index of the increase in remuneration shall be set at:
| Diagnostická skupina | Index navýšení úhrady |
|---|---|
| Dermatologie | 1,29 |
| Dýchací soustava 1 | 1,60 |
| Dýchací soustava 2 | 1,24 |
| Endokrinologie | 1,00 |
| Hematoonkologie | 1,14 |
| Imunitní systém | 1,16 |
| Infekce | 1,18 |
| Metabolické vady | 1,03 |
| Neurologie 1 | 1,26 |
| Neurologie 2 | 1,05 |
| Neurologie 3 | 1,20 |
| Oběhový systém | 1,01 |
| Oftalmologie | 1,16 |
| Onkologie – solidní nádory | 1,20 |
| Osteoporóza | 1,00 |
| Revmatologie | 1,03 |
| Trávicí soustava | 1,04 |
| Cystická fibróza | 1,80 |
| Ostatní | 1,30 |
2.2.4 Reimbursement for the treatment of medicinal products provided to insured persons during the evaluation period above the total reimbursement limit set out in points 2.2.1 to 2.2.3 shall be paid in accordance with a prior agreement between the health insurance undertaking and the provider.
2.3 For each hospitalisation case reported by the provider and recognised by the health insurance company, completed in the evaluation period for which testing for COVID-19 was indicated, the payment to the provider is increased by CZK 1688:
(a) for each current declaration of performance No 82040 and 82041 according to the performance list, if the case is diagnosed with U07.1 according to the international classification of diseases,
(b) once for a case with a diagnosis of U69.75 according to the international classification of diseases and at least once at the same time performance No 82040 and 82041 have been reported according to the list of performance.
Such increases in remuneration shall not be included in the remuneration referred to in points 3 to 6.
2.4 In the case of hospitalisation with a diagnosis of U07.1 according to the international classification of diseases by the provider of the recognised and the health insurance undertaking recognised, completed in the evaluation period, classified according to the rules for the classification of hospitalised patients for the year 20211 (hereinafter referred to as "Classification"), for which performance No 55227 has been declared according to the performance list or one of the DRG markers No 90901 to 90907 according to the Classification, the payment to the provider shall be increased for each reported treatment day (hereinafter referred to as "OD") No 00051 to 00078 according to the performance list of 59 064 CZK. In cases of hospitalisation with a diagnosis of U07.1 according to the international classification of diseases by the provider declared and the health insurance company recognised, completed in the evaluation period, classified according to the Classification for which the condition according to the first sentence is not met, the payment to the provider is increased for each reported OD No 00051 to 00078 according to the list of performances by 39 967 CZK. This increase in remuneration shall not be included in the remuneration referred to in points 3 to 6 and shall be intended to compensate for the increased personnel costs of medical care for patients with COVID-19.
3. Flat payment
3.1 The flat-rate payment shall include the services covered by the Classification in the groups related to the diagnosis listed in Annex 10, Part A, to this Decree.
3.2 In the calculation of variables in the reference period, hospitalisation cases are defined as those converted by the Classification.
3.3 For performances from 00031 and 00032 according to the list of performances, excluded from the flat rate payment, the flat rate for the treatment day is set at CZK 484.
3.4. Medicinal products exempted from the flat-rate payment and listed in Annex 12 to this Order shall be paid by the health insurance undertaking to the provider at the level of their declared unit price, but not more than their declared unit price in 2020.
3.5 Required extramural care means care related to the hospitalisation of an insurer with a provider requested by the provider and provided to the insurer at the time of hospitalisation by another provider charging it to the health insurance company. In cases of hospitalisation with a diagnosis of U07.1 according to the international classification of diseases, the declared performance No 82040 and 82041 according to the performance list shall not be included in the extramural care. In cases of hospitalisation with a diagnosis of U69.75 according to the international classification of diseases, the first simultaneous declaration of performance No 82040 and 82041 according to the list of performance shall not be included in extramural care.
3.6. The amount of the flat-rate remuneration shall be determined as the FOREIGN, CZK-DRG, 2021 as follows:
EMBRPU, CZ- DRG, 2021 = min1; CMred, 2021, CZ- DRG, A0,95 * CM2019, CZ- DRG, A * IPU * IZP-EM2021, A
where:
This Regulation shall enter into force on the twentieth day following that of its publication in the Official Journal of the European Union.
EM2021, A is the total value of the requested extramural care in the context of hospitalisation cases by the provider declared and the health insurance company recognised, terminated in the assessment period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Regulation, valued at the values of the points applicable in the assessment period, including remuneration for the material separately charged and the medicinal products separately charged.
min function minimum which selects the lowest value from the range of values.
and where the IPU is an individual flat-rate remuneration calculated as follows:
(i) IPU = Pudrag, 2019 * 1,18
where:
Pudrg, 2019 is the reference amount of the remuneration for the provider declared and the health insurance company recognised by the services covered by the flat-rate payment.
In case the provider provides urgent income care during the evaluation period, Pudrag, 2019 shall be calculated as follows:
Pudrg, 2019 = max {CM2019, CZ- DRG, A-D, H * ZSmin, 2019, PU; CELK PUDRG, 2019 + ITEM = 1nÚHRISU2019 + EM2019, A-DH} * CM2019, CZ- DRG, ACM2019, CZ- DRG, A-D, H
In other cases, Pudrag, 2019 shall be calculated as follows:
Pudrg, 2019 = CELK Pudrg, 2019 + ITEM = 1nÚHRISU2019 + EM2019, A-D, H * CM2019, CZ- DRG, ACM2019, CZ- DRG, A-D, H
where:
CM2019, CZK-DRG, A-D, H is the number of hospitalisation cases recalculated in accordance with point 3.2 by the provider declared and the health insurance undertaking recognised, terminated in the reference period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Parts A to D and Part H to this Order, multiplied by the relative weights 2021 as set out in Annex 10, Parts A to D and Part H to this Decree.
CM Pudrg, 2019 is the total amount of the flat-rate remuneration in the reference period, including the corresponding increase in the remuneration to health care professionals engaged in the non-medical profession, alternately in a three-shift or continuous operating regime for providers of bed care services.
ZSmin, 2019, PU is the minimum basic rate, which is set at CZK 49711 for a provider who has the status of a centre of highly specialised oncological care and at the same time the status of at least two high specialised care centres from the following list: a centre of highly specialised cerebrovascular care, a centre of highly specialised complex cardiovascular care for adults, a centre of highly specialised pneumooncosurgical care, a centre of highly specialised medical care in oncogylogy, a centre of highly specialised care for the isolation of patients suspected of highly contagious disease under the Health Service Act 2). If the provider does not meet the conditions set out in the first sentence but has the status of a centre of highly specialised oncological care as well as the status of at least two centres of highly specialised care from the following list - a centre of highly specialised cerebrovascular care, a centre of highly specialised complex cardiovascular care for adults, a centre of highly specialised pneumooncosurgical care, a centre of highly specialised medical care in oncology, a centre of highly specialised care for patients with an id, a centre of highly specialised cardiovascular care according to the Health Services Act - the minimum basic rate is set at CZK 44 977. For other providers, the minimum standard rate is CZK 37 875.
This Regulation shall enter into force on the twentieth day following that of its publication in the Official Journal of the European Union.
INTRODUCTION2019 Total remuneration of the provider for services included in individually contracted bases in the reference period.
max function maximum that selects the highest value from the range of values.
(ii) CMred, 2021, CZ-DRG, A is calculated as follows:
(a) Where the number of providers declared and the health insurance undertaking recognised by hospitalisation as referred to in point 3.2 is completed in a reference or assessment period, classified by classification in groups related to the diagnosis referred to in Annex 10, Part A to this Decree, which has been completed by the transfer of a patient to a follow-up provider or to a follow-up department of the same provider (hereinafter referred to as "treatment termination code 4") or by the transfer of a patient to another acute bed care provider (hereinafter referred to as "treatment termination code 5"), less or equal to 100, or if PPRdrg, A, 2021 or if PPrg, A, 2019,4,5 ≤ * 0,1 * PPdrg, A, 2019 are determined as follows:
CMred, 2021, CZ- DRG, A = min {CM2021, CZ- DRG, A; CM2021, CZ- DRG, A0,3 * X * PPdrg, A, 2021 * CM2019, CZ- DRG, APPdrg, A, 20190,7}
where:
The value of X shall be 1,05 where the ratio of the number of insured persons of the insurance undertaking in that district, as referred to in point 1 of Annex 9 to this Decree, is greater than 0,1 and 1,15 where the ratio of the number of insured persons of the insurance undertaking in that district, as referred to in point 1 of Annex 9 to this Order is less than or equal to 0,1.
CM2021, CZK-DRG, A is the number of hospitalisation cases referred to in point 3.2 by the provider declared and the health insurance company recognised, completed in the assessment period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Decree, multiplied by the relative weights 2021 listed in Annex 10, Part A to this Decree.
PPdrg, A, 2021 is the number of providers declared and the health insurance company of recognised hospitalisation cases, completed in the evaluation period, classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Decree.
This Regulation shall enter into force on the twentieth day following that of its publication in the Official Journal of the European Union.
(b) In other cases, the reduced casix shall be determined as follows:
CMred, 2021, CZ-DRG, A = CMred 1 + CMred 2,
where:
CMred1 = min {CM1,2021, CZ- DRG, A; CM1,2021, CZ- DRG, A0,3 * X * PP1, drg, A, 2021 * CM1,2019, CZ- DRG, APP1, drg, A, 20210,7}
where:
CM1,2021, CZ- DRG, A is the number of hospitalisation cases reported by the provider and the health insurance company recognised, terminated in the assessment period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Order, which have not been terminated by the treatment termination code 4 or the treatment termination code 5, multiplied by the relative weights 2021 as set out in Annex 10, Part A to this Decree.
CM1,2019, CZK-DRG, A is the number of hospitalisation cases referred to in point 3.2 by the provider declared and the health insurance company recognised, which were completed in the reference period, classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Regulation, which have not been terminated by the end code of treatment 4 or the end code of treatment 5, multiplied by the relative weights 2021 as set out in Annex 10, Part A to this Regulation.
PP1, drg, A, 2021 is the number of providers reported and the health insurance company of recognised hospitalisation cases, completed in the evaluation period, classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Regulation, which have not been terminated by the end-of-treatment code 4 or the end-of-treatment code 5.
PP1, drg, A, 2019 is the number of providers reported and the health insurance company of recognised hospitalisation cases as referred to in point 3.2, completed in the reference period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Regulation, which have not been terminated by the end-of-treatment code 4 or the end-of-treatment code 5.
and where:
CMred2 = CM2021, CZ- DRG, A, 4,5 * 1,05 * min1; PPRdrg, A, 2019,4,5PPRdrg, A, 2021,4,5 * PPRdrg, A, 2021PPRdrg, A, 2019
where:
CM2021, CZK-DRG, A, 4,5 is the number of hospitalisation cases reported by the provider and by the health insurance company recognised, terminated in the assessment period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Decree, which have been terminated by the end-of-treatment code 4 or the end-of-treatment code 5, multiplied by the relative weights 2021 set out in Annex 10, Part A to this Decree.
PPRdrg, A, 2021,4,5 is the number of providers declared and the health insurance company of recognised hospitalisation cases, completed in the assessment period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Decree, which have been terminated by the end-of-treatment code 4 or the end-of-treatment code 5.
PPRdrg, A2019,4,5 is the number of providers declared and the health insurance company of recognised hospitalisation cases as referred to in point 3.2, completed in the reference period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Part A to this Regulation, which have been terminated by the end-of-treatment code 4 or the end-of-treatment code 5.
(iii) IZP is the index of the change in production calculated as follows:
IZP = max1; ARCTG3 * CMred, 2021, CZ-DRG, ACM2019, CZ-DRG, A-1,443
4. Reimbursement on flat-rate remuneration
4.1 The remuneration allocated to the flat-rate remuneration shall include the services covered by the Classification in the groups related to the diagnosis listed in Annex 10, Parts C to F to this Decree.
4.2 In the calculation of variables in the reference period, hospitalisation cases are defined as those converted by the Classification.
4.3 Medicinal products excluded from the flat-rate payment and listed in Annex 12 to this Regulation shall be paid by the health insurance undertaking to the provider at the level of their declared unit price, but not more than their declared unit price in 2020.
4.4 The requested extramural care is the care related to the hospitalisation of the insured person with the provider requested by the provider and which is provided to the insured person at the time of hospitalisation with the provider by another provider that reports it to the health insurance undertaking. In cases of hospitalisation with a diagnosis of U07.1 according to the international classification of diseases, the declared performance No 82040 and 82041 according to the performance list shall not be included in the extramural care. In cases of hospitalisation with a diagnosis of U69.75 according to the international classification of diseases, the first simultaneous declaration of performance No 82040 and 82041 according to the list of performance shall not be included in extramural care.
4.5 For services covered by a flat-rate remuneration classified under the Classification in the groups related to the diagnosis listed in Annex 10, Parts C to F by the provider recognised and the health insurance undertaking recognised for the period of assessment, a remuneration shall be set at:
Article 20 (1) (b) of Regulation (EU) No 1308 / 2013
where:
CM2021, CZK-DRG, CE is the number of hospitalisation cases completed in the evaluation period and by a recognised health insurance undertaking classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Parts C and E to this Order, multiplied by the relative weights 2021 listed in Annex 10, Parts C and E to this Decree.
CM2021, CZK-DRG, DF is the number of cases completed in the evaluation period and by a health insurance undertaking recognised by the Classification, classified in the groups related to the diagnosis listed in Annex 10, Parts D and F to this Order, multiplied by the relative weights 2021 listed in Annex 10, Parts D and F to this Order.
EM2021, C-F is the total value of the requested extramural care in the context of hospitalisation cases by the provider declared and the health insurance company recognised, completed in the evaluation period classified according to the Classification in the groups related to the diagnosis listed in Annex 10, Parts C to F to this Decree, valued at the values of the points in force in the evaluation period, including remuneration for the material separately charged and the medicinal products separately charged.
IZS2021, CZ-DRG, CE is the individual basic rate of highly homogeneous hospitalisation calculated as follows:
(1) Where:
IZSinput, 2021 ≥ (1 + RCCE, Horni) * ZSCZ - DRG
then:
IZS2021, CZ − DRG, CE = TSCE, upper * (1 + RCCE, upper) * ZSCZ − DRG + (1 − TSCE, upper) * IZSinput, 2021
(2) Where:
IZSinput, 2021 ≤ (1 − RCCE, lower) * ZSCZ - DRG
then:
> TABLE >
(3) In other cases:
IZS2021, CZ − DRG, CE = IZSvodní, 2021
IZS2021, CZ − DRG, DF is the individual basic rate of moderate homogenous hospitalisation calculated as follows:
(1) Where:
IZSinput, 2021 ≥ (1 + RKDF, Horni) * ZSCZ - DRG
then:
IZS2021, CZ − DRG, DF = TSDF, upper * (1 + RKDF, upper) * ZSCZ − DRG + (1 − TSDF, upper) * IZSventu, 2021
(2) Where:
IZSinput, 2021 ≤ (1 − RKDF, lower) * ZSCZ - DRG
Sign in for notes, favorites and notifications
Regulation Information
| Citation | Decree No. 428 / 2020 Coll., on the setting of the values of the points, the amount of the fees paid and the regulatory restrictions for 2021 |
|---|---|
| Regulation Type | Order |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 30.10.2020 |
|---|---|
| Effective from | 01.01.2021 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
Comments 0