Decree No. 471 / 2009 Coll.
Decree on the establishment of the value of the point, the amount of health care payments paid from public health insurance and the regulatory limitation of the volume of healthcare provided by public health insurance for 2010
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01.01.2010
30.12.2009
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471
DECLARATION
of 18 December 2009
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 2010
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 2010 the value of the point, the amount of the health care payments provided to insured persons pursuant to Article 2 (1) of the Act No. 48 / 1997 Coll., on public health insurance and on the amendment and addition of certain related laws, as amended ("the Act ') and to insured persons from other Member States of the European Union, the European Economic Area and Switzerland under the relevant provisions of the European Communities (1) and to insured persons from other States with whom the Czech Republic has concluded international social security agreements (" the Foreign Insurance Act'), covered by public health insurance and regulatory restrictions on the volume of such healthcare for the methods of reimbursement referred to in § 2 to 15, provided by:
(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 provided by the medical institutions referred to in § 1 (b), (d), (e) and (k), paid according to the list of performances, including healthcare provided to foreign insured persons, the value of the point of CZK 0,95 shall be determined, unless otherwise specified.
(1) For health care provided by health care institutions, with the exception of health care provided in professional medical institutions, long-term sick hospitals, in healthcare institutions reporting on treatment day 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 limits are set out in Annexes 1, 9 and 10 to this Decree.
(2) For health care provided in professional medical institutions, long-term sick hospitals, in medical institutions reporting on treatment day 00005, according to the list of performance, and in hospital-type health institutions, paid at a flat rate per day of hospitalisation or in accordance with the list of benefits, the value of the point, the amount of health care payments and the regulatory limit shall be 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 a performance list, the value of the point, the amount of health care payments and the regulatory limit shall be as 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 health care provided by dental practitioners not covered by paragraph 1 shall be paid in accordance with the contractual agreement between the health insurance undertaking and the healthcare establishment. The amount of such health care payments and the relevant regulatory restriction are set out in Annex 11 to this Decree, in accordance with the regulations on price regulation).
(3) The health insurance company shall be entitled, after consultation with representatives of professional associations of dental care providers involved in the conciliation procedure provided for in Article 17 (6) of the Act, to limit the amount of remuneration to medical institutions so that the total cost of medical care provided by dental practitioners in 2010 does not exceed the total amount of those costs provided for 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 for 2009, but at least CZK 850.
(2) For the benefit of the spa care provided by the spa facilities, the payment for one day's stay is set at the amount agreed for 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 for 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 2010.
Minister:
Mgr. Jurásková, Ph.D., MBA v. r.
Příloha č. 1
Annex No. 1 to Decree No. 471 / 2009 Coll.
Value of the point, amount of health care payments and regulatory restrictions pursuant to § 3
A) Constitutional care pursuant to § 3 (1)
1. The remuneration to the health care establishment in 2010 includes an individually contracted remuneration component, a flat-rate payment component for hospital care, a flat-rate payment and an outpatient payment component. The reference period is 2008. All healthcare provided in 2008, medical establishments declared by 31.5.2009 and health insurance companies recognised by 31.9.2009 are included in the reference period.
2. The individually contracted component of the remuneration includes the remuneration for health care classified under the Hospital Patient Classification 5 (hereinafter referred to as "Classification") into groups related to diagnosis:
(a) 08021, 08022, 08023, 08041, 08042, 08043, 08181, 08182, 08183,
(b) 05011, 05012, 05013, 05070, 05161, 05162, 05163, 05111, 05112, 05113,
(c) 02041, 02042, 02043,
(d) 01051, 01052, 01053,
(e) 05191, 05192, 05193,
(f) 06061, 06062, 06063,
(g) 07041, 07042, 07043,
(h) 08191, 08192, 08193,
(i) 13091, 13092, 13093,
listed in Annex 9 (hereinafter referred to as "the listed groups') and reimbursement for medicinal products and foodstuffs for special medical purposes (hereinafter referred to as" medicinal products') paid in 2010 at specialised workplaces under Section 15 (7) (b) of the Act. The amount and method of payment of this health care shall be agreed by the health insurance company with the medical institution. If the health insurance company agrees with the health care establishment, the contractually agreed remuneration component may include reimbursement of healthcare other than that referred to in the first sentence; in that case, this remuneration, as well as the remuneration for health care classified under the Classification in the listed groups, shall not be included in the remuneration referred to in point 3.
(3) The flat-rate component of the hospital care payment (PUHOHP2010) shall be determined for 2010 in accordance with the procedure referred to in points 3.1 to 3.5.
3.1 The standard component of the hospital care remuneration (PUHOHP2010) shall be determined as follows:
PUHOSP2010 = [PUHOSP2008 - (CMalfa2008 * IZSalfa2008)] * Kn
Puhosp2008 = Vhosp * ICBref + ZUMhosp + ZULPhosp + LPhosp + KPhosp
where:
The total number of recognised points declared and reported by the health insurance undertaking for the reference period, for the performance during hospitalisation during the reference period, after deduction of points for the reference period for the performance (including the performance in the listed expertise and consul tests according to the list of performance) carried out during hospitalisation during the reference period, which are classified under the classification in the listed groups referred to in point 2; the number of points according to the first sentence shall be converted according to the list of performance applicable on 1.1.2010
ICBref calculated the individual price of the point of the medical establishment, which shall be determined as the proportion of Uref / Bref where:
Uref total remuneration due to the health care institution for all health care provided in the reference period, after settlement of all regulatory measures, with the exception of the regulation on prescribed medicinal products and medical devices, reduced by the reimbursement for the medicinal products specifically charged and the material specifically charged provided in the reference period, declared and recognised by the health insurance company in connection with patient care, by the lump sum to be paid for the medicinal products under Section 17 (7) of the Act, and by the reimbursement of other care paid in crowns (KPref)
Bref total number of health establishments declared and health insurance undertakings recognised by points, translated according to the list of performance applicable on 1.1.2010, for health care provided during the reference period
ZUMhosp total amount of remuneration for medical establishments declared and recognised by a health insurance undertaking separately charged material in respect of performance during the reference period, carried out during hospitalisation during the reference period, except for the separately charged material provided in respect of performance during the reference period, carried out during hospitalisation during the reference period, which are classified in the listed groups referred to in point 2
ZULPhosp total amount of remuneration for medical establishments declared and recognised by the health insurance company of medicinal products specifically charged in respect of performance during the reference period, carried out during hospitalisation during the reference period, except for those specifically charged in respect of performance during the reference period, carried out during hospitalisation during the reference period, which are classified in the listed groups referred to in point 2
LPhosp flat-rate amount to be paid for medicinal products pursuant to Article 17 (7) of the Act on the treatment dates declared and by a health insurance undertaking recognised as a reference period relating to hospitalisation during the reference period, with the exception of medicinal products provided in connection with performance during the reference period, carried out during hospitalisation during the reference period which are classified in the listed groups referred to in point 2 of the Classification
KPhosp total amount of remuneration for other care paid in crowns (except ZUMhosp, ZULPhosp and LPhosp) declared and by the health insurance undertaking recognised as a reference period, provided to the health institution during hospitalisation during the reference period, except for healthcare provided during the reference period in connection with performance during hospitalisation during the reference period which are classified in the listed groups referred to in point 2
CMalfa2008 Number of hospitalisation cases completed in the reference period which are classified under the Classification as diagnostic groups multiplied by the indices of those groups listed in Annex 10
IZSalfa2008 individual base rate, calculated as follows:
IZSalfa2008 = [(Valfa * ICBref) + ZUMalfa + ZULPalfa + LPalfa + KPalfa] / CMalfa2008
where:
Valfa the total number of health establishments declared and health insurance undertakings recognised by the recognised points for the reference period, for performance during hospitalisation during the reference period which are classified under the Classification in the groups listed in Annex 10; the number of points according to the first sentence shall be converted according to the performance list valid on 1.1.2010
ICBref calculated individual price point of the medical facility
ZUMalfa total amount of remuneration for medical establishments declared and recognised by the health insurance company for the specific material provided in the reference period in respect of performance during hospitalisation during the reference period classified under the Classification in the groups listed in Annex 10
ZULPalfa Total amount of remuneration for medical establishments declared and recognised by the health insurance company of medicinal products specifically charged in respect of performance during the reference period during hospitalisation during the reference period classified under the Classification in the groups listed in Annex 10
LPalfa flat-rate amount to be paid for medicinal products pursuant to Article 17 (7) of the Act on the treatment dates declared and by a health insurance undertaking recognised as a reference period relating to hospitalisation during the reference period classified under the Classification in the groups listed in Annex 10
KPalfa total amount of remuneration for other care paid in crowns (except ZUMalf, ZULPalf and LPalfa) declared and by the health insurance undertaking recognised as a reference period, provided to health care institutions during hospitalisation during the reference period which are classified under the Classification as listed in Annex 10
Kn increase coefficient of flat-rate remuneration to be fixed at 1,052 for 2010
3.2 If the number of hospitalizations for 2010 included in the groups related to the diagnosis according to the Classification set out in Annex 10 is less than 200 in the medical establishment, the deduction from the flat-rate remuneration (PUHOSP2008) according to point 3.1 (flat-rate component of the hospital care remuneration (PUHOSP2010) shall be calculated as PUHOSP2008 * Kn) or the flat-rate payment as set out in point 4.
3.3 The flat-rate component of the hospital allowance (PUHOHP2010) shall belong to the health care establishment if the healthcare institution recognises the number of hospitalizations completed in 2010, included in the groups related to the diagnosis according to the Classification, multiplied by the Indexes listed in Annex 9, at least 98% of the medical establishment declared and the health insurance company recognises the number of hospitalizations completed in 2008, included in the groups related to the diagnosis according to the Classification, multiplied by the Indexes listed in Annex 9, and at the same time, if the health institution reports and the health insurance undertaking recognise the number of hospitalizations terminated in 2008, included in the groups related to the diagnosis according to the Classification, which are listed in Annex 9, at least 95% of the health institutions reported and the health insurance undertaking recognised, as recognised in 2008, completed in 2008, included in the groups related to the classification referred to the classification referred to the Classification, listed in Annex 9. Hospital hospitalisation, classified as listed groups and groups listed in Annex 10, shall not be included in the evaluation or reference period.
3.4 If the health institutions declared and the health insurance undertaking recognised by the number of hospitalizations completed in 2010, included in the groups related to the diagnosis according to the Classification, multiplied by the Indexes listed in Annex 9, are less than 98% less than the number of health institutions declared and the health insurance undertaking recognised by the number of hospitalizations completed in 2008, included in the groups related to the diagnosis according to the Classification, multiplied by the Index set out in Annex 9, or less than 95% by such percentage points corresponding to the number of health insurers declared and the health insurance undertaking recognised by the number of hospitalizations completed in 2008, included in the groups related to the diagnosis according to the classification listed in Annex 9, the flat-rate of remuneration for hospitalisation (PUHOSP2010) shall be reduced by such percentage points corresponding to the percentage points, which were not reached by the relevant 95%, or by the relevant point 3.3%. Hospital hospitalisation, classified as listed groups and groups listed in Annex 10, shall not be included in the evaluation or reference period.
3.5 In 2010, the health insurance company shall, subject to compliance with the conditions set out in points 3.3 and 3.4, provide, in total, the remuneration for the healthcare provided included under point 3.1 to (PUHOSP2010) and the health care classified under the Classification in the listed groups referred to in point 2 at least equal to 107% of the remuneration of such care in 2008.
(4) The flat-rate payment (Pudrg2010) shall include the remuneration for healthcare classified under the Classification in the groups related to the diagnosis listed in Annex 10 and shall be as follows:
Pudrg2010 = CMred * ZSalfa2010
where:
CMred reduced by the amount of CMalfa2010, which is set at the amount of CMalfa2010 with the following exceptions:
(a) if the ratio of CMalfa2010 / CMalfa2008 is greater than 1,15, then
CMred = CMalfa2008 * 1,15
(b) if the ratio of CMalfa2010 / CMalfa2008 lies between 1,05 and 1,15 and at the same time that PPalfa is less than 0,98, then
CMred = CMalfa2008 * (PPalfa + 0,02)
where:
PPalfa ratio of the number of health establishments declared and the health insurance undertaking recognised by hospitalisation, completed in 2010, included in the groups related to the classification as listed in Annex 10 and the health undertaking declared and the health insurance undertaking recognised by the number of hospitalisation, completed in 2008, included in the groups related to the diagnosis as listed in Annex 10.
ZSalfa2010 standard rate for flat-rate payment, calculated for 2010 as follows:
ZSalfa2010 = [IZSalfa2008 * (1 - Kp) + (ZSref * Kp)] * Knalfa
where:
Kp approach coefficient to be fixed at 0,2 for 2010
ZSref reference (national) standard rate, which is set at CZK 24 615
Knalfa coefficient of increase of basic rate ZSalfa2010 fixed for 2010 to 1,052
5. The umbilical component of the remuneration includes the reimbursement of specialised outpatient health care, medical care in the fields of expertise 603 and 604, according to the list of performance, medical care provided by general practitioners for adults and practitioners for children and adolescents, dental care provided by dental practitioners, medical care in the listed professions, medical transport, medical first aid and medical care provided in the fields of expertise 902, 911, 914, 916, 921 and 925 ("outpatient care '), except for the performance of income and discharge examinations.
5.1 For specialised outpatient health care, 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 3 to this Decree. In order to determine the level of remuneration of such healthcare, the calculated amount for each expert shall not be used and the reduced value of the point for healthcare provided in excess of that provided in Annex 3 (A) (1) (f).
5.2. For healthcare provided by professionals 603 and 604, according to the performance list, paid in accordance with the performance list, the value of the point and the amount of health care payments shall be set out in Annex 4 to this Decree.
5.3 For health care provided by general practitioners and practitioners for children and adolescents, paid by a combined capitalisation payment, a combined capitalisation payment with a top-up of the cap or according to the list of benefits, the value of the point and the amount of the health care payments shall be set out in Annex 2 to this Decree.
5.4 Dental care is paid in accordance with Section 7 of this Decree.
5.5 For healthcare provided in the listed expertise, paid according to the performance list, the value of the point and the amount of the health care payments shall be set out in Annex 5 to this Decree.
5.6 For the performance of health transport, paid according to the list of services, the value of the point and the amount of the health care payments shall be as set out in Annex 8 to this Decree.
5.7 The medical care provided under the first-aid medical services is paid in accordance with Section 13 of this Order.
5.8. For healthcare provided in a professional capacity 902, according to the performance list, paid according to the performance list, the value of the point and the amount of the health care payments shall be set out in Annex 7 to this Decree.
5.9 For medical care provided in the 911, 914, 916, 921 and 925 expertise, according to the performance list, paid according to the performance list, the value of the point and the amount of health care payments shall be as set out in Annex 6 to this Decree.
5.10 For the contracted performance 09563, according to the list of performances, the value of the point is set at CZK 0.91.
5.11. The remuneration for health care referred to in points 5.1 to 5.9, granted in 2010 to health care establishments by 31.3.2011 and recognised by a health insurance undertaking by 31.5.2011, shall be equal to the sum of the payments calculated in accordance with points 5.1 to 5.9, if this sum is not less than 105% of the value (Uamb2008) and not more than 109% of the value (Uamb2008). The value (Uamb2008) is calculated as follows:
Uamb2008 = Vamb * ICBref + ZUMamb + ZULPamb + KPamb
where:
Vamb the total number of health establishments declared and health insurance companies recognised points, per reference period, per outpatient care performance; the number of points according to the first sentence shall be converted according to the performance list valid on 1.1.2010
ICBref calculated the individual price of the point of the medical establishment, which is set out in point 3.1.
ZUMamb total amount of remuneration for medical establishments declared and recognised by the health insurance company for the material provided during the reference period in the framework of outpatient care
ZULPamb Total amount of remuneration for medical establishments declared and recognised by the health insurance company for medicinal products specifically charged during the reference period in the framework of outpatient care
KPamb Total amount of remuneration for other care paid in crowns (except ZUMamb and ZULPamb) declared and recognised as a reference period by the health insurance company in outpatient care
The remuneration for health care referred to in points 5.1 to 5.9 shall not include health care that has been paid in the reference period under the contractually agreed remuneration component.
5.12 If the sum of the payments calculated in accordance with points 5.1 to 5.9 is less than 105% of the value (Uamb2008), the resulting remuneration (UVamb2010) shall be determined as:
UVamb2010 = Uamb2008 * 1,05
5.13 If the sum of the payments calculated in accordance with points 5.1 to 5.9 is greater than 109% of the value (Uamb2008), the resulting remuneration (UVamb2010) shall be determined as:
UVamb2010 = Uamb2008 * 1,09
5.14. If the number of points declared and recognised by the health insurance undertaking for outpatient care performance for 2010 is less than 100% of the number of points declared and recognised by the health insurance undertaking for outpatient care performance for the reference period, and if the resulting remuneration for outpatient care is determined in accordance with points 5.11 to 5.13, the resulting remuneration (UVamb2010) shall be reduced for 2010 by the same number of percentage points by which 100% of the value has not been reached (Uamb2008) set out in point 5.11.
6. If changes occur in the scope and structure of the care provided compared to the reference period and the health insurance company approves these changes, they shall be taken into account in the contract, including quantification of the increase (reduction) of the remuneration. In the context of the changes referred to in the first sentence, the health insurance undertaking may adjust the limit on the total remuneration for medical devices of the prescribed medicinal products and medical devices referred to in point C.
7. The health insurance undertaking shall take into account the change in the volume reported and recognised by the health insurance undertaking in 2010 compared to 2008. 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 amount of medical care shall include separately charged medicinal products, the material separately charged, the flat-rate amount to be paid for medicinal products according to § 17 (7) of the Act and the point value of health performance, according to the list of performances, with the value of the point of CZK 0,91. Where exceptionally expensive care also includes individually contracted medicinal products, paid in 2010 at specialised workplaces under § 15 (7) (b) of the Act, under point 2 or in case flat-rate health care under point 4, the health insurance company shall take into account the difference between the calculated amount of such health care and the reimbursement of such health care. Health care shall not be included in the particularly expensive care as referred to in point 2, classified under the Classification in groups related to diagnosis 08021, 08022, 08023, 08041, 08042, 08043, 08181, 08182, 08183, 05011, 05012, 05013, 05070, 05161, 05162, 05163, 05111, 05112, 05113, 02041, 02042, 02043, 01051, 01052, 01053, 05191, 05192, 05193, 06061, 06062, 06063, 07041, 07042, 07043, 08191, 08192, 08193, 13091, 13092, 13093, listed in Annex 9.
8. Health care provided to foreign insured persons shall not be included in the flat-rate component of the hospital allowance referred to in point 3.
9. For health care paid according to the list of performances, the value of the point is set at CZK 0.91.
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 health performance to be reported as income and discharge tests according to the performance list.
(b) The flat rate for one day of hospitalisation, with the exception of psychiatric professional medical institutes reporting treatment days 00021 and 00026 in the performance list, shall be 107% of the flat rate for the treatment day belonging to the medical establishment in 2008.
(c) The flat rate for one day of hospitalisation in psychiatric professional medical institutes reporting treatment days 00021 and 00026 according to the performance list shall be 113% of the flat rate for the treatment day belonging to the medical establishment in 2008.
(d) Where there are changes in the scope and structure of the covered care provided in a health institution compared to 2008 and the health insurance company agrees to those changes, it shall take them into account in the contract, including the calculation of the increase (reduction) of remuneration.
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 fixed to 105% of the volume calculated as follows:
PBRO x POPOPOPOPro
where:
PBRO the total number of health establishments declared and health insurance undertakings recognised by the recognised points, translated according to the list of performance applicable on 1.1.2010, for the reference period. The reference period is 2008.
POPho number of unique insured persons treated with medical devices during the evaluation period. The evaluation period shall mean 2010. 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 by the medical institution in the relevant half-year, the number of individual insured persons of the relevant health insurance undertaking treated in the relevant professional shall include only once.
POFor the number of individual insured persons treated by health care establishments in a given professional capacity during the reference period; 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).
Medical care provided to medical institutions over 105% of the calculated volume is paid with a value of CZK 0.30.
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 insurance undertakings insured (hereinafter referred to as the relevant health insurance undertaking) in 2010, with the exception of medical devices authorised by a medical practitioner, exceeds 105% of the remuneration for medicinal products and medical devices prescribed in 2008, with the exception of medical devices authorised by a medical practitioner, the health insurance company may reduce the remuneration to the medical establishment by a maximum of 40%. The total remuneration is also included in the fees for medicinal products for which the prescriber excluded the possibility of replacement under Section 32 (2) of the Act. The health insurance company shall take into account cases where the health care establishment proves that the increased total remuneration for the health care establishment of the prescribed medicinal products and medical devices was caused by a change in the amount or manner of their reimbursement, possibly due to changes in the structure of the insured persons.
2. In the event that health care was provided by the health care institution in the first half of the year or in the second half of 2010 to 100 and less insured persons by the relevant health insurance undertaking, the health insurance undertaking shall not apply the regulation referred to in point 1.
D) Increase in remuneration
The health insurance company will provide an increase in the remuneration in connection with the improvement of the quality of nursing care (NU2010) to a medical facility which exceeds the requirements for the personnel equipment of medical facilities set out in the performance list. The amount of the increase granted shall be calculated as follows:
NÚ2010 = PPS2010 * 30 000 CZK * Kpp
where:
PPS the number of general nurses and midwives calculated as the sum of the time periods of all general nurses and midwives in a given health care establishment in the relevant county
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 proportion of the number of insured persons of health insurance companies in the total number of insured persons by region of the Czech Republic is shown in Table 1
Table 1:
| kraj | Všeobecná zdravotní pojišťovna | Vojenská zdravotní pojišťovna | Česká průmyslová zdravotní pojišťovna | Oborová zdravotní pojišťovna | Zdravotní pojišťovna Škoda |
|---|---|---|---|---|---|
| Praha hl. m. | 0,6242 | 0,0475 | 0,0035 | 0,2258 | 0,0006 |
| Středočeský | 0,5816 | 0,0415 | 0,0146 | 0,0841 | 0,0777 |
| Jihočeský | 0,6456 | 0,1307 | 0,0436 | 0,0446 | 0,0001 |
| Plzeňský | 0,6225 | 0,0720 | 0,0459 | 0,0673 | 0,0001 |
| Karlovarský | 0,7108 | 0,0684 | 0,0799 | 0,0407 | 0,0001 |
| Ústecký | 0,7038 | 0,0612 | 0,0338 | 0,0521 | 0,0003 |
| Liberecký | 0,7615 | 0,0876 | 0,0250 | 0,0363 | 0,0115 |
| Královehradecký | 0,6228 | 0,0870 | 0,0508 | 0,0397 | 0,0560 |
| Pardubický | 0,7281 | 0,0620 | 0,0559 | 0,0365 | 0,0004 |
| Vysočina | 0,7547 | 0,0331 | 0,0410 | 0,0244 | 0,0001 |
| Jihomoravský | 0,6078 | 0,0562 | 0,0443 | 0,0434 | 0,0001 |
| Olomoucký | 0,4498 | 0,0899 | 0,0849 | 0,0293 | 0,0001 |
| Zlínský | 0,6627 | 0,0204 | 0,0951 | 0,0269 | 0,0000 |
| Moravskoslezský | 0,37 | 0,02 | 0,27 | 0,02 | 0,00 |
| Zdravotní pojišťovna Ministerstva vnitra | Revírní bratrská pokladna | Zdravotní pojišťovna Metal-Aliance | Zdravotní pojišťovna Média | ||
| Praha hl. m. | 0,0926 | 0,0005 | 0,0023 | 0,0030 | |
| Středočeský | 0,0911 | 0,0002 | 0,1053 | 0,0041 | |
| Jihočeský | 0,1319 | 0,0001 | 0,0003 | 0,0030 | |
| Plzeňský | 0,1311 | 0,0001 | 0,0567 | 0,0045 | |
| Karlovarský | 0,0938 | 0,0002 | 0,0009 | 0,0053 | |
| Ústecký | 0,1126 | 0,0070 | 0,0199 | 0,0094 | |
| Liberecký | 0,0698 | 0,0001 | 0,0004 | 0,0077 | |
| Královehradecký | 0,1371 | 0,0001 | 0,0014 | 0,0051 | |
| Pardubický | 0,1112 | 0,0002 | 0,0012 | 0,0045 | |
| Vysočina | 0,0973 | 0,0003 | 0,0433 | 0,0057 | |
| Jihomoravský | 0,1815 | 0,0217 | 0,0403 | 0,0047 | |
| Olomoucký | 0,1014 | 0,0114 | 0,2301 | 0,0031 | |
| Zlínský | 0,0872 | 0,1031 | 0,0017 | 0,0029 | |
| Moravskoslezský | 0,06 | 0,25 | 0,00 | 0,00 |
Příloha č. 2
Annex No 2 to Decree No 471 / 2009 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 hours divided into 5 working days per week, with at least one day of the week being extended to 18 hours and allowing insured persons to book at least two 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 one day of the week the working 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 surrender payment in expertise 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 |
| 04508 | LOKÁLNÍ OŠETŘENÍ GINGIVY/SLIZNICE |
| 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 |
| 04508 | LOKÁLNÍ OŠETŘENÍ GINGIVY/SLIZNICE |
| 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 health benefits not included in the capitalisation payment, for unregistered insured persons of the relevant health insurance company and for foreign insured persons, for medical establishments declared and for health insurance companies recognised, paid according to the list of benefits, the value of the point of CZK 1.05 is determined.
5. For performances 01021, 01022, 02021, 02022, 02031, 02032, 02110, 02120, 02125, 02127 to 02150, according to the performance list, the value of the point of 1.10 CZK shall be determined.
6. The value of the point in the amount of CZK 0.91 is determined for the traffic performance in the visitor service, paid according to the list of performances.
7. 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.
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 (A) (1). 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.
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Regulation Information
| Citation | Decree No. 471 / 2009 Coll., on the determination of the values of the point, the amount of health care payments payable by public health insurance and the regulatory limits on the volume of healthcare provided by public health insurance for 2010 |
|---|---|
| Regulation Type | Order |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 30.12.2009 |
|---|---|
| Effective from | 01.01.2010 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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