Decree No. 475 / 2012 Coll.
Decree on the determination of the value of the points, the amount of the fees paid and the regulatory restrictions for 2013
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Effective from 01.01.2013
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31.12.2012
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475
DECLARATION
of 20 December 2012
on the determination of the value of the points, the amount of the fees paid for the services and the regulatory restrictions for 2013
The Ministry of Health provides pursuant to § 17 paragraph 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. and Act No. 369 / 2011 Coll.:
This decree sets out for 2013 the value of the item, the amount of the payment of the paid services to insured persons under Section 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, (hereinafter referred to as "the Act '), and the paid services to insured persons from other Member States of the European Union, the European Economic Area and Switzerland under the directly applicable European Union1) and to insured persons of other States with whom the Czech Republic has concluded international social security agreements covering the field of paid services (hereinafter referred to as" foreign insured persons'), and regulatory restrictions on the methods of reimbursement referred to in Sections 3 to 17, provided by:
(a) contractual providers of bed care, including special bed care providers pursuant to Article 22a of the Act;
(b) contractual providers of health services in the field of general medical practice and contractual providers in the field of practical medicine for children and adolescents;
(c) contractual providers of specialised outpatient care, including providers of haemodialysis and orthoptic healthcare;
(d) contractual providers of outpatient care in expertise 603 and 604 according to the list of performance with points (3) (hereinafter referred to as "the list of performance"),
(e) contractual providers of dental health services;
(f) contractual providers of outpatient care in the field of expertise 222, 801, 802, 804, 805, 806, 807, 808, 809, 812 to 819, 820, 822 and 823 according to the performance list (hereinafter referred to as "the listed expertise"),
(g) contractual providers of outpatient care in the 911, 914, 916, 921 and 925 expertise according to the performance list;
(h) contractual providers of outpatient care in competence 902 and 917 according to the performance list;
(i) medical emergency service contractors, medical transport service contractors, medical emergency service contractors and dental emergency service contractors;
(j) contractual providers of spa rehabilitation and rehabilitation facilities;
(k) in the framework of urgent care for non-contractual health service providers.
(1) The reference period is the year 2011 for the purposes of Annexes 1, 3 to 8 to this Decree.
(2) The evaluation period is the year 2013 for the purposes of Annexes 1, 3 to 8 to this Decree.
(3) For the purposes of this Decree, a single insured person of the relevant health insurance company treated by the health service provider (hereinafter referred to as the provider) in the relevant professional capacity in the period of assessment or reference shall be considered to be at least once, and it shall not be determined whether the treatment is in the context of its own services or services requested. If the insured person has been treated more than once by the provider in the relevant expert in the relevant assessment period or reference period, the number of individual insured persons shall include the relevant health insurance undertaking treated in that professional only once. In the event of a merger of health insurance undertakings, the number of unique insured persons shall be the sum of the unique insured persons of health insurance undertakings which have merged. If the insured person has been insured by more than one health insurance company during the reference period, the number of individual insured persons shall be included only once.
(4) When calculating the total number of points declared by the provider and the health insurance undertaking as performance for the reference period referred to in Annexes 3, 5 to 8 to this Regulation, those points shall be understood as those points converted in accordance with the list of performance as effective on 1 January 2013.
(5) Where two health insurance undertakings have merged in the reference period or in 2012, the sum of the data for the reference period of the merged health insurance undertakings shall be used for the calculation of the remuneration.
For paid services provided to foreign insurers paid according to the list of performance and for the purposes of determining compensation for the treatment of insured persons, the value of the point referred to in Sections 8, 12 and 14 and Annexes 1 to 8 to this Decree shall be determined.
(1) For paid services provided by bed care providers, with the exception of care provided by post-bed care providers, long-term bed care providers, providers reporting treatment day No 00005 according to the list of performance and special bed care providers, the value of the point, the amount of payments of the paid services and the regulatory limit shall be set out in Annexes 1, 9 to 12, 14 and 15 to this Decree.
(2) For paid services provided by post-bed care providers, long-term bed care providers, providers reporting on treatment day 00005 according to the list of benefits and special-bed care providers, paid at a flat rate per day of hospitalisation or according to the list of benefits, the value of the point, the amount of the payments of the services paid and the regulatory limit shall be set out in Annex 1 to this Decree.
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 payments of the services paid and the regulatory limit shall be as set out in Annex 2 to this Decree.
For specialised outpatient care provided by the outpatient health care providers covered by the performance list, the value of the point, the amount of the payment 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 health care providers in expertise 603 and 604 according to 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.
(1) For paid services provided by dental care providers, the value of the point is CZK 0.95.
(2) The amount of the remuneration of the paid services provided by dental practitioners not covered by paragraph 1 and the relevant regulatory restrictions are laid down in Annex 13 to this Decree.
(3) The health insurance company shall be entitled to limit the amount of remuneration to providers so that the total cost of the health insurance undertaking paid for the services provided by dental care providers in 2013 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 remuneration for the paid services provided by dental care providers provided in the health insurance plan of the health insurance undertaking for those services would be due to the provision of more urgent care compared to 2011, the health insurance company would take this greater amount into account in the remuneration.
For covered services provided by outpatient health 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 health care services in the 911, 914, 916, 921 and 925 expert expertise according to the performance list, the value of the point and the amount of the payments of the services paid shall be as set out in Annex 6 to this Decree.
For services provided by outpatient health care providers in the field of competence 902 according to the performance list covered by the performance list, the value of the item and the amount of the payment of the services paid shall be as set out in Annex 7 to this Decree.
The value of the point of CZK 1.10 shall be determined for the services provided by the health rescue service providers covered by the performance list.
For paid services provided by health transport service providers 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 8 to this Decree.
For paid services provided by providers in the framework of medical emergency or dental emergency services paid according to the list of performances, the value of the point of CZK 0.95 is determined.
(1) For the comprehensive spa rehabilitation care provided in the health facilities of the spa rehabilitation care provider, payment for one day's stay is fixed at the amount agreed on 31 December 2011, but at least CZK 850.
(2) A payment for one day's stay at a rate agreed on 31 December 2011, but at least CZK 280, shall be provided for the health care services of the spa rehabilitation provider.
(3) For the services provided in the recovery facilities, the payment for one day's stay is fixed at the amount agreed on 31 December 2011, but at least CZK 540.
According to § 3 to 15, the procedure is to be followed unless the health insurance company and the provider agree otherwise, subject to the conditions laid down in § 17 (5) of the Act.
For urgent medical care provided by non-contractual providers covered by the performance list, the point value shall be set at 75% of the point value set out in Sections 8, 12 and 14 and Annexes 1 to 8 to this Decree. The resulting point value is rounded to 2 decimal places.
This Decree shall take effect on 1 January 2013.
Minister:
Doc. MUDr. Heger, CSc., v. r.
Příloha č. 1
Annex No 1 to Decree No 475 / 2012 Coll.
The value of the point, the amount of the payments of the services paid and the regulatory limitation referred to in § 4
A) Bound services pursuant to § 4 (1)
1. The payment to the provider in 2013 shall include the contractually agreed remuneration component, the case flat-rate remuneration, the remuneration to be paid in the form of a case flat-rate payment and the payment for outpatient care (the "outpatient remuneration component"). All services paid in 2011, the provider reported by 30 May 2012 and the health insurance company recognised by 30 September 2012 are included in the reference period. All services paid in 2013, the provider reported by 31 March 2014 and the health insurance company recognised by 31 May 2014 are included in the evaluation period.
2. Individual contractually agreed payment component
2.1. The level and method of reimbursement of the services paid under the Hospital Patient Classification (4) (hereinafter referred to as "Classification") to 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,
as listed in Annex No 9 (hereinafter referred to as the listed groups), the health insurance undertaking shall agree with the provider by contract. Where the health insurance undertaking agrees with the provider, the contractually agreed remuneration component may include services other than those referred to in the first sentence; in that case, such remuneration, as well as the services covered by the classication4) in the listed groups, shall not be included in the remuneration referred to in point 3.
If no agreement on the amount of remuneration is reached on an individual contractual basis between the provider and the health insurance undertaking by 30 April 2013, the health insurance undertaking shall provide the provider with a remuneration calculated as the sum of the total remuneration for the listed groups. The total remuneration for each listed group shall be calculated as the product of at least 50% of the number of cases treated for the reference period in the listed group, if at least this number of cases multiplied by the coefficient of KPP is treated for the evaluation period and the average remuneration for the case treated for the listed group in 2012.
The total amount of remuneration granted for each listed group provided by the health insurance undertaking to all providers in total shall be at least 85% of the number of cases covered by the listed group during the reference period.
2.2 The amount of 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 the "Order"), shall be determined according to the provider declared and the health insurance company of the recognised medicinal product, but not more than:
2.2.1 100% 12 times the average monthly remuneration calculated from the months 2012 during which the treatment was provided, multiplied by the number of unique insured persons treated in 2012 for the disease:
(a) Fabry disease,
(b) Gaucher disease,
(c) Niemen-Pick's disease,
(d) Mukopolysaccharidosis I,
(e) Mukopolysaccharidosis II,
(f) Mucopolysaccharidosis VI,
(g) Pompe's disease;
h) Hyperamonaemia in children with hereditary disorders of urea and glutamine metabolism,
(i) Hereditary type I thyroidism.
2.2.2. 98% of the remuneration due to the provider for medicinal products provided to insured persons treated for diseases other than those referred to in point 2.2.1; This remuneration shall be calculated as the product of the average cost of each disease per month of treatment of one unique insured person in the reference period calculated from the months of the reference period during which the treatment was provided and the number of months during which the treatment was provided during the evaluation period. The total remuneration related to the individual disease shall be calculated by multiplying the remuneration per individual insured person determined according to the first sentence and the number of individual insured persons to whom that medicinal product has been provided for the treatment of the disease during the evaluation period. The maximum total remuneration for the period under assessment shall be calculated as a multiple of the remuneration determined in accordance with the first sentence and:
(a) 108% of the number of unique insured persons treated on 31 December 2012 who received a medicinal product for the treatment of the relevant diagnosis: rheumatics, Crohn 's disease, ulcerative colitis, severe psoriasis, multiple sclerosis, pulmonary hypertension.
(b) 102% of the number of unique insured persons treated in 2012 who received a medicinal product for the treatment of a disease other than those referred to in point 2.2.1 and point (a) for the treatment of the relevant diagnosis.
2.2.3. Where the average cost of a medicinal product provider to one unique insured person for the treatment of the relevant disease for a reference period is higher than the national average cost of medicinal products to one unique insured person for the treatment of the relevant disease for a reference period, the remuneration shall be reduced over the evaluation period to the value of the national average cost of the health insurance company for medicinal products provided to a unique insured person for the treatment of the relevant disease in 2012. According to the first sentence, if the health insurance company publishes by 30 April an indication of the national average cost of medicinal products provided to one individual insured person for the treatment of the disease in question in 2012, it shall also transmit it to the provider.
2.2.4 Reimbursement for medicinal products provided to insured persons for treatment newly initiated during the evaluation period above the total reimbursement limit set out in points 2.2.1. to 2.2.3 shall be paid only after prior agreement between the health insurance company and the provider. Without prior agreement between the health insurance undertaking and the provider, the first payment of the services referred to in the sentence may be made only if the payment already provided is used to cover the medicinal products provided for the treatment of another relevant disease.
2.2.5 Within the overall payment limit set in accordance with points 2.2.1. to 2.2.3. medicinal products prescribed in the reference period for the recipe shall be included if, in the evaluation period, these medicinal products are reported as separately charged medicinal products and, at the same time, if, in the evaluation period, they continue to meet the conditions for medicinal products marked "S".
3. Reimbursement by case flat rate
3.1 The flat-rate payment (Pudrg2013) shall include the services covered by the Classification in the groups related to the diagnosis listed in Annex 10 to this Decree and shall be fixed up to the level of CELK Pudrg2013 as follows:
Pudrg2013 = CMred * ZS2013
where:
CMred reduced amount of CMfa2013, to be determined according to the following conditions:
CMred = minCMalfa2011 * 0,95 * Kpp; CMalfa2013; CMalfa2013α * 1,05 * PPalfa2013 * CMalfa2011PPalfa20111-α
where:
min function minimum that gives CMred the value from the range of values that is the lowest of the elements of the range of values
α coefficient to be fixed at 0,2
CMalfa2013 Number of hospitalisation cases reported by the provider and by the health insurance undertaking recognised in the assessment period which are classified under the Classification in groups related to the diagnosis, multiplied by the indices of those groups listed in Annex 10 to this Regulation (hereinafter referred to as "indices 2013 ')
CMalfa2011 number of cases of hospitalisation completed and of health insurance undertakings recognised in the reference period which are classified under the Classification in the groups related to the diagnosis set out in Annex 10 to this Decree and multiplied indices of those groups laid down by the law governing the value of the point and the amount of remuneration for 2011 ("2011 indices')
PPalfa2013 Number of providers declared and health insurance undertakings recognised by hospitalisation, completed in 2013, classified in groups related to the classification as listed in Annex 10 to this Decree
PPalfa2011 number of providers declared and health insurance undertakings recognised by hospitalisation completed in 2011, classified in groups related to diagnosis according to the Classification as set out in Annex 10 to this Decree
Kpp coefficient of the change in the proportion of the number of insured persons of the relevant health insurance undertaking receiving the services paid to that provider in the total number of insured persons receiving the services paid to that provider between 1 January 2011 and 1 January 2013; if two health insurance companies have merged in the reference period or in 2012, this is a coefficient of change in the proportion of the number of insured persons of all merged health insurance companies
Unless otherwise agreed between the provider and the health insurance company, this coefficient shall be determined as an index of the change in the number of insured persons of the relevant health insurance undertaking in the region of the provision of the paid services between 1 January 2011 and 1 January 2013, the coefficients of the change in the number of insured persons of health insurance undertakings according to the regions of the Czech Republic being set out in Annex 14 to this Decree.
ZS2013 standard rate for flat rate settlement, calculated as follows:
(a)
> TABLE > * TZS
where:
n number of insurance undertakings
and health insurance company
The reference individual base rate shall be calculated as follows:
IZS2011 = Uall2011CMall2011
where:
Uall2011 Total amount of remuneration for the provider declared and the health insurance company recognised by the services provided during hospitalisation during the reference period, including taking into account the change in the amount of extra-expensive care, the increase of NÚ2011, the increase of NL2011 and the settlement of regulatory restrictions with the exception of regulation on prescribed medicinal products and medical devices
where:
NÚ2011 Increase in remuneration determined in accordance with Annex 1, Part D, to Decree No 396 / 2010 Coll., on determining the values of the point, the amount of health care payments payable by public health insurance and the regulatory limits on the amount of health care provided by public health insurance for 2011
NL2011 An increase in the remuneration determined in accordance with Annex 1, Part E, to Decree No 396 / 2010 Coll., on the determination of the values of the point, the amount of the health care paid by public health insurance and the regulatory limitation of the amount of the health care provided by public health insurance for 2011, as amended by Decree No 46 / 2011 Coll.
CMall2011 Number of hospitalisation cases completed and by health insurance undertakings recognised in the reference period which are classified under the Classification in the groups related to the diagnosis listed in Annexes 9, 10, 11 and 12 to this Decree and multiplied by indices 2011
Kp approach coefficient to be fixed at 0,30
TZS technical (national) basic rate, which is set at CZK 29 500
(b) If the health insurance undertaking and the provider have not agreed on the calculation referred to in (a) by 30 June 2013, the standard rate shall be calculated as follows:
ZS2013 = [IZS2011 * (1 - Kp) + (TZS * Kp)]
where:
Kp approach coefficient to be fixed at 0,50
TZS technical (national) basic rate, which is set at CZK 29 500
The total amount of Pudrg2013, CELK Pudrg2013, shall be calculated as follows:
CELK Pudrg2013 = max {min [1,07 * CMred * IZS2011; CMred * ZS2013]; 1,02 * CMred * IZS2011}
where:
max function maximum that assigns independent variables exactly that value from the range of values that is the highest of the elements of the range of values
min function minimum that assigns independent variables exactly the value from the range of values that is the lowest of the elements of the range of values
3.2 In the calculation of CMalfa2011 and CMall2011, hospitalisation cases are converted by the rules for classification and compilation of hospitalisation cases applicable for 2011.
3.3 The reimbursement of medicinal products exempted from payment by a flat-rate payment, as set out in Annex 15 to this Order, shall be provided by the health insurance undertaking to the provider at the declared price of the medicinal product used during the reference period.
4. Reimbursement in the form of a flat rate payment
4.1. The remuneration to be paid in the form of a flat-rate payment shall include the services to be paid under the Classification in groups related to the diagnosis referred to in Annexes 11 and 12 to this Decree, which shall be paid in accordance with the list of performance.
4.2. For the services covered by the Classification in groups related to diagnosis and listed in Annex 11 to this Order, which are covered by the list of performance and which are excluded from the flat-rate payment, the provider declared and the health insurance undertaking recognised for the period of assessment, the value of the point of ICBref * 1,05 up to the limit (LIM Pugammadrg2013) calculated as follows:
LIM Pugammadrg2013 = [((Vgammadrg2011 x ICBref) + ZUMgammadrg2011 + ZULPgammadrg2011 + LPgammadrg2011 + KPgammadrg2011] x 1,05 x Kpp
where:
Vgammadrg2011 the total number by the provider declared and the health insurance undertaking of recognised points for the performance performed during hospitalisation for the reference period classified under the Classification in the groups listed in Annex 11 to this Decree. The numbers of points according to the first sentence shall be converted according to the performance list as effective on 1 January 2013.
ICBref calculated the individual price of the provider's point which is determined as the share of Uref / Bref
where:
Uref the total remuneration due to the provider for all the services paid in the reference period, including the increase of NÚ2011, the increase of NL2011, the change in the amount of extra-expensive care and the settlement of all the regulatory measures and the payments made, with the exception of the regulation on prescribed medicinal products and medical devices, reduced by the remuneration for the medicinal products specifically charged and the material specifically charged provided in the reference period, declared and by the health insurance company recognised in connection with patient care, by a lump sum to be paid for the medicinal products under § 17 (6) of the Act, and other services paid in Czech crowns (KPref).
where:
NÚ2011 Increase in remuneration determined in accordance with Annex 1, Part D, to Decree No 396 / 2010 Coll., on determining the values of the point, the amount of health care payments payable by public health insurance and the regulatory limits on the amount of health care provided by public health insurance for 2011
NL2011 An increase in the remuneration determined in accordance with Annex 1, Part E, to Decree No 396 / 2010 Coll., on the determination of the values of the point, the amount of the health care paid by public health insurance and the regulatory limitation of the amount of the health care provided by public health insurance for 2011, as amended by Decree No 46 / 2011 Coll.
Bref the total number of recognised points declared by the provider and the health insurance undertaking, converted according to the performance list as effective on 1 January 2013, for health services provided during the reference period.
ZUMgammadrg2011 Total amount of remuneration for the provider 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 which are classified under the Classification in the groups listed in Annex 11 to this Decree.
ZULPgammadrg2011 total amount of remuneration for the provider declared and recognised by the health insurance company for the medicinal products specifically charged during the reference period in respect of the performance performed during hospitalisation during the reference period classified under the Classification in the groups listed in Annex 11 to this Decree.
LPgammadrg2011 flat-rate amount to be paid for medicinal products pursuant to Article 17 (6) of the Act on the treatment dates declared and by a health insurance undertaking recognised as a reference period related to hospitalisation during the reference period classified under the Classification in the groups listed in Annex 11 to this Decree.
KPgammadrg2011 total amount of remuneration for other services paid in Czech crowns declared and by a health insurance company recognised for the reference period provided by the provider during hospitalisation during the reference period, which are classified under the Classification in the groups listed in Annex 11 to this Decree.
4.3. For the services covered by the Classification included in the groups related to the diagnosis and listed in Annex 11 to this Decree, which are covered by the list of performance and which are excluded from the flat-rate payment, the provider declared and the health insurance undertaking recognised for the period of assessment above the calculated limit (LIM Pugammadrg2013), the value of the point (ICBref * 1,07) * 0,5. The amount of remuneration for the material specifically charged, the medicinal products specifically charged, the flat-rate amount to be paid for the medicinal products pursuant to Article 17 (6) of the Act and for other services paid in Czech crowns shall be calculated above the limit set out in point 4.2 as follows:
(ZUMgammadrg2013 + ZULPgammadrg2013 + LPgammadrg2013 + KPgammadrg2013) x 0,5
where:
ZUMgammadrg2013 the total amount of remuneration for the provider reported and recognised by the health insurance undertaking for the separately charged material provided during the evaluation period in connection with the performance performed during hospitalisation during the evaluation period which are classified under the Classification in the groups listed in Annex 11 to this Decree.
ZULPgammadrg2013 total amount of remuneration for the provider declared and recognised by the health insurance company for the medicinal products specifically charged in connection with performance during the evaluation period during hospitalisation during the evaluation period which are classified under the Classification in the groups listed in Annex 11 to this Decree.
LPgammadrg2013 flat-rate amount to be paid for medicinal products pursuant to Article 17 (6) of the Act on the treatment dates declared and by a health insurance undertaking recognised for the period of assessment, relating to hospitalisation in the evaluation period which are classified under the Classification in the groups listed in Annex 11 to this Decree.
KPgammadrg2013 Total amount of remuneration for other services paid in the crowns declared by the Czech and health insurance company recognised for the period of assessment, provided by the provider during hospitalization during the period of evaluation which are classified according to Classification in the groups listed in Annex 11 to this Decree.
up to the total amount of the remuneration (MAX Pugammadrg2013) calculated as follows:
MAX Pugammadrg2013 = LIM Pugammadrg2013 x 1,05
4.4 For the services covered by the Classification in the groups related to the diagnosis and listed in Annex 12 to this Decree, which are covered by the list of performance and which are excluded from the flat-rate payment, the provider declared and the health insurance undertaking recognised for the period of assessment, the value of the point of ICBref * 1,07 up to the limit (LIM PUbetadrg2013) calculated as follows:
LIM PUbetadrg2013 = [(Vbeta-drg2011 x ICBref) + ZUMbeta-Drg2011 + ZULPbeta-Drg2011 + LPbeta-Drg2011 + KPbeta-Drg2011] x 1,07 x Kpp
where:
Vbeta-drg2011 the total number of recognised points declared by the provider and the health insurance company as performance during hospitalisation for the reference period which are classified under the Classification in the groups listed in Annex 12 to this Decree. The numbers of points according to the first sentence shall be converted according to the performance list as effective on 1 January 2013.
ZUMbetadrg2011 the total amount of remuneration for the provider declared and recognised by the health insurance undertaking for the specific material provided during the reference period in respect of the performance performed during hospitalisation during the reference period which are classified under the Classification in the groups listed in Annex 12 to this Decree.
ZULPbetadrg2011 Total amount of remuneration for the provider declared and recognised by the health insurance company for the medicinal products specifically charged during the reference period in connection with the performance performed during hospitalisation during the reference period classified under the Classification in the groups listed in Annex 12 to this Decree.
LPbetridrg2011 flat-rate amount to be paid for medicinal products pursuant to Article 17 (6) 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 12 to this Decree.
KPbetridrg2011 Total amount of remuneration for other services paid in the crowns declared and by the health insurance company recognised for the reference period, provided by the provider during hospitalization during the reference period, which are classified according to Classification in the groups listed in Annex 12 to this Decree.
4.5 For the services covered by the Classification in the groups related to diagnosis and listed in Annex 12 to this Decree, which are covered by the list of performance, the provider declared and the health insurance undertaking recognised for the period of assessment above the calculated limit (LIM PUbetadrg2013), the value of the point (ICBref * 1,07) * 0,5. The amount of the remuneration for the material specifically charged, the medicinal products specifically charged, the flat-rate amount to be paid for the medicinal products under Article 17 (6) of the Act and for other services paid in Czech crowns shall be calculated above the limit set out in point 4.4 as follows:
(ZUMbetadrg2013 + ZULPbeta Drg2013 + LP beta drg2013 + KPbeta Drg2013) x 0,5
where:
ZUMbetadrg2013 Total amount of remuneration for the provider reported and recognised by the health insurance company for the separately charged material provided during the evaluation period in connection with the performance carried out during hospitalisation during the evaluation period, classified under the Classification in the groups listed in Annex 12 to this Decree.
ZULPbetadrg2013 Total amount of remuneration for the provider declared and recognised by the health insurance company for the medicinal products specifically charged in connection with performance during the evaluation period during hospitalisation during the evaluation period, which are classified under the Classification in the groups listed in Annex 12 to this Decree.
LPbetridrg2013 flat-rate amount to be paid for medicinal products under Article 17 (6) of the Act on the treatment dates declared and by a health insurance undertaking recognised for the period of assessment, relating to hospitalisation during the evaluation period, which are classified under the Classification in the groups listed in Annex 12 to this Decree.
KPbetridrg2013 Total amount of remuneration for other services paid in the crowns declared by the Czech and health insurance company recognised for the period of assessment, provided by the provider during hospitalisation during the evaluation period, which are classified under the Classification in the groups listed in Annex 12 to this Decree.
up to the total amount of the remuneration (MAX PUbetadrg2013) calculated as follows:
MAX Pupatedrg2013 = LIM Pupatadrg2013 x 1,15
4.6 If the provider has treated 20 and less unique insured persons in the relevant MDC group as part of the covered services classified under the classification groups related to the diagnosis listed in Annex 12 to this Regulation during the reference or assessment period, the health insurance undertaking shall not include this remuneration in the calculation of the regulation under points 4.4 and 4.5. The MDC group consists of groups related to the diagnosis according to Clavfication4) whose first two characters from the five-digit code of the groups related to the diagnosis referred to in column IR- DRG are identical.
5. For paid services according to the list of performances, including paid services provided to foreign insured persons, the value of the point is set at CZK 0.90.
6. The amphibious component of the remuneration includes the reimbursement of specialised outpatient health care, paid services in the fields of expertise 603 and 604 according to the list of performance services, paid services provided by general practitioners and providers of practical medicine for children and adolescents, paid services provided by dental practitioners, paid services in the fields of expertise listed, medical transport services, medical emergency services and paid services provided by providers in the fields of expertise 902, 911, 914, 921 and 925 (hereinafter referred to as "outpatient care '), with the exception of those provided by income and discharge examinations.
6.1. 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.
6.2. For the services provided by experts 603 and 604, according to the performance list, paid according to the performance list, the value of the item and the amount of payment of the services paid shall be as set out in Annex 4 to this Decree.
6.3. For paid services provided by providers of general medical practice and by providers of practical medicine for children and adolescents, 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 point and the amount of payment of the services paid shall be as set out in Annex 2 to this Decree.
6.4. The fixed services provided by dental care providers are paid in accordance with Section 8 of this Decree.
6.5. For the services provided by the listed experts, covered by the performance list, the value of the item and the amount of the payments of the services paid shall be as set out in Annex 5 to this Decree.
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Regulation Information
| Citation | Decree No. 475 / 2012 Coll., on the setting of the values of the points, the amount of payments of the services paid and the regulatory restrictions for 2013 |
|---|---|
| Regulation Type | Order |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 31.12.2012 |
|---|---|
| Effective from | 01.01.2013 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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