Decree No. 550 / 2005 Coll.
Order setting the amount of public health insurance payments, including regulatory restrictions, for the first half of 2006
Valid
Order
Effective from 01.01.2006
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550
DECLARATION
of 21 December 2005
determining the amount of public health insurance health care payments, including regulatory restrictions, for the first half of 2006
According to § 17 (11) (b) of Act No. 48 / 1997 Coll., on Public Health Insurance, and amending and supplementing certain related laws, as amended by Act No. 459 / 2000 Coll., hereinafter referred to as "the Act":
This Decree provides for cases where the outcome of the conciliation procedure under Paragraph 17 (8) of the Act is not an agreement or where the agreement is contrary to the public interest,
(a) the amount of health care payments covered by public health insurance including regulatory restrictions
1. provided in health care institutions, including professional medical institutions, treatment of long-term sick and medical establishments reporting treatment day No 00005 under the Decree issuing a list of health performance with point values (1) (hereinafter referred to as "the list of performance"),
2. in outpatient medical institutions providing haemodialysis care,
3. provided by practitioners for adults and practitioners for children and adolescents,
4. in outpatient medical institutions providing specialised outpatient health care,
5. in 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;
6. home health care provided by outpatient medical institutions,
7. in outpatient health care establishments providing medical care in expertise 902 and 918 according to the performance list;
8. provided in the framework of medical emergency services, transport and medical first aid services
(b) the amount of compensation for the provision of emergency medical care in non-contractual medical establishments.
(1) Health care provided in health care institutions of the Czech Republic, with the exception of health care provided in professional medical institutions, long-term sick hospitals and in healthcare institutions reporting on the treatment day No 00005 in accordance with the list of performance establishments (hereinafter referred to as the "institutional care facilities"), is paid at a flat rate.
(2) If the institution provides health care to 100 and less insured persons of the relevant health insurance undertaking, paragraph 1 shall not apply and the healthcare provided shall be paid according to the performance list. The price of the point for the first half of 2001 remains valid for the first half of 20062).
(3) The procedure for calculating the flat rate referred to in paragraph 1 and the regulatory limit is set out in Annex 1 to this Decree.
(4) The health insurance company will provide the health care establishment with a monthly remuneration of the amount set out in Annex 1 to this Decree.
(1) The amount of the payment of health care in professional medical institutions, long-term sick hospitals and in medical institutions reporting on treatment day No 00005 according to the list of performances is fixed at a flat rate for the first half of 2006.
(2) The procedure for calculating the flat rate referred to in paragraph 1 and the regulatory restriction is set out in Annex 2 to this Decree.
(3) The health insurance company will provide a monthly payment to the healthcare establishment of 105% of one sixth of the remuneration due to the healthcare establishment during the reference period.
(4) Where a healthcare institution provides healthcare to 50 and less hospitalised insured persons of the relevant health insurance undertaking, paragraph 1 shall not apply and the healthcare provided shall be reimbursed according to the performance list.
(5) The price of the point for reimbursement of health care referred to in paragraph 4, set for the first half of 2001, remains valid for the first half of 20062).
(1) Hemodialysis care provided in outpatient medical institutions is paid under a contractual arrangement between the health insurance company and the healthcare establishment according to the performance list by remuneration for the medical performance provided, including the material specifically charged and the medicinal products specifically charged.
(2) The price of the point of payment of health care referred to in paragraph 1 agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(3) If there is an increase in the number of insured persons requiring urgent dialysis treatment in a healthcare institution compared to the reference period corresponding to the calendar half of last year, the health insurance undertaking shall be entitled, after consultation with the health care institution, to take into account the increase in the number of insured persons in the remuneration.
(4) The health insurance company will provide a monthly payment to the healthcare establishment
(a) at the level of the value declared by health care establishments or, where appropriate, by a recognised health insurance undertaking, health care for the month concerned; or
(b) at least one sixth of the total amount of remuneration in the reference period;
the method of payment referred to in (a) or (b) shall be maintained throughout the half-year.
(5) The total remuneration referred to in paragraph 1, which shall not exceed 105% of the total remuneration in the reference period corresponding to the calendar half of last year, shall be increased by a coefficient of change in the income and expenditure of the health insurance undertaking relating to the migration of the insured persons. The calculation and application of the adjustment coefficient for the health insurance undertaking's income and expenditure is set out in Annex 7 to this decree. The reimbursement limitation shall not apply where the health care establishment has provided healthcare to 50 and less unique insured persons of the relevant health insurance undertaking during the reference or assessment period.
(6) The regulatory restrictions are set out in Annex 3 to this Decree.
(7) In addition to the total remuneration referred to in paragraph 5, the health insurance undertaking shall pay the amount of medicinal products specifically charged by the health insurance undertaking to the healthcare establishment in the second half of 2005, converted into a unique treated insured person and a diagnosis in the second half of 2005 and multiplied by the number of individuals treated by the health insurance company with the appropriate diagnosis in the evaluation period.
(1) Health care provided by general practitioners for adults and general practitioners for children and young people is paid in the first half of 2006 under the contractual agreement between the health insurance company and the health care establishment
(a) a combined capitalisation charge;
(b) a combined capitalisation charge with a cap; or
(c) according to the performance list.
(2) The amount of the capitalisation charge referred to in paragraph 1 (a) shall be calculated on the basis of the number of registered insured persons with the relevant age index referred to in Annex 4 (C) to this decree multiplied by the standard rate agreed with the medical establishment for the second half of 2005 by 3%.
(3) Proceedings not included in the capitalisation payment, except those showing preventive examinations according to Decree No. 56 / 1997 Coll., establishing the content and time range of preventive examinations, as amended, (hereinafter referred to as the "Preventive search order ') and vaccination according to Decree No. 439 / 2000 Coll., on vaccination against communicable diseases, as amended, (hereinafter referred to as the" Vaccination Order') and on the performance of unregistered insured persons as referred to in paragraphs 1 (a) and (b) shall be paid according to the list of benefits, the price agreed for the 2nd semester 2005 and published in the Ministry of Health Bulletin shall remain valid for the first half of 20063).
(4) The performance of preventive inspections under the Preventive Inspection and Vaccination Ordinance, not included in the surrender payment referred to in points (a) and (b) of paragraph 1, shall be paid in accordance with the performance list by remuneration for the medical performance provided, subject to the limitation of the maximum payment on the individual insured. The price of the item agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063). The maximum remuneration for a unique treated insured person for a particular health care establishment shall be determined as a proportion of the total remuneration for such performance during the reference period corresponding to the half of the last year and the number of unique treated insured persons for whom such performance has been declared. The calculated proportion shall be multiplied by the number of individual insured persons and a coefficient of 1,05. The maximum remuneration limitation shall not apply where 50 and less unique treated insured persons of the relevant health insurance undertaking have been treated during the reference or assessment period.
(5) The amount of the capitalisation charge with a top-up of the capitalisation referred to in paragraph 1 (b), including the remuneration for the performance paid outside the capitalisation payment and the performance for unregistered insured persons, shall be calculated in accordance with paragraphs 2 to 4.
(6) The price of the point for reimbursement of health care referred to in paragraph 1 (c) agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(7) The method of matching the capitalisation referred to in paragraph 1 (b) and the regulatory limitation on remuneration referred to in paragraph 1 (a), (b) and (c) are laid down in Annex 4 to this Decree.
(8) The total remuneration for the performance not included in the capitalisation payment, other than those shown in the Preventive Surveys Ordinance on Preventive Surveys and Vaccines under the Vaccination Order, the performance for unregistered insured persons referred to in paragraph 3, which shall not exceed 105% of the total remuneration for performance other than the capitalisation payment and performance for non-registered insured persons during the reference period corresponding to the calendar half of last year, shall be increased by a coefficient of change in the income and expenditure of the health insurance undertaking in connection with the migration of insured persons. The calculation and application of the adjustment coefficient for the health insurance undertaking's income and expenditure is set out in Annex 7 to this decree. Reimbursement restrictions shall not apply if, during the reference period or evaluation period, the healthcare establishment provides healthcare to 50 or less insured persons of the relevant health insurance undertaking.
(1) Specialised outpatient health care provided in outpatient medical institutions is paid under the contractual arrangement between the health insurance company and the healthcare establishment in accordance with the performance list by remuneration for the medical performance provided, including specifically charged medicinal products and specifically charged medical devices, subject to the limitation of maximum remuneration for the unique insured person of the relevant health insurance undertaking treated in the half-yearly assessment of the medical establishment in question.
(2) For the purposes of this decree, a unique insured person shall mean one insured person of the relevant health insurance undertaking treated by the medical institution in question at least once during the relevant half-year, and shall not be determined whether the treatment is self-care or requested. If the insured person has been treated more than once in the relevant half-year by the institution in question, he shall be included only once in the number of individual insured persons treated in that professional.
(3) The reference period is the corresponding calendar half of last year.
(4) The price of the point of payment of health care referred to in paragraph 1 and in paragraph 7 agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(5) The amount of the remuneration referred to in paragraph 1, including the regulatory restrictions, is set out in Annex 5 to this Decree.
(6) The health insurance company will provide a monthly payment to the healthcare establishment
(a) at the level of the value declared by health care establishments or, where appropriate, by a recognised health insurance undertaking, health care for the month concerned; or
(b) at least one sixth of 100% of the amount of remuneration in the reference period;
the method of monthly remuneration referred to in (a) or (b) shall be maintained throughout the half-year.
(7) Where a healthcare establishment provides healthcare to 50 and less unique insured persons of the relevant health insurance undertaking, paragraph 1 shall not apply and the healthcare provided shall be reimbursed according to the performance list.
(1) Health care provided by outpatient medical institutions in the field of expertise 222, 801, 802, 804, 805, 807, 809, 812 to 819, 822 and 823 according to the performance list shall be paid under the contractual arrangement between the health insurance undertaking and the healthcare establishment:
(a) a flat rate; or
(b) according to the list of performances.
(2) For health care establishments where, due to the significantly fluctuating volume of healthcare provided by public health insurance, the healthcare establishment has provided a flat rate in accordance with paragraph 1 (a) for the reference period corresponding to the calendar quarter of last year, 50 and less unique insured persons of the relevant health insurance undertaking, and where it is not possible to objectively establish a flat rate for each health insurance undertaking in accordance with paragraph 1 (a), the healthcare provided is reimbursed according to the performance list. The price of the expert point 222, 801, 802, 804, 805, 807, 809, 812 to 819, 822 and 823 agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(3) The price of the point of payment of health care referred to in paragraph 1 (b) agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(4) The procedure for establishing the flat rate referred to in paragraph 1 (a), the amount of the remuneration referred to in paragraph 1 (a) and (b) and the regulatory limit are set out in Annex 6 to this Decree.
(1) Domestic health care provided by outpatient health care establishments (hereinafter referred to as "home care") shall be paid under the contractual arrangement between the health insurance undertaking and the healthcare establishment under the performance list by remuneration for the medical performance provided, including specifically charged medicinal products and specifically charged medical devices, according to the type of operation of the healthcare establishment:
(a) within the limit of the time limit of the carrier's 8 hours per calendar day, provided that the health care is provided 7 days per week; or
(b) up to the time limit of the carrier's 8 hours per working day, unless healthcare is provided 7 days per week.
(2) The price of the point of payment of health care referred to in paragraph 1 agreed for the 2nd half of 2003 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(3) The total remuneration referred to in paragraph 1, which shall not exceed 105% of the total remuneration during the reference period corresponding to the calendar half of last year, shall be increased by a coefficient of change in the income and expenditure of the health insurance undertaking relating to the migration of the insured persons. The calculation and application of the adjustment coefficient for the health insurance undertaking's income and expenditure is set out in Annex 7 to this decree. The reimbursement limitation shall not apply where the health care establishment has provided healthcare to 50 and less unique insured persons of the relevant health insurance undertaking during the reference or assessment period.
(1) Health care provided by outpatient health care establishments in expertise 902 and 918 according to the performance list shall be paid in accordance with the contractual agreement between the health insurance undertaking and the healthcare establishment in accordance with the performance list by remuneration for the medical performance provided.
(2) The price of the point of payment of health care referred to in paragraph 1 agreed for the 2nd half of 2003 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(3) Health insurance companies may provide for a monthly remuneration for the relevant quarter of the reference period, which is the separate corresponding calendar quarter of the last year.
(4) The total remuneration referred to in paragraph 1, which shall not exceed 105% of the total remuneration during the reference period, shall be increased by a coefficient of change in the income and expenditure of the health insurance undertaking relating to the migration of insured persons. The calculation and application of the adjustment coefficient for the health insurance undertaking's income and expenditure is set out in Annex 7 to this decree. The reimbursement limitation shall not apply where the health care establishment has provided healthcare to 50 and less unique insured persons of the relevant health insurance undertaking during the reference or assessment period.
(1) Health care provided under the medical emergency services in the expert 709 according to the performance list shall be paid in accordance with the contractual agreement between the health insurance company and the healthcare establishment according to the performance list by payment for the medical performance provided.
(2) The price of the point of payment of health care referred to in paragraph 1 agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(1) Health care provided in the framework of transport shall be paid in accordance with the contractual agreement between the health insurance undertaking and the health care establishment on the basis of the performance list by remuneration for the medical performance provided.
(2) The price of the point of payment of health care referred to in paragraph 1 agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(3) The total remuneration referred to in paragraph 1, which shall not exceed 105% of the total remuneration during the reference period corresponding to the calendar half of last year, shall be increased by a coefficient of change in the income and expenditure of the health insurance undertaking relating to the migration of the insured persons. The calculation and application of the adjustment coefficient for the health insurance undertaking's income and expenditure is set out in Annex 7 to this decree. The reimbursement limitation shall not apply where the health care establishment has provided healthcare to 50 and less unique insured persons of the relevant health insurance undertaking during the reference or assessment period.
(1) Health care provided under the first-aid medical service shall be paid in accordance with the contractual agreement between the health insurance undertaking and the healthcare establishment on the basis of the performance list by remuneration for the medical performance provided.
(2) The price of the point of payment of health care referred to in paragraph 1 agreed for the 2nd half of 2005 and published in the Ministry of Health Bulletin remains valid for the 1st half of 20063).
(1) Reimbursement of urgent health care, unless a contract is concluded between a healthcare establishment and a health insurance company, is made for the health performance provided as follows:
(a) dental outpatient care shall be paid at the rates applicable to dental care in the first half of 2006;
(b) other healthcare is paid according to the performance list and the health insurance company may apply regulatory restrictions on the basis of the Act (4) similar to those for contractual health establishments.
(2) The price of the point for reimbursement of health care referred to in paragraph 1 (b), established for the first half of 2001, remains valid for the first half of 20062).
This Decree shall take effect on 1 January 2006.
Minister:
MUDr. Rath v. r.
Příloha č. 1
Annex No 1 to Decree No 550 / 2005 Coll.
Procedure for calculating the flat rate and the regulatory restriction referred to in Article 2 (3)
(A) Procedure for calculating the flat rate
The flat rate shall be determined using the formula:
PS = (Cúref × 1,05 × Ks × Kpv) + ÚZÚLMref + MNP + PCN
where:
PS flat rate for the relevant calendar semester
CÚref - total remuneration due to the constitutional care facilities for health care provided, reported and recognised by the health insurance undertaking in the reference period corresponding to the calendar half of last year, after settlement of contractually agreed regulations, with the exception of the regulatory mechanism for the volume of prescribed medicinal products and medical devices, after deduction by the recognised and health insurance company recognised as specifically charged medicinal products, including the specifically charged medicinal products, approved by the revision doctor, and the separately charged material provided in the reference period [Part B], points 1 and 6.] This remuneration shall include the care provided to healthcare establishments during the reference period, not later than with the accounts for November 2005 and recognised by the health insurance company.
The total remuneration in the reference period shall include:
- the remuneration for health performance paid in performance during the reference period, with the exception of mammographic screening,
- remuneration for new capacities, where they have been agreed for the reference period.
The total remuneration in the reference period shall not include:
- reimbursement of medical care which is otherwise paid or no longer provided by the healthcare establishment,
- the impact of the financial settlement of the regulatory mechanism on the volume of prescribed medicinal products and medical devices applied during the reference period.
ÚZÚLMref the volume reported and the health insurance company recognised by the specifically charged medicinal products, including the specifically charged medicinal products approved by the revision doctor, and the material specifically charged, provided during the reference period (see Part B) 1 and 6.)
Ks stabilisation coefficient
Ks = 1 + [(ZF - ZM) / VD] × 0,3
ZM = (VD / 180) * 10
where:
ZF information referred to in row B.IV of the statement Basic Health Insurance Fund according to Decree No. 274 / 2005 Coll., on how to provide information on the management of health insurance companies and their extent, as at 31.12.2005
VD the entry in line A.III.1 of the statement Basic Health Insurance Fund according to Decree No. 274 / 2005 Coll., on how to provide information on the economy of health insurance companies and their scope, as at 30.6.2005
ZM financial reserve of the relevant health insurance undertaking
The stabilisation coefficient (Ks) shall be applied only if the ZF > ZM is applied.
The rate of change in income and expenditure of the health insurance company in connection with the migration of insured persons. The calculation and application of the coefficient are set out in Annex 7 to this Decree.
MNP increase in the volume reported and recognised by the health insurance company in 2006 compared to the reference period. Exceptionally expensive health care is for the purposes of this decree health care provided by health care facilities to insured persons whose volume exceeds CZK 1 000 000. The amount of health care shall include separately charged medicinal products, separately charged material and the point value of the health performance according to the performance list multiplied by the price point set for the first half of 2001.2)
PCN share attributable to a particular medical institution for the medicinal products specifically charged and the material specifically charged to the medical establishment by the health insurance company in the 2nd half of 2005, converted into a unique treated insured person and a diagnosis in the 2nd half of 2005 and multiplied by the number of unique treated insured persons with appropriate diagnosis in the evaluation period
The monthly remuneration shall be determined in accordance with the formula:
MU = [(Cúref × 1,05 x Ks) + ÚZÚLMref] / 6
where:
My monthly payment
The amount of the monthly remuneration shall be communicated by the health insurance company to the healthcare establishment by 30 April 2006. The bill of monthly payments for the first half of 2006 shall be forwarded by the health insurance company to the healthcare establishment by 30.11.2006.
(B) Regulatory restrictions
(1) Reimbursement of the amount set out in Part A shall belong to the healthcare establishment if it provides at least 100% of the amount of medical care reported in the first half of 2006 by the healthcare establishment and recognised by the health insurance undertaking as compared to the reference period, expressed in terms of the number of points on the performance list. Other documents, such as the consumption of medicinal products specifically charged or the material specifically charged, shall not be reported to health insurance undertakings and shall not be the basis for billing.
2. The number of points for the reference period shall not include points for health care no longer provided in the first half of 2006.
3. The number of points for the first half of 2006 shall not include points for health care declared and recognised under the new capacity, provided that it has been contracted for the first half of 2006.
4. In the case of less reported and recognised health care than referred to in point 1, the amount of the part A remuneration shall be reduced by the same percentage as the lower level of healthcare expressed in terms of the number of points in the performance list.
5. The new capacities contracted in the first half of 2006 shall be paid by flat-rate payment up to a maximum of 30% of the country-wide average half-yearly payment to installations of the same type in the reference period. The health insurance undertaking shall provide the health care establishment with one sixth of the amount calculated in accordance with the first sentence per month.
6. If the total remuneration for medicinal products and medical devices prescribed by the medical institution in the first half of 2006, including medicinal products authorised by the medical practitioner, exceeds 100% of the remuneration for medicinal products and medical devices prescribed in the reference period, including medicinal products authorised by the medical practitioner, the health insurance undertaking shall not, within the framework of the overall remuneration of the medical institution, pay an amount corresponding to the excess of the reimbursement for medicinal products and medical devices prescribed in the reference period above 100%. The total amount of remuneration for medicinal products and medical devices prescribed in the reference period shall be increased by an amount corresponding to the prescribed and medical insurance company to the health care institution in addition to the amount of medical treatment provided to the medicinal products in the reference period, which in this case is the 2nd half of 2005, converted into a unique treated insured person and a diagnosis in the 2nd half of 2005, multiplied by the number of unique treated insured persons with the appropriate diagnosis in the evaluation period.
7. If the total number of points for requested care in another medical institution, in the experts 222, 801, 802, 804, 805, 807, 812 to 819, 822 and 823 according to the performance list, exceeds 106% of the total number of points in the reference period in the first half of 2006, the health insurance company shall not pay an amount corresponding to the excess in the overall remuneration of the medical establishment.
8. If the total number of points for requested care in another medical institution, in the expert level 809 according to the performance list, other than those of screening mammography according to the performance list, exceeds 110% of the total number of points in the reference period in the first half of 2006, the health insurance undertaking shall not pay an amount corresponding to excess within the overall remuneration of the medical establishment.
9. If, in the first half of 2006, health care is provided to 100 and less insured persons by the relevant health insurance undertaking, the health insurance company shall not apply the regulation referred to in the preceding paragraphs.
10. If the health care institution proves that due to the health condition of the insured person could not prescribe another medical device above 15 000 CZK approved by the medical examiner, the health insurance company will not apply the appropriate regulation unless a comparable medical device has been prescribed to a comparable extent in the reference period.
Příloha č. 2
Annex No 2 to Decree No 550 / 2005 Coll.
Procedure for calculating the flat rate and the regulatory restrictions referred to in Article 3 (2)
(A) Procedure for calculating the flat rate
The flat rate shall be fixed at 105% of the total remuneration due to health care establishments in the first half of 2005 for the health care provided, reported and recognised by the health insurance undertaking in the reference period corresponding to the calendar half of last year, after settlement of contractually agreed regulations, with the exception of the regulatory mechanism for the volume of prescribed medicinal products and medical devices, multiplied by the adjustment coefficient for the income and expenditure of the health insurance undertaking in connection with the migration of insured persons. The calculation and application of the adjustment coefficient for the health insurance undertaking's income and expenditure is set out in Annex 7 to this decree. The total remuneration shall include the care provided to the healthcare establishment during the reference period, not later than with the accounts for November 2005 and recognised by the health insurance company.
(B) Regulatory restrictions
(1) Reimbursement of the amount set out in Part A shall belong to a healthcare establishment, provided that it provides at least 100% of the amount of healthcare in the first half of 2006, declared by the healthcare establishment and recognised by the health insurance undertaking compared to the reference period, expressed as 100% of the number of points per treatment day according to the performance list.
2. The number of points for the reference period shall not include points for health care no longer provided in the first half of 2006.
3. The number of points for the first half of 2006 shall not include points for health care declared and recognised under the new capacity, provided that it has been contracted for the first half of 2006.
4. In the case of less reported and recognised health care than referred to in point 1, the amount of the part A remuneration shall be reduced by the same percentage as the lower amount of healthcare expressed in terms of the number of points in the performance list.
5. If the total remuneration for medicinal products and medical devices prescribed by the medical institution in the first half of 2006, including medicinal products authorised by the medical practitioner, exceeds 100% of the total remuneration for medicinal products and medical devices prescribed in the reference period, including medicinal products authorised by the medical practitioner, the health insurance undertaking shall not pay the sum corresponding to the excess of the reimbursement for medicinal products and medical devices prescribed in the reference period above 100%.
6. If the total number of points for requested care in another medical institution, in the experts 222, 801, 802, 804, 805, 807, 812 to 819, 822 and 823, according to the list of performance, exceeds 106% of the total number of points in the reference period in the first half of 2006, the health insurance company shall not pay the amount corresponding to the excess in the overall remuneration of the medical establishment.
7. If the total number of points for requested care in another medical institution, in the expert 809 according to the performance list, exceeds 110% of the total number of points in the reference period in the first half of 2006, the health insurance undertaking shall not pay an amount corresponding to the excess in the overall remuneration of the medical establishment.
8. The limitation provided for in the preceding points shall not apply where, during the reference period or evaluation period, a health care facility has provided 50 and less hospitalised insurers with the relevant health insurance undertaking.
9. If the health care institution proves that due to the health condition of the insured person could not prescribe another medical device above 15 000 CZK approved by the medical examiner, the health insurance company will not apply the appropriate regulation unless a comparable medical device has been prescribed to a comparable extent in the reference period.
Příloha č. 3
Annex No 3 to Decree No 550 / 2005 Coll.
Regulatory restrictions pursuant to Article 4 (6)
1. If the average remuneration for medicinal products and medical devices prescribed for one unique insured person in the first half of 2006, including medicinal products authorised by the medical practitioner, exceeds the average remuneration for medicinal products and medical devices prescribed in the reference period, including medicinal products authorised by the medical practitioner, within a range of 101% to 105%, the health insurance company shall not pay the sum corresponding to 20% of the excess of the reimbursement for medicinal products and medical devices prescribed in the reference period between 101% and 105% within the overall remuneration of the medical institution.
2. If the average remuneration for medicinal products and medical devices prescribed for one unique insured person in the first half of 2006, including medicinal products authorised by a medical practitioner, exceeds the average remuneration for medicinal products and medical devices prescribed in the reference period, including medicinal products authorised by a medical practitioner, within a range of 105% to 110%, the health insurance undertaking shall not pay an amount equivalent to 40% of the excess of the reimbursement for medicinal products and medical devices prescribed in the reference period of 105% to 110% within the overall remuneration of a medical institution.
3. If the average remuneration for medicinal products and medical devices prescribed for one individual insured person in the first half of 2006, including medicinal products authorised by a medical practitioner, exceeds 110% of the average remuneration for medicinal products and medical devices prescribed for the reference period, including medicinal products authorised by a medical practitioner, the health insurance undertaking shall not, in the context of the overall remuneration for a medical institution, pay an amount corresponding to the excess of the remuneration for medicinal products and medical devices prescribed for the reference period above 110%.
4. If the average number of points for required care in the experts 222, 801, 802, 804, 805, 807, 812 to 819, 822 and 823 according to the performance list, per individual insured person in the first half of 2006, exceeds 106% of the average number of points in the reference period, the health insurance company shall not pay an amount corresponding to the excess within the overall remuneration of the medical institution.
5. If the average number of points for the required care in a professional capacity 809 according to the performance list per individual insured person in the first half of 2006 exceeds 110% of the average number of points in the reference period, the health insurance undertaking shall not pay an amount corresponding to the excess in the overall remuneration of the health care establishment.
6. The limitation provided for in points 1 to 5 shall not apply where the health care establishment has provided healthcare to 50 and less unique insured persons of the relevant health insurance undertaking during the reference or assessment period.
Příloha č. 4
Annex No 4 to Decree No 550 / 2005 Coll.
The method of matching the capitalisation and the regulatory limitation referred to in Article 5 (7) and the age index table referred to in Article 5 (2)
A) Method of matching the capitalisation:
1. The comparison of the cap shall be provided where the adult or adult 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 Office of the Czech Republic) and the provision of such health care is necessary to fulfil the obligations of the health insurance company under Section 46 (1) of the Act.
2. For the purposes of this Decree, one registered insured person shall mean an insured person aged between 15 and 19 who is considered to be a unit in terms of health care consumption. The number of one registered insured persons shall be calculated by multiplying the number of registered insured persons by the age index of the group. The age index expresses the ratio of the cost of the insured person in the age group to the cost of the insured person in the age group 15 to 19 years.
3. A cap of up to 90% of the surrender payment calculated on the national average number of registered insured persons may be granted. In addition, health insurance companies with which the competent practitioner has a contract of provision and reimbursement of health care are involved in a proportion corresponding to the percentage of their insured persons from one registered insured person of that practitioner.
(B) Regulatory restrictions
1. Where the average remuneration for medicinal products and medical devices prescribed by medical devices in the 1st and 2nd quarter of 2006, including medicinal products authorised by a medical practitioner, per registered insured person, taking into account age groups, exceeds the average remuneration for medicinal products and medical devices per registered insured person, taking into account age groups prescribed in the reference period, including medicinal products authorised by a medical practitioner, between 101% and 105%, the health insurance undertaking shall not pay the total remuneration for medical devices equivalent to 20% of the excess payment for medicinal products and medical devices prescribed in the reference period between 101% and 105%.
2. Where the average remuneration for medicinal products and medical devices prescribed by medical devices in the 1st or 2nd quarter of 2006, including medicinal products authorised by a medical practitioner, per registered insured person, taking into account age groups, exceeds the average remuneration for medicinal products and medical devices per registered insured person, taking into account age groups prescribed in the reference period, including medicinal products authorised by a medical practitioner, within a range of 105% to 110%, the health insurance undertaking shall not pay an amount corresponding to 40% of the compensation for medicinal products and medical devices prescribed in the reference period between 105% and 110% in the reference period.
3. Where the average remuneration for medicinal products and medical devices prescribed by medical devices in the 1st or 2nd quarter of 2006, including medicinal products authorised by a medical practitioner, per registered insured person, taking into account age groups, exceeds 110% of the average remuneration for medicinal products and medical devices per registered insured person, taking into account the age groups prescribed in the reference period, including medicinal products authorised by a medical practitioner, the health insurance undertaking shall not pay the amount corresponding to the excess payment for medicinal products and medical devices prescribed in the reference period above 110%.
4. The reference period for regulatory purposes shall be the corresponding calendar quarter of last year.
5. If the total remuneration for treated non-registered insured persons exceeds 5% of the total remuneration for registered insured persons in the first and second quarters of 2006, the health insurance company shall be entitled not to pay the sum corresponding to one half of the excess of the total payment for registered insured persons in the framework of the total remuneration. This regulatory mechanism shall not apply to the care of unregistered insured persons in the ordinary capacity and shall not be applied in the case of reimbursement of health care under Section 5 (1) (c).
6. If the average number of points in the 1st or 2nd quarter of 2006 for the required care in the experts 222, 801, 802, 804, 805, 807, 812 to 819, 822 and 823 according to the performance list, per registered insured person, taking into account age groups, exceeds 106% of the average number of points in the reference period, the health insurance undertaking shall not pay an amount corresponding to the excess for the overall remuneration of the medical institution.
7. If the average number of points in the 1st or 2nd quarter of 2006 for the required care in the skill list 809 according to the performance list, except the performance of the screening mammography according to the performance list, per registered insured person, taking into account age groups, exceeds 110% of the average number of points in the reference period, the health insurance company shall not pay an amount corresponding to the excess in the overall remuneration of the medical establishment.
8. If the average remuneration for the healthcare provided per treated unregistered insured person, taking into account age groups, exceeds by more than 10% the average remuneration for the reference period and by more than 20% the specific part of the health care provided (i.e. either the medical performance payment, or the prescribed medicinal products and medical devices, or the requested care, including the medicinal products specifically charged and the material specifically charged, in the experts 222, 801, 802, 804, 805, 807, 809, 812 to 819, 822 and 823 according to the performance list), the health insurance undertaking shall be entitled not to pay an amount corresponding to one quarter of the above.
9. The regulatory restrictions referred to in the preceding points shall not apply where, in a reference period or an assessment period, 50 or less insured persons have registered the relevant health insurance undertaking or provided health care to 50 or less unregistered insured persons of the relevant health insurance undertaking.
10. If the health care institution proves that due to the health condition of the insured person could not use another treatment or prescribe another medical device above CZK 15,000 approved by the medical examiner, the health insurance company will not apply the appropriate regulation unless comparable medicinal products or medical devices have been prescribed by medical devices to a comparable extent in the reference period.
C) Table of age indices
| věková skupina | Index |
|---|---|
| 0 - 4 let | 3,80 |
| 5 - 9 let | 1,65 |
| 10- 14 let | 1,30 |
| 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 |
Příloha č. 5
Annex No. 5 to Decree No. 550 / 2005 Coll.
Amount of remuneration and regulatory limitation pursuant to Article 6 (5)
(A) Amount of remuneration
1. The maximum remuneration for health care institutions shall be determined after the end of the half-year assessed as the sum of the maximum remuneration for the health care institution for all the expertise contracted by that health care institution with the relevant health insurance undertaking.
(2) The maximum remuneration for expertise shall be determined as follows:
MUO = POPzpo × [(PBPo × CB) × 1,05 + PUZUMo + PUZULPo]
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Regulation Information
| Citation | Decree No. 550 / 2005 Coll., determining the amount of health care payments paid from public health insurance, including regulatory restrictions, for the first half of 2006 |
|---|---|
| Regulation Type | Order |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 30.12.2005 |
|---|---|
| Effective from | 01.01.2006 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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