Full text of Act No. 79 / 1995 Coll.
General Health Insurance Act (full text as resulting from subsequent amendments and additions)
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79
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Announces the full text of the Act of the Czech National Council No. 550 / 1991 Coll., on General Health Insurance, with amendments and supplements implemented by the Act of the Czech National Council No. 592 / 1992 Coll., by the Act of the Czech National Council No. 10 / 1993 Coll., by the Act of the Czech National Council No. 15 / 1993 Coll., by the Act No. 161 / 1993 Coll., by the Act No. 324 / 1993 Coll., by the Act No. 241 / 1994 Coll. and by the Act No. 59 / 1995 Coll.
THE LAW
on general health insurance
The Czech National Council decided on this law:
BASIC PROVISIONS
Purpose of the law
This Act regulates general health insurance ("health insurance ') and the conditions under which health care is provided under this Act. Health care under this Act is provided as care fully or partially covered by health insurance.
Full or partial care covered by health insurance
(1) All or part of the care covered by health insurance includes:
(a) diagnostic care, outpatient and institutional care, including rehabilitation and chronic care;
(b) prevention under generally binding legislation;
(c) the provision of medicines and medical devices under the conditions laid down in this Act;
(d) the transport of sick persons and the reimbursement of travel costs to the nearest contractual health establishment authorised to provide health care, if necessary required by their health status; local transport costs are not reimbursed,
(e) spa care and special medical care provided as recommended by the doctor as an essential part of the treatment process.
(2) The distinction between health care referred to in paragraph 1 and care paid in full or in part shall be made taking into account the nature of the disability and the amount of financial resources to cover such care. If insured persons under the age of 18 are provided with health care marked as partially paid for in the Health Code, the health insurance company shall pay it in full. The full-paid, partially-paid and other details of care provided under this law are laid down in the Health Code. The health rules are binding on all health insurance companies that carry out health insurance.
(3) The Health Regulations will be issued by the Government of the Czech Republic, following a conciliation procedure with representatives of the Ministry of Finance, General Health Insurance (hereinafter referred to as "Insurance"), other health insurance companies, contractual health institutions, professional organisations established by law (1) and professional scientific societies. The conciliation procedure shall be convened by the Ministry of Health (hereinafter referred to as "the Ministry ') at least once a year.
(4) The care fully or partially covered by health insurance shall not include examinations, examinations and other performances carried out in the personal interest of natural persons or in the interest of legal persons who do not pursue a therapeutic purpose. 16) Health care fully or partly covered by health insurance also does not include examinations, examinations and other medical performances carried out at the request of the court, prosecutors, state administration and authorities of the Czech Police. The payment of the health performance referred to in the previous sentence shall be provided to the healthcare establishment by the body for which the health performance is performed, at the level specified by the list of points (§ 13 (3)) and the price statements in force.
(5) Social care, provision in children's homes, nursing homes and nurseries are governed by specific regulations. (2)
Personal extent of health insurance
(1) Under this law they are insured by:
(a) persons resident in the Czech Republic;
(b) persons who do not reside on the territory of the Czech Republic if they are employees (§ 6a) of an employer who is established in the territory of the Czech Republic.
(2) For the purposes of this Act, the registered office of the employer shall be the registered office of the legal person as well as the registered office of the legal entity which is registered in the Commercial Register or, where applicable, in another legally designated register, or shall be kept in a registered register with the competent authority in the Czech Republic, and the place of permanent residence of the natural person or, where applicable, of the foreign natural person, the place of his business.
(3) Health insurance under this Act excludes persons who are not resident in the Czech Republic and who are active in the Czech Republic for employers who enjoy diplomatic benefits and immunities, or for employers in an employment relationship concluded under foreign law or for employers who do not have their registered office in the Czech Republic, and persons who have long-term residence abroad who do not pay insurance (§ 7 (4)).
Reimbursement of treatment abroad
The insurance companies referred to in Article 3 (1) shall be reimbursed for the costs of necessary and urgent treatment abroad, up to the costs associated with such treatment in the Czech Republic.
Establishment and termination of health insurance
(1) Health insurance is established by:
(a) by birth, if it is a permanent resident in the Czech Republic,
(b) on the date of taking up employment (Section 6b (3)) to an employer established in the Czech Republic;
(c) obtaining permanent residence in the Czech Republic.
(2) Health insurance shall cease:
(a) the death of the insured person or his declaration of death;
(b) termination of employment (§ 6b (3)) in the Czech Republic, unless it is an insured person referred to in § 3 (1) (a);
(c) termination of permanent residence on the territory of the Czech Republic, except as regards insured persons referred to in § 3 (1) (b).
INSURANCE
Health insurance policy payers
The payers of health insurance premiums (hereinafter referred to as "the premiums payers') are:
(a) insured persons referred to in § 6a;
(b) employers,
(c) State.
The insured person shall pay insurance premiums if:
(a) he shall be an employee in an employment relationship who is involved in sickness insurance. For the purposes of health insurance, the following shall be considered as staff members in employment (hereinafter referred to as "staff members'):
1. staff members shall act in a proportion which has the content of an employment relationship but which is not so designated or does not have all the formalities required for an employment relationship;
2. staff working under a work agreement;
3. members of cooperatives, if they are not in employment relations with the cooperative but are engaged in the work for which they are remunerated;
4. Associates and agents of limited liability companies and commanditists of a limited liability company, if they are not in employment relations with that company but are engaged in the work for which they are remunerated;
5. Members and Senators;
6. members of municipal councils who perform the function of long-term vacant members of the municipal council;
7. members of the Government and the Heads of the other Central Authorities of the Czech Republic;
8. Judges;
9. prosecutors;
10th President, Vice President and members of the Supreme Audit Office of the Czech Republic;
11. professional soldiers, members of the Police of the Czech Republic, members of the Prison Service of the Czech Republic and members of other armed security forces and security services;
12. internal scientific aspirants;
13. volunteer care staff;
14. foster care in special facilities;
15 persons in prison;
16. Persons with altered working capacity preparing for employment,
if they are involved in sickness insurance under the sickness insurance rules,
(b) is a self-employed person. The following shall be considered as self-employed for health insurance purposes:
1. persons engaged in agricultural production, forest and water management; 17)
2. persons engaged in trade; 18)
3. persons engaged in business under special rules; 19)
4. persons engaged in artistic or other creative activities under the Law on Literary, Scientific and Artistic Works; 20)
5. Associates of public companies and Associates of limited companies; 21)
6. persons engaged in an independent profession which is not a business or a business under special rules; 22)
7. cooperating self-employed persons who, for the purposes of health insurance, are considered to be spouses and, from the end of compulsory education, the children of self-employed persons referred to in points 1 to 3, if they are engaged in their self-employed activities and are not in employment relationships,
(c) has a permanent residence on the territory of the Czech Republic, but it is not mentioned under the preceding letters and there is no payment by the insurance State (§ 6c).
(1) The employer shall pay part of the insurance premiums for his staff, except for staff members who proceed under Paragraph 7 (4).
(2) For health insurance purposes, the employer is a legal or natural person who employs employees and has a registered office or permanent residence in the Czech Republic.
(3) Employment for health insurance purposes means the pursuit of the activities referred to in Article 6a (a).
(1) The State is an insurance payee through the State Budget for the following insured persons:
(a) dependent children; 3)
(b) pensioner of pensions from pension provision, (4) who were awarded pension before 1 January 1993 under the regulations of the Czech and Slovak Federal Republic and after 31 December 1992 under the regulations of the Czech Republic;
(c) the beneficiary of the parental contribution; 5)
(d) women on maternity and other maternity leave, women receiving maternity assistance and men during their absence at work for whom they are granted cash assistance under sickness insurance rules;
(e) job seekers, including job seekers, who have accepted short-term employment; 6)
(f) persons receiving social security benefits on account of social needs; 7)
(g) persons who are primarily or completely helpless and who are looking after the person who is primarily or completely helpless, 8) or a long-term disabled child; 9)
(h) persons engaged in basic (replacement) service in the armed forces or civil service and persons called for military training;
(i) persons in custody or in the execution of a prison sentence;
(j) persons who are dependent on pensioners and who, for this reason, have been treated as the sole source of income; 10)
(k) persons who have reached the age required to qualify for an old-age pension but who do not fulfil the additional conditions for his or her entitlement to an old-age pension and who do not have income from employment, self-employment and do not receive any foreign pension, or that pension does not exceed, on a monthly basis, a minimum wage; 11)
(l) persons who, on a daily basis and duly caring for at least one child under the age of seven or at least two children under the age of 15, shall not be the persons referred to in (c) or (d). The full day care condition shall be deemed to be fulfilled if the child of the pre-school age is placed in a nursery (nursery) or similar facility for a period not exceeding four hours a day and if he / she is a child carrying out compulsory schooling, for the duration of the school visit, except in an establishment with a weekly or year-round stay. Only one person, either the father or the mother of the child, or the person who has taken the child into permanent care replacing the care of the parents, shall be regarded as such (12) unless they have income from employment or self-employment.
(2) If the persons referred to in paragraph 1 (a) to (j) have income from employment or self-employment, the State of insurance shall be the payee of such persons.
Obligation to pay insurance premiums
(1) Insurance shall be paid to the health insurance undertaking in which the insured person is insured (hereinafter referred to as the "relevant health insurance undertaking '). The insurance obligation shall be incurred by the insured person on:
(a) taking up employment;
(b) self-employment;
(c) when he became an insured person under § 6a (c);
(d) return to the Czech Republic, if the insured person has followed § 7 (4);
(e) return to the Czech Republic after a continuous stay abroad which began before 1 January 1993, if the return date falls after 30 April 1995; the insured person is obliged to provide evidence to the relevant health insurance undertaking;
(f) return to the Czech Republic after a continuous stay abroad, which began between 1 January 1993 and 1 July 1993, if the return date falls after 30 April 1995 if the insured person:
1. has been insured abroad,
2. he has not been fully or partially covered by this Act during that period,
3. Asked retroactively the competent health insurance undertaking for the procedure laid down in Article 7 (4).
This is without prejudice to the obligation to pay insurance premiums for the period preceding the stay abroad.
(2) The employer's obligation to pay part of the employee's insurance premiums arises on the day of the staff member's recruitment, except as provided for in Paragraph 6b (1). This obligation shall cease on the date of termination of employment.
(3) The obligation of the State to pay insurance premiums for insured persons arises on the day on which the State becomes the payer of insurance premiums under Paragraph 6c. This obligation expires on the day on which the State ceased to be a payer of insurance premiums under § 6c.
(4) The insured person shall not be obliged to pay insurance premiums for the duration of his or her long-term abroad if he / she is insured abroad and has made a written declaration to that effect with the relevant health insurance undertaking. However, the obligation to pay the premium shall expire only on the date on which the insured person indicated in the declaration referred to in the first sentence, but not before the day following the date on which the declaration was delivered to the relevant health insurance undertaking. From the same day until the date on which the insured person has re-registered with the relevant health insurance company, the insured person shall not be entitled to full or partial medical care under this law. At the same time as re-registration with the relevant health insurance undertaking, the insured person shall submit to that insurance undertaking an additional proof of the insured health insurance abroad and its length. If the insured person does not submit such a document, the competent health insurance undertaking shall pay back the premiums as if it had not acted under this provision. A continuous stay of more than six months shall be considered as a long-term stay abroad.
(5) If the insured person does not pay the premium at the specified amount and on time, the competent health insurance undertaking shall enforce the payment of the premium to the debtor, including periodic penalty payments.
Amount and method of payment of premiums and periodic penalty payments
(1) The amount of premiums, periodic penalty payments and the manner in which they are paid are laid down in a separate law.
(2) Employees' premiums are paid from one third to an employee, from two thirds to an employer.
(3) By written contract between the employee and the employer, the employee may undertake to pay the employer, in whole or in part, the amount corresponding to the insurance premium which the employer is obliged to pay for the employee at the time when the staff member has provided leave without compensation for the income. In the absence of an employee at work, the employee shall pay the employer the amount corresponding to the insurance premiums paid by the employer for that period.
RIGHTS AND OBLIGATIONS OF INSURANCE AND INSURANCE PLANS
Reporting obligation for payers
(1) The employer is obliged to notify the competent health insurance undertaking of:
(a) recruitment and termination of the staff member; if the insured person is subject to § 3 (1) (b), he also announces this fact;
(b) the change of the health insurance undertaking by the employee, if that fact has been communicated to him; the notification shall be made by means of a write-off from the insurance premiums paid by the original health insurance undertaking and an insurance claim made by the health insurance undertaking chosen by the staff member;
(c) the facts relevant to the State's obligation to pay for the employees of the insurance premiums, even in cases where the State's obligation arose at the time when the staff member granted leave without compensation of the income, if he is aware of these facts.
The employer shall keep records and documentation of the facts notified.
(2) The staff member shall notify the relevant health insurance undertaking of the facts referred to in the previous paragraph without delay if he finds that his employer has failed to fulfil that obligation or if he has not communicated the information referred to in points (b) and (c) to his employer.
(3) An insurer who is a self-employed person is obliged to notify the competent health insurance undertaking of the commencement and cessation of self-employed activities no later than eight days after the date on which he has started or ceased that activity.
(4) The insured person shall notify the relevant health insurance undertaking within eight days of the date on which he became an insured person under Paragraph 6a (c).
(5) The insured person shall notify the relevant health insurance undertaking within eight days at the latest of the facts relevant to the formation or termination of the obligation of the State to pay the insurance premiums under § 6c. For persons employed, this obligation shall be fulfilled by the employer, if known. For persons who are minors or persons who are not fit for legal action, that obligation shall be fulfilled by their legal representative.
(6) The birth of the insured person shall be notified by his legal representative within eight days of the date of birth to the health insurance undertaking with which the mother of the child is insured on the day of birth. The competent municipal authority responsible for the management of the matrix shall notify the birth of the insured person to the Central Register of Insurers (23) immediately after the birth number has been assigned.
(7) The death of the insured person or his death declaration shall be notified to the Central Registry of the insured persons (23) within eight days of registration in the matrix by the competent municipal authority responsible for the management of the matrices.
Rights of the insured person
(1) The insured person has the right:
(a) the choice of insurance undertakings carrying out general health insurance, unless otherwise provided for in this law. The health insurance undertaking may be changed once every 12 months only on the first day of the calendar quarter. The application must be lodged by the insured person with the selected insurance undertaking at least two months before the date specified in the previous sentence. A request shall be made by their legal representative for minors or persons who are not legal persons. The provisions of the previous sentence shall not apply when the health insurance undertaking is terminated. The right to choose a health insurance undertaking shall also not apply when the child is born. On the day of birth, the child becomes insured by a health insurance company with which the child's mother is insured on the day of birth. A change in the child's health insurance may be requested only after the birth number has been assigned; the period laid down in the third sentence shall apply to the submission of this request. The insurance undertaking shall comply with the claims of the insured person within the time limits laid down in this provision. The health insurance undertaking shall not be entitled to provide the insured person with the period during which he will be insured; it is also not entitled to terminate the insured person's relationship with the health insurance undertaking itself,
(b) the choice of a doctor or other professional in health and healthcare establishments, with the exception of racing health services, 13) who are in contract with the relevant health insurance company; that right may be exercised once every three months;
(c) the choice of transport services which are in contract with the relevant insurance undertaking;
(d) to cover the costs of health care provided to him to the extent provided for by this law and in accordance with the provisions laid down for its implementation;
(e) to cover the costs of providing medical treatment in urgent cases in medical establishments not under contract with the relevant health insurance undertaking;
(f) reimbursement of travel expenses pursuant to Article 2 (1) (d);
(g) to participate in the control of the care provided fully or partly covered by health insurance;
(h) to cover the costs associated with the necessary transport service, which is not under contract with the insurance undertaking, up to the amount of the remuneration determined by the insurance undertaking.
(2) Soldiers in active duty, with the exception of soldiers in reserve called for military training, and pupils in military schools who prepare for the service of an occupational soldier and are not in active service, are insured with the Military Health Insurance Agency. The basic health care is provided to them by the crew of the health care facility and, if not set up, by another medical facility with which the Military Health Insurance Agency has concluded a health care contract. Follow-up outpatient or constitutional care is provided by a medical facility designated by a doctor who provided basic health care. Physicians may be elected only within the medical facility referred to in sentence two and three. Soldiers in primary and substitute services and pupils in military schools shall be insured by Military Health Insurance until the last day of the calendar month in which they completed basic or substitute service or study at military school. From the first day of the following calendar month, they are insured with a health insurance company whose insured persons were insured before their transfer to the Military Health Insurance Company. To this end, the Military Health Insurance Corporation is required to communicate once a month to the Central Insurance Corporation of the General Health Insurance Corporation 23) the names, surnames, permanent stays and birth numbers of insured persons who have started or completed a basic or replacement service or study at a military school. For the change of the health insurance undertaking by the insured person referred to in the preceding paragraph, the period of insurance with Military Health Insurance shall not be counted within 12 months.
(3) The selection of medical practitioner and transport services shall be limited in accordance with specific regulations for persons serving civil service and persons in custody or in the execution of prison sentences.
(4) The right of the insured person to choose a doctor and a medical institution as referred to in paragraph 1 (a) shall be exercised. (b) it is without prejudice to the right of the doctor to refuse to take custody of the insured person if this would exceed his workload or for other serious reasons, except where it is a matter of urgent treatment for more serious injury or illness. In the same way, the right of the insured person to provide the necessary care within the designated area of employment is not affected, (14) unless such care has been provided by the chosen doctor or health care institution.
Obligations of the insured person
The insured person shall:
(a) comply with the notification obligation provided for in Article 9 with the insurance undertaking if it has not complied with that notification requirement with another health insurance undertaking which it has chosen;
(b) communicate on the day of taking up employment to the employer with whom the health insurance company is insured. It has the same obligation if another health insurance company becomes insured during the period of employment; that obligation shall be fulfilled within eight days of the date of the change of the health insurance undertaking. The employer shall confirm in writing the receipt of the communication according to the previous sentences. The employer shall have the right to require the employee or former employee to pay the periodic penalty payment which he has paid in connection with the non-notification or delayed notification of the change of the health insurance undertaking by the insured person,
(c) to pay insurance premiums to the relevant health insurance undertaking, unless that obligation is to be fulfilled by the State;
(d) comply with the Health Regulations;
(e) provide synergies in the health performance and control of the course of the treatment process and comply with the doctor's established treatment regimen;
(f) submit to preventive inspections at the request of the applicant, where specific provisions so provide;
(g) comply with disease prevention measures;
(h) avoid acts aimed at knowingly damaging their own health;
(i) to be demonstrated in the provision of health care, with the exception of the provision of medicinal products and medical devices, by a valid insurance card or by a replacement document issued by the relevant health insurance undertaking;
(j) notify the relevant health insurance undertaking within eight days of the loss or damage of the insured person's card;
(k) return to the relevant health insurance undertaking within eight days the insured person's card for:
1. the cessation of general health insurance under Article 5 (2) (b) and (c);
2. a change in the health insurance undertaking;
3. long-term residence abroad (§ 7 (4)),
(l) to notify the competent health insurance undertaking of changes in the name, surname, permanent residence or birth number within 30 days of the date on which the change occurred;
(m) on the change of the health insurance undertaking, provide the newly elected health insurance undertaking with proof of the amount of the advances on premiums calculated from the assessment basis, if it is a self-employed person;
(n) when providing health care which the health insurance undertaking pays only partially in accordance with the Health Regulations (§ 2 (2)), to the healthcare establishment the difference between the price of the healthcare provided determined in accordance with the list of health performance and the price scale and the amount of remuneration by the health insurance undertaking concerned (§ 13 (3)). The remuneration shall be rounded down to the nearest ten crowns; payment is at least CZK 10. The medical establishment shall be required to issue an accounting document on the nature and extent of the healthcare provided and the amount of the financial compensation received,
(o) when dispensing medicines and medical devices which are only partially paid by the health insurance company, to pay the difference between the price of the medicinal product or the medical device determined according to the price regulations and the amount of the reimbursement by the relevant health insurance undertaking, in accordance with the list of medicines and medical devices (§ 13 (5)).
ORGANISATION OF HEALTH INSURANCE
Health insurance companies
(1) Health insurance is carried out by the following health insurance companies:
(a) insurance undertaking;
(b) departmental, branch, corporate or other insurance undertakings, as appropriate.
(2) The establishment and operation of the insurance undertakings referred to in paragraph 1 shall be governed by specific laws.
(3) Health insurance companies shall issue their insured persons with an insurance card or a replacement document free of charge. The certificate or replacement document of a minor insured person or persons deprived of legal capacity shall be issued by the competent health insurance undertaking to the legal representative.
Tasks of health insurance companies
(1) The competent health insurance undertaking shall bear the costs of care fully or partially covered by the health insurance provided to insured persons by health care institutions under contracts concluded with health care establishments for a period of two years, unless otherwise agreed, with the possibility of termination of the contract in the event of breach of the terms and conditions before the end of the agreed period.
(2) Contracts are concluded on the scope of those types of care fully or partially covered by the health insurance which the health care establishment is entitled to provide.
(3) The relevant health insurance undertaking shall provide remuneration for the medical performance performed by the healthcare establishment in accordance with the list of performance with points, unless the Health Regulations provide that health care is to be paid by flat-rate amounts. The contract referred to in paragraph 1 may provide for a reduction in the payment of the declared health performance where the health care establishment substantially exceeds the average cost per insured person of the relevant health insurance undertaking for the type of health care establishment and the health care sector. The list of points and the amount of lump sums, including the extent of the health care covered by these amounts, shall be established by the Ministry by means of a decree following a conciliation procedure with representatives of the Ministry of Finance, Insurance companies, other health insurance companies, contractual health institutions, professional organisations established by law and professional scientific societies. Participants shall be convened by the Ministry at least once a year. The Ministry of Finance, after consulting the Ministry of Labour and Social Affairs, sets, on a proposal from health insurance companies, the price of a maximum price point.
(4) The health insurance undertaking concerned shall pay on the basis of:
(a) a medical prescription issued by a contractual health care institution, a doctor providing first aid to an insured person, a doctor providing health care in a social care institution and a doctor providing medical care to himself, his husband, his parents, his grandparents, children, grandchildren and siblings, provided that his expertise is guaranteed by the Czech Chamber of Medicine or the Czech Chamber of Dentistry, and that he concludes a special contract with the health insurance company
1. medical care facilities for medicinal products and medical devices with the exception of medical devices referred to in point 2;
2. to other contracting entities, glasses and eye optics, hair substitutes, orthopaedic prosthetic devices in series and individually manufactured, compensation aids for disabled persons, including carriages and lifting aids for immobile persons, and hearing aids, blind and weak-sighted,
3. medical care facilities and other apparatus used for therapy,
(b) the account submitted to the contractual health service
1. dental prosthetics and therapeutic rehabilitation aids,
2. orthodontic apparatus,
(c) the account submitted by the contractual medical institution or other contracting entities for service interventions on the medical equipment provided;
in accordance with the list of medicinal products and medical devices indicating the amount of the payments made by the relevant health insurance companies.
(5) The list of medicinal products and medical devices is prepared by the Ministry following prior conciliation procedures with representatives of the Ministry of Finance, Insurance, other health insurance companies, contractual health facilities, professional organisations established by law (1) and professional scientific societies; the parties to the proceedings shall be convened by the Ministry at least once a year. A list of medicines and medical devices, its changes and additions, is issued by the Ministry by a decree.
(6) If the prescriber prescribes a medicine or a medical device to which the insured person is involved according to the list of medicines and medical devices, he shall inform the insured person accordingly. However, if the medical condition of the patient is required in accordance with the recommendation of the treating physician, made in agreement with the medical examiner of the relevant health insurance undertaking, the health insurance company shall pay fully the prescribed medicines or medical devices, and, exceptionally, the medicines in the list of medicines and medical devices not listed.
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Regulation Information
| Citation | Full text of Act No. 79 / 1995 Coll., Act on General Health Insurance (full text as shown by later amendments and additions) |
|---|---|
| Regulation Type | Declared full text |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 18.05.1995 |
|---|---|
| Effective from | - |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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