Reimbursement Of Health Care By Health. Insurance For 1. Mid-2005

Original Language Title: úhrady zdravotní péče hrazené ze zdrav. pojištění pro 1. pol. 2005

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50/2005 Sb.



DECREE



of 20 December. January 25, 2005



laying down the amount of reimbursement of health care covered by the public

health insurance, including regulatory restrictions for 1. first half of 2005



The Ministry of health shall lay down pursuant to § 17 para. 7 (b). (b)) of the Act

No. 48/1997 Coll., on public health insurance and amending and supplementing

some related laws, as amended by Act No. 458/2000 Coll., (hereinafter referred to

"the Act"):



§ 1



This Decree lays down, in cases where it is not the result of the conciliation

management agreement pursuant to § 17 para. 8 of the Act, the amount of remittances



and health care paid for by) from public health insurance, including

regulatory restrictions for health care in health facilities

in institutional care, including specialised therapeutic institutes, hospitals in the long term

patients and medical device reporting treatment day no.

00005 pursuant to Decree issuing the list of medical procedures with

point values in "^ 1") (hereinafter referred to as "the list of performance"),



b) out-patient specialists



(c)) in the provision of emergency care in non-Contracting

health-care facilities.



§ 2



(1) the amount of reimbursement of health care in health establishments of the constitutional

care, with the exception of health care in specialised therapeutic institutes,

institutes for long-term patients and in medical devices

returning the treatment day no. 00005 according to the list of performances (hereinafter referred to as

"institutional care"), for 1. half of 2005 shall be

at least 103% of the total remuneration (including especially the posted material,

separately charged and reimbursement of medicinal products in excess of the flat-rate,

If they have been agreed upon) this health care pertaining to establishments of institutional care

in the 1. half of 2004.



(2) the remuneration of the condition laid down in paragraph 1 is to provide

at least 90% of the volume of reported health care medical facilities and

recognized by the health insurance, compared with 1. half of 2004, expressed

the number of points according to the list. In the case of a lower volume of reported and

recognised health care than is stated in the first sentence, the amount of the remuneration

referred to in paragraph 1 shall be reduced by the same percentage, which is the lower volume

health care.



(3) if the establishments of institutional care and the health insurance fund shall conclude an addendum

to the Treaty, or to agree on a new Treaty, containing the new health

performances, provided by residential care facilities, health insurance new

agreed to pay health care beyond the remuneration as defined in paragraphs

1 and 2 in the manner of payment of the agreed in the contract; If there is no

agreement on the method of payment and the amount of, shall be reimbursed by health insurance new

medical procedures according to the list of performances with the price point set for 1.

half of 2001 in the amount of $0.89. ^ 2)



(4) the increase in the volume of health care provided to the insured, for which

the costs of healthcare provided in 1. half of 2005 exceeded 300

EUR, shall be reimbursed by health insurance establishments of institutional care above and beyond

remuneration as defined in paragraphs 1 and 2 of the manner of payment of the agreed

in the contract; If there is no agreement on the method of payment and the amount to pay

health insurance company health care costs over the financial volume for these

the insured person 1. half of 2004, according to the list of performances with the price point

set for 1. half of 2001 in the amount of $0.89. ^ 2)



(5) if the establishments of institutional care provides health care for a small number of

insured persons the competent health insurance company, paragraphs 1 and 2 shall not apply

and provided health care to be paid in the manner of payment of the agreed

in the contract; If there is no agreement on the method of payment and the amount to pay

This health insurance company health care according to the list of performances with the price

provided for in point 1. half of 2001 in the amount of $0.89. ^ 2) a small number of

the insured shall mean 50 and less of insured persons (regardless of the number of

treatment).



(6) if the establishments of institutional care in the 1. first half of 2005 will provide bed

care more than 105% of the treated insured persons (regardless of

the number of treatments) compared to their number in the 1. half-year 2004

total remuneration of health care provided for in paragraph 1 shall be increased by the same

the percentage by which the number of treated policyholders higher than 105%.



(7) the health insurance fund shall provide the medical facility per month

a preliminary payment of at least one-sixth of the reimbursement of health care

laid down in § 2 (2). 1. The Bill for the whole semester health

the insurance company performs and passes the establishments of institutional care within 60 days after

the end of the half.



(8) health insurance and medical facilities may agree on

payment of health care in the form of payments for diagnosis; in this case,

paragraphs 1 to 7 shall not apply.



§ 3



The amount of the reimbursement of health care in specialised therapeutic institutes, hospitals

for long-term patients and in medical devices, returning

treatment day no. 00005 according to the list of performances for the 1. first half of 2005

fixed at a flat rate per treatment day (point value of the treatment

the day, scoring a patient category, the value of the overhead associated with

spot the value of treatment delivery and a lump sum, which is to be paid

medicinal products according to the list of performances) so that the total amount of remuneration

belonging to a medical facility for treatment day (point value

the treatment of the day, scoring a patient category, the value of the overhead

assigned to the point value of the treatment of the day and the flat-rate amount

are reimbursed medicinal products covered by the list of performances) in the 1. half-year 2004

increase index 1.13.



§ 4



(1) Specialized out-patient care provided in out-patient

medical facilities are reimbursed under a contractual arrangement between

health insurance and medical facilities, according to a list of performances

remuneration for provided medical procedures to limit the time the wearer's performance

12 hours per calendar day with the maximum payment restrictions following the

the number of insured persons treated in the clinic. The amount of the

the remuneration shall be laid down in the annex to this Decree.



(2) price point for the payment of health care referred to in paragraph 1 is agreed to in the 2.

half of 2004, and proclaimed in the journal of the Department of health under the

§ 17 para. 9 of the Act shall remain in force for 1. first half of 2005.



(3) a different payment method than the one referred to in paragraph 1, it is possible, if

medical facilities and health insurance fund on the proposal for a medical

device on this method of payment, the total amount of the remuneration agreed between the

higher than the remuneration provided for in paragraph 1 and the method of payment is not

contrary to the laws and regulations governing public health insurance.



§ 5



(1) the reimbursement of emergency health care, if there is no contract between the

medical facilities and health insurance must be carried out

provided by the medical procedures as follows:



and) dental out-patient care are reimbursed according to the rates applicable to

healthcare provided by dentists in the 1. first half of 2005,



(b)) other health care are to be paid according to the list of performance and health

the undertaking may, on the basis of the law ^ 3) apply regulatory measures

as with the contracted medical facilities.



(2) price point for the payment of health care referred to in paragraph 1 (b). (b))

set for 1. half of 2001 remains in force for 1. half-year

2005. ^ 4)



§ 6



This Decree shall take effect on the date of publication.



Minister:



doc. MUDr. Emmerova, CSc. v. r.



XIII.



The amount of remuneration referred to in section 4, paragraph 4. 1



1. the maximum payment to the competent ambulantnímu medical facility

(hereinafter referred to as "medical devices"). and 2. quarter (hereinafter referred to as

"the quarter") 1. first half of 2005, is calculated as the product of

the total number of unique treated policyholders the relevant health

insurance companies treated the medical establishment in the quarter and

the value of the maximum payment per unique treated the insured person

the health insurance companies treated the medical establishment.



2. the value of the maximum payment per unique treated the insured person

the health insurance companies treated the medical establishment for

each quarter is calculated as the product of the values of the maximum remuneration to the

one of the unique treated insured persons the competent health insurance company

treated medical institutions in the corresponding quarter of the previous

the year, multiplied by the coefficient 1.03. The value of the maximum payment per

unique competent health insurance company insured person treated

treated in the relevant quarter of the previous year shall be determined as the value

the proportion of the total number of points declared medical facilities and

the recognized sickness insurance fund in the corresponding quarter of the previous year

divided by the number of unique treated policyholders the treated

the medical establishment in the corresponding quarter of the previous year.



2.1. If the value is the maximum payment per unique treated

the insured person's sickness insurance fund in the relevant expertise in

medical equipment is lower than the national average

the maximum reimbursement per insured person treated the unique


expertise on the relevant health insurance, it shall apply for the calculation of the

the maximum payment per unique treated the insured person

medical device value national average maximum payment

one of the unique expertise of an insured person in that treated the

health insurance, multiplied by the coefficient 1.03.



2.2. the insured person shall mean the Unique treated one insured person without the

regardless of how many times a medical facility reported on this

the insured person within a specified time period of health care.



2.3. the value of the national average, the maximum payment per

a unique skill for the insured person treated the

health insurance shall be determined as a proportion of all Contracting

health facilities, appropriate expertise and declared the

health insurance company recognized in the relevant quarter and points total

number of unique treated insured persons treated by devices

the health insurance fund in the relevant expertise.



2.4. appropriate health insurance For the insured person treated in the

expertise of the insured person are calculated both in their own care, so the insured person in

care requested. The value of the national average, the maximum payment per

the unique expertise of an insured person under treated for each

quarter of the previous year shall notify each health insurance company

medical equipment and publish on the Internet no later than 273 days

After the end of the quarter the previous year.



2.5. In the case that a medical facility in the reference period

the previous year did not exist, or a medical facility treating less

than 150 insured persons the competent health insurance company, limiting the maximum

payment shall not apply.



3. the maximum reimbursement for medical devices is the sum of the maximum

remittances to one unique treated the insured in each skill

specified in the contract concluded between that medical facilities and

health insurance company.



4. in the case of medical devices, where compared to the reference period

the previous year the capacity has changed the scope of health care

stipulated in the contract, health insurance companies the final amount to be paid

into account in the amendment to the contract.



5. payment for prescribed medicines, medical devices and for

pull the care shall be as follows:



5.1. If the total remuneration for the prescribed medicines and medical

resources, with the exception of medicinal products and medical devices

approved the review by a doctor over the reference period and volume for the

pull the care in the fields of medicine, 801-805 222, 809, 812-823, according

list of performances exceed by more than 15% of the average of this medical

devices in the respective quarter of the previous year, the health

insurance against medical device regulatory reduction of 25% of the

such a crossing, and ways in the contract concluded between the

medical facilities and health insurance.



5.2. If the total remuneration for the prescribed medicines and medical

resources, with the exception of medicinal products and medical devices

approved the review by a doctor over the reference period and volume for the

pull the care in the fields of medicine, 801-805 222, 809, 812-823, according

list of performance exceeds by more than 20% of the national average on one

unique to doctors that treated the insured person, the kind of skill

medical equipment (in terms of scope of performance contained in the

the contract) and the type of health care provided, taking into account age

groups in the relevant calendar quarter, the health insurance company

against medical device regulatory reduction of 25% of such

exceeded, and ways in the contract concluded between the

medical facilities and health insurance.



5.3. The values of the national averages of payments for prescribed medicines

and medical devices, with the exception of medicinal products and

medical devices approved by the review by a doctor on one

unique treated the insured's each quarter the previous

year shall be published on the Internet on health insurance to 273 days since the end of

the corresponding quarter of the previous year.



5.4. the health insurance company may apply to medical devices

the regulation of payments for prescribed pharmaceuticals and medical devices and for

pull the care referred to in point 5.1. or according to section 5.2., and

that represents medical device is less a deduction.



5.5. If the total payment in the quarter for medicinal products and

medical devices prescribed by the medical establishment, with the exception of

medicinal products and medical devices approved by the review

doctor and medical facility for taking care to pull in the fields of medicine

222, 801-805, 809 812-823, according to the list of performances is lower than

the total remuneration for medicinal products and medical devices prescribed by

the medical establishment, with the exception of medicinal products and medical

the funds approved a revision doctor, and for the care of a requested

medical facilities in the fields of medicine, 801-805 222, 809, 812-823

According to the list of performances in the quarter the previous year, shall pay the

health insurance medical facility a bonus of 30%

savings, and no later than 60 calendar days after the last

day of the quarter.



1) Decree No. 134/1998 Coll. issuing the list of medical procedures

with point values, as amended by Decree No 55/2000 Coll., Decree No.

135/2000 Coll., Act No. 458/2000 Coll., Decree No. 101/2002 Coll. and the

Decree No 291/2002 Coll.



2) Article. (II) Act No. 458/2000 Coll., amending Act No. 48/1997 Coll.,

on public health insurance and amending and supplementing certain

related laws, as amended. Annex 1, point (B)

1 Government Regulation No. 484/2000 Coll., laying down the point values and above

reimbursement of health care paid for by public health insurance for 1.

half of 2001.



3) § 40 paragraph 2. 2 of Act No. 48/1997 Coll.



4) Article. (II) Act No. 458/2000 Coll.



section 6 (a). (b)) Government Regulation No. 484/2000 Sb.

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