Resolution Of 16 December 2015, Of The General Civil Servants Of The State Mutual, Which Publishes The Concert Signed With Entities Of Insurance To Ensure Access To Health Care In National Territory...

Original Language Title: Resolución de 16 de diciembre de 2015, de la Mutualidad General de Funcionarios Civiles del Estado, por la que se publica el concierto suscrito con entidades de seguro para el aseguramiento del acceso a la asistencia sanitaria en territorio nacional ...

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Pursuant to the provisions of articles 17.1 of the revised text of the law on Social security of the civil officials of the State, approved by Royal Legislative Decree 4/2000, of 23 June, and 77 of the General Regulation of the administrative mutualism, approved by Royal Decree 375/2003 of 28 March, this General mutuality of civil servants of the State (MUFACE) previous public announcement whose advertisement was published in the Official Gazette and the platform of State procurement on October 29, 2015, has signed on December 15, 2015 with different entities of insurance concert for the assurance of access to the provision of health care in national territory to beneficiaries of the same during the years 2016 - 2017.

In order to give public knowledge of the full content of the concert and institutions insurance who subscribed to it, as well as the regulation of change of lender of health care in national territory, this General direction resolves: first.

Publish, annexed to this resolution, the text of the «concert the Mutualidad General civil servants of the State» with entities of insurance to ensure access to health care in national territory to beneficiaries of it, during the years 2016-2017.

Second.

Make public that the concert has been signed with the following medical care insurance entities: ASISA, Interprovincial health insurance assistance, S.A.U.

DKV, insurance and reinsurance, Spanish Corporation.

Igualatorio Médico-quirúrgico schoolboy, Seguros S.A.

SEGURCAIXA ADESLAS, Sociedad Anónima de Seguros y Reaseguros.

Third party.

Determine that during the month of January of every year of the concert, members of MUFACE holders who wish to can change only once of entity, through the timely application, ascribed to one of the entities that have signed concert for the years 2016-2017 and that they relate to in the second paragraph of this resolution, or to the National Institute of Social Security (public health system). Holders who do not request a change will continue to be attached to the same entity that you are at 31 December of each year of the concert.

This term is only for regular changes of entity, and can be made extraordinary changes only in the specific cases provided for in the corresponding concert.

Room.

Provide that services provincial and MUFACE offices delegates reflecting, available to homeowners who wish to consult them, catalogues of suppliers in the respective province corresponding to concerted insurance entities. Such information will also be accessible through the website of mutuality: www.muface.es Madrid, 16 December 2015.-the Director General of the mutuality of General civil servants of the State, p. S. (Royal Decree 577/1997, of April 18), the General Secretariat of the mutuality of civilian officials of the State, Maria Dolores Lopez of the rich.

Annex concert of the General mutuality of civilian officials of the State with entities of insurance to ensure access to health care in national territory to beneficiaries of it, during the years 2016-2017 contents chapter 1. Object of the concert, extent of the protective action and scope.

1.1 purpose of the concert and scope of protective action.

1.2 protected collective.

1.3 birth and extinction of the right to receive health care for the entity.

1.4. changes in healthcare lender.

1.5 health card of the entity.

1.6. the entity actions related to its range of services.

Chapter 2. Portfolio of services.

2.1. General rules.

2.2. portfolio of primary care services.

2.3. portfolio of specialized care services.

2.4. portfolio of urgent and emergency care services.

2.5. preventive programmes.

2.6. palliative care.

2.7 rehabilitation.

2.8. dental health.

2.9. providing pharmaceutical and dietetic products.

2.10 transport for health care.

2.11. other benefits.

2.12. incorporation of new means of diagnosis and treatment. Procedure for the updating of the services portfolio of the concert.

Chapter 3. Means of the entity.

3.1. General rules.

3.2 criteria of availability of means.

3.3. catalogue of suppliers.

3.4 responsibility for editing and delivery of the catalogue of suppliers and information on the web site of the entity.

3.5 invariability of the catalogues of suppliers of the entity.

3.6. the principle of continuity of care.

Chapter 4. Instructions for use of the means of the entity.

4.1. general rule.

4.2 identification.

4.3 members not affiliated with the entity and their beneficiaries.

4.4 access procedure and provision of assistance in consultation.

4.5. procedure of access and providing in home care.

4.6. procedure of access and provision in emergency and emergency assistance.

4.7 access procedure and provision of assistance in regime of hospitalization.

4.8. additional requirements for the use of media.

4.9 non-agreed private hospitals.

Chapter 5. Use of non-agreed.

5.1. general rule.

5.2. unjustified refusal of assistance.

5.3. urgent assistance from vital character in the Middle not concerted.

Chapter 6. Information, documentation, health and quality objectives.

6.1 information and health documentation 6.2 clinical digital history and recipe e 6.3 quality of healthcare Chapter 7. Legal regime of the concert.

7.1 nature and concert and relations in it-based regime.

7.2 nature and system of health care relationships.

7.3. joint committees.

7.4 procedure to substantiate the claims.

7.5. procedure for execution of estimated claims.

7.6 special procedure to substantiate claims with the same object.

7.7 discounts pharmacy costs.

7.8. financial compensation for partial breach of obligations defined in the concert.

Chapter 8. Duration, economic regime and the concert price.

8.1 duration of the concert.

8.2 economic regime of the concert.

8.3 price concert and incentives to the quality.

8.4. deductions for availability failures.

8.5 payment terms.

Annex 1. Cross-border health care.

1. General rules.

2. health benefits subject to prior authorization and procedure to obtain.

3. procedure for the reimbursement of costs for cross-border healthcare.

Annex 2. Media assistance in rural areas.

1. General rules.

2 habilitation to MUFACE.

3. object.

4. content.

Annex 3. Criteria of availability of means by levels of care.

1. general approach.

2. availability of means of primary care.

3. definition of levels of specialized care and services portfolio.

4. availability of specialized care media in external consultations or Ambulatorias.

5. additional conditions for the island territory.

Annex 4. Instructions for the preparation and dissemination of the catalogue of suppliers.

Annex 5. List of services that require prior authorization from the entity and procedure to obtain.

1. services requiring prior authorization from the entity.

2. procedure for obtaining prior authorization annex 6. Health care information system.

1 activity/cost record.

2. information on cross-border healthcare.

3. registration of MBDS.

4. registration of sanitary means.

Annex 7. Financial compensation for partial breach of obligations defined in the concert. Procedure for its imposition.

1. general approach, infringements and economic compensation.

2. procedure for the imposition of economic compensation.

Annex 8. Allocation system of incentives to the quality of the assistance and deductions for availability failures.

1. allocation of an incentive to quality.

2. criteria for allocation of economic incentives linked to quality objectives.

3. deductions for availability failures.

Annex 9. Reports, scans or tests prescribed by the organs of evaluation of disabilities and other organs of MUFACE.

Annex 10. Scale for the reinstatement of tests prescribed for assessment of disabilities.

Annex 11. Rates for the reimbursement of costs for cross-border healthcare.

Chapter 1 subject of the concert, protective action and field of application 1.1 scope object of the concert and scope of protective action.

1.1.1. in accordance with the provisions of article 17 of the revised text of the law on Social security of the civil officials of the State, approved by Royal Legislative Decree 4/2000 of 23 June (hereinafter LSSFCE) and article 77 of the General Regulation of the administrative Mutualism (in later RGMA), approved by Royal Decree 375/2003 of 28 March , the object of the concert between the General mutuality of civil servants of the State (in later MUFACE) and the signing entity (hereinafter entity), is to ensure access to health assistance in the national territory to members and other beneficiaries of MUFACE who choose to receive assistance through the entity (in later beneficiaries).

1.1.2. the contingencies covered by this concert are those derived from common or professional disease, injuries resulting from accident, either that is the cause, even if it's an act of terrorism, and for pregnancy, childbirth and puerperium as well as preventive actions contained therein.


1.1.3 health care will be provided in accordance with the portfolio of services established in the present agreement which shall include, at least, the common services of the national system of health portfolio (in later SNS), in accordance with provisions of the LSSFCE, the Act 14/1986 of 25 April, General health and the law 16/2003, 28 may cohesion and quality of the national health system and their respective implementing rules.

1.1.4. for this purpose, the entity shall make available to the collective protected all own or concerted media precise (hereinafter media entity) in accordance with what is established in Chapter 3 of this concert. If exceptionally the entity not available such means, will take care directly of spending caused by the use of means not approved in accordance with the provisions laid down in this concert.

1.1.5. in addition, the entity undertakes to coverage of cross-border healthcare of their collective protected, in accordance with Royal Decree 81/2014, on 7 February, which lays down rules to ensure cross-border healthcare, and amending the Royal Decree of 1718 / 2010 of 17 December on prescriptions and dispensing orders. The exercise of the right by the beneficiaries, their scope, conditions, requirements and procedure for the reimbursement of costs for such assistance are established in annex 1.

1.1.6. for its part, MUFACE is obligated to pay to the entity the amount per person per month provided in clause 8.3, subject to the specifications and procedure contained in clauses 8.2 and 8.5.

1.2 protected collective.

1.2.1. for the purposes of the present agreement, are benefiting all members and other beneficiaries of health care who MUFACE, in accordance with the applicable legislation, has recognized this condition and have attached them to the entity for the purpose of their health care.

To certain management purposes provided that it thus arises from the actual text of the clauses, the beneficiaries of the concert can be called holders, if they possess document of affiliation to own MUFACE, or simply beneficiaries, when they appear as such in the document of affiliation of a headline.

The beneficiaries will be assigned to the entity while it is the holder of which depend on.

1.2.2. the condition of mutual or beneficiary, is credited by the affiliation document issued by MUFACE.

1.2.3 MUFACE inform the entity daily high, low, and variations in the data of the beneficiaries attached to it. Communication will take place form telematics, depositing the information in a secure directory access by the entity. MUFACE offers institutions a «on-line» to your database connection so that they will know the real situation of affiliation of a given mutual or beneficiary.

1.3 birth and extinction of the right to receive health care for the entity.

1.3.1. the right to receive health care by the entity begins on the date on which the beneficiary has been attached to this by MUFACE services, where there is no lack for assistance any time.

1.3.2. for the aforementioned purposes, is presumed, however, that the newborn is attached to the entity that attend the mother during the first 15 days from the moment of birth. From then on, cited law is conditioned to the formalization of the secondment of the newborn with the consequent economic effects.

1.3.3. the official or officer that during the clarify health care for themselves or their beneficiaries had not yet formalized its affiliation to MUFACE (and consequently had not exercised yet its right of option one of the concerted entities) may require the assistance of the entity and is entitled to receive, or that is paid to your beneficiaries in the terms provided for in clause 4.3.

1.3.4. the right of the beneficiaries is extinguished, in any case, on the date that MUFACE services agreed mutuality low or the end of their secondment to the entity for failure to attend the requirements or alleged fact that allowed in each case be protected by this concert.

1.4 change of lender of health care.

1.4.1. without prejudice to the possibility to choose to receive health care through the public health network, as laid down in article 17 of the LSSFCE and article 77 of the RGMA and the seventh additional provision of the Royal Decree 1192 / 2012, of 3 August, which regulates the status of insured and beneficiary for purposes of health care in Spain (, by public funds, through the national health system, holders attached to the entity may elect to receive health care for themselves and their beneficiaries through another signatory institutions of this concert in the following cases: to) on a regular basis, during the month of January of each year of the concert. This right may be exercised by a single time.

((b) with extraordinary character, throughout the entire period of the concert where any of the following circumstances: 1) when there is a change of destination of the mutual society involving his transfer to another province or island.

(2) aside from the previous course, when keeping your locality of destination the mutual change their domicile to another province or island.

(3) when there is a change of address, change of province or island of residence of the holder, and it retired or beneficiary mutual that have this condition by death, separation, divorce or annulment of the marriage of the mutual society and possess a document to the membership issued by MUFACE. This right may be exercised by only once each year of the concert.

(4) where the mutual gain conformity expressed in writing by the two entities concerned. This course also includes the change to the entity from the public health network.

(5) when the mutualista pass to be understood in the group protected by the concert in the national territory to extinguish their rights to be protected by the concert of healthcare to intended and/or resident members overseas, provided such extinction does not originate from the condition of mutual loss.

(6) when, because circumstances objective to justify the change from a plurality of holders affected by the same problem of health care, the Directorate General of MUFACE agreed the opening special term of choice of entity.

The merger of the entity with one or other of the concerted by MUFACE shall not entail opening a period of extraordinary change, being automatically assigned to the absorbent or resulting entity of the merger the beneficiaries which, at the time of the merger, were attached to the / extinct entity s s / s or to each of the merged entities , and forcing the resulting absorbing entity, since that time, to guarantee all their rights in the terms provided for in the present agreement.

1.4.2 continue attached to the entity holders that were it to December 31, 2015 and that would not opt to stay attached to the public health network or change to another signatory institutions of this concert, as provided for in article 77 of the RGMA and in the previous clause.

1.5 health card of the entity.

1.5.1. in the moment in which the entity is aware of discharge of a mutual or beneficiary, it will give you a provisional medical card, or any other document that will make possible the use of the media concluded from the time of discharge.

Subsequently, proceed to issue the appropriate health insurance card, which will be sent to the address of the mutualist or beneficiary within a maximum period of seven calendar days from the effective communication.

(1.5.2 card you must include prominently the phone 900.../800... of urgent care free of the entity, provided for in clause 3.1.1 c) the beneficiary can call in case of emergency or health emergency. In any case on the front of the card will contain the number of membership of the holder of the same and the MUFACE logo.

1.5.3. by a decision of the Director-General of MUFACE may determine the content of the data which, apart from which the entity required for its own management, shall be included in the system of data storage card for the purposes of the identification of the mutualist or beneficiary that also allow access to interoperable digital medical records systems prescription and pharmaceutical dispensing and manufacturing of the parts of temporary disability (TD), risk during pregnancy (RE) and risk during breastfeeding (RLN).

1.5.4 where a holder had opted to stay attached to the entity and had not received, for itself or its beneficiaries, the temporary card or document that will make possible the use of the media agreed having expressly requested the head of the Provincial service of corresponding MUFACE will issue a certificate which shall be recorded all the expenses caused by assistance to rightholder and beneficiaries by physicians services and centres included in the catalogue of suppliers of the entity may be billed directly to MUFACE for the materialization of the corresponding payment. Subsequently, the amount of these expenses will be deducted from the monthly fees that will be paid to the institution, without prejudice to the financial compensation provided for in clause 7.8.


1.5.5. the entity undertakes to inform and implement the mechanisms needed for the fulfilment of the provisions of the previous clauses by professionals and their suppliers catalog centers.

1.5.6 once they are attached to the entity, members must deliver in MUFACE health cards (their own and their beneficiaries) of the other entity or service public of health of the autonomous community to which had been attached to their health care in the national territory or, where appropriate, abroad.

1.6. the entity actions related to its range of services.

1.6.1. the entity may make advertising on its range of services throughout the life of the concert and during the period of regular change, provided that such advertising is not carried out within premises of institutions or agencies of a public character and occurs generally without targeting specific professional groups. In advertising campaigns that make the entity shall not use the logo or any other sign of MUFACE or of the General Administration of the State.

1.6.2. in no case may offer gifts to members, directly or indirectly via third parties, especially during their regular exchange and processes of high-specific professional groups.

1.6.3. the failure to comply with these obligations will lead to the economic compensation provided for in clause 7.8.

Chapter 2 service 2.1 General standards portfolio.

2.1.1. the health care beneficiaries of MUFACE ascribed to the entity will be provided in accordance with the portfolio of services established in this concert.

The portfolio of services is the set of services, techniques and procedures, understanding as such each of the methods, activities and resources based on knowledge and scientific experimentation, by which health benefits become effective.

2.1.2. the portfolio of services object of the concert includes as a minimum all the features that make up the common portfolio of services in the NHS, with the content, at any time, determine with the sanitary rules of application in the same, and which are detailed in this chapter, also collecting the specificities of each one of them.

(2.1.3 service portfolio object of the concert is divided into the following services: to) primary care.

b) specialized care.

(c) urgent and emergency care.

d) prevention programs.

(e) palliative care.

(f) rehabilitation.

(g) health oral.

(h) performance pharmaceutical and dietetic products.

(i) transportation to health care.

(j) other benefits (Podiatry, respiratory therapies and providing prosthetics).

2.1.4. included in the portfolio of services benefits are guaranteed through the provision of health care resources by levels and geographic areas and population set out in Chapter 3 of this concert and annex 3, with the procedures and rules for the use of these means which are described in Chapter 4. Annex 5 lists the services that require prior authorization from the entity and establishes the procedure for processing and obtaining, where applicable.

2.1.5. the entity will drive aimed to enhance coordination between levels of primary care, specialized care and services of accident and emergency, to ensure the continuity of care and comprehensive care of patients.

2.2. portfolio of primary care services.

Primary care is the basic level and initial health care and will be given by specialists in family and community medicine or general practitioners, specialists in Pediatrics and nursing staff, without prejudice to the collaboration of other professionals, and includes: a) health care demand, scheduled and urgent, both in the consultation and in the home of the patient.

(b) the indication or prescription and carrying out, where appropriate, diagnostic and therapeutic procedures.

(c) palliative care to terminally ill patients.

2.3. portfolio of specialty care services.

(2.3.1 specialized care includes activities care, diagnostic, therapeutic and rehabilitation and palliative care, as well as those of prevention whose nature requires the intervention of medical specialists, and comprises: to) assistance in consultations.

(b) assistance in medical or surgical day hospital.

(c) hospitalization in internment regime.

(d) home hospitalization.

(e) diagnostic and therapeutic procedures.

2.3.2 specifications to the services portfolio of specialized care.

A) mental health.

1 includes the diagnosis and clinical monitoring of mental disorders, including drug treatment and psychotherapy individual, group or family. Mental health care will be held in regime of inpatient, outpatient and emergency, ensuring the necessary continuity of care in any case.

2. It includes individual, group or family psychotherapy, provided that it has been prescribed by psychiatrist of the entity, carried out in media agreed with it and that its purpose is the treatment of psychiatric diseases. The entity is obliged to provide a maximum number of 20 sessions per calendar year (brief psychotherapy or focal therapy), except for the cases of eating disorders, in that all the sessions that the psychiatrist responsible for assistance must be given all necessary for the correct evolution of the case.

3 psychoanalysis, psychoanalytic psychotherapy, hypnosis, ambulatory narcolepsy and social confinement are excluded.

(B) plastic, aesthetic and reconstructive surgery. The entity will assist coverage of plastic, aesthetic and reconstructive surgery when you save related accident, disease or congenital malformation.

In the event of accident in Act of service or occupational disease shall be in all its scope, including, if necessary, plastic, aesthetic and reconstructive surgery in the cases in which, having even been healed lesions, to be distortions or mutilations that produce alterations in the physical aspect or hinder the total recovery of the patient C) diagnosis and treatment of sterility. Assisted reproduction treatments are designed to help achieve pregnancy in those people with inability to do it naturally, not likely to exclusively drug treatments, or following the failure of the same. Also you may have recourse to these procedures in order to prevent diseases or serious genetic disorders in the offspring and when required from an embryo with immunologic characteristics identical to the affected sibling of a serious disease process, which is not susceptible of other therapeutic resource, according to the regulations at all times.

1. General considerations.

(a) the entity is obliged to assume the expenses necessary for the diagnosis of sterility, which will be extended, where appropriate, to the couple.

(b) at the time of the beginning of the study of sterility, the beneficiary must be age 18 or older and less than 40 years, and not suffer any type of pathology that could present you pregnancy severe and uncontrollable risk, both for their health and for their possible offspring. In the case of couples, the male must be over 18 and under 55 years of age.

(c) the techniques of assisted reproduction shall be borne by the entity when women on which to perform the technique be owner or beneficiary of MUFACE and does not have any son, prior and healthy. In the case of couples, without any common, prior and healthy son.

(d) will be included all the techniques included in the portfolio of services of the national health system, pursuant to the Act 14/2006, 26 May, on assisted human reproduction techniques, and to order SSI/2065/2014, of 31 of October, that amending annexes I, II and III of the Royal Decree 1030 / 2006 of September 15, by which establishes portfolio of common services of the national health system and the procedure for its updating, with the conditions and requirements established in the same.

(e) not considered included, among the benefits funded assisted reproduction techniques that occur when the sterility of any member of the couple has been voluntarily or occurrence as a result of the natural physiological process of the completion of the reproductive cycle of the person, or documented medical contraindication is.

(f) in assisted reproduction treatments, tests to be carried out within the scope of such treatment to other Member of the couple will be provided by the institution of secondment of women that are going to perform the technique of assisted human reproduction. Excludes the financing of pharmacological treatments associated with the technique of assisted human reproduction that has submitted the other Member of the couple.

(g) in the case of the donation of gametes and pre-embryos human reproduction techniques, the costs of proceedings and, where appropriate, medications that require donors, shall be borne by the entity to form part of the cost of the technique used. In no case may impact on the beneficiary recipient of the donation.


(h) it shall be borne by the entity coverage of cryopreservation and maintenance of gametes, ovarian tissue for own use deferred beneficiaries expected to undergo medical or surgical treatments that may affect significantly their fertility. The period of coverage in the case of the woman will be up to the day prior to compliance with 50 years of age and in the case of the man until the day prior to the fulfillment of 55 years of age.

(i) they shall be borne by the entity the cryopreservation and maintenance of the surplus pre-embryos of IVF cycles authorized until the previous day that women reached 50 years of age.

(j) will attend the coverage techniques of human assisted reproduction in women where there is a diagnosis of sterility by gynaecological pathology preventing to achieve a pregnancy, regardless of the existence or not of couple.

2 limits the maximum number of cycles of treatment and the woman's age.

In any case the treatments of human reproduction, will be subject to limits in terms of the number of cycles and age of the patient, taking account at the beginning of efficiency and security to ensure the greatest effectiveness with the lowest possible risk.

Limits the maximum number of cycles of treatment and the age of the beneficiary for each technique are: limits insemination artificial in vitro fertilization * couples own gametes gametes donor sperm Semen donated cycles no. Max 4 6 3 3 maximum age of the woman

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