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Royal Decree 1630 / 2011, Of 14 November, Which Regulates The Provision Of Health Services And Recovery By The Mutual Of Accidents At Work And Occupational Diseases From Social Security.

Original Language Title: Real Decreto 1630/2011, de 14 de noviembre, por el que se regula la prestaciĆ³n de servicios sanitarios y de recuperaciĆ³n por las mutuas de accidentes de trabajo y enfermedades profesionales de la Seguridad Social.

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TEXT

Among the services and services legally attributed to the mutual work accidents and occupational diseases of the Social Security, the health care that the workers supply is particularly important. at the service of the associated employers and the self-employed persons, not only for their scope and subject matter and for the origin of the injuries or diseases which motivate such health care, but because such provision constitutes a an important part of the activity entrusted to each other.

The health facilities and services available to each other to dispense with the assistance they are entrusted with, although attached to these entities and for specific purposes of Social Security, with whose resources they are financed, are intended for the coverage of integrated services in the National Health System, so they must be in keeping with the maximum coordination with the human and material resources of the aforementioned system, in accordance with the provisions of the article 4.1 of Law 14/1986 of 25 April, General of Health. It should also be noted that those entities are part of the State public sector in the terms set out in Article 2.1.d of Law 47/2003 of 26 November, General Budget.

On the other hand, the resources with which these benefits are financed form part of the Social Security patrimony without establishing a privileged relationship between a group of companies and workers and a mutual determined, to the detriment of the rest. In addition, the possibility and frequency of changes of a company between different mutual or workers between different companies throughout the working life, shows that the relationship of healthcare and recovery must be understood between the whole of the protected population and the whole of the care resources.

in the light of the above, together with the aim of greater efficiency and rationalisation in the use of public resources managed by mutual societies, which must at all times be at the same time as acting, the establishment of the precise mechanisms for optimising the use of the means by which mutual benefits are provided by the provision of health care and for the coordination of such use with that of other public resources, or public administrations health, as well as other mutuals, as well as the possibility of using private means, compliance with the stated objective and, at the same time, the highest possible quality in the care provided.

the Court of Auditors, for its part, has repeatedly highlighted the under-utilisation of the care resources of mutual, particularly hospitable, at the same time as the proliferation, not always controlled, of assists made through concerts with private means while a part of the own resources remained idle.

The establishment of the mechanisms of optimization of the health resources mentioned above responds to this royal decree, in which it is part, as a general principle, of the full use of the health resources of the mutual, reserving the possibility of using private means for the absence, insufficiency or non-availability of health resources for the mutual or non-existence of agreements with public health administrations, and provided that these private media have the approval of these public administrations. health and meet the rest of the conditions that in this royal decree are established. This is without prejudice to the fact that, in the framework of the regulatory reform provided for in the additional provision of Law 27/2011 of 1 August, on the updating, adequacy and modernisation of the social security system, a (a) more omnicomprensiva on the characteristics of the institutions and the management of the benefits, in accordance with the criteria and objectives set out in that provision, further deepening the efficiency of the management of the resources, through the use in each case of the most suitable equipment.

On the other hand, mutual work accidents and occupational diseases of Social Security can provide care and services for people who do not have the right to health care. pursuant to Article 71.5 of the General Law on Social Security and Standards of Development. It may be that, even in the case of persons who have such a right, there is a third party responsible for civil or criminal liability for the facts giving rise to the benefit, in which case the mutual benefit is entitled to claim the cost of the third party of the health benefits which he would have satisfied, as provided for in Article 71.5 in conjunction with Article 127.3 of the same law.

Consequently, the regulation of the regime applicable to the establishment of tariffs, the definition of the obligation to pay and the procedure for the claim of the debt, are also affected by this royal decree.

Finally, the integral conception of the health system advocated by Law 14/1986 of 25 April, as well as Law 16/2003, of 28 May, of cohesion and quality of the National Health System, leads to this real A joint proposal of the Ministry of Labour and Immigration, which corresponds to the planning and supervision of the management exercised by the social security agencies, and the Ministry of Health, Social Policy and Equality, which is entrusted with the exercise of the powers conferred on the administration State General to assure citizens of the right to health protection.

This royal decree is dictated by the powers granted by article 5.2 of the recast text of the General Law of Social Security, approved by the Royal Legislative Decree 1/1994 of 20 June, as well as by the Law 14/1986, of 25 April, General of Health.

In its virtue, on the proposal of the Minister of Labour and Immigration and the Minister of Health, Social Policy and Equality, in agreement with the Council of State and after deliberation of the Council of Ministers at its meeting of the November 2011,

DISPONGO:

CHAPTER I

General provisions

Article 1. Health and recovery benefits for the mutual benefit of occupational accidents and occupational diseases of social security.

1. Health benefits and recovery of social security arising from professional contingencies, entrusted to the mutual benefit of occupational accidents and occupational diseases of social security, as well as health care corresponding to common contingencies which are legally authorised or which can be made and invoiced in accordance with the applicable rules, may be made effective by some or some of the following:

(a) Through the health and recovery resources managed by the mutual societies, including those of the joint institutions and institutions.

b) By means of agreements with public health administrations or through concerts with private means.

2. The development of the mentioned health and recovery activities will be carried out by the mutuals in the terms indicated in this royal decree.

3. The health and recovery facilities and services of the mutual societies, as they are intended for the coverage of benefits included in the protective action of Social Security and integrated into the National Health System, will be submitted to the inspection and control of public health administrations.

4. The conclusion of the contracts that are necessary to comply with the forecasts contained in this royal decree will be adjusted, as soon as it is applicable, to the established to the effect in the Law 30/2007, of October 30, of contracts of the field public.

5. To the health personnel who carry out the health and recovery activities entrusted to each other in the manner referred to in paragraph 1, and which is affected by the provisions of Article 3.1 of Law 53/1984, 26 of December, with the incompatibilities of the staff at the service of the public administrations, the system of incompatibilities in force in the autonomous community in which such activities are developed will apply.

6. In the terms and content established by the Ministry of Labour and Immigration, the Directorate General for Social Security Management will take a record of the health and recovery resources for the supply of the benefits entrusted to each other, which shall include, at least, information relating to the own and concerted centres, health personnel providing services in the centres and activities of such centres.

Article 2. Criteria for the creation of health facilities and services and the recovery and formalization of conventions and concerts.

The criteria to be met by the establishment of health facilities and services and the recovery of mutual funds, as well as the minimum conditions and content necessary for collaboration with other mutual societies, formalization of agreements with public health administrations or concerts with private means, are those that are established in this royal decree.

CHAPTER II

Healthcare and recovery assistance with mutual-managed media

Section 1. Health Facilities and Services and Recovery of Mutual Services

Article 3. Creation and modification of health facilities and services and recovery of mutual benefit.

1. Mutual assistance may be provided by mutual assistance and recovery facilities for the provision of health care and the full recovery of workers who are injured in the workplace and who are suffering from occupational disease, in accordance with the planning to be established by the Ministry of Labour and Immigration, taking into account the availability of health services and the recovery of other mutual societies, as well as the existence of agreements with public health administrations in the geographical area of influence in which such services are intended to be created.

2. In the event of non-existence, failure or non-availability of health facilities and services and recovery of mutual benefit or non-existence of agreements with public health authorities in the geographical area of influence, those may submit to the approval of the Directorate-General for Social Security the creation or modification of health facilities and services and recovery services, together with a memory in which the ends which are they then point out, in union of certification of agreement of the board of directors on the Source of creation or modification of such facilities and services:

(a) Justification of the need for the creation or modification of facilities and services requested by the absence, insufficiency or unavailability of adequate health resources and retrievers from other mutual or by non-existence of agreements with public health administrations through which health and recovery assistance could be dispensed.

(b) The amount and distribution of the corresponding investments, as well as the operating cost estimates (Chapters 1 and 2 of the budget).

c) Predictable execution calendar.

3. The Directorate-General for Social Security Management shall forward the application, together with the accompanying memory, to the health authorities of the autonomous communities affected by the application, to issue a value report, with a view to prescriptive and determining the location and characteristics of the proposed facilities and services and their suitability for the purposes to be met and the specific rules applicable to the community. autonomic.

4. The Directorate-General for the Management of Social Security shall issue a resolution approving or rejecting the request for the creation or modification of health facilities and services and the recovery of which the mutual benefit has been made within six months. following the date of the presentation.

The approval resolution of the application shall determine the conditions under which it shall be implemented.

5. In relation to investments or property operations leading to the creation or modification of health facilities or services and retrievers, the relevant articles of the Regulation on the collaboration of mutual accidents at work and occupational diseases of social security, approved by Royal Decree 1993/1995 of 7 December.

Investments or property operations indicated by Social Security resources may only be made in the event of the prior authorization being made available, in accordance with the provisions of the Royal Decree 1221/1992 of 9 October on the patrimony of Social Security.

Article 4. Accreditation of sufficiency. Removal of sanitary and recovery facilities and services.

1. Mutual assistance shall be provided to the Directorate-General for the Management of Social Security for the adequacy of its health facilities and services and recovery services, provided by the relevant bodies of the Autonomous Communities.

2. The abolition of health and recovery facilities and services shall be carried out in accordance with the provisions of Article 12.1 of the Regulation on the cooperation of mutual occupational accidents and diseases of the Social security, approved by Royal Decree 1993/1995 of 7 December.

Article 5. Provision of clinical professional services.

Under the terms and conditions laid down in the implementing and development provisions, mutual assistance may be used by mutual and legal persons with natural or legal persons in facilities and services. referred to in Article 3, where the reasons for specialisation, management volume or other concurrent circumstances make it advisable. The rates to be applied shall be in accordance with Article 13, with the deduction of the cost for the use of the mutual facilities.

Within one month of the conclusion of the contract, the mutual agreement will be communicated by the mutual agreement to the General Directorate for the Management of Social Security. Such communication shall demonstrate the concurrence of the circumstances referred to in the preceding paragraph.

Section 2. Collaboration between mutual benefits in the field of health and recovery benefits

Article 6. Collaboration between mutuals.

In order to achieve greater efficiency and rationalisation of the resources they manage, mutual societies will be able to establish collaboration agreements between them that are necessary for the health and recovery of Their position can be made effective through the use of all of their care and recovery resources.

Article 7. Economic conditions.

The implementation and development provisions will be able to set the rates for the supply of health services and recovery between mutual, general application for the entire sector.

Article 8. Communication of the agreements.

The agreements to be formalised between the two sides will be communicated to the Directorate-General for Social Security Management within one month of its formalisation, accompanied by a copy of the agreements. In the same period, the modifications and divisions that occur shall be communicated.

CHAPTER III

Collaboration of the mutual work accidents and occupational diseases of Social Security with the public health administrations and with the management entities of the Social Security.

Article 9. Collaboration with public health administrations and with social security management entities.

1. Mutual assistance may be concluded by mutual associations with the public health authorities of the autonomous communities for the reciprocal use of the respective health and recovery resources.

In such collaboration agreements, in addition to the content and terms of the collaboration, the billing arrangements and the applicable reciprocal tariffs, which may be fixed by processes or in terms of flat-rate prices.

2. Mutual funds shall be borne by the Member States in respect of the authorized budget, without prejudice to the subsequent compensation for the health services of the Autonomous Communities or the social security management entities, the cost incurred in carrying out the diagnostic tests, treatments and functional recovery processes aimed at avoiding unnecessary prolongation of temporary disability processes by common contingencies, in accordance with the provisions of the additional provision the first of the General Law of Social Security and in the terms and conditions which establish the implementing and development provisions.

3. Mutual assistance may be provided by mutual assistance to the management bodies of the social security system for the development of the powers entrusted to them by the legal instruments which are applicable.

Article 10. Communication of the instruments of collaboration with the public health administrations and with the management entities of the Social Security.

The health care and recovery agreements formalised by mutual associations with the public health authorities referred to in Article 9.1, as well as the instruments subscribed to with the managing bodies of the Social security under Article 9.3 shall be communicated to the Directorate-General for the Management of Social Security within one month of its formalisation, accompanied by a copy thereof. In the same period, their modifications or divisions shall be communicated.

CHAPTER IV

Providing healthcare and recovery through concert with private media

Article 11. Provision of health services and retrievers with private means.

In the event that the mutual funds do not have health and recovery resources, including the communes, nor is there any possibility of the use of other mutual facilities under economic conditions at least as advantageous as those who offer private concerts or do not have an agreement with the public health authorities through which the provision of health care and recovery in the geographical area of influence can be adequately dispensed where such assistance is required, mutual assistance may be provided by mutual assistance (a) a concert with private means, provided that they fulfil the conditions set out in Article 12. Such concerts, which must be in accordance with the provisions of Law 30/2007 of 30 October, will not be able to replace the contributing function attributed to the mutual funds, in whose name the assistance will be provided, nor to exclude the possibility that such concerts are extended to other mutual ones.

The validity of such concerts may not exceed the two-year period when the provision of services is performed in hospital settings, or one year in the rest of the cases, and may be expressly extended equally period, by agreement of the Board of Directors, in the event of persisting the circumstances outlined in the preceding paragraph.

Article 12. Requirements for private health and recovery facilities to be arranged with each other.

In the cases referred to in Article 11, mutual associations may arrange for the provision of health and recovery services to be provided by private health centres, whether legal persons or natural persons, which meet the following conditions:

a) Dispose of your own, material and personal means to carry out the services that are the subject of the concert.

(b) Contar with due authorisation of operation and accreditation of sufficiency and adequacy of means by the competent health authority of the Autonomous Community and be registered in the register of entities authorized health care of that autonomous community.

(c) To be registered in the corresponding register which will be carried out for these purposes in the Directorate-General for Social Security Management.

d) Not having any kind of connection or commercial, financial or any other kind, with companies represented on the board of directors of the mutual, with the representative of the same, with the managing director or any another person exercising executive management functions in the mutual.

e) Credit a billing volume for benefits satisfied in the three years preceding the completion of the concert in excess of the estimated turnover for the benefits under the contract.

Article 13. Economic conditions of the concerts.

The fixing of the rates applicable to health care concerts that will be signed by mutual health care and private recuperators must be adjusted, among the market prices in the geographical area of influence, and depending on the use of such health and recovery services, at the economically most advantageous price for the mutual benefit.

Article 14. Communication of concerts with private media and recuperators.

Within one month of the completion of the health care and recovery concert, the mutual will communicate it to the Directorate General for Social Security Management. In the same period, the carry-overs and concertos of concerts which take place shall be communicated.

In this communication, the concurrence of the circumstances referred to in Article 11 and the agreement of the board of directors of the mutual justification of having been examined the concert by that and of the have checked the concurrency in the agreed health centre of the conditions and requirements stipulated in the concert, as well as having adjusted to the provisions of Law 30/2007 of 30 October.

Article 15. Use of health personnel from mutual in concerted centres.

1. The private centres with which the health and recovery provision is designed must have sufficient and adequate own resources to carry out the benefit in question.

2. Exceptionally, the Directorate-General for the Management of Social Security may authorise the provision of surgical or post-surgical treatment with personal means of mutual benefit in duly concluded hospital centres. authorised, where the reasons for the craft, the volume of management or other concurrent circumstances, sufficiently accredited, make it advisable.

3. Together with the reasons for the authorisation for the provision of the treatments referred to in the previous paragraph in hospital centres arranged with private means, the application shall specify and identify the means personal personal of the mutual who are going to carry out the treatments. Such professionals shall not be able to provide any other service at the agreed health facility or to take care of patients other than those protected by the mutual applicant. Such professionals, as well as the members of the board of directors, the managing director, any other person exercising executive management functions in the mutual trust may not have any direct or indirect participation in the ownership or management of the concerted facilities, either individually or societarium.

4. The charges to be applied in the case referred to in paragraphs 2 and 3 above shall be deducted from the cost of the contribution of personal means made by the mutual fund, so that the total cost for the latter does not exceed that laid down in the Article 13.

CHAPTER V

Provision of health care in favour of persons who lack the right or where there is a third party obliged to pay them

Article 16. Applicable rate.

1. In the case of the provision of care and health benefits in favour of persons who are not entitled to the health care of the Social Security referred to in Article 71.5 of the General Law on Social Security, the The applicable price tariff shall be fixed on the basis of the criteria laid down in Articles 25 and 26 of Law 8/1989 of 13 April of public interest rates and prices.

2. This fee shall also apply where the supply of care, benefits and health services is carried out in favour of persons who have the right to health care, in cases where there is a third party who is obliged to payment.

3. The rate referred to in the preceding paragraphs shall also apply to the waiver by the mutual of health benefits and services to persons other than their collective of protected workers or to other persons or to other persons with whom they do not the mechanisms for collaboration provided for in Section 2 of Chapter II are available.

Article 17. Subject to payment.

1. In the case referred to in Article 16.1, the payment of the health benefits and services shall be the beneficiary of the benefits.

2. Where, while the beneficiary is still entitled to the health provision of social security, such benefit has been in fact assumed to involve criminal or civil liability of a person, the mutual benefit shall be effective benefit, but shall be entitled to claim the third party responsible, the third party liable for payment or, where appropriate, the legal or contractually subrogated in his or her obligations, the cost of the health benefits that he would have satisfied.

3. The Secretary of State for Social Security may subscribe to the conventions that are necessary for the best compliance with the provisions of this Chapter.

Article 18. Debt claim procedure.

1. The mutual settlement shall settle the credit generated by the health benefits and services referred to in Article 16 and shall require the payment of the persons obliged to it within the maximum period of two months from the date of receipt of the claim, in accordance with the provisions of the second paragraph of Article 71.5 of the General Law on Social Security.

2. Where the persons who are obliged do not pay the debt within the time limit laid down in paragraph 1, the latter shall forward it to the General Treasury of Social Security for the purposes laid down in the General Law on Social Security, in the previous section.

3. In accordance with the provisions of the last paragraph of Article 127.3 of the General Law on Social Security, mutuals may be directly involved in the criminal or civil procedure followed in order to make the compensation effective, as well as for promote it directly, considering itself as a third party to the effect of Article 113 of the Criminal Code.

Additional disposition first. Determining the geographical area of influence.

For the purposes of this royal decree, the implementing and development provisions will determine the geographical area of influence, taking as a reference the province, except in the cases of insularity and autonomous cities of Ceuta and Melilla, as well as other criteria according to the protected population, geographical extent or other relevant circumstances that may be present.

Additional provision second. Collaboration between mutuals.

For the purposes of Article 6, mutual associations shall communicate to the Directorate-General for the Management of Social Security their availability for the use by other members of their health facilities and services. retrievers, duly classified by location, dimension and specialty, in accordance with the criteria to be laid down in the implementing and development provisions.

Additional provision third. Reordering of health resources and recovery and concert adaptation.

1. A working group will be set up in the Directorate-General for Social Security Management to study, with the collaboration of mutual technicians of different dimensions, the possible future optimization of care centers and recovery of the mutual and/or distribution of specialties, as well as the adequacy of the concerts with private means existing to that established by this royal decree.

Among the criteria to be taken into account by the working group, the care device currently managed by the mutuals, and their joint entities and centres, as well as the volume of protected population in the the provincial level, and the minimum number of workers required for the existence of own welfare centres to be operational, below which the care coverage must be carried out by another or other mutual benefit implementation in this field, in accordance with the provisions of Section 2 of Chapter II.

2. Within six months of the entry into force of this royal decree, the working group will have to make a corresponding proposal to the Ministry of Labour and Immigration.

Additional provision fourth. Collaboration in the prevention of occupational disease and in the reduction of temporary disability processes.

Within the partnership in the management of Social Security referred to in Article 68. 2 and 3 of the General Law on Social Security, mutual associations may participate, in the terms and content laid down in the implementing and development provisions, in the assessment and development of plans for the prevention of the disease. (a) to prevent the sickness of the work referred to in Article 11 (2) (e) of that law, and to reduce the temporary incapacity for common contingencies, which have been agreed between the undertakings and the representatives of workers in the framework of collective bargaining. In the same way, mutual societies will be able to participate in the elaboration of processes and protocols to return to work, as well as relocation and redesign of the jobs, in collaboration with the company and the services of prevention of the same and with the participation of workers ' representatives.

Also, when the objective circumstances that advise it, such as risk factors for health, chronic pathologies or repeated low, mutual, with knowledge of the company and consent of the worker, are present, may participate in the early diagnosis, treatment and rehabilitation processes necessary for the reinstatement to work, in terms and with the content to be established in the implementing and development provisions of this real decree.

Such participation shall be carried out with respect, in any case, to the right to privacy and the dignity of the workers, and to guarantee the confidentiality of the information referred to its state of health, subject to strict to the provisions of the Organic Law 15/1999 of 13 December on the Protection of Personal Data.

First transient disposition. The validity of existing collaboration instruments.

As long as the agreements and instruments of collaboration with the public health administrations of the autonomous communities and the management entities of the Social Security provided for in Article 9 are not formalized, Currently existing agreements and conventions will continue to apply.

Second transient disposition. Processing of concerts with private media.

Until the Ministry of Labor and Immigration establish the terms and conditions of the adequacy of the concerts with private means as established in this royal decree, the mutual ones will be able to continue processing new concerts under Order TIN/2786/2009 of 14 October, for which the standard telematic process Cas @ is implemented, for the processing of applications for authorization and communications of concerts with private means to make (a) the health and recovery benefits of the mutual benefit of accidents at work and occupational diseases of Social Security.

Single repeal provision. Regulatory repeal.

The provisions of equal or lower rank shall be repealed as set out in this royal decree, and in particular Article 12 (3) and (4) of the Regulation on the cooperation of mutual accidents in Social security work and occupational diseases, approved by Royal Decree 1993/1995 of 7 December.

Final disposition first. Application and development powers.

1. The Minister for Labour and Immigration and the Minister for Health, Social Policy and Equality, within their respective powers, are empowered to make any precise provisions for the implementation and development of this royal decree.

2. The Secretary of State for Social Security is also empowered to set the terms and conditions for the adequacy of the concerts with existing private means as established in this royal decree and to regulate the registration to which it refers. Article 12 (c).

Final disposition second. Competence title.

This royal decree is issued in accordance with the provisions of Article 149.1.16. and the 17th of the Constitution, which attributes to the State, respectively, the competence on the basis and general coordination of health and on the rule of law Economic and Social Security.

Final disposition third. Entry into force.

This royal decree will enter into force on the day following its publication in the "Official State Gazette".

Given in Madrid, on November 14, 2011.

JOHN CARLOS R.

The Minister of the Presidency,

RAMON JAUREGUI STUNNED