As of 1 January 2019, an amendment to the Public Health Insurance Act has come into force which brings substantial changes in the realm of insurance coverage for medical aids. How to prepare properly?
Much ink has been spilled over the new concept for the reimbursement of medical aids by public health insurance. In the present article, we want to point out certain obligations and deadlines associated with the transition to the new system of reimbursement. The new system will only apply to medical aids issued on prescription to individuals, i.e., nothing changes for medical aids which are used in in-patient care.
The main duty of manufacturers of medical aids (or, as it were, of their authorized representative) is to notify the State Institute for Drug Control (SÚKL) about the specific reimbursement category in which to place their product (or, as the case may be, notify the SÚKL that the given medical aid should be put in the group of substitute products, if such was created by SÚKL). Each reimbursement category contains medical aids with a similar (but not identical) therapeutic purpose and similar functional characteristics. The notifying party may ask SÚKL to issue an official opinion on the correct categorization of its medical aid.
This notification process is not an administrative procedure in the formal sense. Such procedures are reserved for excessive situations, to resolve e.g. the wrongful placement of specific medical aids in one of the reimbursement categories. The issue is broad and complex, and so is the range of medical aids which may potentially be eligible for coverage; because of this, the new reimbursement system is being rolled out on a staggered schedule.
What dates and deadlines are of crucial importance for notifying parties?
Notification of medical aids is supposed to take place electronically, via an information system that is slated to go live (according to SÚKL) on 1 April 2019. As of that date, notifying parties may ask for login credentials for this system. Medical aids which were already covered before then, may be re-registered, but only within the time window from 1 through 30 June 2019. In such a case, the new amount of reimbursement and the new terms of eligibility apply as of 1 December 2019. If, however, the notifying party fails to re-register by the above date, then coverage within the public health insurance system ends as of 1 August 2019 already.
Medical aids which weren’t hitherto covered by insurance may also be notified beginning as of 1 June 2019. Those “new” medical aids which are being registered during the month of June 2019 become eligible for reimbursement as of 1 October 2019. In cases of “outliers” with respect to the re-registration of reimbursable medical aids, SÚKL has until 1 November 2019 to commence administrative proceedings. In such a case, the relevant medical aid will only be reimbursed by public health insurance after the procedure has been brought to a close.
With a view to the above dates and the short time window for re-registration of medical aids with existing coverage, our recommendation is to get a head start on preparation work so as to be ready for a smooth transition to the new reimbursement system for medical aids.
Act No. 48/1997 Coll., on public health insurance and on changes and additions to certain related laws
Website of the National Medical Aids Information System, www.niszp.cz