Basic principals of the Czech Health System - legislation

1. Basic principals of the Czech Health System - legislation Ludwig O. Dittrich June 3, 2014 CULS in Prague

2. Three basic principals • Access to health care is guaranteed by the state • Health care is provided to the Czech citizens and to other qualified persons through public health insurance system • Health care is provided by the network of independent health facilities which are contracted by the General Health Insurance Fund (Company) or by other health insurance funds (companies)

3. First principle: State guarantees the access to health care The first principle is expressed in the Constitution of the Czech Republic (Ústava ČR) -List of the Basic Human Rights, Article No. 31 (Listina základních práv a svobod, čl. 31): „All citizens have a right for the health protection. Citizens have a right for the health services and health aids provided free of charge (at the point of consumption) with respect to conditions set up by the law “. At present: Act No. 48 / 1998 „Public Health Insurance Act“ ( O veřejném zdravotním pojištění)

4. The second principle: The provision of health care is financed through the public health insurance – according to Public Health Insurance Act No. According to Law the insured are: • All Czech residents • All employees of employers which are registered in the ČR • Dependents of foreigners/EU residents working in the CR; Employers must be registered in the ČR

5. Third principle: the basic relationship - insured, insurance fund (ZP) and contracted health facilities (ZZ) • Insured person – rights and obligations Right to free choice of insurance fund (possibility to change health insurance fund once a year; exceptions = prisoners, soldiers, occupational health services ); right to free choice of physician and health facility, which are in contractual relationship with his./ her insurance fund. Change of physician or health facility is possible once per 3 months Obligation – to pay insurance fees, to adhere to medical procedures {dodrzovat léčebný režim} • Health Insurance Fund(HIF): obligation to assure healthcare for all clients through contracts with health facilities; HIF`s is not allowed to refuse any client; HIF is not allowed to abolish contract with any client. • Health facility: must provide needed healthcare to all insured persons without any extra payment; health care must be “lege artis” =. in accordance with current medical knowledge and medical practice

6. Who are payers of health insurance? • All economically active Czech citizens • State\government (Ministry of Finance) is payer of health insurance for roughly 55% of the population : pensioners, children, students up to 26 years, woman on the maternity leaves, unemployed, prisoners, very low income individuals/living under poverty line. • Individuals without any taxable income: for example students older 26 years, housewives, etc.

7. Healthcare covered by public health insurance • All indicated medical procedures, incl.dental care, diagnostic procedures, long-term care, preventive care and pharmaceuticals, health aids, medical equipments, transport to/from health facility, experts activities, medical check up of dead persons, autopsy

8. Coverage of dental care Health care insurance system in Czech Republic categorizes dental care as follows: • a) dental procedures(fillings, tooth extraction, preventive care..) • b) prosthodontics (dentures and implants, etc.) and orthodontics (braces, etc.) • Reimbursable dental procedures are defined by the extent of the given procedure and also by the material which can be used and they are fully covered by the insurance.

9. The „Above-standard“ Dental Care • Dental procedures using a different materials, or methods other than those procedures on the list of reimbursable dental care are fully paid for by patients. • Dentist has the right to set his own price for the “above – standard” procedures. • Prices vary considerably and depend on local market conditions • Patient can’t combine reimbursable dental care with the above standard procedures. In other words, the patient either pays for the treatment out of the pocket, or he accepts treatment by pre - defined reimbursable dental procedures.

10. Coverage of Dental care • In the case of crowns, bridges, braces and other orthodontics and prosthetics, a part of the dental work can be paid for by the insurance. Rest of the work is paid for by the patient. • Some simple dentures and crowns are also paid for by the insurance in full. • Dentist is obliged to let the patient know about the procedures and prices for that part of the dental work, the patient will need to pay out of his pocket.

11. Healthcare not covered by the health insurance: • Acupuncture, dental procedures as described, cosmetic surgery, homeopathy… (It is specified in Annex of the Public Health Insurance Act) • Medical examinations requested by the patient,butnot medically indicated,

12. Coverage of pharmaceuticals • Three groups of pharmaceuticals: full coverage ; partial coverage ; no coverage • Ministry of Health sets up a list of pharmaceuticals with full and partial coverage (there is a special expert´s committee responsible for the categorization of drugs ) • At least one fully covered pharmaceutical must be included in each indication groups of pharmaceuticals!

13. Uncovered pharmaceuticals • Pharmaceuticals not covered by the health insurance: vitamins, hypnotics,homeopathic, nutrition adds, contraceptives, all nasal drops, common drugs used for intestine disorders ( endiaron, ), some analgetics (např. alnagon, valetol, superpyrin…). • Some pharmaceuticals with no coverage are sold at free market (OTC) and some of them are tied to medical prescription (contraceptives, alnagon).

14. Coverage of health aids and medical devices (in ambulatory care) • 75 % of full price is reimbursed • A list of medical aids fully paid for by patients is published in Annex No. 3 of Public Health insurance Act Details i: www.vzp.cz - legislativa

15. Act No.592/1992 On Public Health Insurance Premium • Insurance premium is set up at 13,5 % of gross wage. Payers of insurance premium are the following subjects: employees, employers, entrepreneurs, individuals without tax-related income • Re-distribution of health insurance premiums on 100% level among health insurance funds (according to age structure of clients)

16. Insurance premium • Employees pay 4,5% + employers 9%; • Entrepreneurs: 13,5% - with a minimum and maximum base for assessment in place • Minimum base in. 2013: =12 971 CZK • Maximum base: 486 000 CZK • Base for the assessment of the insurance premium the government pays for its employees and other public charges is about 5826 CZK • Base for the assessment of the premium due for individuals without any tax-related income is 8500 CZK in 2006