Health insurance system in CZ
- Last Updated: Saturday, 10 May 2008 05:10
A Brief Summary of the Czech Public Health Insurance System:
1. Who is insured?
The Czech public health insurance system is based on obligatory participation of insured persons . There is no possibility of voluntary participation. Every person is insured individually, there are no derived rights („family insurance“) in cases limited to the territory of Czech Republic.
The following persons are obligatorily insured only according to the national law:
- People with the permanent residence in the territory of the Czech Republic (automatically all the Czech citizens)
- Employees of employers based in the territory of the Czech Republic
The following persons are also obligatorily insured on the basis of European social security coordination rules (EU Regulation 883/2004 and 987/09) and principle of equal treatment with Czech citizens:
- self-employed persons from other EU - countries, active in the territory of Czech Republic and covered by Czech social security legislation
- employees from other EU states, working on Czech territory for employer based in other EU- country, if they are covered by Czech social security legislation
- non-active family members of migrant workers from other EU states insured in the Czech Republic
2. Who pays the contributions?
1. The employee and employer pay altogether 13.5% of the gross income of the employee. The employee pays 4.5% and the employer 9% of it. Overall amount of contribution is paid to the fund of employee by his/her employer.
2. Self-employed persons pay 13.5 % of 50% of their profit. The minimum contribution is 1752 CZK per month.
3. People without a taxable income (f.e. housewives) pay their contributions themselves. The monthly contribution is 1148 CZK.
4. The State pays the contributions for unemployed, pensioners, students, women on the maternity leave, women taking care of one child less than 7 years old or more children less than 15 years old, prisoners, soldiers and people receiving social security benefits.
The State pays the contributions for 58% of the population. The amount of state contribution is regulated by Czech government. At present the State pays for the state insured persons 787 CZK per month.
Every health insurance company collects the contributions directly from employers, employees, self-employed and people without a taxable income.
The State pays the contributions to the so called Redistribution Fund. The collected contributions are divided to the individual health insurance companies.
3. Health Insurance Structure:
The Czech health insurance system is administered by seven health insurance companies.
The biggest one, Všeobecná zdravotní pojišťovna /The General Health Insurance Company/, covers approx. 60% of the population. Its ability to pay is guaranteed by the State. Its activities are governed by a special law called Act on the General Health Insurance Company. The other health insurance companies are governed in their activities by the Act on Employee Insurance Companies.
Each insured person can change his/her health insurance company once a year.
Health insurance companies are not allowed to make profit.
Although it was the original intention that health insurance companies should be competitive in their various services, they don’t have much space for their competition at present.
4. Healthcare Covered by Health Insurance
- preventive care
- diagnostic care
- ambulant and hospital care, including rehabilitation and care of chronic diseases
- dental care
- medicines and medical aids
- patient transport
- spa care
Only the basic material and treatment is paid in the case of a dental treatment.
Only a small part of healthcare is excluded from the health insurance, for example cosmetic surgery without any health reason.
Medical aids are paid from the health insurance fully or partially.
5. Contracts with Healthcare Providers
There are regular frame negotiations among the representatives of healthcare providers, health insurance companies, hospital associations, scientific organisations and patient associations. The so called framework contracts are the result of these negotiations.
The health insurance companies make their own contracts with particular healthcare providers based on these framework contracts. The conditions set in these individual contracts can be partly different.
A healthcare provider can make a contract with more or even with all of the health insurance companies.
Only a very small percentage of healthcare providers has no contract with any health insurance company.
Healthcare costs are paid to contracted provider directly by health insurance company (patient mostly doesn´t need to pay any part of the cost to provider).
6. Financial participation of the patient
Every insured person (or his/her legal representative) is obliged to pay the regulation charge to the healthcare provider for the medical treatment provided by him. There are two levels of the regulation charges:
1) 30 CZK
- for the visit at a general practitioner, pediatrist, gynaecologist, dentist, specialist (outpatient care), during which a clinical investigation has been made. Children up to 18 years of age are not obliged to pay.
- for issued prescription of medicament that is fully or partially covered by the health insurance or nourishment for special medical purposes, irrespective of the number of prescribed packages or medicaments on the prescription.
2) 90 CZK
- for emergency care that was provided by the first aid medical service including first aid medical service provided by the dentists,
- for hospital emergency service provided on Saturday, Sunday and holidays and in working days from 17.00 to 7.00 unless the insured person is subsequently admitted to a hospital.
The legal act also exhaustively mentions the exceptions from this rule, when the insured person does not have the obligation to pay the regulation charges – for example for some preventive examinations (inspections), dialysis, protective treatment ordered by a court, obligatory treatment of an infectious disease etc.
The overall limit of 2.500 and 5.000 CZK
If the total amount of regulation charges paid by the insured person (or his/her legal representative) exceeds 5.000 CZK per a calendar year, the health insurance company is obliged to pay the insured person (or his/her legal representative) back the exceeding amount no later than 60 days after the end of the calendar quarter in which the limit was exceeded.
The overall limit for children under the age of 18 and for pensioners above the age of 65 is 2.500 CZK per a calendar year.
Only the following regulation charges are counted into the overall limit: regulation charges of 30 CZK and supplementary payments for prescribed medicaments and nourishments fully or partially covered by the health insurance that were issued on the territory of the Czech Republic.
The healthcare provider has to issue a document confirming a payment of the regulation charge only upon a request of the insured person (or his/her legal representative).
7. Overall expenses of the health insurance system
The yearly expenses of the Czech health insurance system represent about 9 billion EUR (Overall healthcare expenses represent 10 billion EUR).
The average yearly expenses of health insurance funds are about 900 EUR per capita.
The financial participation of patients in overall costs of healthcare is about 17 % in average. It concerns medicaments and dental care above all.