In September 2021, the Czech Parliament adopted a long-awaited, extensive amendment to the Public Health Insurance Act (the Amendment, the Act), which became effective on 1 January 2022. The Amendment introduces several changes, including some significant developments concerning the reimbursement of highly innovative drugs and orphan drugs, the procedure for the exceptional reimbursement of health services pursuant to the well-known Section 16 of the Act, the rules regarding patients’ organisations, and many more.
In this Law-Now article, we briefly highlight the new rules relating to exceptional reimbursement pursuant to Section 16 of the Act. In following Law-Now articles, we will focus on other parts of the Amendment.
Section 16 of the Act regulates the reimbursement of healthcare services which are not otherwise reimbursed through the public healthcare insurance system, provided that the provision of such (non-reimbursed) services is the only treatment option given the patient’s health condition.
Either a patient or a healthcare provider (in practice this is usually the examining physician working for the healthcare provider) can apply for an extraordinary reimbursement to the patient’s respective insurance company. If the insurance company rejects the application or does not give its consent within 15 days, the insurance company must begin official administrative proceedings to decide upon the application. The patient who is seeking reimbursement of their treatment is a participant in the proceedings and the healthcare provider is obliged to cooperate with the patient and the insurance company in the proceedings.
If the insurance company does not approve the application in full, the decision can be appealed. A special commission consisting of four individuals appointed by the director of the respective insurance company and one individual appointed by the Ministry of Health are responsible for deciding on the appeal. As with other administrative decisions, the decision of the commission in regards to the appeal can be further challenged with an administrative lawsuit, which would then be heard in the Czech courts in line with the rules set out in the Administrative Procedure Code.
In conclusion, although the Amendment does not change the nature of exceptional reimbursement pursuant to Section 16 of the Act, it unifies the rules which up until this point have been disjointed and unclear, meaning that each insurance company followed its own internal practices rather than one common procedure.