HEALTH INSURANCE

A health insurance policy consists of a basic programme, which is often combined with one or more supplementary programmes. The basic programme is essentially the part of the policy that provides coverage for essential services and typically includes:

Reimbursement of patient co-payments – when receiving state-funded healthcare services, part of the cost must still be covered by the patient. Within the insurance policy, any patient co-payment made is reimbursed in full; therefore, personal funds do not need to be spent even on relatively small amounts.

Coverage of paid outpatient services:

• Consultations with general practitioners, associate professors, professors, and various medical specialists are reimbursed without a referral from a doctor. This means that waiting in line for a state-funded consultation is not necessary — when booking an appointment, a paid service provider may be chosen.

• Instrumental (diagnostic) examinations – if a doctor refers the insured person for high-cost examinations such as magnetic resonance imaging (MRI), ultrasound, X-ray, etc., the insurance will cover the cost of the examination, provided that the referral can be presented.

• Laboratory tests – a wide range of laboratory examinations prescribed by a doctor are reimbursed. In this case as well, a referral must be submitted to the insurer.

• Medical procedures – various treatment procedures are covered, such as injections, blockades, punctures, irrigations, wound treatment, and similar procedures.

• Emergency medical assistance – although emergency services are generally free of charge, in cases where payment is required, these expenses are also reimbursed. The policy may include coverage for both public and private emergency service call-outs.

• Medical certificates (e.g. for firearm acquisition or driver medical commissions), as well as mandatory health examinations, are usually reimbursed either in full or up to a specified limit.

• Vaccinations – the specific vaccinations covered under the policy are determined individually by each insurer. Typically, certain vaccines are covered, but it is also possible to include broader vaccination coverage with a defined limit.

• Physical therapy procedures – the basic programme may include coverage for physiotherapy, usually allowing reimbursement for up to 10 procedures within one diagnosis.

Coverage of paid inpatient services – the policy covers hospitalisation with a doctor’s referral, including the costs of planned surgery, medical consultations, procedures, medications, and other services received in day-care or overnight inpatient facilities, including the option of an upgraded (higher service level) hospital room. As inpatient services may be complex and costly, the cost estimate for each operation must be agreed with the insurer a few days prior to the scheduled procedure.

The basic programmes of health insurance policies are divided into three types — 100% reimbursement programmes, price-list programmes, and percentage-based programmes:

• 100% reimbursement programmes – the main feature is full reimbursement of medical services in institutions with which the insurer has concluded cooperation agreements (so-called network providers). Services received outside these institutions (out-of-network providers) are reimbursed according to a price list, i.e. medical expenses are covered up to the limits specified in the price list.

• Price-list programmes – the principle is similar to receiving services outside network providers. In such programmes, each category of services has a defined reimbursement limit. If the cost of a service exceeds this limit, the remaining amount must be paid by the insured person. Price-list policies are often less expensive; however, this does not necessarily mean they are less beneficial, as limits are often set at a level that allows most services to be covered without out-of-pocket expenses. If a chosen medical provider charges more than the limit specified in the policy, it is advisable to select another provider where the service cost falls within the policy limits and is therefore fully reimbursable.

• Percentage-based programmes – the principle is straightforward: the insurer reimburses, for example, 50% or 70% of the cost of services. An exception is the patient co-payment, which is always reimbursed in full, as well as certain elements of the basic programme that may have separate reimbursement conditions.

Basic programmes of health insurance policies. If the basic programme can be compared to a fire brigade that extinguishes an already burning house, then supplementary programmes can be likened to smoke detectors. In other words, the purpose of supplementary programmes is to provide preventive support for maintaining health at a good level — these are additional services that can significantly improve a person’s well-being and quality of life. The following supplementary programmes may be added to a health insurance policy:

• Dental coverage – dental services are reimbursed at 50% of the amount indicated on the receipt issued by the dentist or dental hygienist.

• Outpatient rehabilitation – during the policy period, expenses for therapeutic exercise sessions, medical massages, hydrotherapy procedures, and physiotherapist consultations are reimbursed up to a specified limit.

• Inpatient rehabilitation – if a rehabilitation course is required following inpatient treatment, these expenses are reimbursed within the sum insured upon submission of the receipt, referral, and hospital discharge documentation to the insurer.

• Medication coverage – the policy reimburses 50% of the cost of prescribed medications based on the pharmacy receipt.

• Optical goods coverage – based on a prescription issued by an optometrist or another medical specialist, the policy reimburses part of the cost of contact lenses or optical glasses.

• Paid pregnancy care – reimburses paid services related to pregnancy care.

• Paid childbirth coverage – the policy covers paid inpatient childbirth services, including the participation of a doctor or midwife of the insured person’s choice, anaesthesia, and hospital stay.

• Critical illness insurance – upon first diagnosis of a life-threatening illness (such as cancer, stroke, myocardial infarction, etc.), a fixed indemnity amount is paid, typically a four-digit sum.

• Sports activity coverage – if the insured person wishes to attend a gym, aerobics classes, swimming pool, or other sports facilities, the policy covers a specified number of visits or the purchase of a membership during the insurance period.