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Description of the Procedure for Exercising Compulsory Health Insurance Rights

by Floreena Thomas - 17 Jun 2022, Friday 318 Views Like (0)
Description of the Procedure for Exercising Compulsory Health Insurance Rights

Description of the procedure for exercising compulsory health insurance rights

Insured persons exercise their rights from compulsory health insurance through an administrative procedure based on a complete application submitted with submitted documentation.

The request is completed with the submitted documentation, and the insured person submits to the Regional Unit of the Fund in which he is presented in the compulsory  health insurance.

As a body of the first instance, the regional unit of the Fund starts the procedure for deciding with a confirmation of the factual situation based on the request and evidence (appendices) to the request.

The regional unit must prepare the decision within 30 days and, if necessary, the opinion of the Fund's medical commission within 45 days from the day of submission of the request. The same must be submitted to the requesting party.

The insured person has the right to appeal the decision of the body of the first instance, within 15 days from the receipt of the decision, to the Minister of Health of the Republic of Macedonia, who decided in the second instance.

An administrative dispute may be brought before the Administrative Court of the Republic of Macedonia against the final decision of the Minister of Health.

Until the regional unit of the Fund does not bring the decision for the realization of compulsory health insurance, i.e., does not bring the decision for rejection of the request within the deadline determined by law, the applicant has the right within three working days after the expiration of the deadline. They are defined by statute as bringing the decision to request deciding the archive of the Fund to the Director of the Fund.

The request is made in completed form - Request Form BD (Request for decision making after the proposal submitted for the realization of the right from compulsory health insurance), where the Director of the Fund is obliged to decide within five days.

All forms for realizing health insurance rights can be found at the counters of regional units and on the Fund's website, where they can be obtained and completed electronically.

Participation of insured persons - participation

Exemption from participation

The following are exempted from participation following Article 34 of the Law on Health Insurance:

  • persons insured for medical examination at the chosen doctor and emergency calls for medical assistance;
  • children with special needs, according to the principles of social care;
  • users of continuing social assistance, persons placed in social care institutions and other families, according to the principles of social care, except for drugs from the list of prescription drugs in primary health care and for treatment abroad;
  • mentally ill persons placed in psychiatric hospitals who have no parental care and
  • Insured persons who during the calendar year have paid participation in special care - consultative and hospital health care, except for drugs from the list of prescription drugs in primary health care and for treatment abroad, with much higher than 70% of the average salary of the Republic, during the last year.

Children up to 18 and insured persons who need prostheses for upper and lower extremities, orthopedic equipment and wheelchairs, and medical aids for functioning physiological discharges are also exempted from participation.

Programs for preventive health care and treatment of certain serious diseases that aim at health care of the entire population, approved by the Government of the Republic of Macedonia, are implemented and are under the jurisdiction of the Ministry of Health of the Republic of Macedonia.

Participation fee

Insured persons participate with personal means while using health services and drugs, but up to 20% of the average value of the total cost for health services, i.e., drugs.

For health services for approved overseas treatment, the insured person participates with 20% of the total cost.

The amount of participation in fixed amounts, despite the proportionality of service prices, is verified by the FUND.

Insured persons participate up to 50% of the verified price of prostheses, orthopedic equipment, and other assistive devices and medical tools made of standard materials.

The amount of participation is verified by the Fund with a general act.