Table 3.
Entitlements and benefits: services of curative care (HC.1)
| HC | Functional category | Regulatory regimea | Benefit catalogue (regulation no. from Table 2, method of classification, date passed, last updateda), taxonomy | |
|---|---|---|---|---|
| 1.1 | Inpatient curative care | Updating of classification systems for payment purposes (4) | ||
| Acute inpatient care–somatic, intensive care, mental special area: transplantation | 21, Annex 3 (and Annex 8 for high cost high tech interventions; Annex 10 for course-type treatments); itemized by case (linked to diagnosis and therapy); 2 April 1993, 6 August 2004. 26 main groups (major diagnostic categories), altogether with 786 items (DRGs) |
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| 1.2 | Day cases of curative care | |||
| Specialist outpatient care—day surgery | 21, Annex 9; itemized by service; 2 April 1993, 6 August 2004. 227 items in two lists: (a) 194 elective surgical procedures (Sect. I), (b) 33 other (“clinical”) interventions (Sect. III) |
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| Special area: hemodialysis | 21, Annex 11; itemized by service; 2 April 1993, 2 March 2001. 6 items: (a) hemodialysis, hemofiltration, hemodiafiltration; (b) same for patients under 18 years old; (c) peritoneal dialysis, (d) hemoperfusion, (e) hemodialysis with reusable dialysator, (f) mobile treatment |
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| 1.3 | Outpatient care | |||
| 1.3.1 | Basic medical and diagnostic services | |||
| (Curative) primary care | Traditional (2, 4) | – | ||
| 1.3.2 | Outpatient dental care | |||
| Dental prophylaxis, care, surgery | Traditional (2, 4) | 13; itemized by service; 17 December 1997, 1 November 2001. 3 main groups: (a) dental screening, with 7 items in three subgroups; (b) dental emergency services with 10 items; (c) dental primary and secondary care, defined as the payment list, detailed in a separate decree (no. 21) |
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| Updating of classification systems for payment purposes (4) | 21, Annex 12; itemized by service; 2 April 1993, 11 March 2003. 125 items in 10 groups: (a) examinations, documentations, 9; (b) prevention, 5; (c) radiography, 5; (d) anesthesia and drug prescription, 5; (e) tooth preserving services and endodontia, 12; (f) oral diseases and parodontology, 11; (g) dental surgery, 24; (h) dental prosthetics, 26; (i) child, school, and youth dental services, 13; (j) orthodontia, 15 |
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| 1.3.3 | All other specialized health care | |||
| Specialist outpatient care–somatic | Updating of classification systems for payment purposes (4) | 21, Annex 2; itemized by service; 2 April 1993, 27 August 2004. List contains 3,166 (and together with the dispensary specific services 3,204) items (based on the 1978 ICPM of WHO) |
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| Specialist outpatient care–mental; special area: psychoanalysis, -therapy | 21, Annex 15; itemized by service; 11 May 2004. Altogether 120 items (82 items overlap with Annex 2) in five main groups: (a) skin and STD, 29 items; (b) oncology, 26 items; (c) pulmonology, 25 items; (d) psychiatry, 19 items; (e) addictology, 21 items |
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| 1.3.9 | All other outpatient curative care | |||
| Outpatient care by other professionals | Updating of payment classification systems (4) | As with 1.3.3, which are included (e.g., logopedia, physiotherapy, dietetics, optometry, acupuncture); the rest are implicitly excluded (e.g., chiropody, bioenergy treatments, iris diagnostics, hydrotherapy) | ||
| Alternative and complementary medicine | ||||
| Special area: balneotherapy and physiotherapy | Traditional (4) | 11 (definition of entitlements, regulation of prescription, utilization, and professional requirements); itemized by service; indications and contraindications; 9 November 2004. Annex 1, balneotherapy services, 10 items; Annex 4, physiotherapy services, 13 items; Annexes 5 and 6, indications and contraindications |
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| Price negotiations (4) | 18; itemized by service; 19 September 2003. 3 groups with the same 10 items; copayment is different for spas, which have national, regional, and local qualification |
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| 1.4 | Services of curative home care | Traditional (4) | 23, Annex 1 (specifies professional requirements); itemized by service; 26 July 1996, 9 June 1999. 13 service categories, 22 items (includes hospice at home) |
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a Benefit catalogues with the traditional regulatory regime are updated on an ad hoc basis, while the updating of payment lists is regular. All benefit catalogues are issued as ministerial decrees.