Atspausdinta iš e-seimas.lrs.lt

Republic of lithuania

 

LAW

 

ON

 

HEALTH INSURANCE

 

 

 

CHAPTER I

GENERAL PROVISIONS

 

Article 1. Purpose of the Law

 

The Law establishes the types of health insurance, the compulsory health insurance system: persons covered by compulsory health insurance, principles of the compulsory health insurance fund formation and compensation of individual health care service costs with the compulsory health insurance fund resources, institutions which transact compulsory health insurance, the rights and duties of the insured persons and health care institutions in compulsory health insurance, and the procedure of dispute settlement.

 

Article 2. Types of Health Insurance

 

1. Health insurance is:

1) compulsory; and

2) additional (voluntary) insurance.

2. Compulsory health insurance is a State-established system of individual health care and economic measures which guarantee, in accordance with the principles and terms and conditions laid down by this Law, the provision of individual health care services to persons covered by compulsory health insurance and reimbursement of the provided services costs.

3. Additional (voluntary) health insurance means individual health care services specified in additional health insurance contracts, the costs whereof are reimbursed under the contracts upon the happening of the insured event covered by additional health insurance. Additional health insurance shall be effected in accordance with the procedure established by this Law, the Law on Insurance and other statutory acts.

4. The provision of individual health care services and reimbursement of costs of services provided to persons insured by other types of compulsory insurance shall be regulated by other laws and statutory acts.

 

Article 3. Institutions Effecting Compulsory Health Insurance

 

1. Compulsory health insurance shall be transacted by the following institutions:

1) Compulsory Health Insurance Council at the Government of the Republic of Lithuania (hereinafter - Compulsory Health Insurance Council);

2) National Patients’ Fund (hereinafter - NPF);

3) territorial patients’ funds (hereinafter - TPF).

2. The activities of institutions effecting compulsory health insurance shall be determined by this Law and other statutory acts.

 

Article 4. Compulsory Health Insurance Insured Events

 

Compulsory health insurance insured events are health disorders or state of health of individuals insured by compulsory health insurance which are specified in this Law and diagnosed by a medical doctor and which entitle the persons covered by compulsory health insurance to be provided individual health care services provided for by this Law and other statutory acts. The health care service costs shall be paid under established terms and conditions from the compulsory health insurance fund budget.

 

Article 5. The Insured and Persons Covered by Compulsory Health Insurance

 

1. Citizens of the Republic of Lithuania and foreign nationals as well as stateless persons who are permanent residents in the Republic of Lithuania shall be insured under the compulsory health insurance plan (hereinafter - the insured).

2. Citizens of the Republic of Lithuania who are in countries with which the Republic of Lithuania has signed agreements concerning compulsory health insurance shall be insured by compulsory health insurance in accordance with said agreements.

3. The following persons shall be considered as persons covered by compulsory health insurance (hereinafter - the covered persons) :

1) persons for whom compulsory health insurance contributions specified in paragraphs 1, 2, 3 and 5 of Article 16 of this Law are paid;

2) persons who pay compulsory health insurance contributions provided for in paragraphs 4, 5 and 6 of Article 16 of this Law;

3) persons listed in paragraph 4 hereof who are insured with public funds.

4. The following persons shall be considered as the covered persons insured with public funds (except those, listed in sub-paragraphs 1 and 2 of paragraph 3 hereof):

1) persons entitled to any type of pension;

2) persons of working age who are registered with the employment service of their place of residence as willing and able to accept suitable work as well as their dependent family members;

3) expectant mothers on maternity leave determined by law;

4) mothers (fathers in single-parent family) until their children become 8 years of age, and also mothers (fathers in single-parent family) with two or more children until the latter become of age;

5) persons under the age of 18 years;

6) full-time students of schools of general education, professional education, higher schools and higher educational institutions;

7) persons supported by the state who are entitled to social benefit;

8) persons with group I and group II disability and unemployed persons with group III disability;

9) persons ill with diseases which are on the list compiled by the Ministry of Health;

10) person whose health has been impaired by a crime, provided that, according to the procedure laid down by statutory acts, said persons are the injured party or witnesses in a criminal case;

11) rehabilitated political prisoners, deportees and persons who suffered injuries during the events of January 13th, 1991 and other events while defending Lithuania’s independence and statehood;

12) persons who contributed to the mitigation of consequences of nuclear accident at the Chernobyl nuclear power plant;

13) former inmates of the ghetto and juvenile prisoners of the fascist forced confinement institutions;

14) other persons who are fit for work but are unemployed for valid reasons specified by law.

5. Medical service costs of the Ministry of National Defence and Ministry of the Interior servicemen who are on the active list, and also medical service costs of persons detained by the police or kept in places of pre-trial detention as well as those of convicted prisoners shall be covered with the National Budget funds in the manner laid down by the Government.

 

Article 6. Registration of Persons Insured by Compulsory Health Insurance

 

1. Persons insured by compulsory health insurance shall be registered and their registration shall be kept by the TPF.

2. A single social insurance and compulsory health insurance certificate shall be introduced. It shall be issued to each citizen of the Republic of Lithuania who is of age and to foreign nationals and stateless persons who are permanently residing in the Republic of Lithuania. The certificate shall entitle the insured to choose, in the manner laid down by statutory acts, a health care institution with which the TPF has concluded a contract pursuant to Article 25 of this Law.

3. The procedure of registration of persons insured under the compulsory health insurance plan as well as of introduction, issuing and filling out of the single social insurance and compulsory health insurance certificates shall be approved by the Government on the recommendation of the Ministry of Health and Ministry of Social Security and Labour.

 

Article 7. Compulsory Health Insurance Validity Verification

 

1. State tax inspectorates and State social insurance institutions shall check the payment of compulsory health insurance contributions. State tax inspectorates and State social insurance institutions must verify the information submitted by the NPF and TPF concerning failure to pay insurance contributions. State tax inspectorates and State social insurance institutions must furnish the information and document copies required by the NPF and TPF.

2. If the cost of individual health care services provided to an insured person during a calendar month exceeds 25 MLS (minimum living standard), the person’s payment of the compulsory health insurance contributions must be checked. If the cost of individual health care services provided to an insured person does not exceed 25 MLS, the payment of compulsory health insurance contributions shall be checked selectively.

3. If it is established that a person has not paid all compulsory health insurance contributions, he shall not be considered as covered by insurance from the moment he stopped payment of contributions prescribed by paragraphs 4, 5, and 6 of Article 16 of this Law or from the moment payment for him of contributions specified in paragraphs 1, 2, 3, and 5 of Article 16 of this Law is stopped.

4. The person who is not considered the covered person under paragraph 3 hereof shall be again deemed covered from the day said person liquidates his arrears in payments to the compulsory health insurance fund budget and resumes payment of contributions prescribed by paragraphs 4, 5, and 6 of Article 16 of this Law or when arrears in payments for him to the compulsory health insurance fund budget are fully liquidated and payment of contributions specified in paragraphs 1, 2, 3, and 5 of Article 16 is resumed.

5. Individual health care service costs, except for the necessary medical treatment financed from the compulsory health insurance fund budget and provided to a person not considered the covered person, shall be paid to the territorial patients’ fund by the person who pays for himself when he is the payer of the contribution prescribed by paragraphs 4, 5, and 6 of Article 16 of this Law or by the payers of contribution specified in paragraphs 1, 2, 3, and 5 of Article 16 of this Law when they pay for the persons receiving individual health care services.

6. All unpaid amounts due for individual health care services and as well as those payable as compulsory health insurance contributions shall be collected from persons in accordance with the procedure established by this Law and other laws and statutory acts.

 

 

CHAPTER II

COMPULSORY HEALTH INSURANCE SERVICES

AND REIMBURSEMENT OF THEIR COSTS

 

Article 8. Individual Health Care Services Paid for with the Compulsory Health
                            Insurance Fund Budget Resources

 

1. The costs of the following individual health care services shall be covered from the compulsory health insurance fund budget: preventive medical assistance, restorative medical assistance, medical rehabilitation, nursing, social services attributed to individual health care, and individual health examination.

2. The costs of the following preventive medical assistance shall be covered from the compulsory health insurance fund budget:

1) provision of information on the issues of disease prophylaxis;

2) prophylactic health check-ups of the insured prescribed by the Compulsory Health Insurance Council the procedure whereof shall be regulated by the Ministry of Health.

3. The following types of restorative treatment shall be financed from the compulsory health insurance fund budget:

1) individual health care services provided on the primary, secondary and tertiary levels of health activities;

2) assistance prescribed by this Law to be given to the insured in relation to the making of limb, joint and organ prosthetics and assistance in the acquisition of dental prosthesis;

3) assistance prescribed by this Law for the insured of the categories specified by the Compulsory Health Insurance Council in the acquisition of spectacles and hearing aids;

4) reimbursement of expenses for the insured related to the purchasing of medicines and medical aids acquired for out-patient treatment.

4. Medical rehabilitation, nursing, and social services attributed to individual health care, which are financed from the compulsory health insurance fund budget, shall comprise:

1) nursing and social services at supportive hospitals for a period not exceeding 4 months per calendar year;

2) medical rehabilitation, including treatment at sanatoria/resorts.

5. The costs of the following individual health examination services shall be covered from the compulsory health insurance fund budget:

1) temporary disability examination of the insured:

2) long-term and total disability examination of the insured;

3) an autopsy in case of death.

6. Individual health care services the costs whereof are covered from the compulsory health insurance fund budget shall be specified in the list of individual health care services financed with the compulsory health insurance fund budget resources. The list of individual health care services the costs whereof are covered from the compulsory health insurance fund budget shall be approved by the Ministry of Health on the proposal of the Compulsory Health Insurance Council.

7. The list of individual health care services financed from the compulsory health insurance fund budget shall be specified in detail in contracts concluded by the TPF with health care institutions. The criteria for drawing up a detailed list of individual health care services financed from the compulsory health insurance fund budget shall be approved by the Ministry of Health on the proposal of the Compulsory Health Insurance Council.

8. The State shall assign to the compulsory health insurance fund the function to dispose of the funds designated for (free) individual health care supported by the State.

 

Article 9. Reimbursement to the Insured of Medicines and Medical Aids
                            Purchasing Expenses

 

1. The expenses incurred by the insured in relation to the purchasing of the essential medicines and medical aids prescribed, in the established manner, for out-patient treatment shall be reimbursed in accordance with the list approved by the Ministry of Health on the proposal of the Compulsory Health Insurance Council. The list of the essential medicines and medical aids shall be compiled by the Ministry of Health on the proposal of the Compulsory Health Insurance Council. Expenses incurred in relation to the acquisition of medicines and medical aids essential for out-patient treatment shall be reimbursed according to the basic cost calculated by the Ministry of Health in accordance with the procedure laid down by the Government.

2. The basic cost of the essential medicines and medical aids shall be reimbursed in full to the following insured persons:

1) children under the age of 3 years;

2) persons with group I disability; and

3) persons who fall ill with diseases included in the list approved by the Ministry of Health and Ministry of Social Security and Labour.

3. 80% of basic cost of medicines and medical aids shall be reimbursed to:

1) children in the age group from 3 to 7 years; and

2) persons with group II and group III disability and other unemployed persons who either receive or are entitled to state social insurance pension.

4. The procedure for reimbursing the expenses connected with the purchasing of the essential medicines and medical aids required for out-patient treatment shall be laid down by the Ministry of Health .

5. For the insured who are hospitalised in in-patient individual health care institutions the costs of medicines and medical aids shall be paid from the compulsory health insurance fund budget, except in cases where the insured person chooses, on his own initiative and following his physician’s recommendation, more costly medicines or medical aids compared to those used in the Republic of Lithuania in accordance with the established methods of treatment. In such case the insured must pay the health care institution the difference in the price of the medicine or medical aid prescribed by the physician and that chosen by the insured.

 

Article 10.   Reimbursement for the Insured of Expenses Related to Treatment
                               at Sanatoria/Resorts

 

1. Children under 7 years of age and disabled children under 16 years of age shall be reimbursed for the total basic cost of treatment at sanatoria/resorts provided that the child is proceeding to undergo treatment under a separate individual voucher; total basic cost shall also be reimbursed to persons with group I disability, persons who are sent to complete treatment after a severe disease that is on the list approved by the Ministry of Health and Ministry of Social Security and Labour.

2. Children under 7 years of age and disabled children under 16 years of age shall be reimbursed 90% of the total basic cost of treatment at sanatoria/resorts provided that the child is proceeding to undergo treatment under a general voucher together with other insured persons.

3. The insured persons who receive or are entitled to state social insurance pensions shall be reimbursed 80% of the basic cost of treatment at sanatoria/resorts.

4. Other insured persons who are sent to sanatoria and resort medical institutions according to the procedure established by the Ministry of Health shall be reimbursed 50% of the fixed basic cost of treatment at sanatoria/resorts.

5. The basic sanatoria/resort treatment cost shall be calculated by the Ministry of Health in accordance with the procedure established by the Government of the Republic of Lithuania. Compensation for sanatoria/resorts treatment shall be paid only for one medical treatment course at sanatoria/resorts per calendar year.

6. The procedure for granting and paying out compensations for the expenses incurred while undergoing sanatoria/resort treatment shall be established by the Government.

 

Article 11.   Reimbursement of Expenses Related to the Limb, Joint and Organ
                               Prosthetics and of Prostheses Purchasing Expenses

 

The procedure for reimbursing the insured persons for the expenses related to limb, joint and organ prosthetics and for expenses related to the acquisition of prosthesis shall be laid down by the Government of the Republic of Lithuania.

 

 

CHAPTER III

FINANCES OF COMPULSORY HEALTH INSURANCE

 

Article 12. Financial Basis of Compulsory Health Insurance

 

The financial basis of compulsory health insurance shall be the independent state compulsory health insurance fund budget which is not included in the National and municipal budgets.

 

Article 13. Compulsory Health Insurance Fund Budget

 

1. The budget of the compulsory health insurance fund and the annual budget report shall be approved by the Government of the Republic of Lithuania.

2. The budget of the compulsory health insurance fund shall be drawn up for a calendar year period. Every year the budget and its implementation report shall be publicly announced in accordance with the procedure established by the Government of the Republic of Lithuania.

3. The draft budget of the compulsory health insurance fund as well as its annual implementation report shall be drawn up and presented to the Government of the Republic of Lithuania for approval by the Compulsory Health Insurance Council.

4. Regulations for drawing up and implementing the compulsory health insurance fund budget shall be approved by the Government of the Republic of Lithuania.

 

Article 14. Compulsory Health Insurance Fund Budget Revenue

 

1. Compulsory health insurance fund budget revenue shall consist of :

1) compulsory health insurance contributions of the covered persons;

2) National Budget contributions for the covered persons insured with Public funds;

3) earnings of the institutions transacting compulsory health insurance;

4) additional allocations from the National Budget ;

5) voluntary contributions of natural and legal persons;

6) amounts collected by the TPF from health care institutions for unlawfully provided individual health care services.

2. The Seimas of the Republic of Lithuania shall grant additional allocations from the National Budget to the compulsory health insurance fund budget if, due to reasons unforeseen at the moment of budget approval, the budget expenditure increases or income decreases and the fund budget is not in the position to fulfil all obligations determined by this Law.

3. The Seimas may allocate National Budget funds for the entire amount or a certain part of the compulsory health insurance contributions of the farmers provided for by paragraph 5 of Article 16 of this Law.

 

Article 15.   Contributions from the National Budget into the Budget
                               of the Compulsory Health Insurance Fund

 

1. Each year when passing the National Budget the Seimas of the Republic of Lithuania shall approve, on the proposal of the Government, the amount of contribution into the compulsory health insurance fund for each covered person insured with public funds.

2. The procedure for paying the total amount of the National Budget funds transferable to the compulsory health insurance fund for the covered persons insured from public funds shall be laid down by the Government.

 

Article 16. Compulsory Health Insurance Contributions

 

1. Enterprises, institutions and organisations shall pay compulsory health insurance contributions amounting to 3% of the wage for persons who work under employment contract or on membership basis in elective institutions and receive remuneration for their work.

2. For persons receiving remuneration in connection with labour relations at enterprises, institutions and organisations within the territory of the Republic of Lithuania and enterprises, institutions and organisations of the Republic of Lithuania located abroad, the enterprises, institutions and organisations shall pay compulsory health insurance contributions equal to no less than 30% of the amount payable as natural persons income tax.

3. Partnerships and owners of individual (personal) enterprises (sole proprietorships) shall pay for partnership members and owners of individual (personal) enterprises (sole proprietorships) compulsory health insurance contributions equalling to at least 30% of the natural persons income tax amount calculated for partnerships and individual (personal) enterprises (sole proprietorships).

4. Self-employed persons shall pay for themselves compulsory health insurance contributions equalling to at least 30% of the natural persons income tax amount.

5. Farmers shall pay for themselves and for their family members of legal age working on the farm compulsory health insurance contributions in the amount of 10% of their declared income (not less than the minimum wage as fixed by law).

6. Persons who do not fall within the categories of the covered persons specified in paragraphs 1, 2, 3, 4, and 5 hereof and paragraph 4 of Article 5 of this Law shall pay for themselves compulsory health insurance contributions in the amount of the average wage of the previous month as announced by the Department of Statistics.

Article 17. Procedure of Payment of Compulsory Health Insurance Contributions

 

1. The payers of compulsory health insurance contributions specified in Article 16 of this Law shall themselves calculate the amount of compulsory health insurance contributions and shall transfer said amounts to the account of the compulsory health insurance fund budget.

2. Compulsory health insurance contributions payment dates and procedure shall be determined by the Government.

 

Article 18.   Responsibility for Payment of Compulsory Health Insurance
                               Contributions

 

1. Delay in the payment into the compulsory health insurance fund budget of compulsory health insurance contributions provided for by Article 16 of this Law shall incur 0.2% interest for each day of delay.

2. In the event of unlawful underpayment or non-payment of contributions the total unpaid or underpaid amount and a penalty double the unpaid amount shall be collected.

3. The contributions not paid by the due date, interest and penalties shall be collected without suit, but for no longer than the last 2-year period. In any case interest and penalties shall be paid first.

4. Contributions, interest and penalties shall be collected without suit into the compulsory health insurance fund budget.

5. Correctness of payment of contributions prescribed by paragraphs 1 and 5 of Article 16 of this Law shall be checked by state social insurance institutions, and of those prescribed by paragraphs 2, 3, 4 and 5 of this Law - by State Tax Inspectorate.

 

Article 19.   Relations between the Institutions Effecting Compulsory Health
                               Insurance and Lithuania’s Banking Institutions

 

1. Lithuania’s banking institutions shall perform operations with the compulsory health insurance fund budget resources free of charge.

2. When closing the accounts of economic entities, banking institutions must demand that the TPF, the State Tax Inspectorate and the state social insurance institution present certificates testifying that the economic entity has no debts to the National Budget and compulsory health insurance fund budget.

3. Banking institutions shall give priority to the claims of the State Tax Inspectorate and state social insurance institutions for the collection of the compulsory health insurance fund budget sums in proportion to the amount of debt to the compulsory health insurance fund budget and State social insurance fund.

4. Lithuania’s banking institutions which violate the provisions hereof and inflict damage on the compulsory health insurance fund budget must compensate for the damage in accordance with the procedure established by laws and other statutory acts.

 

Article 20. Compulsory Health Insurance Fund Budget Expenses

 

1. Compulsory health insurance fund budget expenses shall comprise:

1) payment from the compulsory health insurance fund budget to the health care institutions contracted by the TPF of individual health care service costs specified by this Law;

2) reimbursement to the insured persons in accordance with the procedure established by this Law of expenses related to the purchase of medicines and medical aids;

3) reimbursement to the insured persons in the manner established by this Law of sanatoria/resort treatment costs;

4) compensation to the insured persons of expenses related to limb, joint and organ prosthetics and prosthesis acquisition costs;

5) payment of business expenses of institutions which effect compulsory health insurance.

2. On the decision of the Compulsory Health Insurance Council the compulsory health insurance fund budget resources may be allocated to finance national and municipal health programmes.

3. The NPF and TPF may use up to 2% of the compulsory health insurance fund budget resources for business expenses.

 

Article 21. Compulsory Health Insurance Fund Budget Reserve

 

1. In order to stabilise compulsory health insurance budget the NPF shall build up a reserve which must not exceed 10% of the amount of the annual compulsory health insurance fund budget revenue. The reserve shall be built up from the share of revenue which exceeds the expenses.

2. The procedure for building up the reserve of the compulsory health insurance fund budget shall be approved by the Compulsory Health Insurance Council.

3. On the decision of the Compulsory Health Insurance Council, the reserve funds may be used to defray expenses which could not be foreseen at the moment of the compulsory health insurance fund budget approval, also to cover temporary deficiency of revenue.

4. The regulations of the compulsory health insurance budget reserve shall be subject to approval by the Compulsory Health Insurance Council.

 

Article 22.   Use of Compulsory Health Insurance Budget Reserve and Other
                               Temporarily Idle Money of the Compulsory Health Insurance
                               Fund Budget

 

1. The NPF and TPF must keep the compulsory health insurance budget reserve and other temporarily idle money of the compulsory health insurance fund budget in banking institutions where the Government holds over 50% of shares or invest them in Government or Bank of Lithuania securities. The income received must be used for the needs of the compulsory health insurance.

2. Operations with temporarily idle money of the compulsory health insurance fund budget shall be controlled by the Compulsory Health Insurance Council.

Article 23. Operating Cash

 

1. Operating cash shall be provided for in the compulsory health insurance fund budget. It shall be formed from the balance of the compulsory health insurance fund budget resources and, should it prove insufficient, from the planned compulsory health insurance fund budget resources. The amount of operating cash shall be determined when approving the compulsory health insurance fund budget.

2. Operating cash shall be used for covering temporary operating cash deficiency and must be refunded not later than by the end of the budget year.

 

Article 24.   Procedure for Determining the Basic Costs of Individual Health
                               Care Services Covered from the Compulsory Health Insurance
                               Fund Budget

 

1. Basic costs of individual health care services covered from the compulsory health insurance fund budget shall be determined by the Ministry of Health upon co-ordination with the Compulsory Health Insurance Council, the NPF and the TPF. If the rate of inflation is higher 10% per quarter, basic costs of individual health services covered from the compulsory health insurance fund budget must be subjected to indexing at least once per quarter.

2. The methods for determining the basic costs of individual health care services paid for with the compulsory health insurance fund budget resources shall be approved by the Government of the Republic of Lithuania on the recommendation of the Ministry of Health.

 

Article 25. Contracts between the TPF and Health Care Institutions

 

1. Payment of the individual health care costs of the insured shall be based on the contract between the TPF and health care institutions. The TPF must conclude contracts with state and municipal individual health care institutions, also with individual health care institutions accredited in the manner prescribed by the Government and having a licence to practice individual health care. All the covered persons shall have the right of access to a copy of the contract between the TPF and health care institutions.

2. The terms of the contract between the TPF and health care institutions and the contracting procedure shall be laid down in this Law, the Civil Code and other statutory acts. The following shall be specified in the contracts:

1) requisites of the contracting parties;

2) the number of the covered persons;

3) amount of the insurance contributions and the procedure of payment;

4) duration of the contract;

5) liability of the parties;

6) procedure for changing the terms of the contract and for cancelling the contract.

 

Article 26. Principles of Making Payments to Health Care Institutions by the TPF

 

1. The TPF must pay the accounts submitted by individual health care institutions with which it has concluded contracts under the terms provided for in the contract.

2. The TPF shall pay only the basic cost of individual health care services guaranteed by compulsory health insurance.

3. If the court determines that the insured event was conditioned by unlawful activities of the insured, the TPF shall recover from the insured, in the manner prescribed by law, the costs of the provided individual health care services guaranteed by compulsory health insurance, except for the costs of first medical aid.

 

Article 27.   Procedure and Time Limits of Making Payment by the TPF
                               to Health Care Institutions

 

1. Health care institutions shall submit accounts for the performance of individual health care services for the payment therefor to that TPF with which it has concluded a contract. Once in 7 calendar days, the TPF shall submit to the National Patients’ Fund a joint account which shall include all accounts of health care institutions, received by the TPF following the day of submission to the NPF of the previous joint account. Upon the receipt of the joint account from the TPF, the NPF shall pay therefor no later than within 7 calendar days. Having received the money from the NPF, the TPF shall pay for the accounts of health care institutions which have concluded a contract with it. The TPF must pay for the accounts of health care institutions no later than within 21 calendar days from the receipt thereof.

2. When the correctness of the accounts submitted by health care institutions is challenged and the TPF is conducting an investigation of the quality of services and accounting documents, the time limit for the payment therefor may be extended for not longer than 14 calendar days.

3. The NPF may, within the first 10 calendar days of each month, transfer in advance to the TPF the amount which is equal to not more than 50% of the amount received the previous month for the accounts of the TPF.

 

 

CHAPTER IV

INSTITUTIONS EFFECTING COMPULSORY HEALTH INSURANCE

 

Article 28. Compulsory Health Insurance Council

 

1. The Compulsory Health Insurance Council shall be formed and its composition and regulations shall be approved by the Government of the Republic of Lithuania

2. The Compulsory Health Insurance Council shall:

1) determine target and current tasks of compulsory health insurance;

2) submit proposals to the Ministry of Health concerning the list of individual health care services paid for from the compulsory health insurance fund budget;

3) submit draft budget of the compulsory health insurance fund and annual budget report to the Government of the Republic of Lithuania for approval;

4) enact legal statutes regulating compulsory health insurance;

5) approve the list of staff of the NPF and the TPF and expenditure limits for organising compulsory health insurance, as well as terms and conditions of the payment for work;

6) submit recommendations to the Prime Minister of the Republic of Lithuania concerning the appointment and dismissal of the Director of the NPF and to the Director of the NPF concerning the appointment and dismissal of the directors of the TPF;

7) control and study financial - economic activities of the NPF;

8) consider and resolve other issues of compulsory health insurance.

3. The Compulsory Health Insurance Council shall be composed of:

1) the Minister of Health ;

2) two representatives of the Ministry of Social Security and Labour and the Ministry of Finance;

3) one representative of the NPF;

4) one representative of the TPF;

5) two representatives of the trade unions of health care specialists;

6) three representatives of other trade unions;

7) one representative from primary, secondary and tertiary health care institutions;

8) one representative of the Association of Municipalities;

9) one representative of the Insurance Affairs Council.

4. The Government of the Republic of Lithuania shall be represented in the Compulsory Health Insurance Council by the Ministry of Health and the representatives of the Ministry of Social Security and Labour, and the Ministry of Finance.

5. The Compulsory Health Insurance Council shall be headed by the Chairperson elected by a 2/3 majority vote with at least 2/3 of the members of the Compulsory Health Insurance Council participating.

 

Article 29. The NPF

 

1. The NPF shall be established and its regulations shall be approved by the Government of the Republic of Lithuania.

2. The Director of the NPF shall be appointed and dismissed by the Prime Minister of the Government of the Republic of Lithuania on the recommendation of Compulsory Health Insurance Council.

3. The NPF is a legal entity, having its seal with the State Emblem of the Republic of Lithuania, accounts with the banks of the Republic of Lithuania and with foreign banks. The NPF must select a bank in the Republic of Lithuania by holding tenders inviting bids from the banks where the State holdings amount to over 50%. The procedure for organising tenders shall be laid down by the Compulsory Health Insurance Council.

4. The NPF shall be accountable for its activity to the Government of the Republic of Lithuania and the Compulsory Health Insurance Council.

 

Article 30. Functions of the NPF

 

The NPF shall perform the following functions:

1) implement the budget of the compulsory health insurance fund ;

2) supervise the activities of the TPF;

3) form the reserve fund from of the compulsory health insurance fund budget resources and use it in the manner specified by this Law and other statutory acts;

4) use the temporarily idle compulsory health insurance fund budget resources in the manner specified by this Law;

5) exercise control over the quality of individual health care services paid for with the compulsory health insurance fund budget resources and perform financial - economic analysis of the use of the compulsory health insurance budget resources;

6) carry out the audit of the TPF or conclude contracts with audit companies for carrying out an audit of the TPF;

7) organise the general meeting of the TPF Supervisory Boards representatives;

8) carry out other functions prescribed by laws, the NPF’s regulations and other statutory acts.

 

Article 31. Rights of the NPF

 

The NPF shall have the right to:

1) use budget resources of the compulsory health insurance fund transferred to it and other legally acquired funds and assets in the manner laid down by laws and other statutory acts;

2) conclude contracts in accordance with the procedure established by laws and other statutory acts. The NPF may conclude contracts concerning the use of the NPF’s assets only with the consent of its founder;

3) acquire and dispose of the Government and the Bank of Lithuania securities;

4) implement measures for generating additional revenue in the manner established by the Compulsory Health Insurance Council;

5) determine the structure of the NPF;

6) obtain from ministries, other government institutions, administrations of county governors, executive institutions of local authority, the TPF, State social insurance institutions, health care institutions, other enterprises and organisations, in the manner established by laws and other statutory acts, free information necessary for the performance of the NPF functions. The list of such information shall be specified in the regulations of the NPF;

7) organise and carry out the audit of the TPF in the manner and within the time limits prescribed by the Compulsory Health Insurance Council;

8) the NPF may be entitled to other rights established by laws, the NPF regulations and other statutory acts.

 

Article 32. The TPF

 

1. The TPF shall be established and its regulations shall be approved by the NPF. Each county shall have only one TPF.

2. The TPF shall be headed by the Director, who shall be appointed and dismissed from office by the NPF on the recommendation of the Compulsory Health Insurance Council.

3. The TPF is a legal entity, having its seal and accounts with the Lithuanian and foreign banks. The TPF must select the bank in the Republic of Lithuania by holding tenders among the banks where the State holding amounts to over 50%. The procedure for holding tenders shall be laid down by the Compulsory Health Insurance Council.

4. The TPF shall be accountable for its activities to the Compulsory Health Insurance Council and the NPF.

 

Article 33. The Functions of the TPF

 

The TPF shall perform the following functions:

1) conclude contracts with health insurance institutions and pay them for the services provided to the insured persons within the time limits and under the terms and conditions laid down in the contracts;

2) reimburse the insured persons, in the manner established in Articles 9, 10 and 11 of this Law, for the costs of limb, joint and organ prosthetics and also the acquisition of prostheses, essential medicines and necessary medical aids, as well as the costs of sanatoria/resort treatment;

3) keep the register of persons insured by compulsory health insurance;

4) organise and pay for selective monitoring of the insured persons’ state of health;

5) study and evaluate the data on the state of health of county municipality residents and their demographic structure, impact on health of commercial-economic and other activities of enterprises, institutions and organisations operating in the TPF territory, give recommendations on the above issues to the TPF Supervisory Board;

6) carry out quality control of individual health care services paid for with the compulsory health insurance fund budget resources and the financial - economic analysis of the use thereof;

7) monitor the accessibility and suitability of individual health care services provided to persons insured under the terms and conditions laid down by the Ministry of Health;

8) publish information on its activities, inform the insured about health care services, procedure and conditions of the provision thereof;

9) carry out other functions prescribed by laws, the TPF’s regulations and other statutory acts.

 

Article 34. The Rights of the TPF

 

The TPF shall have the right to:

1) use the compulsory health insurance fund budget resources transferred to it and also other legally acquired funds and assets in the manner specified by laws and other statutory acts;

2) conclude contracts in accordance with the procedure prescribed by laws and other statutory acts. The TPF may conclude contracts concerning the use of the TPF’s assets only with the consent of its founder;

3) implement, in the manner laid down by the Compulsory Health Insurance Council, measures for generating additional revenue ;

4) determine the internal structure of the TPF;

5) obtain from ministries, other government institutions, county governor’s administration, local authority executive institutions, state social insurance institutions, health care institutions, other enterprises, institutions and organisations, in the manner established by laws and other statutory acts, free information necessary for the performance of the TPF functions. The list of such information shall be specified in the TPF regulations;

6) upon establishing the facts of non-conformity of individual health care services to statutory acts, request that the health care institution administration should test the individual health care specialist’s qualification;

7) propose to the State Accrediting Service for Health Care by the Ministry of Health to cancel the accrediting for individual health care activities of health care institution, its structural subdivision or individual health care specialist;

8) submit proposals to the Compulsory Health Insurance Council and the NPF concerning the organisation of compulsory health insurance;

9) bring an action against persons for recovery of costs of services provided to them unlawfully;

10) the TPF may also have other rights established by laws, the TPF regulations and other statutory acts.

 

Article 35. The Supervisory Board of the TPF

 

1. The Supervisory Board of the TPF shall be formed for the term of 3 years. The Supervisory Board of the TPF shall consist of one representative of the NPF, the county medical doctor and 2 representatives from each Municipal Council within the county. The work of the TPF’s Supervisory Board shall be directed by the Chairman who shall be elected from among the members of the TPF’s Supervisory Board by simple majority vote, with no less than half of the members of the TPF’s Supervisory Board attending.

2. The Supervisory Board of the TPF shall:

1) elect the TPF’s medical audit commission and the TPF’s reconciliation commission;

2) approve the contracts concluded by the TPF with health care institutions and supervise their implementation;

3) submit proposals to the Compulsory Health Insurance Council relative to the appointment and dismissal of the TPF Director;

4) approve the staff list of the TPF employees and the estimate of expenditure;

5) supervise and analyse the activities of the TPF Administration and the use of finances;

6) approve the annual cash balance sheet and financial statement of the TPF submitted by the Director. The annual balance sheet and financial statement shall be published in the press not later than on 1 May of the current year;

7) organise medical and financial - economic audit of health care institutions with whom the TPF has concluded contracts;

8) appoint two representatives to the meeting of the TPF Supervisory Board;

9) consider and resolve other issues of health care institutions assigned to the functions of the TPF.

3. The Supervisory Board of the TPF shall have the right to organise the audit of the TPF to be financed with the funds allocated for the management of the TPF. Upon establishing shortcomings in the TPF book keeping and financial reporting, the TPF Supervisory Board Chairperson must call a special meeting of the Supervisory Board of the TPF.

4. The character of activities of the TPF Supervisory Board shall be specified in its regulations.

 

Article 36. Medical Audit Commission of the TPF

 

1. The Medical Audit Commission of the TPF, consisting of three persons, shall be elected by the Supervisory Board of the TPF on the nomination of its Chairperson for the term of three years. Members of Medical Audit Commission of the TPF must be individual health care specialists.

2. The Medical Audit Commission of the TPF shall control, within the scope of its competence, the suitability and accessibility of the individual health care services provided by health care institutions with whom the TPF has concluded contracts, or propose to the Director of the TPF to conclude contracts with independent experts for the control of these matters.

3. The character of activities of the TPF Medical Audit Commission shall be specified in its regulations.

 

Article 37. The Reconciliation Commission of the TPF

 

1. The Reconciliation Commission of the TPF, consisting of three persons, shall be elected by the Supervisory Board of the TPF on the nomination of its Chairperson for the period of three years. The Commission shall settle disputes between the insured, health care institutions and the TPF about the payment of individual health care service costs payable from the compulsory health insurance fund budget and about the performance of health care contracts.

2. The character of activities of the TPF Reconciliation Commission shall be specified in its regulations.

 

Article 38. Meeting of the TPF Supervisory Board Representatives

 

1. The meeting of the TPF Supervisory Board representatives shall be an advisory body of the Compulsory Health Insurance Council and the NPF.

2. The NPF shall organise a meeting of the TPF Supervisory Board representatives no less frequently than twice a year. The meeting of the TPF Supervisory Board representatives shall:

1) resolve issues referred to in items 2 and 4 of paragraph 2 of Article 28 of this Law, if so is requested by the Compulsory Health Insurance Council;

2) consider draft budget of the compulsory health insurance fund and the annual budget report, give recommendations relative thereto to the Compulsory Health Insurance Council;

3) consider other issues of compulsory health insurance and give proposals relative to their solution to the Compulsory Health Insurance Council.

3. The character of activities of the TPF Supervisory Board representatives meeting shall be specified in the regulations of the NPF.

 

 

CHAPTER V

RIGHTS AND DUTIES OF THE INSURED AND HEALTH CARE INSTITUTIONS

WHICH HAVE CONCLUDED CONTRACTS WITH THE TPF

IN EFFECTING COMPULSORY HEALTH INSURANCE

 

Article 39. The Rights of the Insured in Compulsory Health Insurance

 

The insured shall have the right to:

1) choose, in the manner prescribed by laws and other statutory acts, an individual health care institution contracted by the TPF and receive individual health care services guaranteed by compulsory health insurance;

2) obtain from health care institutions contracted by the TPF information about the state of his health, planned medical tests, medical procedures, method of treatment and its effect, the scope of the provided individual health care services, conditions and place of their provision. Legal representatives of legally incapable persons shall be entitled to obtain analogous information about the latter;

3) lodge a complaint with the Medical Audit Commission of the TPF about health care institutions contracted by the TPF if the quality of individual health care services, the time of their provision does not meet the requirements laid down in the contracts;

4) receive compensation from health care institutions for damage caused to their health through the fault of health care institutions or individual health care specialists, regardless of whether or not the compensation was provided for in the contracts concluded by the TPF with health care institutions. The amount of compensation and procedure for the payment thereof shall be specified by laws or other statutory acts;

5) appeal to the commissions of the TPF, the NPF, the court about the violations of laws or other statutory acts regulating compulsory health insurance.

 

Article 40.   The Duties of Health Care Institutions which have Concluded
                               Contracts with the TPF in Effecting Health Insurance

 

1. The health care institutions which have concluded contracts with the TPF must:

1) guarantee to the insured the provision of health care services guaranteed by compulsory health insurance, also the accessibility and suitability of the services;

2) ensure the confidentiality of information concerning the person’s health, except in cases specified by laws;

3) in case of an insured event guarantee to all the insured equal rights in receiving individual health care services;

4) guarantee the keeping of medical and financial documentation in compliance with the requirements established by statutory acts;

5) timely submit the required information to the NPF and the TPF;

6) furnish information to the insured about individual health care services which are not attributed to services the costs whereof are covered from the compulsory health insurance fund budget, and the conditions and procedure of their provision.

2. Health care institutions shall have no right to demand from the insured additional charges for health care services guaranteed by the compulsory health insurance.

 

 

CHAPTER VI

PROCEDURE OF SETTLEMENT OF DISPUTES CONCERNING

THE EFFECTING OF COMPULSORY HEALTH INSURANCE

 

Article 41.   Procedure of Settlement of Disputes between the Insured and the
                               TPF Concerning the Effecting of Compulsory Health Insurance

 

1. Disputes between the insured and the TPF concerning the effecting of compulsory health insurance shall be examined by the Director of the TPF. The Director of the TPF must within 30 days or, where additional information and investigation is necessary, within additional 15 days, investigate the appeal and adopt a decision.

2. Upon receiving the decision of the TPF Director, the insured shall have right to appeal, within 30 days, to the TPF Reconciliation Commission. The Reconciliation Commission of the TPF must within 10 days investigate the appeal and adopt a decision.

3. The insured may appeal in court against the decision of the TPF Reconciliation Commission in accordance with the procedure established by laws.

 

Article 42.   Procedure of Settlement of Disputes between the Insured
                               and Health Care Institutions Concerning the Effecting
                               of Compulsory Health Insurance

 

1. Disputes between the insured and health care institutions concerning the provision of services guaranteed by the compulsory health insurance shall be resolved by the Ministry of Health. The Ministry of Health must within 30 days or, where additional information and investigation is necessary, within another 15 days investigate the appeal and take a decision.

2. The insured or the health care institution may appeal in court against the decision of the Ministry of Health in accordance with the procedure specified by laws.

 

CHAPTER VII

ADDITIONAL (VOLUNTARY) HEALTH INSURANCE

 

Article 43. Additional (Voluntary) Health Insurance Institutions

 

Additional (voluntary) health insurance institutions are legal entities which have been issued a licence in the manner laid down by statutory acts to engage in health insurance activity.

Article 44. Insured Events of Additional (Voluntary) Health Insurance

 

Insured events of additional (voluntary) health insurance shall be health disorders or the state of health of the persons insured by additional health insurance that are identified in the insurance contracts and diagnosed by the medical doctor, also the health care conditions of the insured on the grounds whereof the insured may be rendered health care services of the type and scope provided for by the contracts the costs whereof shall be covered by the insurer under the terms and conditions laid down in additional (voluntary) health insurance contracts.

 

Article 45. Additional (Voluntary) Health Insurance Contract

 

1. The contract of additional (voluntary) health insurance shall be concluded between the insurance institution which effects additional (voluntary) health insurance and the health care institution.

2. The following data shall be stated in the additional (voluntary) health insurance:

1) requisites of the parties to the contract;

2) the number of the insured;

3) the amount of insurance contributions and payment procedure;

4) the period of validity of the contract;

5) liability of the parties;

6) the procedure for changing terms and conditions of the contract and contract cancellation procedure.

 

Article 46. Procedure for Effecting Additional (Voluntary) Health Insurance

 

1. The health care institution shall present to the insurance institution information about the additional (voluntary) health insurance regulations and costs.

2. The health care institution which provides individual health care services to the person insured by additional (voluntary) health insurance shall submit to the insurance institution and the person insured by additional (voluntary) health insurance information about the scope and costs of services provided to the latter.

3. The insurance institution shall pay the health care institution the costs of individual health care services provided to the person insured by additional (voluntary) health insurance under the terms and within the scope specified in the contract or shall reimburse the person insured by additional (voluntary) health insurance if the latter himself paid the account presented by the health care institution.

4. Disputes between the parties shall be settled in the manner prescribed by law.

CHAPTER VIII

FINAL PROVISIONS

 

Article 47. Implementation of the Law on Health Insurance

 

The Law on Health Insurance shall be implemented in the manner laid down by the Law on the Implementation of the Law on Health Insurance.

 

I promulgate this Law passed by the Seimas of the Republic of Lithuania.

 

 

Algirdas Brazauskas

President of the Republic

 

Vilnius

21 May 1996 

No. I-1343