25.05.2015

prasalnik-zdravstvni-pravaAccess to the right of Health insurance

Permanent amendments to the Regulations on the manner and procedure for exercising the rights of citizens contribute to creating continuous obstacles, even in cases when laws are in their favor.

For instance – amendments were made to the Law on contributions of compulsory social insurance from 1st December 2014 and by these amendments the Statement of income in the previous year was abolished from the procedure for pre-registration of health insurance for unemployed and people with lower incomes.

It is confirmed – Health Insurance Fund of Macedonia will check the income through Public Revenue Office ex officio, and by that crowds and giving false information by the insurers would be avoided → pre-registration of the insurers who enjoy the right on the burden on the budget of the Republic of Macedonia will be facilitated.

09.02.2015 – changes to the Regulations on the content and manner of exercising the rights and obligations of the compulsory health insurance by which a new form was introduced in the procedure i.e. Request for determination of the status of the insurer – “crucial” document/form that completes offered option about the amount of income in the previous year.

Attached documents:

  • Application for compulsory health insurance,
  • A copy of birth certificate of the applicant and all members of the family (certificate of the book of marriage if he/she is married),
  • A copy of the identity card with consent of the applicant,
  • Health insurance card for the applicant and family members.

What is the procedure for exercising the right to health insurance for the first time?

  1. Families/person with lower incomes on the burden on the Budget of the Republic of Macedonia

– do not have income higher than 105.600,00 denars in the previous year.

– they have income higher than 105.600,00 denars but not exceeding 189.864,00 denars, they are able to exercise the right if in the last two months of the current year had had income lower than 17.600,00 denars.

      2. Families/person with higher income who pay health insurance by themselves

If in the previous year they had income higher than 105.600,00 denars and income higher than 17.600,00 denars in the last two months of the current year, the amount of the contribution will be:

– 1155,00 denars per month for income higher than 105.600,00 and lower than 189.864,00 denars,

– 2310,00 denars per month for income higher than 189.864,00 denars.

How is the pre-registration process of insurers implemented?

  1. Extension of the right

For families/person who during 2014 have pre-registered by submitting a Statement of income, the right to health insurance will be automatically extended from 1st April 2015 by adopting a Decision for extension of the right.

      2. Termination of right

A Decision to terminate the right will be issued for the following categories:

– starting from 01.06.2015 for insurers who in 2013 had income higher than 96.600 denars and in the Statement they had submitted in 2014 did not declare this condition,

– starting from 01.09.2015 for insurers who in 2014 had income higher than 105.600,00 denars and will not report the change to the Health Insurance Fund of Macedonia in this period.

What are the consequences:

– a prohibition to use orthopedic devices within 6 months,

– compensation for using  health services after calculation made by the Health Insurance Fund of Macedonia by sending an invitation to the holder of the insurance that if he/she does not pay the damage, a procedure in front of enforcement agent will follow.

      2. Extension of the right when it is terminated

When the right is terminated by а Decision from 01.06.2015, and in 2014 insurers did not have income higher than 105.600,00, they should submit complete documentation to the Health Insurance Fund of Macedonia as a family/person who seeks access to compulsory health insurance for the first time.

      3. Change on the basis of insurance

If they have income higher than anticipated in 2014 for the category Families/person with lower income, it is necessary to change the basis for insurance through submission of complete documentation to the Health Insurance Fund of Macedonia as Families/person with higher income in order not to face termination/consequences.

What makes it easier?

– Obligation for pre-registration of unemployed who do not have income higher than 105.600,00 denars in the previous year has been abolished and the right is automatically continued.

– Families who had higher income in the previous year may change the basis for insurance no later than 1st September of the current year in order not to face termination of the right (a period when the PRO issues Certificates of income).

What makes it difficult?

– Health Insurance Fund of Macedonia introduces a template in the procedure which has not been previously determined by legal provision → repetitive application of an unlawful act.

– Termination of the right from 01.06.2015 on the basis of a submitted Statement of income in 2013 without the Health Insurance Fund of Macedonia to prove the guilt of the insurer in a criminal proceeding (applied procedure for given false statements for 2011 and 2012) → retroactive application of the Regulations from 09.02.2015.

– In the new Form insurers provide data on their income in the previous year → repetition of the practice of personal responsibility and providing false information.

– For compensation for used health services in cases when false data were provided by the insurers, the Health Insurance Fund of Macedonia will initiate a procedure in front of an enforcement agent and direct payment from transaction account → contrary to the Law on Health Insurance: “If the damage is not compensated in the specified period, the Health Insurance Fund of Macedonia may submit an appeal to the competent court.”