14 January 2020 10:28

The benefit package contains 2550 different medical services

The benefit package for mandatory health insurance was approved with resolution #5 of the Cabinet of Ministers of the Republic of Azerbaijan on January 10, 2020. The benefit package is a set of health services provided to insured person accordingly to the type, volume and conditions of health services. The benefit package includes different medical services for emergency and urgent care, 35 primary healthcare services, 1265 specialized outpatient care services, and 1244 inpatient care services. Of these, 6 emergency and urgent medical care services, 35 primary health care services, 1265 specialized outpatient care services, and 1244 inpatient care services are covered by insurance. Medicated and surgical inpatient treatment of the most widespread illnesses with risk of disability and death are covered by the mandatory health insurance. Services covered by the insurance also include more than 150 costly and life-critical operations.

The benefit package is aimed at increasing the population’s frequency of visits to medical facilities. It also aims to provide relevant medical services in a timely manner in order to improve health conditions and healthcare of the population, improve access to healthcare services and the quality of healthcare services, and ensure early detection of illnesses by improving primary healthcare services (such as home visits, the promotion of a healthy life style, and the collection and regular control of population health data). Medical Services (except emergency and urgent medical care) will be provided in case of availability of medical indications only in medical facilities that have signed contracts with the State Agency on Mandatory Health Insurance or upon referral of such medical facilities in accordance with the Law on Health Insurance.

The benefit package contains names, tariffs, and insurance limits, as well as information on application of co-financing, the terms and conditions of services depending on the type of medical services and waiting periods.

A certain part of the healthcare tariff paid by the insured in an insurance event is the amount of co-financing. The amount of co-financing will apply to all insured people in case of non-compliance with the terms set out in the Benefit Package when applying for specialized outpatient and inpatient care. The terms of paying the co-financing amount are determined by the Benefit Package and paid directly to the medical facility.

The amount of co-financing for outpatient care is as follows within the administrative territory:

When applying for outpatient medical care to a medical facility located in the administrative area where a citizen is registered, but without referral of a family doctor, insured is required to pay co-payment in the amount of  5 (five) manats for each insurance event. For example, if you are registered in Sheki and without consulting your family doctor, you go directly to a medical facility in Sheki, to see a specialist doctor. Because you do not comply with the terms and conditions set out in the Benefit Package, you will have to pay a co-financing amount of 5 (five) manats to the medical facility.

Within medical territorial division:

When applying to a medical facility in another administrative area within a medical territorial division but without a referral, a co-financing amount of 5 (five) manats will be paid for each insurance event. For example, if you are registered in Sheki. You visit a medical facility (to see a specialist doctor) located in Gakh (within the medical territorial division, but outside of the administrative area where you are registered) and you don't consult a  family doctor of the medical facility assigned to you. In this case, you will have to pay a co-financing amount of 5 (five) manats to the medical facility.

Outside medical territorial division:

Copayment in the  amount of 15 (fifteen) manats for each insured event must be paid when applying without a referral for outpatient medical services at a medical facility located outside the medical territorial division, where a citizen is registered (i.e. in another administrative area where mandatory health insurance is applied) . For example, a citizen registered in Sheki should pay copayment in the amount of 15 (fifteen) manats for each insured event when applying without a referral to a specialist doctor at a medical facility in Shamakhi. 

The amount of co-financing for in-patient care is paid as follows within the medical territorial division:

When applying for in-patient medical care at a medical facility located in another administrative area within a medical territorial division without a referral from the medical facility located in the area where applicant is registered, co-payment in the amount of 30 (thirty) manats is required to be paid for each insurance event over 100 (one hundred) manats. For example, you are registered in the Guba region. You visit a medical facility located in Khachmaz (within the medical territorial division but outside of the administrative area where you are registered) for in-patient service without referral. In this case, you will have to pay a co-financing amount of 30 (thirty) manats to the medical facility, as you do not comply with the terms set out in the Service Package.

Outside medical territorial division:

When  applying for in-patient service at a medical facility located in a different administrative area outside of medical territorial division where mandatory health insurance is being applied without a referral insured person is required to pay copayment in the amount of 90 (ninety) manats for each insured event exceeding 100 (one hundred) manats. For example, you are registered in the Guba region. You visit a medical facility located in Shamakhi (outside medical territorial division) for in-patient medical care without referral. In this case, you will have to pay a co-financing amount of 90 (ninety) manats to the medical facility, as you do not comply with the terms set out in the Benefit Package.

At the same time, a copayment in the amount of 20 manats must be paid for each insurance event for all magnetic resonance and computer tomography services provided in outpatient conditions. All medical services for the insured are provided upon referral of a physician (such as a qualified physician, family doctor, field therapist, or field pediatrician). All laboratory and diagnostic services provided without medical examination are not covered by compulsory health insurance and are paid at the expense of the citizen.

The co-financing amount is not paid when a citizen applies for specialized outpatient care (excluding CT and MRT services) or inpatient medical care, including emergency or urgent medical care under mandatory health insurance, in accordance with the conditions set out in the Benefit Package: when initially referring to a family doctor, referring a qualified physician upon referral from a family doctor.

Payment of the co-financing amount will begin April 1st, 2020.