MEDICAL SERVICES PACKAGE IN OFFSET SPECIALTY MEDICAL ASSISTANCE FOR CLINICAL SPECIALTIES |
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| Basic package of services | ||||
| NAME OF THE MEDICAL SERVICE | FREQUENCY / MAXIMUM | |||
| c1 | c2 | |||
| 1. Medical services for emergency medical-surgical situations | 1 consultation / insured patient older than 18 for each emergency situation | |||
| maximum 2 consultations for children 0-18 years for each emergency situation | ||||
| 2. Specialized medical consultation for acute and subacute disorders as well as exacerbations of chronic diseases | maximum 3 consultations / insured patient / episode that can be granted within a maximum of 60 calendar days from the date of the first consultation | |||
| maximum 2 consultations for the insured with a diagnosis already confirmed at hospital discharge | ||||
| 3. Specialized medical consultation for chronic diseases | maximum 4 consultations / quarter / insured patient, but no more than 2 consultations per month | |||
| maximum 2 consultations for the insured with a diagnosis already confirmed at the hospital discharge | ||||
| 4. Detection of diseases with potential endemo-epidemic | 1 consultation per insured person for each disease with suspected and confirmed endemo-epidemic potential | |||
| 5. Consultations for family planning services | 4 consultations per calendar year / insured patient | |||
| 6. Palliative care services – palliative care consultations | maximum 4 consultations / quarter / insured patient, but no more than 2 consultations per month | |||
| 7. Pregnancy and postpartum services | ||||
| a) monitoring the progress of the pregnancy, quarterly; | 1 consultation / quarter | |||
| b) follow up of the mother in the first trimester after birth. | 1 consultation | |||
| Name of medical service | Number of points | Minimum guaranteed value of the point per service (lei) | Rate settled by the health insurance house for a medicine doctor (lei) | Tariff settled by the health insurance house for the primary doctor (lei) |
| c1 | c2 | c3 | c4=c2*c3 | c5=c4+c4*20% |
| Consultation for medical specialties for the child between 0 and 3 (up to the age of 4) | 16,2 | 2,8 | 45,36 | 54,4 |
| Consultation for surgical specialties for the child between 0 and 3 (up to the age of 4 ) | 17,25 | 2,8 | 48,3 | 58,0 |
| Consultation of pediatric psychiatry and psychiatry of the child between the ages of 0 and 3 (up to the age of 4) | 32,4 | 2,8 | 90,72 | 108,9 |
| Consultation of the child and the adult between the ages of 4 and 59 for medical specialties | 10,8 | 2,8 | 30,24 | 36,3 |
| Consultation of the child and the adult between the ages of 4 and 59 years for surgical specialties | 11,5 | 2,8 | 32,2 | 38,6 |
| Family planning consultation | 10,8 | 2,8 | 30,24 | 36,3 |
| Consultation of neurology for the child between 0 and 3 (until the age of 4) | 21,6 | 2,8 | 60,48 | 72,6 |
| Consultation of neurology of the child and the adult between the ages of 4 and 59 | 14,4 | 2,8 | 40,32 | 48,4 |
| Consultation of psychiatry and pediatric psychiatry of the child and the adult between the ages of 4 and 59 | 21,6 | 2,8 | 60,48 | 72,6 |
| Psychiatry consultation over 60 years old | 23,6 | 2,8 | 66,08 | 79,3 |
| Consultation for medical specialties over 60 years old | 12,8 | 2,8 | 35,84 | 43,0 |
| Consultation for surgical specialties over 60 years old | 13,5 | 2,8 | 37,8 | 45,4 |
| Consultation of neurology over 60 years old | 16,4 | 2,8 | 45,92 | 55,1 |
| Consultation for palliative care | 18 | 2,8 | 50,4 | 60,5 |
Health services related to the medical act |
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| List of health services related to the medical act | Number of points | Minimum guaranteed value of the point per service (lei) | Rate settled by the health insurance house for a medicine doctor (lei) | |
| c1 | c2 | c3 | c4=c2*c3 | |
| a) Pediatric neurology and neurology: | ||||
| a1) the services provided by the psychologist specialized in clinical psychology, psychological counseling and psychotherapy: | x | |||
| a1.1) clinical and psychological psychiatric evaluation; | 30 points / session | 2,8 | 84 | |
| a1.2) clinical psychological counseling for children / adults; | 30 points / session | 2,8 | 84 | |
| a1.3) child / adult psychotherapy; | 30 points / session | 2,8 | 84 | |
| c) Pediatric psychiatry and psychiatry: | ||||
| c1) the services provided by the psychologist in the specialty clinical psychology, psychological counseling and psychotherapy: | x | |||
| c1.1) clinical and psychological psychiatric assessment | 30 points / session | 2,8 | 84 | |
| c1.2) clinical psychological counseling for children / adults | 30 points / session | 2,8 | 84 | |
|
c1.3) Clinical psychological counseling for children diagnosed with autism spectrum disorders (only at the recommendation of the pediatric psychiatry specialist) – in a psychotherapeutic method applicable to the child diagnosed with autism spectrum disorders. > |
30 points / session | 2,8 | 84 | |
| c1.4) child and family psychotherapy – for children (only at the recommendation of the doctor with pediatric psychiatry specialty) – in a psychotherapeutic method applicable to the child diagnosed with autism spectrum disorders | 30 points / session | 2,8 | 84 | |
| g) Diabetes, nutrition and metabolic diseases | ||||
| Services provided by psychologist specialized in clinical psychology, psychological counseling and psychotherapy: clinical psychological counseling for children and adults with confirmed diagnosis of diabetes | 30 points / session | 2,8 | 84 | |
| Diagnostic and therapeutic services | |||||
No. crt.
| Name of the diagnostic / therapeutic procedure / treatments / therapies |
Clinical specialties that can perform that service |
Minimum guaranteed point value per service in effect (lei) |
Fees paid by the health insurance company for specialist doctors (lei) |
Fees settled by the primary health insurance house (lei) |
|
| c1 | c2 | c3 | c4=c2*c3 | c5=c4+c4*20% | |
| A. Simple diagnostic procedures: 10 points score | x | ||||
| 5 | EKG standard | cardiology, internal medicine, geriatrics and gerontology, pneumology, nephrology | 2,8 | 28 | 33,6 |
| 7 | spirometry | allergy and clinical immunology, pneumology, internal medicine, geriatrics and gerontology, pediatrics | 2,8 | 28 | 33,6 |
| 8 | pulse oximetry | internal medicine, geriatrics and gerontology, cardiology, pneumology, pediatrics | 2.8 | 28 | 33,6 |
| 15 | Wood lamp examination | dermatovenerology | 2,8 | 28 | 33,6 |
| 16 | determination of the ankle / arm pressure index, respectively finger / arm pressure | surgery, rheumatology, neurology, pediatric neurology, diabetes, nutrition and metabolic diseases, internal medicine, geriatrics and gerontology | 2.8 | 28 | 33,6 |
| 17 | muscle strength measurement with dynamometer | neurology, pediatric neurology, geriatrics and gerontology | 2.8 | 28 | 33,6 |
| 18 | sensitivity tests (filament test, tuning test, caloric sensitivity test and discriminatory sensitivity test) | neurology, pediatric neurology, diabetes, nutrition and metabolic diseases, internal medicine, geriatrics and gerontology, ENT | 2,8 | 28 | 33,6 |
| 19 | clinical trials (EDS, myasthenic score, UPDRS, MMS, Raisberg) | neurology, pediatric neurology, psychiatry, geriatrics and gerontology | 2,8 | 28 | 33,6 |
| 20 | harvest bioptic material | dermatovenerology, general surgery, pediatric surgery and pediatric orthopedics | 2,8 | 28 | 33,6 |
| B. Medium complexity diagnostic procedures: score 20 points | x | ||||
| 7 | dermatoscopy | dermatovenerology | 2,8 | 56 | 67,2 |
| C. Complex diagnostic procedures: score 40 points | x | ||||
| 2 | determining the evoked potentials (visual, auditory, somatoesthetic) | neurology, pediatric neurology, ophthalmology, ENT | 2,8 | 112 | 134,4 |
| D. Simple therapeutic procedures / surgical treatments: 15 points score | x | ||||
| 17 | cryotherapy in skin lesions | dermatovenerology | 2,8 | 42 | 50,4 |
| 18 | surgical treatment of skin lesions – superficially cut wounds, superficial punctures, skin necrosis, scales, wound dehiscence (anesthesia, excision, suture, including removal of wires, dressing) | dermatovenerology, surgery, including cosmetic plastic surgery and reconstructive microsurgery, pediatric surgery and pediatric orthopedics, orthopedics and traumatology | 2,8 | 42 | 50,4 |
| E. Therapeutic procedures / complex surgical treatments: 25 points score | x | ||||
| F. Therapeutic procedures / simple medical treatments: 7 points score | |||||
| 3 | administration of treatment by injection of the soft parts (intramuscular, intradermal and subcutaneous) | all specialties | 2,8 | 19,6 | 23,52 |
| J. Psychiatric therapies: score 30 points | x | ||||
| 1 | non-specific individual and family psychiatric counseling | 2,8 | 84 | 100,8 | |
| K. Medical genetics therapies: score 30 points | x | ||||
| 1 | Genetic advise | 2,8 | 84 | 100,8 | |
BASIC PACKAGE OF MEDICAL SERVICES IN HOSPITAL MEDICAL ASSISTANCE *)
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| Each health care unit displays only the conditions (diagnoses) contracted with the health insurance company | ||||
| List of medical conditions (diagnoses) resolved medical case in day hospitalization | ||||
No. crt.
| Diagnostic code |
Disease name (diagnosis) |
Maximum rate per medical case resolved (lei) |
Solution fee per medical case negotiated and contracted with the Health Insurance House (lei) |
|
| 11. | E10.65 | Type 1 diabetes mellitus (poor control) | 303,12 | 303,12 |
| 12. | E10.71 | Type 1 diabetes mellitus with multiple microvascular complications | 378,9 | 378,9 |
| 13. | E11.65 | Type 2 diabetes mellitus (poor control) | 341,86 | 341,86 |
| 14. | E11.71 | Type 2 diabetes mellitus with multiple microvascular complications | 427,32 | 427,32 |
| 15. | E11.9 | uncomplicated type 2 diabetes mellitus (sugar) | 305,81 | 305,81 |
| 16. | E13.65 | Other specified forms of poorly controlled diabetes mellitus | 427,32 | 427,32 |
| 17. | E44.0 | Moderate protein-energy malnutrition | 362,46 | 362,46 |
| 18. | E44.1 | Poor protein-energy malnutrition | 362,46 | 362,46 |
| 19. | E66.0 | Obesity due to caloric excess | 305,19 | 305,19 |
| 20. | E78.2 | Mixed hyperlipidemia | 381,48 | 381,48 |
| 25. | I20.8 | Other forms of angina pectoris (* without coronary artery) | 273,62 | 273,62 |
| 26. | I25.11 | Atherosclerotic cardiomyopathy of the native coronary artery | 322,4 | 322,4 |
| 27. | I25.9 | Chronic ischemic heart disease, unspecified, without coronary artery | 302,74 | 302,74 |
| 28. | I34.0 | Mitral insufficiency (valve) (* without indication of surgery) | 379,67 | 379,67 |
| 29. | I35.0 | Aortic stenosis (* without indication of surgery) | 400,68 | 400,68 |
| 30. | I35.1 | Aortic insufficiency (* without coronary artery; no indication of surgery) | 381,12 | 381,12 |
| 31. | I67.2 | Cerebral atherosclerosis | 322,4 | 322,4 |
| 32. | I67.8 | Other cerebrovascular diseases, specified | 322,4 | 322,4 |
| 33. | I83.9 | Varicose veins of the lower extremities without ulceration or inflammation | 383,92 | 383,92 |
| 99. | Z50.9 | Care involving a rehabilitation procedure, unspecified | 331,17 | 331,17 |
| 100. | Z51.88 | Other specified health care | 331,17 | 331,17 |
| 101. | I25.5 | Ischemic cardiomyopathy | 273,62 | 273,62 |
| 102. | I70.21 | Atherosclerosis of the limbs with intermittent claudication | 273,62 | 273,62 |
| 103. | I80.3 | Unspecified lower limb phlebitis and thrombophlebitis | 383,92 | 383,92 |
| 105. | I83.0 | Varicose veins with ulceration of the lower extremities | 383,92 | 383,92 |
| 106. | I87.2 | (chronic) (peripheral) venous insufficiency | 383,92 | 383,92 |