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Forthcoming changes to the public health insurance system in the Czech Republic: what you need to know

As with many healthcare systems worldwide, the Czech Republic faces challenges regarding sustainable funding and escalating healthcare costs, particularly concerning chronic and rare diseases.

Aiming to address emerging needs in public healthcare, on 12 April 2024, the Ministry of Health of the Czech Republic introduced a draft amendment to the Act on Public Health Insurance and other related laws, which is proposed to take effect on 1 January 2026. In this article, we provide an overview of the key areas affected by the legislative proposal, namely (i) price and reimbursement regulation of medicinal products and medical devices, (ii) preventive care support, (iii) reimbursement of cross-border healthcare services, and (iv) dental care reimbursement.

1/ Price and reimbursement of medicinal products

Enabling earlier initiation of proceedings for a new indication

The draft amendment enables marketing authorization holders (“MAHs”) and health insurance companies to initiate new administrative proceedings to determine the price and/or reimbursement of a medicinal product with the State Institute for Drug Control (SIDC), even if the proceedings for the same product are already pending, provided that the applicant initiates the proceedings for a different indication and the pending proceedings are at least at the stage where a decision (even a non-final one) has been issued. This change that partially deviates from the current interpretation of lis pendens aims to avoid delays in the market entry of the new indications of the same medicinal product.

Exclusion of foreign reference prices in reimbursement proceedings

The draft amendment unifies the proceedings to determine the price and reimbursement of medicinal products using foreign reference prices. Under the proposed amendment, a party to the reimbursement proceedings of a medicinal product (typically an MAH) may ask the SIDC to exclude the foreign price if the party provides evidence that the reference medicinal product is not actually traded on the respective foreign market. To date, the exclusion of foreign reference price on the grounds of absence of the product on the relevant foreign market was only possible in the proceedings to determine the price.

Significant medicinal products

To address the shortage of medicinal products significant for the provision of health care, the draft amendment proposes special procedural rules for determining the price of such medicinal products. As a result, the price determined by the SIDC for these medicinal products should be higher than that determined in the standard proceedings.

Medicinal products to which the above proceedings will apply will be selected by the Ministry of Health, taking into account the public interest in maintaining their availability.

Modification of the definition of highly innovative drugs (HIDs)

The draft amendment adds the progression-free survival parameter to the current definition of HIDs. Pursuant to the explanatory memorandum, the aim is to eliminate cases where a cancer medicinal product enters the public health insurance system as an HID, but due to no impact on survival and a nominally minimal impact on progression-free survival it should not profit from HID regulation, as it does not provide a significant innovation.

2/ Other areas

Promoting prevention through positive motivation of insured persons

The draft amendment aims to encourage insured persons in maintaining their health through proper preventive self-care practices. One of the instruments is a significant increase in financing of prevention funds of health insurance companies, from which they will provide financial contributions to insured persons who engage in preventive self-care practices, including engaging in routine preventive health screenings or vaccinations.

The draft amendment also proposes expanding the range of healthcare services for which insured persons can draw the contribution, such as  healthcare services not otherwise reimbursed, co-payment for a partially reimbursed healthcare service, services offered by providers to insured persons in connection with reimbursed healthcare services, other products and services intended to alleviate or compensate for a disability or illness of the insured, or which have a preventive function, or recreational activities.

Insurance companies will also have new powers to create their own incentive programs to promote better self-care practices. 

Cross-border healthcare services

The draft amendment allows for the authorization of healthcare services abroad at the level of foreign reimbursement, even for repeated or long-term cases (i.e. not just for one-off cases), if there is a lack of availability in a certain field in a certain region. Insurance companies will also be allowed to conclude contracts with foreign healthcare providers located near borders.

Dental treatment

The draft amendment also addresses systematic shortcomings in reimbursement of dental treatment. The current reimbursement regulations prioritize the use of inexpensive materials, which are frequently viewed by dentists as outdated. Consequently, patients often opt to pay for more advanced treatment options themselves rather than relying on treatment reimbursed from the public health insurance system.

To involve more dentists in the public health insurance system (currently more and more dentists opt for private practices) and to prevent further decline in the share of public spending on dental care, the draft amendment proposes some new legislative instruments, in particular the possibility of partial reimbursement in the case of costly methods. For insured persons who undergo regular preventive health screenings, it will be possible to draw a contribution from the prevention fund to cover the non-reimbursed part of the price.

Conclusion

The draft amendment introduces a multitude of changes, primarily comprising incremental enhancements aimed at refining the efficacy and precision of the public health insurance system and avoiding significant systemic overhauls.

Currently, the draft amendment is undergoing the inter-ministerial comment procedure, after which it will be discussed by the Czech Parliament. Given the early stage of the legislative procedure, the final text of the amendment may be subject to changes.

Authors: Kateřina Slavíková, Denisa Fuchsová