06.12.2024
WHICH MEDICAL DEVICES DOES THE HEALTH INSURANCE FUND PAY FOR?
For most people, even the names of most medical devices sound a bit daunting and are difficult to pronounce: pacemaker, cardioverter defibrillator, heart valve, stent graft, joint prosthesis. But they are life-saving when we need them.
What is important to know about medical devices?
In outpatient care, some of the most popular devices are test strips for self-monitoring blood sugar, insulin pumps, sensors for measuring glucose levels, bags and accessories for patients with stomas, and others. And in 2025, the National Health Insurance Fund will also pay for special dressings, bandages, gels, and antiseptic solutions for the treatment of moderate and severe chronic and complicated wounds.
In hospital care, some of them are heart valve prosthesis, vascular prosthesis for thoracic and abdominal aorta, stents, joint prostheses for hip or knee joint, cochlear implants, pacemakers, devices for the treatment of brain aneurysms and stroke, spinal stabilization, neurostimulation implants, "artificial heart" and others. NHIF is expanding the scope of medical devices that it will pay for, and next year it will start paying for innovative closed systems for automatic insulin delivery, intratectal system for the treatment of spasticity, ureteral stents, stents for upper respiratory tract, capsule endoscopy system, pump consumables for precisely controlled therapies and others.
Does the National Health Insurance Fund pay for all medical devices?
The National Health Insurance Fund pays for medical devices in both outpatient and inpatient care.
The medical devices that the National Health Insurance Fund pays for in outpatient care can be dispensed by any pharmacy in the country that has signed a contract with the National Health Insurance Fund. The devices are dispensed on the basis of issued electronic prescriptions (prescriptions), and for some of them it is necessary to issue an electronic protocol, which is certified by the National Health Insurance Fund or the Regional Health Insurance Fund. They are included in a list published on the website of the National Health Insurance Fund, at the following address: https://www.nhif.bg/bg/medicine_food/nonmedical
Some of the medical devices are given to patients in hospital. The National Health Insurance Fund pays for them only if they are included in the algorithm of the relevant clinical pathway or procedure by which the patient is treated, and which one it will be, is decided by the treating doctors. Some of the medical devices that the National Health Insurance Fund pays for are included in the price of the respective clinical pathway or clinical/outpatient procedure. Another part of the devices is paid for by the National Health Insurance Fund outside the cost of the clinical pathways or procedures.
The medical devices that the National Health Insurance Fund pays for in hospital care outside the cost of the clinical pathways and clinical/outpatient procedures are published on the website of the National Health Insurance Fund, at the following address https://www.nhif.bg/bg/medicine_food/medical, from where each patient can familiarize themselves with the specific models, as well as with the cost that the National Health Insurance Fund pays for them.
Important!
In certain cases, the National Health Insurance Fund pays for the relevant medical device up to a certain value. These devices are included in the “List of medical devices by groups that the National Health Insurance Fund pays under the conditions of hospital medical care, and the value up to which the National Health Insurance Fund pays for each group, compiled in accordance with the procedure of Art. 13, para. 2, item 2, letter “a” of Ordinance No. 10 of 2009”. When the price of the device is higher than the value indicated in the list, the patient must pay the difference.
The medical devices included in the “List of medical devices belonging to one group and used in hospital medical care, which the National Health Insurance Fund pays in full on the basis of Art. 13, para.2, item 2, letter "b" of Regulation No. 10 of 2009", are fully paid by the National Health Insurance Fund and the patient does not owe any co-payment for them.
Important!
In some clinical pathways there are medical devices that the National Health Insurance Fund does not pay for, such as an eye lens, for example, in the treatment of a "curtain" of the eye. Such medical devices are at the patient's expense and their payment is not covered by the budget of the National Health Insurance Fund.
All groups and subgroups of medical devices that the National Health Insurance Fund pays for in full or in part in hospital care can be seen at: https://www.nhif.bg/bg/medicine_food/medical
Does the patient receive the money for the medical device he needs?
Even if the medical device is paid for by the National Health Insurance Fund, the funds for it are not received by the patient, and the National Health Insurance Fund transfers them to the relevant medical institution or pharmacy.
The type of medical device required is determined by the attending physician. The patient's co-payment depends on the device that is needed specifically for his case. If the patient has to pay for a medical device, he gives an amount that represents the difference between the price of the device and the amount paid by the National Health Insurance Fund. The hospital or pharmacy must issue documents (including a receipt, invoice) indicating what the patient paid.
The National Health Insurance Fund does not reimburse funds paid by the patient. The Fund is in contractual relations with medical institutions - providers of hospital medical care - for medical devices paid under the conditions of hospital medical care and retailers of medicinal products (pharmacies) - for medical devices paid under the conditions of outpatient medical care.
The medical institution is obliged to announce in a prominent place the agreed clinical pathways and the prices that the National Health Insurance Fund pays for them, as well as the types of medical devices and expensive consumables, and the prices up to which the National Health Insurance Fund pays for them.
Which medical devices do patients most often need?
Hip joint
The hip joint is implanted within clinical pathways No. 217.2 and 218 “Operative procedures with alloplasty of the hip and knee joint”. The National Health Insurance Fund pays the providers of hospital care for all medical activities, including: examinations, preoperative preparation, anesthesia, surgery, treatment in the hospital with an appointment for up to two follow-up examinations within 30 days after discharge, which must be recorded in the epicrisis, in the same medical institution for hospital care.
The fund pays the hospital the cost of the hip prosthesis, separately from all activities.
Stent
The National Health Insurance Fund pays for stents, but it is necessary to know exactly what kind of stent will be placed, because there are different types, subtypes, sizes with different prices. In the Lists of medical devices belonging to one group and used in hospital medical care, which the National Health Insurance Fund pays for, in group 4 and its subgroups, all types of stents and balloons that the National Health Insurance Fund pays for and their values are included. The lists are published on the website of the National Health Insurance Fund, section "Medical devices and dietary foods" - sub-section "Medical devices used in hospital medical care".
Ocular lens or "Eye Curtain" surgery
Cataract treatment is paid for by the National Health Insurance Fund and is performed under outpatient procedure (APr) No. 19 "Operative cataract removal", which includes procedures for removing cataracts from the eyes and inserting intraocular lenses. The National Health Insurance Fund pays hospital care providers for the surgical activity, the necessary clinical and diagnostic examinations and procedures, for medications and consumables. In outpatient procedure No. 19 it is explicitly mentioned that the expensive medical devices for carrying out the treatment - ocular lens and viscosubstance, are not paid for by the National Health Insurance Fund, i.e. they are paid for by the patient.
