The Extent of Rights Deriving from Compulsory Health Insurance

The extent of rights deriving from compulsory health insurance is specified by the Law on health care and health insurance and The Regulations on compulsory health insurance, i.e. the act adopted by the assembly of the Health Insurance Institute of Slovenia.

Compulsory health insurance comprises insurance in the case of illness or injury outside work, and insurance in the case of injury at work and occupational diseases. The extent of rights to health care services is defined in percent share of the total service costs. This means that the compulsory health insurance "covers" the majority of health related risks, however, not necessarily all of them and neither in full. The balance is either to be paid by the insured person, or, alternatively, the insured person can take out a supplementary insurance policy of copayment.

Urgent medical treatment and urgent medical assistance are fully covered by compulsory health insurance and therefore require no additional payments. In addition to these services some others are fully covered by compulsory insurance, as follows:

• systematic and other preventive medical examinations of children, pupils, secondary-school students and university students up to the age of 26; medical examinations of women in connection with pregnancy, and other adult persons pursuant to the programme, with the exception of medical examinations provided by employers on the basis of the Act;
• prevention, screening and early detection of diseases in line with the programme of the Health Council;
• counselling, education, training, and assistance in changing unhealthy lifestyles;
• treatment and rehabilitation of children, pupils and students in regular schooling, and of children and teenagers with physical and mental disorders, and of children and teenagers with head trauma and brain damage;
• health security of women linked to counselling on family planning, contraception, pregnancy, and labour;
• prevention, detection and treatment of HIV infection and contagious diseases with legally determined steps taken to prevent further contagion;
• compulsory vaccinations, immunoprophylaxis, and chemoprophylaxis pursuant to the programme;
• treatment and rehabilitation of malignant diseases, muscular and neuromuscular diseases, paraplegia, tetraplegia, cerebral paralyses, epilepsy, haemophilia, mental illnesses, developed types of diabetes, multiple sclerosis, and psoriasis;
• holistic treatment and rehabilitation related to blindness and myopia in compliance with the classification of the World Health Organisation, of total and extreme hearing defects according to the International Classification of Impairments, Disabilities and Handicaps of the World Health Organisation (1980), cystic fibrosis and autism, and treatment and rehabilitation related to accidental head injuries and brain damage,
• treatment and rehabilitation for professional diseases and injuries at work;
• health care regarding the donation and exchange of tissues and organs for transplantation to other persons;
• emergency medical assistance, including emergency transportation;
• home-care visits, treatment and care at home and in social security institutions;
• medicinal products from the positive list needed for the treatment of persons and conditions included in paragraphs 4-13 of this point, medicinal devices for the treatment of persons and conditions from paragraphs 1-13 of this point;
• medicinal products and foods for special medicinal purposes from the positive and interim list for children, pupils, high-school students, apprentices and university students, and persons with disorders in mental and physical development;
• foods for special medicinal purposes with ingredients adapted for the treatment of insured persons with inherited digestive disorders;
• one parent accompanying a patient up to 5 years of age in a health care institute;
• preliminary and periodic medical analyses for athletes competing in official competitions of national branch sporting associations.

Other necessary services are only provided free of charge to a certain percentage, so that for some medical services the difference to the full price has to be paid which depends on individual cases and amounts to from 10 % to 90 % of the value of the medical service or appliance.
In the continuation medical services that have to be additionally paid for and the percentages of such additional payments are stated:

• transplantations of organs, most demanding surgical operations irrespective of the reason for them, intensive therapy, dialysis and other most demanding therapeutic and rehabilitation services – 10 % additional payment;
• medical services in the field of specialist-outpatient and inpatient activities; services in the field of health resort treatment as the continuation of hospital treatment, with the exception of injuries that were not caused at work; services in the field of dental and oral cavity treatment; orthopaedic, orthotic, hearing and other medical appliances – 20 % additional payment;
• specialist-outpatient, inpatient and health resort services as continuation of hospital treatment, and the non-medical part of nursing in a hospital or health resort as continuation of hospital treatment, as well as orthopaedic, orthotic and other appliances related to the treatment of injuries that were not caused at work – 30 % additional payment;
• medical services of health resort treatment and non-medical nursing within health resort treatment (the hotel part of the hospitalization) which is not a continuation of hospital treatment – 90 % additional payment;
• dental prosthetic treatment of adults, ophthalmic appliances for adults – 90 % additional payment;
• medical products from positive list - 0-30 % additional payment;
• medical products from interim list - 90 % additional payment;
• medical products from negative list - 100 % additional payment;
• ambulance transport which in not urgent - 90 % additional payment;

Table. The percentage of other necessary service prices covered by compulsory health insurance, varies from 90% to 10%, in accordance with regulations. The shares are specified by the Institute assembly, with the consent of the government of the Republic of Slovenia, while the Law specifies their lower limit.