Deprecated: mysql_connect(): The mysql extension is deprecated and will be removed in the future: use mysqli or PDO instead in /irehabilitujemy/config/database.php on line 13

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Refundacja sprzętu ortopedycznego - Fizjoterapeuta. Rehabilitacja. | iRehabilitujemy.pl
    • 06
      sty
      2014

    Refundacja sprzętu ortopedycznego

    W ramach ubezpieczenia zdrowotnego przysługuje Państwu refundacja wyrobów medycznych (przedmiotów ortopedycznych i środków pomocniczych). Są to np. wózki inwalidzkie, różnego rodzaju protezy, aparaty ortopedyczne, aparaty słuchowe, soczewki okularowe, obuwie ortopedyczne, materace przeciwodleżynowe, laski i kule, a także pieluchomajtki, cewniki czy sprzęt stomijny.
    Wyroby medyczne są refundowane w różnej wysokości, jednorazowo na określony czas. Wysokość refundacji oraz okres użytkowania określają przepisy Rozporządzenia Ministra Zdrowia z dnia 6 grudnia 2013 r. w sprawie wykazu wyrobów medycznych wydawanych na zlecenie (Dz.U. z 2013 r. poz. 1565). Szczegółowy wykaz wyrobów medycznych wraz z kwotami refundacji i okresami ich użytkowania znajdziecie Państwo w załączniku do ww. Rozporządzenia MZ.

    Krok pierwszy – zlecenie od lekarza ubezpieczenia zdrowotnego
    W przypadku, gdy lekarz zdiagnozuje u Państwa lub Państwa bliskich konieczność korzystania z określonego wyrobu medycznego (z wyłączeniem wyrobów medycznych przysługujących comiesięcznie) wystawia na nazwisko pacjenta "Zlecenie na zaopatrzenie w wyroby medyczne będące przedmiotami ortopedycznymi i środki pomocnicze”, jeżeli natomiast wymagać będziecie Państwo zaopatrzenia w wyroby medyczne przysługujące comiesięcznie lekarz wystawi zlecenie na druku „Zlecenie na zaopatrzenie w środki pomocnicze przysługujące comiesięcznie „Część A”, na specjalnych formularzach (do 30 czerwca 2014 r. obowiązują dotychczasowe druki zleceń). W zależności od rodzaju wyrobu medycznego lekarz może wypisać zlecenie raz na określony w przepisach okres użytkowania. Zlecenie na wyroby medyczne przysługujące comiesięcznie może być wypisane na okres nie dłuższy niż trzy kolejne miesiące, z wyłączeniem miesięcy, które upłynęły. Dla każdego rodzaju wyrobu medycznego oznaczonego odrębnym kodem, musi być wystawione odrębne zlecenie.
    Wykaz lekarzy ubezpieczenia zdrowotnego uprawnionych do wypisywania zleceń w zależności od rodzaju wyrobu medycznego znajduje się we wspomnianym wyżej rozporządzeniu Ministra Zdrowia.

    Krok drugi – potwierdzenie zlecenia do refundacji
    Otrzymane zlecenie lekarskie musi zostać potwierdzone do refundacji przez Oddział Wojewódzki NFZ, na terenie którego jesteście Państwo zarejestrowani w oparciu o adres zamieszkania. W przypadku gdy konieczne jest natychmiastowe zaopatrzenie pacjenta w wyrób medyczny poza obszarem zarejestrowania chorego - w potwierdzeniu zlecenia faxem może pośredniczyć ten Oddział Funduszu, na terenie którego pacjent przebywa. Zlecenie może być potwierdzone osobiście przez pacjenta, inną osobę w jego imieniu lub drogą pocztową (zlecenie przysyłane pocztą będzie odsyłane na adres świadczeniobiorcy), z wyjątkiem świadczeniodawcy, który zawarł umowę o udzielanie świadczeń opieki zdrowotnej – zaopatrzenie w wyroby medyczne oraz osób przez niego zatrudnionych lub udzielających świadczeń w jego imieniu na innej podstawie niż umowa o pracę, a także osób którym udzielanie świadczeń powierzył. Informację o miejscach, gdzie w danym województwie potwierdzane są zlecenia na zaopatrzenie w wyroby medyczne uzyskacie Państwo w Oddziale Wojewódzkim NFZ lub znajdziecie na jego stronie internetowej (w Małopolsce wnioski potwierdzane są w 23 Punktach Ewidencyjnych - wykaz Punktów znajduje się w dolnej części strony.)
    W przypadku zaopatrzenia comiesięcznego nie musicie Państwo każdorazowo potwierdzać zlecenia lekarskiego w NFZ przed jego realizacją. Przy tego typu cyklicznym zaopatrzeniu wydawane jest choremu tzw. Zlecenie na zaopatrzenie w środki pomocnicze przysługujące comiesięcznie „Część B” – ważne maksymalnie 12 miesięcy i na okres nie dłuższy niż do 31 grudnia 2014 r.. „Część B” otrzymacie Państwo w Punktach Ewidencyjnych Małopolskiego OW NFZ, gdzie odbywa się rejestracja zleceń - przy potwierdzeniu pierwszego zlecenia "Część A". Dzięki takiej „Części B” nie musicie Państwo co miesiąc potwierdzać refundacji zlecenia w Punktach Ewidencyjnych Oddziału Wojewódzkiego NFZ.

    Czas oczekiwania na potwierdzenie i realizację zlecenia
    Refundacja i potwierdzanie zleceń na wyroby medyczne prowadzone są zwykle na bieżąco. Może jednak zdarzyć się, że dany Oddział Wojewódzki NFZ wprowadza listę oczekujących na potwierdzenie i realizację zleceń. Dzieje się tak w przypadku braku środków finansowych na pełne pokrycie potrzeb w zakresie zaopatrzenia pacjentów w wyroby medyczne. Wówczas Oddział Funduszu tworzy listę pacjentów oczekujących na potwierdzenie i realizację zleceń, na którą wpisuje pacjentów w kolejności zgłoszenia. Pacjent otrzymuje wówczas - w miejscu, gdzie potwierdzane są zlecenia - informację o numerze zlecenia wprowadzonego do kolejki i informację o konkretnym terminie, w którym możliwe będzie potwierdzenie i realizacja zlecenia.

    Krok trzeci – zakup wyrobu medycznego
    Zlecenie na wyroby medyczne przysługujące comiesięcznie może być zrealizowane na okres nie dłuższy niż trzy kolejne miesiące, z wyłączeniem miesięcy, które upłynęły. Zlecenia te mogą być zrealizowane w miesiącach, których dotyczą bez możliwości realizacji za miesiące, które upłynęły i pod warunkiem, że ważna jest „Część B” zlecenia. Zlecenia na pozostałe (inne niż comiesięczne) wyroby medyczne mogą być zrealizowane po potwierdzeniu refundacji przez Odział Wojewódzki NFZ, na terenie działalności którego pacjent ma zgłoszony adres zamieszkania.
    Mając potwierdzone do refundacji zlecenie lub zlecenie „Część A” i „Część B” zlecenia (w przypadku wyrobów medycznych o miesięcznym okresie użytkowania) możecie Państwo zgłosić się do wybranej placówki na terenie całego kraju, która podpisała umowę z NFZ o udzielanie świadczeń opieki zdrowotnej – zaopatrzenie w wyroby medyczne. Może to być np. sklep medyczny, apteka, zakład optyczny czy punkt protetyki słuchu. Wybór konkretnej placówki danego typu należy do Państwa – nie obowiązuje w tym wypadku rejonizacja.
    Po zakup wyrobów medycznych pacjent zgłasza się osobiście. Jeśli nie jest w stanie sam udać się do punktu z zaopatrzeniem może mu w tym pomóc inna osoba - przedstawiciel ustawowy albo inna osoba na podstawie pisemnego upoważnienia wystawionego przez świadczeniobiorcę lub zaświadczenia lekarza ubezpieczenia zdrowotnego o stanie zdrowia świadczeniobiorcy uniemożliwiającym wystawienie przez niego upoważnienia, z wyjątkiem świadczeniodawcy bądź pracownika świadczeniodawcy, który ma podpisaną umowę z NFZ na realizację świadczeń – zaopatrzenie w wyroby medyczne. Po dokonaniu zakupu refundowanego wyrobu medycznego osoba odbierająca potwierdza podpisem odbiór właściwego zaopatrzenia. Przed złożeniem podpisu warto zwrócić uwagę czy wpisana w III części zlecenia pełna nazwa wydawanego produktu jest zgodna ze zleceniem lekarza oraz opisem na opakowaniu i dokumencie sprzedaży dotyczącym wybranego wyrobu medycznego.

    Zasady refundacji wyrobów medycznych
    Macie Państwo prawo wyboru rodzaju i typu zaopatrzenia zgodnie z kodem zleconym przez specjalistę lekarza ubezpieczenia zdrowotnego, spośród zróżnicowanej oferty różnych producentów. Produkty o tych samych funkcjach mogą różnić się ceną i jakością.
    NFZ finansuje wyroby medyczne do wysokości limitu refundacji określonego w przepisach Ministerstwa Zdrowia. Jeśli cena wybranego przez Państwa wyrobu jest wyższa niż cena określona limitem, Oddział Wojewódzki NFZ pokrywa koszt wyrobu do wysokości limitu, a różnicę pomiędzy ceną brutto, a kwotą refundacji dopłaca pacjent. Obowiązkiem każdej placówki mającej umowę z NFZ na realizację zaopatrzenia w wyroby medyczne jest posiadanie przynajmniej jednego produktu w cenie nie przekraczającej limitu cenowego określony przez Ministra Zdrowia, spośród każdego wyrobu medycznego oznaczonego grupą i liczba porządkową, oferowanego pacjentom w ramach umowy z NFZ. Wyjątek stanowią te wyroby medyczne, które wykonywane są na indywidualne zamówienie. Cena w takich przypadkach ustalana jest przez realizatora w oparciu specyfikację wybranego przez pacjenta wyrobu medycznego.
    Zgodnie z rozporządzeniem Ministra Zdrowia refundacja danego wyrobu medycznego przysługuje Państwu na konkretny okres czasu i dopiero po jego upływie (licząc od daty odbioru poprzedniego zaopatrzenia) możliwe jest wystawienie przez lekarza i potwierdzenie przez NFZ refundacji kolejnego zlecenia, dlatego warto uważnie dokonywać zakupu zaopatrzenia, tak by wybrany wyrób medyczny był zgodny ze zleceniem lekarza, spełniał Państwa oczekiwania i funkcje zdrowotne przez cały okres użytkowania.

    Czy jeśli pacjent sam zakupi wyroby medyczne może liczyć na zwrot kosztów przez NFZ?
    Nie. Jedyną podstawą refundacji – zgodnie z przepisami - jest zlecenie wystawione przez lekarza, potwierdzone do refundacji przez Oddział Wojewódzki NFZ przed jego realizacją. Potwierdzone do refundacji zlecenie jest rodzajem czeku wystawionego Pacjentowi, na podstawie którego otrzymuje on zaopatrzenie, za który punkt realizujący zaopatrzenie rozlicza się z NFZ. Jeśli cena wyrobu medycznego przekracza limit refundacji określony w przepisach Pacjent dopłaca jedynie różnicę ceny brutto i kwoty refundacji.
    Obowiązujące przepisy nie pozwalają natomiast na zwrot pacjentowi kosztów, poniesionych przy pełnopłatnym zakupie refundowanego wyrobu medycznego poza systemem ubezpieczenia zdrowotnego, na podstawie przedłożonego przez pacjenta Oddziałowi NFZ paragonu, rachunku czy faktury.

    Naprawy wyrobów medycznych
    Zgodnie z ministerialnymi przepisami część refundowanych wyrobów medycznych podlega refundowanej naprawie (np. wózek inwalidzki, aparaty ortopedyczne, protezy kończyn). Podstawą do naprawy jest wypełnienie przez Państwa zlecenia na wykonanie naprawy wyrobu medycznego, który następnie potwierdzicie Państwo w Oddziale Wojewódzkim NFZ. Realizacja napraw odbywa się z reguły w placówce w której pacjent dokonał zakupu wyrobu medycznego.

    Zasady przedterminowego zaopatrzenia w wyroby medyczne
    Zdarzają się sytuacje, że dany wyrób medyczny w wyniku zmian w stanie zdrowia u chorego przestaje spełniać swoją funkcję. Przypadki takie mogą dotyczyć np. dzieci, które ze względu na rozwój fizyczny nie mogą dalej posługiwać się danym wyrobem medycznym, gdyż wyczerpały się możliwości jego regulacji, jak również osób dorosłych, u których nastąpiły takie zmiany w stanie zdrowia, które uniemożliwiają korzystanie z dotychczasowego zaopatrzenia.
    W opisanych sytuacjach możecie Państwo starać się o skrócenie okresu użytkowania. Przedterminowe zaopatrzenie przysługuje wyłącznie w przypadkach i w odniesieniu do wyrobów medycznych wskazanych w przepisach Ministra Zdrowia.
    Zlecenie na przedterminowe zaopatrzenie w wyroby medyczne, musi być wystawione przez specjalistę - lekarza ubezpieczenia zdrowotnego i zawierać wyczerpujące uzasadnienie medyczne, potwierdzające zmiany w stanie fizycznym pacjenta. Takie wnioski są potwierdzane przez Oddział NFZ – może się zdarzyć, że w razie niejasności co do zasadności przedterminowego zlecenia będzie ono dodatkowo weryfikowane przez Oddział Funduszu. W przypadku pozytywnego rozpatrzenia zlecenia przez NFZ, zostanie ono potwierdzone do refundacji i realizacji zgodnie z przepisami.

     

    Źródło: nfz-krakow.pl

    Do pobrania :

    Wykaz świadczeń gwarantowanych z zaopatrzenia ortopedycznego 

     

    Wzrór zlecenia na zaopatrzenie w środki pomocnicze przysługujące comiesięcznie

    Wzrór zlecenia na zaopatrzenie w wyroby medyczne będące przedmiotami ortopedycznymi i środki pomocznie

     

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