The Health Insurance Fund with Two Significant Processes in the Interest of Insured Persons

Today, at the premises of the Health Insurance Fund, the Director General, Mr Sasho Klekovski, held a briefing with media representatives, at which he informed journalists, and through them the entire public, about two extremely important processes currently being implemented.

Review of the health insurance criteria

At the initiative of the Health Insurance Fund, by decision of the Government of the Republic of Macedonia, a process has begun for reviewing the health insurance criteria.
Macedonia has one of the most comprehensive laws in the region, which provides a basis for health insurance for every citizen, with the aim of – universal health insurance for all. At present, the Fund’s system has registered 1.845.007 insured persons.

The focus of the reassessment is on the basis for insurance of persons with lower and higher incomes who are not formally employed. On this basis, around 477 thousand personsare insured, among whom there is a risk of abuse, particularly among persons who work in the grey economy or live and earn income abroad, and have no registered income in the country.

As a result, the Fund incurs losses both on the basis of unpaid contributions, and on the basis of higher capitation payments to family doctors, since the number of insured persons is the basis for their payment.
The process is being carried out by  a working group composed of representatives of the Fund, the Ministry of Health, the Ministry of Finance and the Public Revenue Office, while the Ministry of Interior is also consulted as needed.

Expansion of the Positive List by the end of November

The second significant process is aimed at expanding the Positive List of medicines.
The Fund is in the final phase of the procedure for including two anticoagulants – Enoxaparin and Nadroparin (known as Clexane and Fraxiparine), which will be available for extended home treatment.

Until now, these medicines were on the hospital list and were reimbursed by the Fund. With their transfer to

the Positive A List, a dual benefit will be achieved:

• patients will have easier and faster access to the therapy, which they will receive directly on prescription,
• the Fund will have a reduced administrative burden in the reimbursement process.

The necessary analyses and agreements with distributors are under way, with the aim of finalising the procedure by the end of November.

The challenges of the process relate to:

• a lack of reliable data on medicine consumption,
• the need for full implementation of the e-prescription, which will enable IT control instead of physical control,
• and the establishment of an agreed entry onto the positive list, thereby guaranteeing price protection and limiting any possible co-payment for citizens.

Following the briefing, the Director General, Mr Sasho Klekovski, answered questions from the journalists present.