Why doesn't the insurance company cover some medical devices? Isn't it enough that they can help the patient?
Imagine a situation where a doctor recommends a medical device that would help you manage health problems. One automatically assumes that when it comes to an aid recommended by a doctor, the insurance company will pay for it. But then comes an unpleasant surprise: the device is available on the market, but its cost comes out of your own pocket. Why is this the case? And is it determined by price, effectiveness, or perhaps how much the patient actually needs the device? And is there a way to get it even if the insurance company doesn't normally cover it?
Not Every Device Automatically Gets into the Reimbursement System
Have you ever wondered why we collect bottle caps from PET bottles for those in need when insurance companies have enough money to cover the care? You're certainly not alone. Unfortunately, it's not as simple as we would like it to be.
The fact that a medical device is being sold and the manufacturer talks about it as a useful aid is not enough. Reimbursements have their rules and medical devices must meet certain conditions to even get into the system.
How the entire process works is explained for LP-Life.cz by Ing. Elenka Mazurová, press spokesperson of the Czech Industrial Health Insurance Company.
According to what criteria does the insurance company decide which medical devices it will cover and which it will not?
"Health insurance companies cover medical devices based on the Public Health Insurance Act and the appendix to the categorization law. Medical devices are then registered into reimbursement groups by their manufacturers and suppliers."
It's Not Enough to Claim That a Device Works
The difference between a reimbursed and non-reimbursed medical device often lies in what can actually be documented in black and white. A manufacturer may have a product they believe in and whose benefit to patients they don't doubt. However, if there is insufficient convincing evidence of effectiveness, health insurance companies will not contribute to it. Each device must therefore undergo rigorous testing and approval procedures.
This is precisely the phase where the rubber meets the road. Promises, good impressions from a handful of users, or even the best marketing are not enough. Only hard facts from clinical studies matter. Moreover, the reason for non-approval doesn't have to be just the device's functionality itself. Often it's a purely administrative matter where the device manufacturer hasn't reported to the authorities at all.
"The reason for not being included among reimbursed medical devices may be a missing application from the manufacturer/importer for reimbursement, or notification. Medical devices are also not reimbursed from public health insurance funds in cases where there is insufficient clinical evidence of added value or effect," explains Mazurová from ČPZP for LP-Life.cz.
Besides effectiveness, money is also being addressed. However, it's not just about whether the device is expensive or cheap. While a solution may work, the insurance company also considers whether another solution already exists that is capable of offering a comparable result. The financial burden on the entire public health insurance system is also being addressed.
What role do the price of the device, its effectiveness and available scientific evidence play in decision-making?
"Scientific evidence is the absolute foundation for demonstrating effectiveness. Price is assessed in relation to the real clinical benefit for the patient and the cost ratio compared to existing alternatives, and it also plays a crucial role in budget impact analysis,"
emphasizes editor Mazurková.
When the insurance company doesn't cover the device, all may not be lost
What if a patient needs a specific device and can't find it in the standard list of covered supplies? One option is to request individual reimbursement according to § 16 of the Public Health Insurance Act. The path to the goal is complicated even in this case, but it is possible.
And what if the patient simply can't afford the device?
An individual request may not always be a solution and not everyone can afford to pay for a medical aid out of their own pocket. But money doesn't grow on trees.
After consulting with a doctor and insurance company, non-profit organizations, foundations or patient organizations that help with financing medical aids are also an option. The possibilities vary depending on the specific device and the patient's life situation. However, foundations usually require proof of how much the insurance company has paid or that they have rejected the aid.
According to ČPZP, the reimbursement system covers a large part of clinical needs. However, if a patient needs something that is not covered, they can turn to other sources of financing, according to the insurance company.
For the patient, it is best to find out about reimbursement options before purchasing. This can prevent an unpleasant surprise, and sometimes also find another solution that will be medically suitable and more financially affordable.
