ORDER OF THE MINISTER OF HEALTH OF THE REPUBLIC OF KAZAKHSTAN

of November 26, 2009 No. 801

About approval of Rules of forming of rates for the medical services rendered within the guaranteed amount of free medical care and in system of compulsory social medical insurance and the Technique of forming of rates for the medical services rendered within the guaranteed amount of free medical care and in system of compulsory social medical insurance

According to the Code of the Republic of Kazakhstan of September 18, 2009 "About health of the people and health care system", PRIKAZYVAYU:

1. Approve:

1) Rules of forming of rates for the medical services rendered within the guaranteed amount of free medical care and in system of compulsory social medical insurance according to appendix 1 to this order;

2) the Technique of forming of rates for the medical services rendered within the guaranteed amount of free medical care and in system of compulsory social medical insurance according to appendix 2 to this order.

2. To the director of the department of the organization of medical care of the Ministry of Health of the Republic of Kazakhstan (Aydarkhanov A. T.) provide in the procedure established by the legislation state registration of this order in the Ministry of Justice of the Republic of Kazakhstan.

3. To department of administrative and legal work of the Ministry of Health of the Republic of Kazakhstan (Bismildin F. B.) provide in the procedure established by the legislation official publication of this order after its state registration.

4. To impose control of execution of this order on the vice-minister Birtanov E. A.

5. This order becomes effective after ten calendar days after day of its first official publication.

Rules of forming of rates for the medical services rendered within the guaranteed amount of free medical care and in system of compulsory social medical insurance

Chapter 1. General provisions

1. These rules of forming of rates for the medical services rendered within the guaranteed amount of free medical care and in system of compulsory social medical insurance (further - Rules) are developed according to Item 2 of article 23 of the Code of the Republic of Kazakhstan of September 18, 2009 "About health of the people and health care system" (further - the Code) and determine procedure for forming of rates for the medical services rendered within the guaranteed amount of free medical care and in system of compulsory social medical insurance.

2. In these rules the following concepts are used:

1) information system - the organizational ordered set of the information and communication technologies, service personnel and technical documentation realizing certain technological actions by means of information exchange and intended for the solution of specific functional objectives;

2) administrative data - individual quantitative and (or) high-quality data on physical person or legal entity and the data of pokhozyaystvenny accounting created by administrative sources, except for primary statistical data;

3) fund of social medical insurance (further - fund) - the non-profit organization making accumulation of assignments and fees, and also performing purchase and fee of the subjects of health care providing medical care in amounts and on the conditions provided by the agreement of purchase of medical services and other functions determined by the laws of the Republic of Kazakhstan;

4) authorized body in the field of health care (further - authorized body) - the central executive body performing management and cross-industry coordination in the field of protection of public health, medical and pharmaceutical science, medical and pharmaceutical education, sanitary and epidemiologic wellbeing of the population, drug circulation and medical products, control of quality of medical services;

5) subjects of health care - the organizations of health care, and also the physical persons practising private medicine and pharmaceutical activities;

6) the treated case - complex of the medical services rendered to the patient in stationary and (or) hospital-replacing conditions from the moment of receipt to the statement;

7) the private partner - the individual entrepreneur, particular partnership, consortium or the legal entity, except for persons acting as the state partners according to the Law of the Republic of Kazakhstan "About public-private partnership", signed the agreement of public-private partnership;

8) working body - the legal entity responsible for collection, processing, storage, the analysis and provision of information on questions of tariff setting for ensuring activities of authorized body;

9) kliniko-costly groups (further - KZG) - clinically uniform groups of diseases similar on costs for their treatment;

10) medico-economic rate (further - MET) - the average cost for one treated case created on the basis of clinical protocols for payment to the subjects of health care providing stationary and (or) hospital-replacing medical care to children up to eighteen years with oncological diseases within the guaranteed amount of free medical care;

11) public-private partnership - the form of cooperation between the state partner and the private partner corresponding to the signs determined by the Law of the Republic of Kazakhstan "About public-private partnership";

12) compulsory social medical insurance (further - OSMS) - complex of legal, economic and organizational measures on delivery of health care to consumers of medical services for the asset account of fund;

13) the system of compulsory social medical insurance is set of the regulations and rules established by the state, governing the relations between participants of system of compulsory social medical insurance;

14) the correction coefficient for subjects of PPP is coefficient which is used for adjustment of the total sum of rate which is subject to payment to the private partner and the organization of health care;

15) operating expenses - the costs connected with maintenance in operating state of the used systems, machines, the equipment, buildings and other expenses;

16) pilot testing - practical application developed and earlier not applied rates, including payment of certain types of medical services in certain period, with research purpose, the analysis of prospects and risk minimization of implementation of new rates;

17) the reference subject - the subject of health care on provision of information for development and review of rates within the guaranteed amount of free medical care and in the OSMS system;

18) the medical record of the inpatient - the document approved by the order of the acting minister of health care of the Republic of Kazakhstan of November 23, 2010 No. 907 "About approval of forms of primary medical documentation of the organizations of health care" (it is registered in the Register of state registration of regulatory legal acts No. 6697) and intended for data recording about the state of health of the patients reflecting nature, amount and quality of the provided medical care in hospital;

19) rate - estimated cost of unit of service or complex of medical services within the guaranteed amount of free medical care and (or) in system of compulsory social medical insurance;

20) tasksetter - the list of rates for medical services approved by authorized body according to Item 2 of article 23 of the Code;

21) forming of rates - process of development and approval new, review and approval of applicable fares on medical services (complex of the medical services) rendered within the guaranteed amount of free medical care and (or) in the OSMS system;

22) review of rate - the increase or decrease in the size of rate performed by authorized body in the course of development and approval new, review and approval of applicable fares for ensuring balance of the budget of the guaranteed amount of free medical care and the income of the OSMS system with obligations on delivery of health care within the guaranteed amount of free medical care and in the OSMS system;

23) the guaranteed amount of free medical care (further - GOBMP) - amount of the medical care provided at the expense of budgetary funds according to the list determined by the Government of the Republic of Kazakhstan, to citizens of the Republic of Kazakhstan, oralmans, and also the foreigners and persons without citizenship who are constantly living in the territory of the Republic of Kazakhstan according to Item 1 of article 34 of the Code;

24) rate in koyko-day - rate for payment in the day spent by the patient in the conditions of hospital;

25) the authorized subject in the field of electronic health care - the organization determined according to the current legislation performing activities and entering legal relationship regarding enhancement of information infrastructure of health care system (electronic health care) and medical statistics (further - the subject of informatization).

3. Process of forming of rates for the medical services rendered within GOBMP and (or) in the OSMS system is based on the principles:

Availability of medical care - forming of rates, and also their enhancement not to lead 1) to deterioration in availability of the population to medical care within GOBMP and (or) in the OSMS system;

2) transparency - obligatory publication of results of the main stages of process of forming of rates, except for office information of limited distribution, and also openness of process of forming of rates for the public;

3) effectiveness - forming of the rates in forms, types and profiles of medical care oriented to achievement of strategic objectives, the directions and tasks of development of health care system of the Republic of Kazakhstan;

4) realness - compliance of the sizes of rates with approved (specified, corrected) indicators of the budget and the sizes of assets of fund;

5) the sequences - observance by all persons who are taking part in process of forming of rates, earlier made decisions;

6) justification - forming of rates on the basis of regulatory legal acts and other documents determining need of development new and (or) enhancement of the existing rates, and also use of budgetary funds and assets of fund according to the legislation of the Republic of Kazakhstan;

7) regularities - planned review of rates is performed on permanent basis, but is not more often than once a year.

Chapter 2. Procedure for forming of rates for the medical services rendered within GOBMP and in the OSMS system

4. Forming of rates for the medical services rendered within GOBMP and (or) in the OSMS system is determined in the following procedure:

1) approval of the work plan on forming of rates for medical services (complex of medical services) rendered within GOBMP and (or) in the OSMS system (further - the plan);

2) selection of reference subjects by working body and approval of the list of reference subjects by authorized body (except as specified calculation and modeling of rates at the initiative of the subject of health care);

3) collection of financial and economic, statistical and clinical information for calculation of rates;

4) calculation and modeling of rates on the basis of the plan or at the initiative of the subject of health care;

5) pilot testing of rates based on the decision of authorized body;

6) consideration, coordination and approval of the size of rates;

7) monitoring of application of rates for medical services (complex of medical services) rendered within GOBMP and (or) in the OSMS system (further - monitoring).

5. The draft of the plan is annually developed by working body and affirms authorized body until the end of the year, preceding the planned year, taking into account:

1) priorities in the field of health care according to documents of system of state planning of the Republic of Kazakhstan;

2) implementations in the Republic of Kazakhstan of new methods of diagnostics, treatment and medical rehabilitation;

3) reasonable offers of the medical organizations;

4) balances of the budget of GOBMP and the income of the OSMS system with obligations on delivery of health care within GOBMP and (or) in the OSMS system.

Project development of the plan is performed by forms of medical care with determination of actions for introduction new and to review of applicable fares.

6. The plan is placed on official Internet resource of authorized body and the corporate website of fund.

7. Modification and amendments in the approved plan is allowed not more often than once a half-year in cases:

1) adoptions of new documents of system of state planning of the Republic of Kazakhstan and legal acts of the Republic of Kazakhstan concerning health care;

2) enhancement of standards of delivery of health care in the field of health care;

3) implementations in the Republic of Kazakhstan of new methods of diagnostics, treatment and medical rehabilitation.

8. Selection of reference subjects is performed by working body taking into account forms and profiles of medical care based on the following criteria:

1) rendering medical services by the subject of health care within GOBMP and (or) in the OSMS system on which development and (or) review of rates, during at least three-year period, the selection preceding date are planned;

2) availability of the existing certificate on accreditation in form, according to appendix, the Minister of health and social development of the Republic of Kazakhstan approved by the order of March 10, 2015 No. 127 "About approval of Rules of accreditation of health care" (it is registered in the Register of state registration of regulatory legal acts for No. 10735);

3) territorial representativeness by selection at least three subjects of health care on one of three various areas (the city of republican value);

4) availability of medical information systems, allowing to perform the personified accounting of the actual costs of the subject connected with delivery of health care;

5) specific weight of medical services on which development or review of rates is planned, is not lower than ten percent for multidisciplinary organizations of health care and not lower than fifty percent for the specialized organizations of health care.

9. The working body creates the list of reference subjects and sends for coordination in authorized body within fifteen working days.

10. The list of reference subjects is considered and affirms authorized body within five working days from the date of receipt.

11. The working body within three working days from the date of approval of the list of reference subjects in any form notifies on it reference subjects.

12. Reference subjects within ten working days from the date of receipt of the notification, stipulated in Item 11 these rules, provide to working body the following financial and economic, statistical and clinical information confirmed at the request of working body by the proving documents (agreements, invoices, financial records, internal documents):

for development and (or) review of KZG:

1) the form intended for collection of the administrative data "Information on Direct Actual Costs on 1 Treated Case" according to appendix 1 to these rules;

2) the form intended for collection of the administrative data "Area of the Subject of Health Care" according to appendix 2 to these rules;

3) copy of technical data sheet of object;

4) copy of the staff list;

5) information on bed fund, in form according to appendix 3 to these rules;

6) information on consumption of medicines and medical products (including reagents), in form according to appendix 4 to these rules;

7) information on the number of the executed medical services, in form according to appendix 5 to these rules;

8) information on the executed surgeries, in form according to appendix 6 to these rules;

9) information on the number of the patients who arrived in departments of anesthesiology, resuscitation and intensive therapy in form according to appendix 7 to these rules;

10) the form intended for collection of the administrative data "Information on Actually Occupied Rates" according to appendix 8 to these rules;

11) expense information on personnel, in form according to appendix 9 to these rules;

12) the form intended for collection of the administrative data "Expense Information, Not Connected with Personnel" according to appendix 10 to these rules.

Selection of medical records of the inpatient of the written-out patients is performed by working body in coordination with authorized body, on formula of selection of copies of medical records of the inpatient of the written-out patients according to appendix 11 to these rules;

for development and (or) review of tasksetter:

1) calculation of cost of medical services, in form according to appendix 12 to these rules;

2) the form intended for collection of the administrative data "Expense Structure of the Subject of Health Care for Calculation of Overheads" according to appendix 13 to these rules;

for development and (or) enhancement of MET:

1) the form intended for collection of the administrative data "Calculation of MET on One Treated Case" according to appendix 14 to these rules;

2) the form intended for collection of the administrative data "Calculation of Costs for the Salary of Medical Personnel" according to appendix 15 to these rules;

3) the form intended for collection of the administrative data "Calculation of Costs for Medicines and Medical Products" according to appendix 16 to these rules;

4) the form intended for collection of the administrative data "Calculation of Costs for Food of Patients" according to appendix 17 to these rules;

5) the form intended for collection of the administrative data "Calculation of Costs for Medical Services" according to appendix 18 to these rules;

6) the form intended for collection of the administrative data "Expense Structure of the Subject of Health Care for Calculation of Overheads" according to appendix 19 to these rules;

for development and review of rate in one koyko-day:

information on the amount of financing and the number of koyko-days for the next planning period, in form according to appendix 20 to these rules;

for development and review of rate for transport services of sanitary aircraft:

price proposals of the suppliers rendering aviation transport services (at least 3 price offers).

13. In case of development, review of other types of rates the working body requests financial and economic, statistical and clinical information on the forms which are previously approved with authorized body from reference subjects.

14. Development, review of the rates including costs for updating of fixed assets is performed by working body only according to the Plan, according to requirements of the Technique of forming of the rates for medical services rendered within GOBMP and in the OSMS system (further - the Technique) according to Item 2 of article 23 of the Code.

15. The subject of informatization provides to working body access to electronic information resources and information systems of health care after provision of official request with indication of data of the responsible person and required effective period. The working body uses the provided access according to requirements of article 28 of the Code providing personal data protection of physical persons (patients).

16. When forming by reference subjects of the financial and economic, statistical and clinical information specified in Items 12 and 13 of these rules the expenses which are not relating directly to rendering services are not considered including:

1) payments for above-standard emissions (dumpings) of pollutants;

2) bad debts;

3) penalties, penalty fee, penalty and other types of sanctions for violation of conditions of economic agreements, legal costs, including according to the procedure of regress;

4) penalties and penalty fee for concealment (understating) of the income;

5) losses from plunders;

6) on content of the assets which are not involved in delivery of health care, including the idle medical equipment;

7) on content of the objects which are functionally not connected with process of delivery of health care on the corresponding profile;

8) on holding cultural and educational, sporting events;

9) on rendering the sponsor's help;

10) on acquisition, lease and content of apartments, residential buildings and constructions, places in hostels and hotels for personnel of subjects;

11) on acquisition of gifts to anniversaries or issued in the form of encouragement to workers;

12) on above-standard technical and commercial losses, spoil and shortage of inventory items, inventories in warehouses and non-productive costs;

13) on carrying out and the organization of the training rates, seminars, trainings, lectures, exhibitions, discussions, meetings with scientists and arts, scientific and technical conferences, except for the actions connected with business necessity;

14) insurance payments (the fees paid by the subject under agreements of personal and property insurance, concluded by the subject for benefit of the workers), the obligatory insurance payments except for established by the legislation of the Republic of Kazakhstan;

15) on payment of educational leaves of the workers studying in the organizations of education;

16) on payment in addition provided (over stipulated by the legislation the Republic of Kazakhstan) leaves to workers;

17) privileges to the subject's workers, except stipulated by the legislation the Republic of Kazakhstan;

18) assignments to labor unions on the purposes determined by the collective agreement;

19) on repayment of loans, loans, including interest-free, financial aid, received by employees of the organization;

20) on the membership fees in public organizations and associations;

21) depreciation charges of fixed assets.

17. Reference subjects of health care provide to working body information specified in Items 12 and 13 of these rules according to the following requirements:

1) materials of the request are stitched, numbered and certified by seal and the signature of the head of the reference subject, or person replacing him, or the deputy manager whose competence questions of financial accounting and finance enter;

2) financial records are signed by the head and the chief accountant of the reference subject or persons replacing them and certified by seal of the reference subject.

18. The working body no later than five working days from the date of receipt of information specified in Items 12 and 13 of these rules checks completeness of the provided materials and in writing in any form notifies reference subjects on acceptance of materials for consideration or on need of provision of the additional documents confirming expenses.

19. Calculation and modeling of rates, is carried out by working body on the basis of the plan and includes the following events:

1) carrying out calculations and the analysis of the received results;

2) modeling of results of calculation of rates;

3) development of offers on the choice of type of rate;

4) forming of the draft of the list of rates;

5) provision of results of calculation and modeling of rates to authorized body.

19-1. Before calculation and modeling of rates by working body the analysis of the acquired information regarding compliance to standards of the organization of delivery of health care and to clinical protocols and marginal compliance to prices for the trade name of medicine or medical product, either the international non-proprietary name of medicine or technical characteristic of medical product within GOBMP and in the OSMS system is made.

20. Calculation of rates is perfromed by the worker of bodies within 6 months from the date of obtaining from reference subjects of information, taking into account the requirements established by Items 17, of 18 these rules according to the Technique.

21. Modeling of results of calculation of rates is performed for the purpose of impact assessment of the developed and reviewed rates on:

1) amounts of consumption of medical care within GOBMP and (or) in the OSMS system;

2) the expenses connected with rendering medical services within GOBMP and (or) in the OSMS system.

22. Modeling of results of calculation of rates is performed by working body in terms of carrying out calculation of rates taking into account the following information:

1) the year preceding the current financial year;

2) the current financial year taking into account development until the end of the year.

23. Following the results of calculation and modeling of rates the working body creates the report on development and (or) review of rates (further - the Report) including:

1) results of calculations and the analysis of the obtained data;

2) results of modeling of the calculated rates;

3) offers on the choice of type of rate, including on introduction of new type of rates taking into account the international experience;

4) draft of the list of rates;

5) reasonable offers on review of rates for other medical services.

24. The report goes working body to authorized body.

25. The authorized body within ten working days from the date of receipt of the Report dispatches requests on competence in the relevant divisions and the subordinated organizations, carries out expertize of the received materials and creates the conclusion of authorized body regarding:

1) compliance of results of calculation and modeling of rates to requirements of these rules and (or) Techniques;

2) compliance to strategic, program documents of the Republic of Kazakhstan in the field of health care;

3) feasibility of the choice of type of rate, including on introduction of new type of rates;

4) feasibility of implementation of additional budgeted expenses and expenses of means of the OSMS system in connection with introduction of the rates offered calculated, reviewed;

5) feasibility and need of review of rates for other medical services.

26. The authorized body requests source documents based on which calculation and modeling of rates were perfromed from working body.

27. In case of forming of the negative conclusion by authorized body on the bases provided by subitems 1) and 2) of Item 25 of these rules the report returns to working body to completion within ten working days from the date of receipt of the conclusion.

28. Authorized body within five working days from the date of receipt of the modifed report create the repeated conclusion according to the procedure, provided by Items 25 and 26 of these rules.

29. The positive conclusion of authorized body about introduction of the new and (or) reviewed rates is accepted taking into account respect for the principles of forming of rates, stipulated in Item 3 these rules with indication of:

1) terms of their introduction;

2) need of carrying out preliminary approbation of rates for scales of the subject (subjects) of health care and (or) region and (or) country;

3) durations of carrying out preliminary approbation of rates;

4) recommendations about review of other rates.

30. The decision on completion of the new and (or) reviewed rates includes the specific financial and economic, statistical and clinical parameters requiring completion.

In case of review of rates within financial year, in calculation data taking into account the actual execution for last accounting periods of the current financial year are applied.

31. In case of adoption by authorized body of the decision on completion of the new and (or) reviewed rates:

1) the working body within thirty working days from the date of adoption of such decision performs completion of the new and (or) reviewed rates;

2) the authorized body provides the repeated conclusion, according to the procedure, provided by Items 25 and 26 of these rules.

32. The new and (or) reviewed rates are subject to approval by authorized body according to Item 2 of article 23 of the Code.

33. Copies of acts of authorized body which adoption is provided by Items 29 and 31 of these rules go to the subject of informatization within one working day for input of the relevant information to electronic information resources and information systems of health care, to working body and fund.

34. The decision of authorized body to reject introduction of the new and (or) reviewed rates is accepted taking into account respect for the principles of forming of rates, stipulated in Item 3 these rules, with indication of the bases for adoption of such decision.

35. The subject of health care providing medical care within GOBMP and (or) in the OSMS system (further - the subject of health care) files in authorized body petition on development and (or) review of rates, in form according to appendix 21 to these rules, on development, review of rates.

36. The authorized body considers the application of the subject of health care and notifies on the made decision in the terms established by the Law of the Republic of Kazakhstan of January 12, 2007 "About procedure for consideration of appeals of physical persons and legal entities".

37. The statement of the subject of health care is transferred by authorized body to working body for calculation and modeling of rates if development and (or) review of rates on the corresponding profile of medical care are provided by the plan.

38. If development, review of rates are not provided by the plan, the authorized body considers the statement of the subject of health care in case of:

1) forming of the plan for the next planned year;

2) modification and amendments in the approved Plan for the bases, stipulated in Item 7 these rules.

39. If the method of diagnostics, treatment and medical rehabilitation for which payment development, review of rates is planned is not allowed to application in the territory of the Republic of Kazakhstan within GOBMP and (or) in the OSMS system, the authorized body leaves the statement of the subject of health care without consideration.

The subject of health care repeatedly directs to authorized body the application, stipulated in Item 35 these rules, after receipt of the corresponding permission to application of new method of diagnostics, treatment and medical rehabilitation in the territory of the Republic of Kazakhstan within GOBMP and (or) in the OSMS system.

40. For calculation of rates the subject of health care current of 20 working days from the date of receipt of the notification from the authorized body specified in Item 36 of these rules provide to working body the financial and economic, statistical and clinical information confirmed at the request of working body by the proving documents (agreements, invoices, financial records, internal documents) provided by Items 12 and 13 and taking into account requirements of stipulated in Item 18 these rules.

41. Calculation of rates is perfromed by working body within 6 months from the date of obtaining from the subject of health care of information specified in Items 12 and 13, taking into account requirements, stipulated in Item 17 these rules according to the Technique.

42. Modeling of results of calculation of rates is performed by working body according to the procedure and terms the established Items 21 and 22 of these rules.

43. Consideration, coordination and approval of rates is performed according to the procedure, provided by Items 25-32 of these rules.

44. During monitoring collection of the up-to-date and objective information about influence of rates is performed on:

1) amounts of consumption of medical services within GOBMP and (or) in the OSMS system;

2) availability of the rendered medical services within GOBMP and (or) in the OSMS system;

3) development of the competition in the sphere of rendering medical services.

45. Monitoring is performed by fund by:

1) forms of delivery of health care within GOBMP and (or) in the OSMS system;

2) types of rates.

46. The subject of informatization, based on request of fund:

1) is provided to employees of fund by access to electronic information resources and information systems of health care according to article 35 of the Law of the Republic of Kazakhstan of November 24, 2015 "About informatization" taking into account requirements of article 28 of the Code;

Carries out 2) in information systems of health care of action for modification of necessary reporting and analytical forms.

46-1. The fund carries quarterly out the analysis and monitoring of rates in information systems regarding their compliance to the rates approved by the order of the Minister of Health of the Republic of Kazakhstan of September 5, 2018 No. KR DSM-10 "About approval of rates for the medical services rendered within the guaranteed amount of free medical care and in system of compulsory social medical insurance" (it is registered in the Register of state registration of regulatory legal acts for No. 17353).

47. The report on the monitoring including suggestions for improvement of rates is created by fund quarterly and following the results of year in November of the current year and is provided to authorized body no later than the 20th following for reporting.

Appendix 1

to Rules of forming of rates for the medical services rendered within the guaranteed amount of free medical care and system of compulsory social medical insurance

The form intended for collection of the administrative data "Information on Direct Actual Costs on 1 Treated Case" *

Index: 1-PFZ

Frequency: as required

The group of people, providing information: Reference subjects

Where the form is represented: Working body

Term of representation of form: within 10 working days from the date of receipt of the notification

No. end-to-end	Name of the region	Name of the medical organization	Patient's IIN	clinical record No.	Date of hospitalization	Date of the statement	Name of department of the statement	The name of the place of write-off where the medical service was applied, is used by LS and/or MI (clinical department, the operational block, OARIT)	Code of the main diagnosis (MKB-10)	Transaction (MKB-9)
1	2	3	4	5	6	7	8	9	10	11

Disclaimer! This text was translated by AI translator and is not a valid juridical document. No warranty. No claim. More info