Patients who cannot go to the office can benefit, under the conditions provided by the legislation, from consultations or medical care at home, through the public health system. Visits to the family doctor are also accessible to the uninsured, registered on his list. Instead, the settlement of the services offered by the specialized providers requires the quality of the insured, a recommendation and the fulfillment of the eligibility criteria.
For the patient and family, the first step is to clarify the type of medical help needed. From here starts the route to the right service and the procedure by which it can be requested.
Consultations and home care have different rules
Government Decision no. 521/2023, in the updated form published by the CNAS, regulates separately the consultations performed at home by the family doctor and the package of medical care at home. The former are part of primary healthcare. The others include interventions such as the administration of treatments or wound care, carried out by providers who have contracts with insurance companies.
The distinction matters to the uninsured. The fact that they can receive a consultation at home, within the minimum package, does not automatically give them access to the entire package of care intended for the insured. Each category has its own award conditions.
Who can be consulted at home by the family doctor
Home consultations are granted to people registered on the family doctor’s list, in the program dedicated to these visits. Eligible are:
- patients who cannot be moved due to a permanent or temporary disability;
- patients with chronic diseases or with an acute episode that prevents travel to the office;
- children aged 0-1 years;
- children aged 0-18 with infectious diseases;
- the lauds.
These provisions are found both in the minimum package, accessible to the uninsured, as well as in the basic package.
Who can benefit from settled medical care
For home care from the basic package, the evaluation follows the degree of autonomy of the insured. The rules state that services are provided “only for the insured’s ECOG 3 or 4 performance status”.
- CLASSIFICATION ECOG 3 describes the patient who cannot carry out household activities, spends more than half of the day in bed or in an armchair and requires help with hygiene, nutrition or mobilization;
- ECOG 4 refers to the person who is completely bedridden, totally dependent on someone else for basic care.
Therefore, having a diagnosis is not enough. The physician must establish the need for interventions and record the functional framework that allows them to be granted through this mechanism.
Who issues the recommendation and what it must contain
The recommendation (Appendix 31 C form) can be issued by the family doctor, the outpatient specialist or the hospital doctor, if they have a contract with the insurance companies.
The form must include the diagnosis, ECOG status and frequency of recommended services. Insurance companies do not settle referrals where this information is missing or where the provider who will take over the case is nominated.
If the recommendation is issued upon discharge from the hospital, it must be accompanied by a copy of the medical letter or discharge note. The insurance company checks whether the recommended interventions correspond to those recorded in the discharge document, before certifying the number of days.
What services can be provided at home
The basic package includes monitoring of physiological parameters, administration of medications, care of urinary catheters, wounds, bedsores and stomas, as well as maneuvers to prevent complications associated with immobilization. These interventions are granted according to medical indication, not automatically to all beneficiaries.
Individual physiotherapy, speech therapy, manual lymphatic drainage or the collection of biological products are also provided. For certain procedures there are specific requirements regarding personnel training and the conditions under which they can be performed. For example, physiotherapy is carried out by the physiotherapist who legally works at the care provider.
How many days are settled for adults, children and cancer patients
The duration of medical care at home is determined by the doctor, within the limit of 90 days in the last 11 months.
For children under 18 and people with oncological conditions, the ceiling is 180 days in the same interval. If these beneficiaries also receive palliative services at home, the cumulative limit for the two categories reaches 300 days.
An episode can include a maximum of 15 days, with the possibility of extending to a maximum of 30 in medically justified situations by the prescriber. Each stage requires a new recommendation. When the interventions do not take place on consecutive days, only those in which the services were actually provided are taken into account when calculating the ceiling.
Where to submit the recommendation and what deadlines must be met
The recommendation is submitted to the health insurance company, which certifies the number of care days available and makes available the list of providers under the contract. The action can also be taken by a relative or an authorized person.
According to the Annex 31 C form, the insured presents himself to the insurance company and the supplier within a maximum of 5 working days from the issue. The recommendation is valid for 30 calendar days, not counting the day of issue, and care must begin within this interval. If the deadline expires before the case is taken over and the patient’s condition still requires care, a new recommendation is needed.
