"Black hole" in the support system: caregivers lose access to the National Health Fund's offer

Here you will find all the materials from the 21st Health Market Forum

• The reimbursement of the care benefit following the decision of MOPS withdraws the caregiver's health insurance by up to several months, creating gaps in access to the National Health Fund
• The Social Insurance Institution cannot grant insurance for the period before submitting the application for the support benefit
• Carers can only benefit from the insurance from the moment the support benefit is granted, which means that the earlier months remain unprotected

The Infor portal reported that caregivers of people with disabilities may find themselves in a difficult situation when the Social Welfare Center (MOPS) withdraws care benefits for earlier months. They will then lose their National Health Fund (NFZ) health insurance for the retroactive period, for example, from February to August 2024, even though they were covered during that time.

ZUS (Social Insurance Institution) cannot re-insure them for this period because regulations prohibit it. As a result, the caregiver is listed as uninsured in the register, which creates real problems when accessing medical services .

This situation most often arises when a disabled person applies for support benefits. While waiting for a decision from the Social Insurance Institution (ZUS), the caregiver can continue to receive the care benefit.

However, once a decision is made, the funds must be repaid. As a result, MOPS withdraws health insurance coverage during the period of financial support.

When does a caregiver become entitled to health insurance?

The right to insurance stems from the Act on Publicly Financed Healthcare Services. Individuals providing care to a person receiving support benefits who are not employed are subject to mandatory health insurance.

However, only from the date indicated in the application as the beginning of care, and not from the date of actual granting of the benefit.

The provisions on support benefits further complicate the situation. According to Article 26 of the Act:

• the right to the support benefit is established from the month in which the application for it was submitted,
• if an application is submitted within 3 months of the decision determining the level of support need, the right is established from the month of submission of the application for this decision.

For example:

• January 2024 - application to determine the level of support (WZON),
• September 2024 - application for support benefit (ZUS),
• December 2024 - application for health insurance coverage for the caregiver.

As a result, insurance is granted from December 2024, although the support benefit is paid from January 2024. This means that in the January-November period the caregiver is listed as uninsured, which may cause serious complications in access to health services and drug reimbursement .

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