The Extent of Rights Deriving from Compulsory Health Insurance

The extent of rights deriving from compulsory health insurance is specified by the Law on health care and health insurance (hereinafter: ZZVZZ) and The Regulations on compulsory health insurance, i.e. the act adopted by the assembly of the Health Insurance Institute of Slovenia.

Compulsory health insurance comprises:

  • insurance in the case of illness or injury outside work, and
  • insurance in the case of injury at work and occupational diseases.

Compulsory health insurance provides insured persons with:

  • payment of medical services,
  • wage compensation during temporary absence from work,
  • reimbursement of travel expenses related to the application of medical services.

Insured persons are guaranteed payment of medical services with compulsory health insurance in accordance with Article 23 of the ZZVZZ in the following cases:

1. preventive health services:

  • systematic and other preventive health examinations at the primary level of health activity for children, schoolchildren and students up to the age of 26, other adults in accordance with the program, including for registered athletes, family planning counseling and preventive health examinations of pregnant women, except for preventive health examinations provided by the employer,
  • medical services for the early detection of risk factors for the occurrence of chronic non-communicable diseases at the primary level of medical activity, including screening tests, in accordance with the program adopted by the Health Council,
  • health services for strengthening health and changing unhealthy lifestyles at the primary level of health activity
  • vaccination and mandatory protection with drugs in accordance with the law governing infectious diseases,

2. treatment, which includes diagnostic health services (e.g. examination or investigation), therapeutic health services (e.g. outpatient services, surgery), health services in the field of reproduction (e.g. contraception, health services related to pregnancy, childbirth, treatment reduced fertility, artificial insemination, sterilization and artificial termination of pregnancy) and medical services related to the donation and exchange of tissues and organs for transplantation to other persons,

3. treatment abroad, in accordance with ZZVZZ,

4. medical rehabilitation, including spa treatment,

5. nursing care, unless the insured person is entitled to comparable nursing care services related to basic daily tasks in the compulsory long-term care insurance,

6. palliative care,

7. ambulance transports:

  • emergency ambulance transport within the scope of emergency medical assistance,
  • non-emergency ambulance transports, if the insured person is immobile or for transport to and from dialysis, or if he needs the accompaniment of a medical professional due to his health condition, or if transport by public transport or a private car would be harmful to his health,

8. cohabitation of one of the parents, foster carer, guardian, spouse or common-law partner, when living with the child of his or her spouse or common-law partner, in a health institution or spa with a sick child up to and including the age of 14, with a sick child up to the age of 18 or as long as parental rights last in the event of a severe impairment or injury to the brain or spinal cord, in which training for subsequent medical rehabilitation at home is required, or in the event of a chronic illness or impairment during training for subsequent medical rehabilitation at home, or in the event of treatment for a serious medical condition, regardless of age, with a person with special needs who needs 24-hour care and support, or with a person with a status according to the law, which regulates the social inclusion of disabled people,

9. group health programs to strengthen the health status of children up to the age of 18 who are hospitalized several times or are ill at least twice during the calendar year,

10. group health programs due to training for managing the health condition of children up to the age of 18 with cerebral palsy, neuromuscular diseases or other types of mobility impairment, head injury, children with juvenile rheumatoid arthritis, diabetes, phenylketonuria, celiac disease or overweight weight and a child with an autism spectrum disorder, developmental delay or intellectual disability,

11. group health programs for improving, maintaining or preventing deterioration of the health status of persons with muscular and neuromuscular diseases, with paraplegia, tetraplegia, cerebral palsy, head injury, with the most severe form of hemiplegia or generalized psoriasis, multiple sclerosis, poliomyelitis, Parkinson's disease or more severe or severe intellectual disability with a certain functional impairment.

Medical services from points 1, 2, 3 and 4 also include dental services. Medical services from points 1 to 6 also include pharmacy services and medicines, foodstuffs for special medical purposes and medical devices that are prescribed on the ZZZS certificate or provided by the health care provider himself as part of the health service.

ZZZS can determine the condition of prior insurance for up to six months for the rights to dental prosthetics and medical devices.