Procedures for the Organisation of and Payment for Health Care Services

Issued pursuant to
Section 5, Paragraphs two and three, Section 6,
Paragraph two, Clauses 7 and 14, and Paragraph four,
Section 7, Section 8, Paragraph two, and Section 10,
Paragraph three of the Health Care Financing Law,
Section 3, Paragraph two of the Medical Treatment Law,
Section 11, Clause 2 of the Disability Law,
and Section 14 of the Law on Social Protection
of the Participants of Liquidation of Consequences
of the Accident at the Chernobyl Nuclear Power Plant
and the Victims of the Accident
at the Chernobyl Nuclear Power Plant
[10 December 2019]

1. General Provision

1. This Regulation prescribes:

1.1. the health care services included in the State paid medical assistance minimum and State mandatory health insurance, the procedures for organising the provision of these services and making payment for them, and also the amount of payment for the abovementioned services;

1.2. the procedures for the receipt of emergency medical assistance;

1.3. the health care services not financed from the State budget subsidy from the general revenue granted to the programme of the Ministry of Health for ensuring health care (hereinafter - the State budget);

1.4. the procedures by which a patient shall make a co-payment for a State paid health care service, the amount of the co-payment, and also the total amount of co-payments for the health care services received;

1.5. the procedures for the formation of queues for the receipt of health care services;

1.6. the health care services financed from the State budget subsidy from the general revenue granted to the programmes of the Ministry of Justice, the Ministry of Defence, and the Ministry of the Interior for ensuring health care, the groups of persons which have the right to receive the abovementioned health care services, and also the groups of persons for which the patient co-payment shall be covered from such resources;

1.7. the infectious diseases and the services of palliative care when a person is exempted from the patient co-payment;

1.8. the procedures by which health care of pregnant women, persons up to 18 years of age (hereinafter - the child), and persons with a predictable disability shall be organised and financed, and also ensuring of human resources for such care shall be performed;

1.9. the procedures by which the persons specified in Section 14 of the Law on Social Protection of the Participants of Liquidation of Consequences of the Accident at the Chernobyl Nuclear Power Plant and the Victims of the Accident at the Chernobyl Nuclear Power Plant shall receive free-of-charge services or healthcare allowances in dentistry and dental prosthetics.

2. Health Care Services not Financed from the State Budget Resources, Health Care Services Included in the State Paid Medical Assistance Minimum and State Mandatory Health Insurance

2. The following health care services shall not be financed from the State budget:

2.1. homeopathic medical treatment and medical treatment using methods of unconventional medicine;

2.2. aesthetic surgeries and cosmetology services, including plastic surgeries of external genitalia, vagina, and cervix for the purposes of aesthetics;

2.3. abortions, except for abortions due to medical indications;

2.4. sexological treatment and sex reassignment;

2.5. maintaining of a stem cell bank and germinative cell bank;

2.6. consultations, clinical and paraclinical diagnostic examinations which are conducted for victims of unlawful offences upon assignment from a forensic medical expert;

2.7. health examinations which are necessary for work or for the receipt of special permits, as well as health examinations for drivers of vehicles and preventive examinations which are not referred to in Annex 1 to this Regulation;

2.8. laboratory testing performed on an outpatient basis, except for the testing referred to in Sub-paragraphs 3.8, 3.11, and 4.4 of this Regulation;

2.9. surgical assistance in the following cases:

2.9.1. correction of prolapses, except for second-degree to fourth-degree incomplete vaginal prolapse and complete uterovaginal prolapse;

2.9.2. [7 May 2019];

2.9.3. conservative myomectomy, except for the cases when bleeding is detected or the functioning of adjacent organs is impaired, or there are complaints of pain, or if the myoma is the reason for infertility;

2.9.4. urinary incontinence surgeries if urodynamic testing confirming stress or mixed incontinence has not been performed;

2.9.5. [10 December 2019];

2.10. health care services provided by an art therapist, except for medical rehabilitation services provided within the scope of a multiprofessional team, as well as services provided on an outpatient basis in the consulting room of functional specialists, ensuring psychiatric assistance;

2.11. health care services provided by a nutritionist on an outpatient basis, except for medical rehabilitation services provided within the scope of a multiprofessional team, as well as health care services provided on an outpatient basis in the consulting room of rare diseases or in the consulting room of functional specialists, ensuring psychiatric assistance;

2.12. determination of exposure to alcohol, narcotic, psychotropic, or toxic substances, except for the cases when it is necessary for ensuring the medical process;

2.13. dentistry, except for the cases referred to in Sub-paragraph 4.1 of this Regulation;

2.14. other health care services which are not referred to in Paragraphs 3 and 4 of this Regulation or are provided without conforming to the procedures laid down in this Regulation or to the conditions of the contract entered into by and between the National Health Service (hereinafter - the Service) and the medical treatment institution, including without conforming to the list of manipulations to be paid for from the State resources approved by the Service and published on the website and the conditions of payment for manipulations included therein (hereinafter - the list of manipulations).

[7 May 2019]

3. A person who has the right to receive the State paid medical assistance minimum shall be ensured with the following in accordance with the procedures laid down in this Regulation:

3.1. emergency medical assistance provided by a team of the State Emergency Medical Service;

3.2. the provision of emergency medical assistance in the reception wards of inpatient medical treatment institutions and at emergency rooms, including in cases of traumas, as well as in cases when removal of an ectoparasite is necessary;

3.3. the provision of emergency medical assistance in an inpatient medical treatment institution for persons whose health condition in accordance with Annex 2 to this Regulation has been assessed as the condition where:

3.3.1. there are disorders of the vital functions;

3.3.2. without the provision of immediate medical assistance, disorders of the vital functions may set in for the patient;

3.3.3. the health condition of the patient has deteriorated without the provision of immediate medical assistance, there are potential threats to life or serious consequences for the health of the patient;

3.4. birth assistance, including care for pregnant women, and also postnatal care for a woman who has recently given birth and for a newborn in accordance with the laws and regulations regarding the procedures for ensuring birth assistance;

3.5. forensic psychological and forensic psychiatric expert-examination;

3.6. health care provided by a general practitioner and the medical practitioners employed at his or her practice, including:

3.6.1. preventive examinations, and also determination of the risk of cardiovascular diseases in accordance with Annex 1 to this Regulation;

3.6.2. vaccination included in the vaccination calendar and vaccination against influenza in accordance with the laws and regulations regarding the procedures for reimbursement of expenditures for the acquisition of medicinal products and medical devices intended for the outpatient medical treatment;

3.6.3. house visits of a general practitioner to the following groups of persons:

3.6.3.1. children;

3.6.3.2. persons for whom Group I disability has been determined;

3.6.3.3. persons who are more than 80 years old;

3.6.3.4. persons who require palliative care (patients who are incurable (in accordance with the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (hereinafter - ISC-10), principal diagnosis codes B20-B24, C00-C97, D37-D48, G05, G12, G13, G35, G54.6, G55.0, G60.0, G61.0, G63.1, G70, G95.1, G95.2, G99.2, I50, I69, K22.2, L89, or T91.3 and additional diagnosis code in all cases - Z51.5 (hereinafter - the palliative care));

3.6.3.5. persons who have died in domestic environment in order to establish the fact of death;

3.6.3.6. persons who require continuous mechanical ventilation of lungs;

3.6.3.7. persons who receive house care in accordance with the procedures laid down in this Regulation;

3.6.3.8. persons who are sick with influenza during the period of influenza epidemic;

3.6.3.9. persons to whom an emergency medical assistance team has gone in response to a call and the general practitioner has agreed on a house visit in accordance with the procedures laid down in this Regulation;

3.6.3.10. persons with mental disorders (in accordance with the ICD-10, principal diagnosis codes F01, F20, and F73);

3.6.4. manipulations have been performed at the practice of the general practitioner according to the competence of medical practitioners in conformity with the conditions specified in the list of manipulations;

3.7. measures of cancer screening organised by the State (hereinafter - the State organised screening) in accordance with the procedures laid down in this Regulation;

3.8. laboratory testing and other diagnostic examinations performed:

3.8.1. upon referral of a general practitioner in conformity with the conditions specified in the list of manipulations;

3.8.2. at a laboratory which has been granted the status of a national reference laboratory in the issue of epidemiological safety;

3.9. renal replacement therapy procedures and specialist consultations related to such procedures;

3.10. continuous mechanical ventilation of lungs, including house visits of a specialist and medical rehabilitation for persons who require continuous mechanical ventilation of lungs;

3.11. health care services for making a diagnosis, for medical treatment, and medical rehabilitation for a person:

3.11.1. with mental and behavioural disorders (in accordance with the ICD-10, diagnosis codes F00-F99), including house visits of a psychiatrist to psychiatric patients who are not able to visit a medical treatment institution due to the health condition;

3.11.2. with malignant neoplasms and neoplasms of uncertain or unknown behaviour (in accordance with the ICD-10, diagnosis codes C00-C97, D00-D09, D37-D48), including positron emission tomography examinations with computed tomography in conformity with the payment conditions for the health care services specified in the contract with the medical treatment institution if a doctors' council has decided on the necessity of the service;

3.11.3. with diabetes mellitus (in accordance with the ICD-10, diagnosis codes E10-E14);

3.11.4. with any of the infectious diseases referred to in Annex 3 to this Regulation;

3.12. intradermal, subcutaneous, intramuscular, and intravenous injections to be administered on an outpatient basis upon providing:

3.12.1. emergency medical assistance;

3.12.2. medical assistance to pregnant women and women during the period following childbirth of up to 70 days, and also to persons with diabetes mellitus, tuberculosis, oncological diseases or mental illnesses, and persons who are receiving continuous mechanical ventilation of lungs at home;

3.13. medicinal products and medical devices, including parenteral medicinal products which are acquired by the Service in a centralised manner, and also the medicinal products and medical devices to be compensated in accordance with the regulatory enactment regarding the procedures for reimbursement of expenditures for the acquisition of medicinal products and medical devices intended for the outpatient medical treatment in the cases referred to in Sub-paragraph 3.11 of this Regulation.

[7 May 2019; 10 December 2019]

4. A person who has the right to receive health care services within the scope of the State mandatory health insurance (hereinafter - the insured person) shall be ensured, in accordance with the procedures laid down in this Regulation, with the following in addition to the health care services referred to in Paragraph 3 of this Regulation:

4.1. dental services in the following cases:

4.1.1. dental services to children;

4.1.2. primary orthodontic consultation to children and orthodontic treatment in case of hereditary orofacial clefts for persons up to 22 years of age;

4.1.3. dental assistance to asylum seekers in an urgent case;

4.1.4. dental prosthetics to the persons specified in Section 14 of the Law on Social Protection of the Participants of Liquidation of Consequences of the Accident at the Chernobyl Nuclear Power Plant and the Victims of the Accident at the Chernobyl Nuclear Power Plant for whom expenses for dental services shall be covered in the amount of 50 %, but expenses for dental prosthetics with removable plastic prosthesis - in full amount;

4.1.5. tooth extractions in urgent cases under general anaesthesia for patients with Group I disability which has been determined due to mental and behavioural disorders;

4.2. the following health care services at home:

4.2.1. administration of medicinal products (intradermal, subcutaneous, and intravenous injections);

4.2.2. care for skin lesions;

4.2.3. change of and care for a long-term urinary catheter, care for an artificial opening (stoma), including education and training of the patients and their relatives regarding care for an artificial opening (stoma) to be financed by the Service not more than five times per person, except for care for tracheostomy, gastrostomy, nephrostomy, cystostomy to be financed by the Service according to the number of the services actually provided;

4.2.4. enteral feeding through a probe;

4.2.5. rehabilitation services to persons with sequelae of injury of the spinal cord (in accordance with the ICD-10, diagnosis code T91.3), persons with a cerebrovascular disease (in accordance with the ICD-10, diagnosis codes I60, I61, I63, I64, I69), and children who are registered with the palliative care consulting room of valsts sabiedrība ar ierobežotu atbildību "Bērnu klīniskā universitātes slimnīca" [State limited liability company Children's Clinical University Hospital];

4.2.6. parenteral feeding of such children who are registered with the palliative care consulting room of the State limited liability company Children's Clinical University Hospital;

4.2.7. if a person receives the health care services referred to in Sub-paragraph 4.2.2, 4.2.3, 4.2.4, 4.2.5, or 4.2.6 of this Regulation, the following shall be ensured additionally, if necessary:

4.2.7.1. testing and delivery of the materials obtained as a result of testing to the laboratory;

4.2.7.2. control of vital signs;

4.2.7.3. education and training of the patient and his or her relatives regarding health promotion measures and patient care;

4.2.7.4. giving of the enema;

4.2.7.5. intradermal, subcutaneous, intramuscular, and intravenous injections;

4.3. health care which is provided by a midwife or a doctor specialising in a specific speciality, except for a general practitioner (hereinafter - the specialist), other medical practitioners and medical treatment support persons in accordance with Annex 4 to this Regulation, including:

4.3.1. the health care services provided by a sports doctor to athletes up to 18 years of age and children with an increased physical load in accordance with the regulatory enactment determining the procedures for the health care and medical supervision of athletes and children with an increased physical load;

4.3.2. house visit of specialists in conformity with the following conditions:

4.3.2.1. house visits of a doctor of rehabilitation and physical medicine to children who are registered with the palliative care consulting room of the State limited liability company Children's Clinical University Hospital and are receiving health care at home, and also to persons with sequelae of injury of the spinal cord (in accordance with the ICD-10, diagnosis code T91.3), persons with a cerebrovascular disease (in accordance with the ICD-10, diagnosis codes I60, I61, I63, I64, or I69) who are receiving health care at home;

4.3.2.2. house visits of a specialist of the palliative care consulting room to children who are registered with the palliative care consulting room of the State limited liability company Children's Clinical University Hospital;

4.3.3. medically assisted insemination, except for the cases when two unsuccessful procedures of medically assisted insemination (clinically confirmed pregnancy has not set in after the transfer of the embryo) have been financed from the State budget resources, for women up to 37 years of age, and also after attaining this age if the stimulation of ovary cells with medicinal products commenced up to the age of 37 years has been successful and medically assisted insemination is continued until transfer of the embryo without freezing it;

4.3.4. prescribing of optical products correcting visual acuity for children;

4.4. laboratory testing performed on an outpatient basis which have been performed:

4.4.1. upon referral of specialists in conformity with the conditions specified in the list of manipulations;

4.4.2. in the consulting room of rare diseases according to the conditions specified in the contract with the Service;

4.4.3 in accordance with the procedures laid down in this Regulation, in another Member State of the European Union (hereinafter - the EU), state of the European Economic Area (hereinafter - the EEA), or the Swiss Confederation (hereinafter - Switzerland) if it is necessary to prevent irreversible deterioration of the life functions or health condition of a person and:

4.4.3.1. the examinations are required for a child according to the opinion of the council of the State limited liability company Children's Clinical University Hospital;

4.4.3.2. the examinations are required for a person according to the opinion of the council of sabiedrība ar ierobežotu atbildību "Rīgas Austrumu klīniskā universitātes slimnīca" [limited liability company Riga East University Hospital] if hymerism monitoring must be performed after allogeneic stem cell transplantation from a non-related donor or control of minimal residual disease must be performed according to the method - real-time polymerase chain reaction on bone marrow aspirate - in case if there are indications for allogeneic stem cell transplantation for a person for whom molecular genetic changes have been detected and search for a non-related donor is required, and also in the case if molecular genetic changes have been detected after allogeneic stem cell transplantation from a non-related donor;

4.5. diagnostic imaging performed upon referral of specialists on an outpatient basis in conformity with the conditions specified in the list of manipulations, including positron emission tomography examinations with computer tomography if a doctors' council has decided on the necessity of the service in conformity with the payment conditions for the health care services specified in the contract with the medical treatment institution;

4.6. the health care services provided at a day hospital in accordance with Annex 5 to this Regulation, including intradermal, subcutaneous, intramuscular, and intravenous injections to be administered on an outpatient basis;

4.7. psychotherapeutic and psychological assistance in the following cases:

4.7.1. if assistance is provided in psychiatric inpatient medical treatment institutions or units;

4.7.2. if it is necessary upon ensuring outpatient psychiatric assistance or palliative care;

4.7.3. if assistance is provided by a multiprofessional team within the scope of a medical rehabilitation programme;

4.7.4. if a forensic psychological expert-examination is performed;

4.7.5. if the necessity for such assistance has been specified by a psychiatrist in order to prevent committing of criminal offences against morality and sexual inviolability of a child;

4.7.6. if a health care service in the consulting room of rare diseases is provided;

4.7.7. if a health care service in the consulting room of methadone maintenance treatment is provided;

4.8. inpatient health care in accordance with Annex 6 to this Regulation, including:

4.8.1. the following health care services in traumatology and orthopaedics:

4.8.1.1. medical treatment of trauma sequelae, bone and joint diseases if a council of traumatologists and orthopaedists has decided on the necessity of the service;

4.8.1.2. medical treatment of osteomyelitis, septic arthritis, and soft tissue inflammations, including spine surgery;

4.8.1.3. endoprosthetic surgeries;

4.8.1.4. reconstructive arthroscopy if it is performed at level IV and V hospitals;

4.8.1.5. repeated spine surgeries if relapse occurs within a year from the moment of performing the surgery or if a doctors' council of spine surgery has decided on the necessity of the service;

4.8.1.6. medical treatment of degenerative-dystrophic diseases of spine for persons with progressive spine deformity if a doctors' council of spine surgery has decided on the necessity of the service, or with symptoms of spinal cord or cauda equina compression;

4.8.1.7. planned surgeries for a person with a predictable disability according to the individual rehabilitation plan approved by the State Medical Commission for the Assessment of Health Condition and Working Ability or for persons who have been ill for a protracted period of time and who are of the working age;

4.8.1.8. surgeries for the elimination of intervertebral disc damages - microdiscectomy and microfenestration if a doctors' council of spine surgery has decided thereon;

4.8.2. organ and tissue transplantation in the following amount:

4.8.2.1. autologous and allogeneic stem cells, including search for the donor;

4.8.2.2. kidneys, liver, heart, and heart valves;

4.8.2.3. bones and connective tissues, fascia, skin, tendons, and cartilaginous tissue;

4.8.2.4. corneas;

4.8.2.5. lungs for persons with a rare disease if a doctors' council has decided on the necessity of the service;

4.8.3. pulmonary endarterectomy for persons with a rare disease if a doctors' council has decided on the necessity of the service;

4.9. medical rehabilitation in accordance with Sub-chapter 3.11 and Chapter 4 of this Regulation;

4.10. health care services in the following amount shall be ensured, in the priority order specified in this Regulation, to persons who have been ill for a protracted period of time and who are of the working age for the prevention of setting in of disability or for the prevention of its progress if the person has received a decision of the doctors' council in which the disease has been recognised as endangering the capacity for work and the methods for medical treatment have been indicated, justifying their choice:

4.10.1. surgical, traumatological, or rehabilitation services to persons with traumas, polytraumas, dorsopathies, nerve, nerve root and plexus damages, decubitus ulcers, burns and corrosions, frostbites, and orthopaedic diseases;

4.10.2. invasive cardiology services to persons after an infarction;

4.10.3. surgical services to persons with imminent blindness (cataract, glaucoma, and other eye and adnexa diseases);

4.10.4. implantation of the cochlear implant;

4.10.5. medical rehabilitation service according to the rehabilitation plan developed by a doctor of rehabilitation and physical medicine after a stroke, cardiac surgeries, and endoprosthetic replacement of large joints;

4.11. medicinal products and medical devices in the following amount:

4.11.1. the medicinal products and medical devices which are acquired by the Service in a centralised manner, including spectacle lenses, spectacle frames, and contact lenses for children who have been diagnosed with a high-degree congenital myopia (above 5.0 Dsph), high-degree hypermetropia (above 4.0 Dsph), high-degree astigmatism (above 1.0 D), high-degree anisometropia (above 2.0 D), aphakia in case of congenital cataract or aphakia in case of acquired cataract for one eye or both eyes, acquired short-sightedness above 7.0 Dsph, keratoconus, accommodative esotropia, paresis (bifocal spectacle lenses), albinism, congenital retinal cone dystrophy with photophobia (photochromic spectacle lenses) proved with objective examination techniques, retinal scarring, opacities (prosthetic contact lenses), low vision of 3rd-4th degree regardless of the degree of refraction anomaly;

4.11.2. the reimbursable medicinal products and medical devices in accordance with the laws and regulations regarding the procedures for reimbursement of expenditures for the acquisition of medicinal products and medical devices intended for the outpatient medical treatment;

4.11.3. the medicinal products specified in the contract with the Service for medical treatment of rare diseases. The Service shall include new medicinal products for medical treatment of rare diseases in the contract according to the decision of the commission established by the Coordination Centre of Rare Diseases which has been taken on the basis of a decision of a doctors' council and an assessment of the medicinal product performed by the Service in accordance with the laws and regulations regarding the procedures for reimbursement of expenditures for the acquisition of medicinal products and medical devices intended for the outpatient medical treatment, as well as taking into account the State budget resources allocated for medical treatment of rare diseases;

4.11.4. hearing implants for children or persons with a predictable disability and for persons who have been ill for a protracted period of time and who are of the working age;

4.11.5. the medicinal products indicated in Annex 7 to this Regulation, and also the medicinal products and medical devices which have been included in the list of manipulations;

4.12. State paid health care services in another EU Member State, EEA state, and Switzerland in accordance with the procedures laid down in this Regulation and the conditions of Regulation (EC) No 883/2004 of the European Parliament and of the Council of 29 April 2004 on the coordination of social security systems (hereinafter - Regulation No 883/2004) and Regulation (EC) No 987/2009 of the European Parliament and of the Council of 16 September 2009 laying down the procedure for implementing Regulation (EC) No 883/2004 on the coordination of social security systems (hereinafter - Regulation No 987/2009);

4.13. reimbursement of expenses for health care services received in another EU Member State, EEA state, or Switzerland in accordance with the procedures laid down in this Regulation (cross-border healthcare).

[7 May 2019; 10 December 2019]

3. Organisation of the Health Care Services Included in the State Paid Medical Assistance Minimum and State Mandatory Health Insurance

3.1. General Principles

5. Health care services financed from the State budget according to the by-laws shall be provided by State administration institutions, and also the medical treatment institutions which have entered into a contract with the Service for:

5.1. provision of primary health care services - the Service shall select service providers from the waiting list of primary health care service providers (general practitioners, medical treatment institutions providing dental services, medical treatment institutions ensuring health care at home) to be created and maintained by the Service;

5.2. provision of secondary outpatient health care services - the Service shall select service providers on the basis of a selection procedure of health care service providers developed by the Service, except for the following cases:

5.2.1. for ensuring of the functions of the national reference laboratory - with a medical treatment institution which has acquired the relevant status in accordance with a regulatory enactment determining the procedures for granting and cancellation of the status of the national reference laboratory in the field of epidemiological safety or suspension of its operation, and also regarding the rights and obligations of the national reference laboratory;

5.2.2. for ensuring of post-exposure prophylaxis (PEP) to medical practitioners, for ensuring of vertical prophylaxis of human immunodeficiency virus infection, for ensuring of therapy of opportunistic infections of human immunodeficiency virus, for storage of immunobiological preparations, and also for distribution of medicinal products for tuberculosis the contract shall be entered into with limited liability company Riga East University Hospital;

5.2.3. if it is possible to agree with a secondary outpatient health care service provider which already is in contractual relations with the Service on the provision of secondary outpatient health care services of other types if:

5.2.3.1. the secondary outpatient health care service provider has submitted an appropriate offer;

5.2.3.2. sufficient accessibility of such health care services has not been ensured;

5.2.3.3. financial resources for payment for such health care services are available;

5.2.3.4. the resources available to the secondary outpatient health care service providers who are providing such health care services are fully stretched;

5.2.4. if a contract regarding provision of health care services is entered into with medical treatment institutions of other states;

5.3. provision of inpatient health care services. A contract shall be entered into with the medical treatment institutions referred to in Annex 6 to this Regulation according to the level of the relevant medical treatment institution and the payment conditions for programmes of inpatient health care services referred to in Annex 6 to this Regulation, except for the following cases:

5.3.1. for ensuring of birth assistance the contract shall be entered into with the medical treatment institution which has provided State paid birth assistance in at least 200 cases in the previous year;

5.3.2. for inpatient health care services for the provision of which the Service has announced a procedure for selecting service providers the contract shall be entered into with the medical treatment institutions which have applied to the relevant selection of health care service providers and conform to the criteria brought forward therein;

5.3.3. if a contract regarding provision of health care services is entered into with medical treatment institutions of other states;

5.4. ensuring of organisational and methodological work. The contract shall be entered into with a medical treatment institution which has specialised in the provision of the relevant health care services.

6. Upon creating the waiting list of primary health care service providers referred to in Sub-paragraph 5.1 of this Regulation, the Service shall conform to the following conditions:

6.1. within a year after completion of the State paid residency a general practitioner has the right to request to register him or her in the waiting list of general practitioners on a priority basis. If there are several such general practitioners in the waiting list, they shall be registered in the order of submitting the submission before other doctors who are in the waiting list of general practitioners;

6.2. if a general practitioner discontinues the contractual relations with the Service, the Service shall, without conforming to the chronological order of the waiting list, offer the opportunity to take over the relevant practice to a general practitioner who:

6.2.1. in accordance with the procedures laid down in this Regulation has continuously substituted the relevant general practitioner for more than six months;

6.2.2. has received a scholarship from the local government on the basis of an agreement entered into regarding provision of services of a general practitioner in the territory of the local government after receipt of the certificate of a general practitioner;

6.2.3. has agreed with the relevant general practitioner on taking over of the practice (except for the case if, as a result of the planned taking over, the practice would be acquired by a medical treatment institution providing secondary outpatient health care services and the general practitioner becomes an employee), and also has received information regarding the work organisation, liabilities, cooperation institutions of such practice and the different health care and prevention programmes of patient groups;

6.3. the Service shall refuse to register a health care service provider in the waiting list if a dentist is not employed and does not provide health care services in a medical treatment institution providing dental services.

[7 May 2019]

7. The Service shall organise the State organised screening on the basis of the contracts entered into regarding:

7.1. cervical cancer screening examinations - with primary health care service providers, with secondary outpatient health care service providers which have the type of service "Gynaecology" included in the contract, and also with outpatient laboratory service providers which have the type of service "Laboratory testing" included in the contract and which have performed at least 1000 State paid examinations of cervical cytological smears in the previous year;

7.2. colorectal cancer screening examinations - with primary health care service providers, and also with service providers with which a contract regarding performance of outpatient laboratory testing has been entered into and which ensure fecal occult blood tests in accordance with the procedures laid down in this Regulation;

7.3. mammography screening examinations - with the service providers with which a contract regarding the provision of secondary outpatient health care services has been entered into and which ensure mammography examinations of breast cancer screening.

8. State paid health care services may be provided only by such health care service providers which meet the following conditions:

8.1. have registered in the register of medical treatment institutions;

8.2. conform to the mandatory requirements which have been laid down for medical treatment institutions and their units in the laws and regulations;

8.3. the health care service provider has the medical staff necessary for the provision of services and, where necessary, the medical support staff or drivers of an ambulance emergency response vehicle;

8.4. the health care service provider has appropriate materials and technical facilities;

8.5. are able to ensure complete, accurate, and timely exchange of information with the system for the settlement of payments for health care services "Management Information System" (hereinafter - the management information system);

8.6. have entered into a contract with the Service regarding use of the unified electronic information system of health sector (hereinafter - the health information system) and fulfil the obligations specified in the laws and regulations governing the operation of the health information system;

8.7. [Sub-paragraph shall come into force on 1 January 2022 and shall be included in the wording of the Regulation as of 1 January 2022; see Paragraph 237].

9. The conditions referred to in Sub-paragraphs 8.5 and 8.6 of this Regulation shall not be applicable to the State Emergency Medical Service.

9.¹ [Paragraph shall come into force on 1 January 2022 and shall be included in the wording of the Regulation as of 1 January 2022; see Paragraph 237]

10. The Service shall enter into a contract with health care service providers, except for a contract regarding ensuring of methodological work, for a time period which is not less than three years and does not exceed 10 years. The Service has the right to terminate contractual relations with a health care service provider which does not conform to the conditions referred to in this Regulation or in the contract entered into with the Service.

11. The Service shall, in accordance with the conditions referred to in Annex 8 to this Regulation, perform centralised procurements for ensuring the medicinal products and medical devices referred to in Sub-paragraph 4.11.1 of this Regulation. Information on the conditions of the centralised procurement shall be published on the website of the Service.

12. The Service shall post the following on its website in a language that is easy to understand, as well as provide upon request:

12.1. information on the physicians who are providing State paid health care services and the physicians who have the right to refer persons for the receipt of State paid health care services or to prescribe medicinal products or medical devices to be reimbursed by the State on the basis of the conditions of a memorandum of understanding, indicating the medical treatment institution, the given name, surname, speciality of the physician and whether the physician is entitled to refer for the receipt of State paid health care services and is entitled to prescribe medicinal products and medical devices to be reimbursed from the State budget resources and intended for outpatient medical treatment;

12.2. information on the health care system in the Republic of Latvia:

12.2.1. the rights of patients;

12.2.2. organisation of and payment for health care (also the Plan of Patient Hospitalisation Sites);

12.2.3. health care service providers;

12.2.4. the mandatory requirements for medical treatment institutions and their units, including the requirement to ensure accessibility of the environment for persons with functional disorders;

12.2.5. operation of the Medical Treatment Risk Fund;

12.2.6. the procedures for submitting a complaint regarding the quality of a health care service;

12.3. information on the procedures by which it is possible to receive health care services in foreign states, and also on the procedures by which it is possible to receive a reimbursement of expenditure for the health care services received in foreign states;

12.4. the amount of information to be included in the prescription;

12.5. data on the performance indicators of health care service providers.

13. The following persons have the right to refer a person for the receipt of State paid health care services or to prescribe medicinal products and medical devices to be reimbursed from the State budget resources and intended for outpatient medical treatment:

13.1. the doctors for whom such rights have been specified in the contract entered into by and between the Service and the medical treatment institution regarding provision of health care services and financing from the State budget resources;

13.2. the doctors who work at medical treatment institutions of places of imprisonment and to whom such rights have been specified according to a memorandum of understanding regarding cooperation entered into by and between the Service and the Prisons Administration;

13.3. the doctors who work at long-term social care and social rehabilitation institutions providing State or local government financed long-term social care and social rehabilitation services and to whom such rights have been specified according to the contract entered into by and between the Service and the long-term social care or social rehabilitation institution;

13.4. the doctors who are employed at medical treatment institutions of the National Armed Forces and to whom such rights have been specified according to a memorandum of understanding regarding cooperation entered into by and between the Service and the National Armed Forces;

13.5. the doctors who are providing health care services at an accommodation centre for asylum seekers and to whom such rights have been specified according to a memorandum of understanding regarding cooperation entered into by and between the Service and the Office of Citizenship and Migration Affairs.

[7 May 2019]

14. In addition to the conditions referred to in Paragraph 13 of this Regulation:

14.1. a midwife has the right to refer a person for the receipt of State paid birth assistance in accordance with a regulatory enactment regarding the procedures for the provision of birth assistance, if such rights have been specified in the contract entered into by and between the Service and the medical treatment institution regarding provision of health care services and payment from the State budget resources;

14.2. the doctor's assistants (feldshers) and nurses employed at the practice of a general practitioner have the right to prescribe the medicinal products and medical devices to be reimbursed from the State budget resources and intended for outpatient medical treatment in accordance with the procedures laid down in the laws and regulations regarding writing out prescriptions, if such rights have been specified in the contract entered into by and between the Service and the medical treatment institution regarding provision of health care services and payment from the State budget resources;

14.3. the doctor's assistants working at a medical treatment institution of the Prisons Administration have the right to prescribe the medicinal products and medical devices to be reimbursed from the State budget resources and intended for outpatient medical treatment in accordance with the procedures laid down in the laws and regulations regarding writing out prescriptions, if it is determined by the contract entered into by and between the Service and the Prisons Administration.

[7 May 2019]

15. A person with an E 106, E 109, E 121, or S 1 form issued by another EU Member State, EEA state, or Switzerland shall obtain the right to receive health care services in a medical treatment institution of Latvia after registration of the relevant form with the Service.

3.2. Organisation of Primary Health Care

16. Primary health care is an aggregate of outpatient health care services which are provided to a person at a medical treatment institution or his or her place of residence by:

16.1. a general practitioner and medical practitioners employed at his or her practice:

16.1.1. a doctor's assistant (feldsher);

16.1.2. a nurse;

16.1.3. a midwife;

16.2. medical practitioners employed at a medical treatment institution providing dental services:

16.2.1. a dentist, including a paediatric dentist;

16.2.2. a dentist's assistant;

16.2.3. a dental nurse;

16.2.4. a dental technician;

16.2.5. a dental hygienist;

16.3. medical practitioners ensuring health care at home.

17. A person shall receive primary health care services:

17.1. upon his or her initiative by turning to a primary health care service provider, except for health care at home;

17.2. upon an invitation of a general practitioner, including for the performance of preventive examination or State organised screening measures;

17.3. at home in accordance with Sub-paragraph 4.2 of this Regulation and Sub-chapter 3.4 of this Regulation.

18. The boundaries of the area within which a general practitioner provides primary health care services shall be determined by the Service, coordinating it with the relevant local government (hereinafter - the basic area of operation of the general practitioner).

19. In areas with insufficient provision of services provided by general practitioners and with more difficult access to health care services the Service may, in an exceptional case, enter into a contract with the local government regarding operation of a feldsher station (in which a certified doctor's assistant (feldsher) is working) for ensuring primary health care services if one of the following conditions is in effect:

19.1. there is no practice of a general practitioner registered in the municipality parish where the feldsher station is located or the distance from the feldsher station to the closest practice of a general practitioner exceeds 10 km;

19.2. not less than 400 inhabitants are declared in the service area of the feldsher station (in the area the inhabitants of which are receiving the health care services provided by the doctor's assistant (feldsher));

19.3. there is no practice of a general practitioner registered in the area and the Service has received a certification from the relevant local government or from a general practitioner - resident that the general practitioner - resident will ensure the services of a general practitioner in the particular area after receipt of the certificate.

[7 May 2019]

3.3. Organisation of Health Care Provided by a General Practitioner

20. Each person has the right to choose a general practitioner and to register in the list of patients of the general practitioner in conformity with the following conditions:

20.1. the person may be registered only with one general practitioner;

20.2. only children shall be registered with a paediatrician;

20.3. the person registered in the list of patients of the general practitioner has the right to choose another general practitioner and to perform re-registration.

21. In order to register in the list of patients of a general practitioner or to re-register a person shall use the unified electronic information system of health sector or the State administration service portal www.latvija.lv. If the person does not have the opportunity of registering electronically, the person shall turn to the selected general practitioner and enter into an agreement.

22. An agreement regarding registration in the list of patients of a general practitioner, except for electronic registration, shall be prepared in two copies, and each copy shall be signed by the person and the general practitioner. One copy of the agreement is issued to the person, and the second copy remains with the general practitioner who stores it while the person is registered in the list of his or her patients.

23. The general practitioner shall, within five working days after entering into the agreement, enter information in the management information system of the Service regarding agreement to register the person in the list of patients of the general practitioner.

24. The general practitioner has the option of not agreeing to registration of the person in the list of his or her patients if:

24.1. the declared place of residence of the person is located outside the basic area of operation of the general practitioner;

24.2. the number of patients registered in the list of patients of the general practitioner forms a full practice, except for:

24.2.1. first-degree relatives in ascending or descending order or spouse of an already registered person;

24.2.2. persons living in the basic area of operation of the general practitioner (declared place of residence).

25. The Service shall post information on its website regarding general practitioners the number of patients registered in their list of patients forms a full practice. A full practice shall be formed by the following number of patients registered in the list of patients of a general practitioner:

25.1. if children are not registered in the list of patients of a general practitioner - 1800 persons;

25.2. if only children are registered in the list of a general practitioner - 800 persons;

25.3. if both adults and children are registered in the practice of a general practitioner, the Service shall determine the proportion of the number of children and adults registered in the practice against to the total number of patients and assess it against the number of patients indicated in Sub-paragraphs 25.1 and 25.2 of this Regulation.

26. Upon request of a person, the Service shall provide information regarding general practitioners with whom it is possible to register, the location of practices of such general practitioners, and the procedures for registration, and also shall post information on the website of the Service regarding practices of general practitioners, indicating the name of the medical treatment institution, the given name, surname of the general practitioner, the address, telephone number (which has been submitted to the Service for publishing on the website) of the medical treatment institution, electronic mail address for communication with patients (if the institution has indicated such), the area of basic operation, the working hours of the practice, and the reception hours of the general practitioner.

27. The Service shall block registration of a person with a general practitioner:

27.1. for patients of psychiatric inpatient medical treatment institutions who are continuously undergoing medical treatment for more than three months;

27.2. imprisoned persons;

27.3. for persons regarding whom the Service has received information from the Population Register regarding the place of residence indicated outside the Republic of Latvia.

28. Blocking of registration of a person with a general practitioner shall suspend the existing registration and preclude re-registration of the person with another general practitioner, but the person shall not lose the right to receive State paid health care services according to his or her status - insured person or person who has the right to receive the State paid medical assistance minimum.

29. If the grounds for blocking registration of a person with a general practitioner have ceased to exist, the Service shall unblock registration of the person and renew registration of the patient in the list of patients of a general practitioner.

30. A person shall be excluded from the list of patients of a general practitioner:

30.1. if the general practitioner has terminated contractual relations with the Service - within five working days from the moment of termination of the contract;

30.2. in the cases specified in Section 42 of the Medical Treatment Law, on the basis of a submission of the general practitioner and the opinion of the examination by the Health Inspectorate regarding the particular case. The Service shall inform the person of the case;

30.3. if the person has attained 18 years of age and the relevant general practitioner is a paediatrician. The relevant paediatrician shall inform the person of such fact;

30.4. the person has lost the right to receive State paid health care services;

30.5. if according to the information included in the Population Register the person has died;

30.6. on the basis of a submission of the patient - within five working days after receipt thereof.

31. If a general practitioner terminates contractual relations with the Service, the Service shall re-register the persons registered in the list of his or her patients to the list of general practitioner taking over the practice or basic area of operation (also its part) of the general practitioner who has terminated the contractual relations, except for Riga where only such patients shall be re-registered whose declared place of residence is in the basic area of the general practitioner.

[10 December 2019]

32. The Service shall publish the information regarding exclusion of patients from the list of patients of a general practitioner and re-registration with the general practitioner taking over the practice or basic area of operation (also its part) of the general practitioner on the website of the Service and send it to the local government.

[7 May 2019]

33. A general practitioner who enters into a contract with the Service regarding provision of health care services in the basic area where services were previously provided by a general practitioner the contractual relations with whom have ended due to his or her death or due to other previously unforeseen circumstances (for example, a prohibition to provide State paid health care services has been imposed in accordance with the procedures laid down in the laws and regulations) shall take over the medical documentation of such patients who were registered with the previous general practitioner.

34. The general practitioner shall receive a full list of his or her registered patients and information on the changes in the list, using the management information system of the Service.

35. A patient of a general practitioner shall be:

35.1. a person who is registered in the list of patients of the general practitioner;

35.2. a person whose registration with the general practitioner has been blocked;

35.3. a person who has not registered in the list of patients of the general practitioner (hereinafter - the temporary patient) and who:

35.3.1. has fallen ill during temporary stay (for example, official travel, visit) and has turned for assistance at the practice of the general practitioner which is nearest to the place of stay;

35.3.2. is periodically under care of relatives or guardians in the basic area of operation of the relevant general practitioner;

35.3.3. has never been registered with the general practitioner but has turned for assistance to the general practitioner;

35.3.4. is a patient registered with another general practitioner who has turned to the general practitioner as the substitute of the general practitioner of the patient (in case of temporary substitution).

36. Each general practitioner shall, according to the contract with the Service, provide health care services in the basic area of his or her operation, ensuring health care for the patients registered in his or her list of patients, and also shall:

36.1. provide health care services to a patient registered in his or her list of patients also outside the basic area of his or her operation, agreeing thereupon with the relevant person;

36.2. provide the necessary health care services to the temporary patients, including perform vaccination according to the calendar of vaccination;

36.3. regularly assess the health condition of the persons registered in his or her list of patients, ensuring that during the calendar year the health condition is assessed for not less than half of all the patients registered in the list of patients of the general practitioner;

36.4. issue a statement on the health condition of a child;

36.5. ensure primary diagnostics of malignant neoplasms and, in accordance with the procedures laid down in Annex 1 to this Regulation, perform determination of the risk of cardiovascular diseases and subsequent care for patients according to the determined risk in conformity with the conditions specified in the contract with the Service;

36.6. ensure that not later than during the following working day the general practitioner or a medical practitioner employed at his or her practice contacts the person in order to agree on subsequent health care if the general practitioner has received information regarding a visit by an emergency medical assistance team to the person registered in the list of patients of the general practitioner and such person has not been admitted;

36.7. establish the fact of death of a person registered with him or her or under his or her care, or a person who has died in domestic environment in his or her basic area of operation, and also issue the documents specified in the laws and regulations regarding the procedures for keeping medical records if the cause of death is known to the general practitioner;

36.8. in accordance with the laws and regulations regarding the procedures for the determination of the fact of brain death and biological death and the transferring of a deceased person for burial, send the deceased person for pathological-anatomical examination;

36.9. inform the territorial institution of the State Police if the general practitioner suspects violent death;

36.10. perform other obligations specified in laws and regulations or the contract with the Service.

37. Upon assessing the health condition of a person and taking into account the amount of the rights of the person for the receipt of State paid services (insured person or person who has the right to receive the State paid medical assistance minimum), the general practitioner may refer the person for receipt of secondary health care services.

38. The general practitioner shall perform health care for patients jointly with medical practitioners employed at the practice of the general practitioner in conformity with the following conditions:

38.1. an appropriate working place has been arranged for the medical practitioners employed at the practice;

38.2. if the number of patients registered with the general practitioner exceeds the number of patients forming a full practice, it is ensured that at the practice of the general practitioner:

38.2.1. at least two medical practitioners (nurse, doctor's assistant (feldsher), or midwife) are employed in addition to the general practitioner;

38.2.2. the regular reception hours of patients for the employed medical practitioners (nurse, doctor's assistant (feldsher), or midwife) are not less than 10 hours a week;

38.3. the general practitioner who has more than 2400 persons registered with him or her ensures that:

38.3.1. at least one of the medical practitioners employed at the practice of the general practitioner is a doctor's assistant (feldsher), except for the case when the resident is trained at the practice of the general practitioner and functions of the receptionist are carried out by another person;

38.3.2. there is a room that is separated from the working place of the general practitioner at the practice of the general practitioner where the medical practitioners employed at the practice of the general practitioner can provide health care services according to their competence.

39. The general practitioner shall, jointly with medical practitioners employed at the practice of the general practitioner, ensure health care for patients at the place of practice of the general practitioner (or working place if the general practitioner is an employee in a medical treatment institution) and at the places of residence of patients in accordance with the following procedures:

39.1. the reception hours of patients of the general practitioner shall be determined (the total working hours shall be added up if the general practitioner has several places of reception):

39.1.1. not less than 20 hours a week if the number of persons registered in the practice is up to 2000, including not less than 15 hours a week at the principal practice if the general practitioner has several places of reception;

39.1.2. not less than 25 hours a week if the number of persons registered in the practice is more than 2000, including not less than 19 hours a week at the principal practice if the general practitioner has several places of reception;

39.1.3. according to the conditions regarding other reception hours at the principal practice if the general practitioner has agreed thereupon with the Service in the following cases:

39.1.3.1. the number of patients registered in the practice is less than 500 patients;

39.1.3.2. the general practitioner has more than two additional places of reception;

39.1.3.3. similar number of registered patients live in each administrative territory which is part of the basic area of operation of the general practitioner;

39.2. the working hours of the practice shall be determined as not less than 40 hours a week, ensuring the availability of the general practitioner or a medical practitioner employed at the practice of the general practitioner at the place of principal practice of the general practitioner during these hours;

39.3. the reception hours of the general practitioner shall be determined in a way that at least once a week the reception of patients is ensured from 8.00 and at least once a week - until 19.00, except for the case when the general practitioner has agreed upon other procedures with the Service;

39.4. the reception hours for persons without a prior appointment (for acute patients) shall be determined as not less than one hour each day, ensuring the availability of the general practitioner for such persons on the same day when the person has turned to the practice of the general practitioner or on the following working day if the person has turned to the practice of the general practitioner after the end of the reception hours of the general practitioner;

39.5. the time of reception shall be determined for persons with a prior appointment;

39.6. the primary health care services shall be ensured within five working days. In order to ensure the service within five working days, the general practitioner shall, if necessary, extend the reception hours of patients;

39.7. patients shall be provided with an opportunity to apply for house visits on working days at least until 15.00.

40. The general practitioner may organise an external reception at a feldsher station located in the basic area of operation of the general practitioner, coordinating the schedule of external visits with the Service.

41. If the absence of the general practitioner exceeds:

41.1. five days but does not exceed two months - the general practitioner shall inform the Service of the time of his or her absence and submit information accepted by the substitute regarding substitution and its conditions in writing;

41.2. two months - the Service shall suspend the contract with such general practitioner and shall enter into a fixed-term contract with his or her substitute if the general practitioner submits a document to the Service justifying his or her absence, certifying that:

41.2.1. the general practitioner is on a parental leave;

41.2.2. the general practitioner is incapacitated for work, and such incapacity for work is lasting for more than two months;

41.2.3. training related to health care and lasting not more than six months is planned, provided that the general practitioner may participate in the training not more than once every three years.

42. Outside the working hours of general practitioners:

42.1. the health care services provided by the general practitioner (except for house visits) and the determination of the fact of death of a person who has died in domestic environment in a city may be ensured by a doctor on duty who receives patients on working days after 15.00 and on weekends according to the schedule of working hours of the doctor on duty specified in the contract with the Service;

42.2. on working days during the hours from 17.00 to 8.00 and on weekends throughout day and night persons may receive medical consultations and recommendations for action in case of exacerbation of acute or chronic diseases also using the general practitioner's consultative telephone number.

[7 May 2019]

43. The general practitioner shall ensure information to the patient regarding the procedures for the receipt of primary health care services provided by the general practitioner during working hours, outside working hours, and in case of substitution, and also information regarding the possibilities of receiving other health care services. The general practitioner shall ensure that information regarding substitution is publicly available at his or her place of work.

44. The general practitioner shall ensure substitution of the medical practitioners employed at his or her practice during their absence, taking into account the amount of obligations to be performed by such medical practitioners and the competence of medical practitioners specified in laws and regulations.

45. If the general practitioner is an employee in a medical treatment institution, substitution of the general practitioner and the medical practitioners employed by the general practitioner shall be ensured by the medical treatment institution.

3.4. Health Care at Home

46. If a person requires an outpatient health care service but he or she is unable to arrive to a medical treatment institution for the receipt of such service due to medical indications, such service shall be provided to the person at home if:

46.1. the person has a chronic disease and movement disorders due to medical indications;

46.2. the person has been discharged from an inpatient medical treatment institution or from a day hospital after a surgical intervention;

46.3. the person with a cerebrovascular disease (according to the ICD-10, diagnosis codes I60, I61, I63, I64, or I69) requires medical rehabilitation services and their provision has been commenced within three months after the beginning of the disease;

46.4. medical rehabilitation services are necessary to such children who are registered with the palliative care consulting room of the State limited liability company Children's Clinical University Hospital;

46.5. the person with sequelae of injury of the spinal cord (in accordance with the ICD-10, diagnosis code T91.3) which manifests as tetraplegia or paraplegia and for the majority of muscles under the damage the strength is less than three points requires medical rehabilitation services after receipt of the primary medical rehabilitation in the programme of inpatient services "Rehabilitation for Patients with Cross-sectional Injury of the Spinal Cord (Spinal Patients)" if a doctor of rehabilitation and physical medicine employed at valsts sabiedrība ar ierobežotu atbildību "Nacionālais rehabilitācijas centrs "Vaivari"" [State limited liability company National Rehabilitation Centre Vaivari] refers to such services.

47. A person shall receive health care services at home in conformity with the following conditions:

47.1. if there is a referral of the general practitioner or a referral of the medical treatment institution after discharging from the inpatient medical treatment institution or day hospital (except for medical rehabilitation services) and the following information has been indicated in the referral:

47.1.1. diagnosis due to which health care at home is necessary;

47.1.2. diagnosis due to which there are movement disorders;

47.1.3. instructions of the attending physician for health care at home, including for administration of medicinal products;

47.1.4. the time period during which health care at home must be ensured;

47.2. in order to receive medical rehabilitation services, there must be a referral of a doctor of rehabilitation and physical medicine to which a medical rehabilitation plan developed in accordance with the procedures laid down in this Regulation has been appended.

48. Health care services at home shall be provided by a certified nurse or doctor's assistant (feldsher) but medical rehabilitation services at home - by a certified physiotherapist, occupational therapist, or audio speech therapist. Health care services at home shall be provided only by such persons referred to in this Paragraph who work at a medical treatment institution which has entered into a contract with the Service regarding provision of health care services at home and payment for them.

49. The Service shall enter into a contract regarding provision of health care services at home with a medical treatment institution which submits a certificate (copy) issued to the nurse or doctor's assistant (feldsher) certifying that an accredited vocational in-service training programme in the amount of 40 hours regarding the process of medical treatment and care at home has been acquired within the last five years.

50. A medical treatment institution which provides health care services at home shall ensure:

50.1. the possibility for persons to apply health care services at home on working days from 9.00 to 16.00, on weekends and holidays from 9.00 to 13.00;

50.2. the provision of the service is commenced not later than within 24 hours from the moment of receipt of the application;

50.3. the provision of such services on working days, weekends, and holidays.

51. A health care service provider which provides health care services at home shall, within three working days, inform the general practitioner of the person (if the person is not registered with a general practitioner - the general practitioner of the basic area according to the actual place of residence of the person) regarding commencement of the relevant service, making a note thereon in the medical card of the person.

52. The duration of one episode for health care services at home for a person with a chronic disease and movement disorders due to medical indications shall be up to 30 calendar days, except for medical rehabilitation, continuous mechanical ventilation of lungs, and parenteral feeding of children. If it is necessary to receive health care services at home for a longer period of time, the general practitioner shall visit the person within two working days before the end of the abovementioned time period and provide an opinion to the service provider on the necessity to continue the provision of the relevant service or to discontinue it.

53. After discharging from an inpatient medical treatment institution or day hospital due to a surgical intervention the duration of provision of health care services at home shall be up to 10 calendar days. If the health care service at home is required for a longer period of time, the general practitioner shall, upon request of the relevant service provider, visit the person and provide an opinion on the necessity to continue the provision of the relevant service or to discontinue it.

54. Health care services at home shall be provided for a person who requires medical rehabilitation services until the time indicated in the referral and in the medical rehabilitation plan, but not longer than for 60 calendar days. If the health care service at home is necessary for a longer period of time, the doctor of rehabilitation and physical medicine shall visit the person within two working days before the end of the abovementioned time period and provide an opinion to the service provider on the necessity to continue the provision of the relevant service or to discontinue it. The total period of medical rehabilitation provided at home for persons with sequelae of injury of the spinal cord who receive medical rehabilitation service at home as a continuation of the receipt of primary medical rehabilitation at an inpatient medical treatment institution may not exceed six months.

55. The service provider, after it has terminated the provision of health care services at home, shall submit to the general practitioner of the person or to the general practitioner of the basic area according to the actual place of residence of the person, and also to the person an opinion on the health care service provided.

3.5. Secondary Health Care

56. A person shall receive State paid secondary health care services:

56.1. upon referral of a general practitioner or specialist, except for positron emission tomography examinations with computer tomography for the receipt of which a decision of the doctors' council is necessary;

56.2. by turning to the following direct access specialists upon his or her own initiative:

56.2.1. a psychiatrist or paediatric psychiatrist if the person is suffering from a mental illness (in accordance with the ICD-10, diagnosis codes F00-F09, F20-F62, F63.1-F99);

56.2.2. a narcologist;

56.2.3. a pneumonologist if the person is ill with tuberculosis (in accordance with the ICD-10, diagnosis codes A15-A19, B90, J65, P37.0, R76.1, Y58.0, Y60.3, Z03.0, Z20.1);

56.2.4. a dermatovenerologist if the person is ill with a sexually transmitted disease (in accordance with the ICD-10, diagnosis codes A50-A64, B35.0,4,8, B37.3,4, B86, L01.1, L08.0, L24.4, L30.2, Z11.3,4, Z20.2,6, Z22.4, Z29.2, Z86.1);

56.2.5. an endocrinologist if the person is ill with diabetes mellitus (in accordance with the ICD-10, diagnosis codes E10-E14.9);

56.2.6. an oncologist, oncologist-chemotherapist if the person is ill with an oncological disease (in accordance with the ICD-10, diagnosis codes C00-C97, D00-D09, D37-D48);

56.2.7. a gynaecologist;

56.2.8. an ophthalmologist;

56.2.9. a paediatric surgeon;

56.2.10. a paediatrician;

56.2.11. an infectologist if:

56.2.11.1. a person is ill with human immunodeficiency virus (hereinafter - HIV) infection (in accordance with the ICD-10, diagnosis codes B20-B24, Z21);

56.2.11.2. a person with the signs of HIV infection has undergone an HIV rapid test using capillary blood or saliva (in accordance with the ICD-10, diagnosis code Z20.6) at an HIV prevention point which has a cooperation contract with the Centre for Disease Prevention and Control;

56.2.11.3. he or she is a contact person (in accordance with the ICD-10, diagnosis code Z20.6) for a person with diagnosed HIV infection who receives medical treatment at an inpatient medical treatment institution;

56.2.12. a sports doctor in the State limited liability company Children's Clinical University Hospital;

56.3. by turning to medical treatment institutions upon his or her own initiative, including to emergency room in order to receive emergency medical assistance;

56.4. upon referral of an emergency medical assistance team;

56.5. within the scope of the State organised screening of breast and cervical cancer, by turning to a medical treatment institution implementing the screening programme upon her own initiative (if there is a valid letter of invitation in the management information system of the Service) or with the letter of invitation sent by the Service;

56.6. with the letter of invitation sent by the Service for the receipt of medically assisted insemination service.

[10 December 2019]

57. The general practitioner or specialist shall draw up the referral for the receipt of secondary health care services in accordance with the laws and regulations regarding the unified electronic information system of health sector. In exceptional case, if a special form of referral is necessary for outpatient laboratory services as well as other services, the conditions for the drawing up of the referral are specified in the contract of the Service with the medical treatment institution.

[10 December 2019]

58. The medical treatment institution shall inform the general practitioner or specialist who issued the referral of the secondary health care service provided and:

58.1. if the person requires further examinations or consultations, issue a referral to the person for the receipt of such services;

58.2. if necessary, prescribe the reimbursable medicinal products and medical devices in accordance with the laws and regulations regarding the procedures for reimbursement of expenditures for the acquisition of medicinal products and medical devices intended for the outpatient medical treatment.

59. The medical treatment institution shall ensure the issuance of the results of examinations to the patient or medical practitioner who referred the patient for the performance of an examination not later than within five working days after performance of the examination or in other time if an agreement with the patient has been reached thereupon.

60. Medical treatment institutions shall mutually recognise the results of the performed examinations within a month from the day of performing the examination.

3.6. Conditions for the Formation of Queues for the Receipt of Health Care Services

61. A medical treatment institution shall form queues for the receipt of health care services in conformity with the following conditions:

61.1. the medical treatment institution shall provide health care services to children and pregnant women on a priority basis;

61.2. the medical treatment institution shall plan the provision of State paid health care services in a way to ensure the availability of health care services throughout the calendar year;

61.3. the medical treatment institution shall ensure the secondary outpatient health care service necessary to the person not later than within 10 working days in the following cases and according to the following procedures:

61.3.1. if the person requires the first consultation with an oncologist chemotherapist, haematologist, paediatric haemato-oncologist, or oncological gynaecologist - from the day when the person has turned to the medical treatment institution for the receipt of the service;

61.3.2. if the person has been referred to the primary diagnostic examination of malignant neoplasms according to the conditions published on the website of the Service - from the day when the person has turned to the medical treatment institution for the receipt of the service;

61.3.3. if the person requires a consultation of such specialist who ensures secondary diagnostics of malignant neoplasms in the medical treatment institution indicated on the website of the Service - from the day when the person has been applied for the receipt of such service by the general practitioner, gynaecologist, or prison doctor;

61.4. the medical treatment institution shall, within the following time period counting from the day when the patient had turned to the medical treatment institution, ensure the provision of the necessary service to a patient with the diagnosis code Z03.5 who has been referred by the general practitioner for determination of the risk of cardiovascular diseases according to the procedures indicated on the website of the Service:

61.4.1. electrocardiogram - within three months or within one month if the general practitioner has made a note in the referral regarding high or very high risk of cardiovascular diseases;

61.4.2. echocardiogram - within six months or within three months if the general practitioner has made a note in the referral regarding high or very high risk of cardiovascular diseases;

61.4.3. carotid ultrasound - within six months or within three months if the general practitioner has made a note in the referral regarding high or very high risk of cardiovascular diseases;

61.4.4. cycle ergometry - within three months;

61.4.5. consultation of a specialist (cardiologist, vascular surgeon) - within a month if the general practitioner has made a note in the referral regarding high or very high risk of cardiovascular diseases.

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62. The medical treatment institution which according to the contract with the Service ensures the post-screening examinations referred to in this Regulation shall perform them within 30 days from the day when a person has turned to the medical treatment institution for the receipt of the service.

63. For a person with a predictable disability the medical treatment institution shall commence the provision of the State paid planned health care services which are included in the individual rehabilitation plan approved by the State Medical Commission for the Assessment of Health Condition and Working Ability within the following time periods:

63.1. outpatient health care services - within 15 working days;

63.2. planned outpatient and inpatient medical rehabilitation services - within 15 working days;

63.3. planned surgeries - within five months.

64. Medical treatment institutions which perform planned endoprosthetic replacement of large joints shall form and maintain the following queues of applicants for the receipt of State paid planned health care services:

64.1. endoprosthetic replacement as a matter of urgency according to the criteria specified in the contract with the Service;

64.2. endoprosthetic replacement according to general procedures.

65. If a person who is in the queue for endoprosthetic replacement of large joints refuses the time offered for performing the surgery of endoprosthetic replacement of large joints or does not provide an answer within two months from the day of sending the offer, he or she shall be deleted from the abovementioned queue.

66. An inpatient medical treatment institution which provides surgical assistance shall plan the provision of inpatient health care services in the following priority order:

66.1. emergency medical assistance;

66.2. planned surgical assistance in the following cases:

66.2.1. surgical treatment for children;

66.2.2. surgical treatment in case of inflammatory bowel diseases;

66.2.3. surgical treatment of hormonally active endocrine glands;

66.2.4. planned surgeries for persons who have been ill for a protracted period of time and who are of the working age to the extent specified in Sub-paragraph 4.10 of this Regulation;

66.2.5. for persons with a predictable disability according to the individual rehabilitation plan approved by the State Medical Commission for the Assessment of Health Condition and Working Ability;

66.2.6. surgical treatment in the programmes of health care services indicated in Paragraph 2 of Annex 6 to this Regulation;

66.3. other planned surgeries performed at the inpatient medical treatment institution which, in accordance with this Regulation, are included in the amount of the State paid health care services.

67. The Service shall form a centralised queue of applicants for the receipt of State paid health care services of medically assisted insemination (hereinafter - the register of queues) in conformity with the following conditions:

67.1. the procedures by which medical treatment institutions ensuring State paid services of medically assisted insemination shall provide information to the Service regarding persons who require health care services of medically assisted insemination for the receipt of which the Service maintains the register of queues shall be determined in the contract with the Service;

67.2. the following information shall be included in the register of queues:

67.2.1. the given name, surname, personal identity number, electronic mail address, telephone number of the person;

67.2.2. the date when the person was accepted into the queue and the medical treatment institution in which the person has been accepted into the queue;

67.2.3. the sequence number of the person in the queue;

67.2.4. the date when the invitation regarding the possibility to receive a State paid service was sent;

67.2.5. information regarding the process and result of provision of the service;

67.3. the Service shall send the invitation to the patient to receive the service at any medical treatment institution providing State paid services of medically assisted insemination to the electronic mail address indicated in the register of queues (official electronic address if an e-address account has been activated for the patient);

67.4. the Service shall determine the number of invitation letters to be sent to persons according to the financial resources available.

68. A person shall be excluded from the queue referred to in Paragraph 67 of this Regulation if:

68.1. receipt of health care service is not necessary for the person or is not possible due to medical indications;

68.2. the person does not meet the criteria for the receipt of the health care service of medically assisted insemination anymore;

68.3. the person has refused to receive a State paid health care service of medically assisted insemination;

68.4. within six months since sending of the invitation the person has not turned to the medical treatment institution for receipt of the health care service of medically assisted insemination;

68.5. the person has died or has lost the right to receive a State paid service of medically assisted insemination.

3.7. Secondary Outpatient Health Care

69. In order for a person to receive a secondary outpatient health care service, a general practitioner or specialist shall jointly with the person choose the place of receipt of the health care service, assessing the urgency of receipt of the service, and shall inform the person of the necessity to apply to the relevant medical treatment institution for the receipt of the health care service, except for the case if the person needs a consultation of such specialist after primary diagnostics of malignant neoplasms who ensures secondary diagnostics of malignant neoplasms. In such case the general practitioner, the prison doctor, or the gynaecologist shall apply the person for the receipt of the consultation and inform him or her of the planned time for the receipt of the service.

69.¹ Upon organising outpatient ensuring of psychiatric assistance, the initial assessment of the patient shall be performed by the psychiatrist or paediatric psychiatrist who shall send the patient for the receipt of the service to a psychologist/psychotherapist, indicating the number of the necessary visits in the referral.

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70. Types of State paid secondary outpatient health care services which are provided by each medical treatment institution shall be determined in the contract with the Service and published on the website of the Service.

71. In order to detect precancerous diseases and cancer at early stages, the Service shall organise and supervise the State organised screening which is a health care programme based on the data of the Population Register involving sending of centralised invitations and continuous monitoring of results. The State organised screening shall include the following examinations for the following target groups:

71.1. cervical cancer screening which is performed once in three years for women from 25 to 70 years of age;

71.2. colorectal cancer screening which is performed once a year for patients from 50 to 74 years of age as a screening test for colorectal cancer;

71.3. breast cancer screening with the mammography method which is performed once in two years for women from 50 to 69 years of age.

72. State organised screening shall be performed in conformity with the following conditions:

72.1. the Service shall, once in three years, send an invitation letter regarding cervical cancer screening to the women of the target group, except for the following cases:

72.1.1. if according to the information in the management information system of the Service the woman has undergone the following:

72.1.1.1. cervical amputation;

72.1.1.2. extirpation of the uterus with removal of Fallopian tubes or without removal of Fallopian tubes;

72.1.1.3. vaginal extirpation of the uterus;

72.1.1.4. extirpation of the uterus during childbirth or in early period following childbirth with removal of appendages or without removal of appendages;

72.1.1.5. the Wertheim's operation;

72.1.1.6. extirpation of the uterus with lymphadenectomy of true pelvis or deomentisation;

72.1.1.7. laparoscopic hysterectomy with or without appendages;

72.1.2. if according to the information in the management information system of the Service the woman has undergone a cytological examination of cervix within a year until the date of preparation of the invitation letter;

72.1.3. if the diagnosis C53, C54, C56, or C57 (in accordance with ICD-10) has been indicated for the woman in the register of patients suffering from certain diseases;

72.1.4. if at the time of preparation of the invitation letter the woman did not have a declared place of residence in the Republic of Latvia;

72.2. the Service shall, once in two years, send an invitation letter regarding the organised breast cancer screening to the women of the target group, except for the following cases:

72.2.1. if the diagnosis C50 (in accordance with ICD-10) has been indicated for the woman in the register of patients suffering from certain diseases;

72.2.2. if according to the information in the management information system of the Service the woman has undergone a mammography examination within a year until the date of preparation of the invitation letter;

72.2.3. if at the time of preparation of the invitation letter the woman did not have a declared place of residence in the Republic of Latvia;

72.3. the practice of a general practitioner shall, once in a calendar year, provide information regarding the organised colorectal cancer screening to the patients of the target group registered with its practice of the general practitioner, and also shall invite to perform the fecal occult blood test and ensure the performance of such test.

73. The conditions for the performance of primary and secondary diagnostics of malignant neoplasms at medical treatment institutions shall be published on the website of the Service, providing for preconditions in order to ensure taking of a decision on the tactic of medical treatment of a patient within one month from the moment when secondary diagnostics of a malignant neoplasm has been commenced for the person.

74. The Coordination Centre of Rare Diseases which has been established by the State limited liability company Children's Clinical University Hospital and which, on the basis of a mutual agreement, cooperates with valsts sabiedrība ar ierobežotu atbildību "Paula Stradiņa klīniskā universitātes slimnīca" [State limited liability company Pauls Stradiņš Clinical University Hospital] and limited liability company Riga East University Hospital shall ensure:

74.1. coordination of the flow of patients with rare diseases, referring the patient with a rare disease for further medical treatment to the State limited liability company Children's Clinical University Hospital, the State limited liability company Pauls Stradiņš Clinical University Hospital, or the limited liability company Riga East University Hospital accordingly;

74.2. a doctors' council for the determination of the specific treatment with medicinal products of rare diseases for the diagnoses indicated in Annex 9 and for further monitoring or genetic diagnostics;

74.3. a doctors' council for the determination of pulmonary transplantation;

74.4. the methodological management of rare diseases, forming a uniform approach in medical treatment of rare diseases;

74.5. issuance of the patient card for a patient with a rare disease.

75. For patients with rare diseases:

75.1. a decision on the provision of the pulmonary endarterectomy service shall be taken by a doctors' council organised by the State limited liability company Pauls Stradiņš Clinical University Hospital or the limited liability company Riga East University Hospital in the composition of not less than three doctors, with the participation of a vascular surgeon and a cardiologist;

75.2. after taking of the decision on the specific treatment with medicinal products of rare diseases and upon commencing the administration of the medicinal products by the patient, the Coordination Centre of Rare Diseases shall monitor whether the administration of medicinal products achieves the initially intended result of medical treatment. If the initially intended result of medical treatment is not achieved, the doctors' council organised at the Coordination Centre of Rare Diseases has the right to repeatedly decide on the necessity of the specific treatment with medicinal products, revoking or changing the assigned medical treatment and informing the patient with the rare disease of the decision taken.

76. The conditions for the health care services provided at consulting rooms of health care services shall be determined in the contract with the Service.

77. Pain control and control of other symptoms shall be performed on a priority basis within the scope of palliative care, ensuring the needs necessary for the patient regardless of the place where he or she is located - at home or in an inpatient medical treatment institution - and retaining the best possible quality of life until the moment when death sets in.

78. A medical treatment institution which receives a monthly fixed payment for the work of specialists or units of medical treatment institutions (except for the payment for the work of the emergency room) shall ensure that the working hours of the relevant specialist or consulting room has been specified according to the following conditions:

78.1. for one load of a doctor - reception of patients for not less than 30 hours a week;

78.2. for one load of a nurse - work for not less than 40 hours a week.

79. Tertiary health care shall be organised and financed from the State budget resources in accordance with the procedures by which secondary health care is organised and financed.

3.8. Health Care Provided at a Day Hospital

80. Such health care services shall be provided at a day hospital which cannot be provided on an outpatient basis due to their complexity, risk, or them being time-consuming, but due to which admission of a patient into an inpatient hospital for ensuring day-and-night monitoring by medical practitioners is not necessary.

81. The health care services to be provided at a day hospital shall be medical treatment or diagnostic services during the provision of which medical treatment and health care is ensured to the person at the medical treatment institution for partial day-and-night (not earlier than from 6.00 and not later than until 22.00), manipulations are performed for not less than three hours, or observation of the person is ensured after performance of manipulations, and they display the following characteristic signs:

81.1. admission one or several times;

81.2. the time period between two consecutive admissions is at least six hours;

81.3. the duration of one admission is up to 16 hours.

82. The State paid services to be provided at a day hospital are indicated in Annex 5 to this Regulation.

83. Examinations, medical treatment procedures, and surgeries which are not directly related to the services to be provided at the day hospital and which, in accordance with the laws and regulations regarding the mandatory requirements for medical treatment institutions or their units, may be performed at the day hospital in an equipped consulting room of a specialist or procedures shall not be performed in a day hospital.

84. The health care services of the day hospital according to their potential risk of complications shall be as follows:

84.1. first level health care service of the day hospital - shall be provided by the medical treatment institution which has an intensive care unit, an anaesthesiology unit, and a blood transfusion room;

84.2. second level health care service of the day hospital - the medical treatment institution does not require an intensive care unit, an anaesthesiology unit, or a blood transfusion room for the provision of such service.

85. If it is intended to provide an invasive cardiology, invasive radiology, or surgical service (hereinafter - the surgical operation) to a person at the day hospital, prior to the issuance of a referral the general practitioner or specialist shall assess:

85.1. the age, health condition of the person and, according to the medical indications, shall refer the person for the performance of such examinations which are necessary to assess whether the surgical operation could be performed at a day hospital;

85.2. the risk of complications of the necessary surgical operation;

85.3. the communication abilities of the person (the ability to understand and comply with the recommendations regarding further care after performance of the surgical operation);

85.4. the possibilities of the person to receive medical assistance after the surgical operation if it is going to be necessary, also ascertain whether a phone is available to the person;

85.5. whether pain control after the surgical operation may be ensured, using oral analgesics or regional anaesthetic.

86. The medical treatment institution which performs the surgical operation at a day hospital shall ensure that:

86.1. the patient is admitted once for the performance of the surgical operation at the day hospital;

86.2. prior to the surgical operation the attending physician informs the patient of the planned operation, and also of movement of the patient to an inpatient medical treatment institution if complications are to arise for the patient and monitoring by medical practitioners will be necessary outside the working hours of the day hospital (after 22.00);

86.3. after the surgical operation the attending physician assesses the health condition of the patient;

86.4. the patient is transferred to an inpatient medical treatment institution which ensures day-and-night emergency medical assistance if due to medical reasons he or she requires monitoring of medical practitioners outside the working hours of the day hospital (after 22:00), except for the case if the medical treatment institution concurrently meets the following conditions:

86.4.1. the medical treatment institution has the staff resources and it ensures monitoring of the patient in the necessary amount;

86.4.2. the patient is discharged from the day hospital not later than on the following day after admission into the day hospital;

86.4.3. the medical treatment institution provides first level health care services of a day hospital;

86.5. upon discharging the patient from the day hospital to home, the attending physician provides recommendations to the patient for postoperative care, and also informs of the visiting hours of the specialist for repeated assessment of the health condition, if necessary.

87. If a person requires laboratory testing which is directly related to the health care service to be provided in the day hospital, the specialist which sends the sample of the material to be examined for laboratory testing shall indicate in the referral that the person is a patient of a day hospital.

3.9. Health Care Provided at an Emergency Room and in the Reception Ward

88. If a person has a trauma, an acute disease, or exacerbation of a chronic disease and requires urgent intervention by medical practitioners, and also if the necessary assistance is beyond the competence of the primary health care practitioner, the person may receive the necessary health care services:

88.1. at an emergency room which has been established in the medical treatment institutions referred to in Annex 10 to this Regulation;

88.2. in the reception ward of an inpatient medical treatment institution.

89. If a person who has turned to an emergency room, according to the health condition, requires emergency medical treatment at an inpatient medical treatment institution, the medical treatment institution shall call an emergency medical assistance team to deliver the person to the nearest corresponding inpatient medical treatment institution, taking into account the health condition of the person and the conditions referred to in the contracts of the Service with medical treatment institutions.

90. If a person has turned to the reception ward of an inpatient medical treatment institution and it is not necessary to admit the person, outpatient health care services are provided to the person at the reception ward of the inpatient medical treatment institution.

91. If incapacity for work has been detected for a person who has turned to an emergency room or the reception ward of an inpatient medical treatment institution, the medical treatment institution shall ensure the issuance of a sick-leave certificate to a person in accordance with the regulatory enactment determining the procedures by which temporary incapacity for work of a person is certified.

92. The medical treatment institution which provides health care services at an emergency room shall ensure that:

92.1. the urgent medical assistance is available at least 12 hours a day and shall agree with the Service regarding specific working hours in the contract in conformity with the following conditions:

92.1.1. working hours on working days are primarily specified in the time period from 16.00 to 8.00, working hours outside this time period are determined only in case if the emergency room is open for more than 12 hours;

92.1.2. working hours on weekends and holidays may be specified within the scope of the whole 24 hours;

92.2. the urgent medical assistance is provided by at least one doctor and at least one doctor's assistant (feldsher) or a nurse, except for the case when the Service has agreed with the medical treatment institution on other procedures.

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3.10. Inpatient Health Care

93. In order for a person who requires 24-hour monitoring by a medical practitioner to receive an inpatient health care service, the general practitioner or specialist shall issue a referral to the person in conformity with the following conditions:

93.1. jointly with the person (except for a person who is in a place of imprisonment) choose the inpatient medical treatment institution, assessing the urgency of receipt of the service;

93.2. indicate in the referral or append to the referral an extract with the results of examination which justify the particular objective of referral and the health condition of the person.

94. In order for a person who is in a place of imprisonment to receive a planned inpatient health care service, the prison doctor shall, on the basis of the medical indications and urgency, agree on the time of provision of the service with the inpatient medical treatment institution where it is possible to receive the relevant service.

95. State paid inpatient health care services shall be provided to a person by the inpatient medical treatment institutions referred to in Annex 6 to this Regulation according to the level specified for each medical treatment institution (the level of services to be ensured) in conformity with the payment conditions of inpatient health care services specified in Annex 6 to this Regulation and in the contract with the medical treatment institution.

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96. If an admitted person has medical indications for the receipt of such inpatient health care services which are provided by an inpatient medical treatment institution of higher level, the inpatient medical treatment institution shall ensure movement of the person for admission to the inpatient medical treatment institution of the corresponding level.

97. If an admitted person has medical indications for the receipt of such health care services which are not provided by the inpatient medical treatment institution, the inpatient medical treatment institution shall ensure the delivering of the person to another medical treatment institution for the receipt of the necessary medical manipulations and back to the inpatient medical treatment institution. In such case the Service shall cover the expenses for the manipulations for such inpatient medical treatment institution in which the person is admitted. The relevant inpatient medical treatment institution shall settle the accounts with the performer of manipulations.

98. If the medical treatment institution temporarily discontinues any inpatient health care service which has been specified in the contract entered into with the Service, the former shall cover expenses for the inpatient health care services provided to the patient in another medical treatment institution during this period of time and reach an agreement regarding the payment procedures with the medical treatment institution which has actually provided the relevant health care service.

99. The inpatient medical treatment institution has the right to reach an agreement (by entering into a relevant agreement) with another medical treatment institution regarding delivering of the patients to such medical treatment institution for the receipt of the necessary health care services also in other cases not referred to in this Regulation, including reaching an agreement regarding the procedures for mutual settlement of accounts and other issues, informing the Service thereof.

100. The medical treatment institution shall ensure that a doctor of rehabilitation and physical medicine evaluates the person who is discharged from the inpatient medical treatment institution after medical treatment of a cerebrovascular disease (in accordance with the ICD-10, diagnosis codes I60, I61, I63, and I64). If the relevant person requires medical rehabilitation services, he or she shall be issued a referral of a doctor of rehabilitation and physical medicine and a rehabilitation plan for the receipt of medical rehabilitation prepared in accordance with the procedures laid down in this Regulation. The medical treatment institution shall ensure the following to other persons with functional restrictions for whose medical treatment medical rehabilitation is required and who are discharged from the inpatient medical treatment institution:

100.1. the preparation of a referral of a doctor of rehabilitation and physical medicine and a rehabilitation plan if a doctor of rehabilitation and physical medicine is employed at the medical treatment institution;

100.2. the preparation of recommendations of the attending physician regarding the necessity of further medical rehabilitation, describing the rehabilitation commenced at the inpatient institution, if a doctor of rehabilitation and physical medicine is not employed at the medical treatment institution.

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3.11. Medical Rehabilitation

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101. The objective of medical rehabilitation services is to ensure the reduction or elimination of functional restrictions for persons with specific functional restrictions, and also the assessment and reduction of the risk of complications.

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102. The medical rehabilitation services shall be as follows:

102.1. services of acute rehabilitation which are provided concurrently with medical treatment of an acute disease or an exacerbation of a disease up to three months from the beginning of the disease or the moment of commencing medical treatment of the exacerbation of the disease;

102.2. services of subacute rehabilitation which are provided up to six months from the beginning of the disease or the moment of commencing medical treatment of the exacerbation of the disease;

102.3. long-term rehabilitation services in case of chronic functional restrictions which are provided for more than six months from the beginning of the disease or the moment of commencing medical treatment of the exacerbation of the disease, or in case of perinatal development disorders by including the patient in dynamic observation of medical rehabilitation.

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103. Medical rehabilitation services shall be organised in conformity with the following conditions:

103.1. by inpatient medical treatment institutions according to the profiles of medical treatment institutions and programmes of inpatient health care services specified in Annex 6 to this Regulation;

103.2. at a day hospital - acute (only for children), subacute, and long-term medical rehabilitation services;

103.3. on an outpatient basis - acute, subacute, and long-term medical rehabilitation services.

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104. Selection of persons (including persons with oncological diseases) for the receipt of State paid medical rehabilitation services shall be performed:

104.1. by a doctor of rehabilitation and physical medicine who, upon a person undergoing medical treatment at an inpatient medical treatment institution or being discharged from an inpatient medical treatment institution in the cases referred to in Paragraph 100 of this Regulation, or upon consulting a person on an outpatient basis, shall examine the person or assess the referral of another doctor or medical documentation prepared by the functional specialist;

104.2. in case of psychiatric assistance - by a psychiatrist or paediatric psychiatrist;

104.3. in case of narcological assistance - by a narcologist;

104.4. by a general practitioner or specialist if rehabilitation services provided by the functional specialist up to five visits are required for a patient whose functional restrictions in one type of functioning conform to the International Classification of Functioning, Disability and Health.

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105. Upon performing the selection of persons for the receipt of rehabilitation services, a doctor of rehabilitation and physical medicine (or a psychiatrist, paediatric psychiatrist, or narcologist accordingly) shall evaluate:

105.1. the health condition of the person and the functional restrictions related thereto;

105.2. the potential of medical rehabilitation;

105.3. the motivation of the person and his or her relatives;

105.4. the stability of the health condition for the receipt of rehabilitation services;

105.5. the type of receipt of medical rehabilitation services which is the most optimal for the person, taking into account that medical rehabilitation services can be received at an outpatient medical treatment institution, including at a day hospital, at an inpatient medical treatment institution, and at home.

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106. A medical treatment institution shall provide medical rehabilitation services in the following priority order, taking into account that children up to three years of age with high risk for the development of functional disorders, children from three to six years of age with moderately severe and severe functional restrictions, and employees of emergency service who have suffered damage to health in rescue operations in disasters with more than five victims, shall be the first to receive rehabilitation services in the indicated groups of persons:

106.1. persons with acute and subacute functional disorders manifesting as restrictions of communication, cognitive abilities, movement, self-care, instrumental activity of daily living;

106.2. persons with subacute functional restrictions which restrict the capacity for work of the person and may cause disability;

106.3. persons with chronic functional restrictions at the intervals specified in the rehabilitation plan if the person is under dynamic observation;

106.4. other persons with functional restrictions.

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107. Medical rehabilitation services shall be provided by a doctor of rehabilitation and physical medicine (or a psychiatrist, paediatric psychiatrist, or narcologist accordingly) and functional specialists in the form of consultations, multiprofessional or monoprofessional medical rehabilitation services in conformity with the procedures indicated in Paragraphs 108 and 109 of this Regulation.

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108. A monoprofessional medical rehabilitation service is an individual rehabilitation service provided by a doctor of rehabilitation and physical medicine (or a psychiatrist, paediatric psychiatrist, or narcologist accordingly) or a functional specialist for the provision of which other medical practitioners and medical support persons may be attracted and which is provided on an outpatient or inpatient basis within the scope of acute rehabilitation.

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109. A multiprofessional medical rehabilitation service is a specialised form of organising a medical rehabilitation service which is implemented by a multiprofessional medical rehabilitation team at a day hospital or inpatient medical treatment institution in conformity with the following conditions:

109.1. the service is provided by a doctor of rehabilitation and physical medicine (or a psychiatrist, paediatric psychiatrist, or narcologist accordingly) and functional specialists with the participation of medical practitioners and medical support persons as well as clinical or health psychologists;

109.2. the specialists to be involved in ensuring of a multiprofessional medical rehabilitation service are determined by a doctor of rehabilitation and physical medicine (or a psychiatrist, paediatric psychiatrist, or narcologist accordingly) who coordinates the work of the multiprofessional team;

109.3. a multiprofessional medical rehabilitation service is provided:

109.3.1. as the base service which lasts two to three hours and includes individual work of functional specialists with the person, using at least three different medical technologies;

109.3.2. as the intensive rehabilitation course which lasts three to four hours and includes individual work of functional specialists with the person, using at least three different medical technologies;

109.4. meetings of the multiprofessional medical rehabilitation team take place at least once a week, and the decisions taken during meetings are recorded in the medical documentation of the patient.

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110. In case of chronic functional restrictions, if rehabilitation is required for more than six months, a psychiatrist, a paediatric psychiatrist, a narcologist, or a doctor of rehabilitation and physical medicine may include the person in dynamic observation of medical rehabilitation. A doctor of rehabilitation and physical medicine (or a psychiatrist, paediatric psychiatrist, or narcologist accordingly), upon implementing dynamic observation of medical rehabilitation, shall:

110.1. determine the intervals of control of the health condition and functioning of the person, organise the preparation or revision of the rehabilitation plan (not less than once a year), and organise the implementation thereof;

110.2. prescribe the necessary technologies, medicinal products, examinations, and consultations of medical rehabilitation;

110.3. send the person to receive State paid medical rehabilitation services;

110.4. if necessary, coordinate the developed medical treatment and rehabilitation plan with the general practitioner and the local government social service office and coordinate the execution thereof.

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111. A medical treatment institution which has included a person in dynamic observation of medical rehabilitation shall ensure:

111.1. the record-keeping of the persons included in dynamic observation of medical rehabilitation;

111.2. the aggregation of the results of evaluation of health and functional condition and rehabilitation of the person.

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112. A doctor of rehabilitation and physical medicine (or a psychiatrist, paediatric psychiatrist, or narcologist accordingly) shall develop a medical rehabilitation plan for persons who receive medical rehabilitation services on an inpatient basis or at a day hospital or who require more than five outpatient visits to the functional specialist and persons who are included in dynamic observation of medical rehabilitation. One copy of the plan shall be issued to the patient and the other shall be appended to the outpatient or inpatient medical card. The following shall be included in the plan:

112.1. the evaluation of the patient, determining the restrictions of functioning and the restrictions of activities;

112.2. the objective of medical rehabilitation;

112.3. the type of the planned medical rehabilitation services;

112.4. the specialists to be involved and the objectives of medical rehabilitation to be achieved;

112.5. the necessary technical aids;

112.6. the planned intensity of medical rehabilitation.

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113. After completion of the medical rehabilitation course, a medical practitioner shall evaluate the result of medical rehabilitation, determining whether the objective of medical rehabilitation has been achieved, partially achieved, or has not been achieved, and assess the necessity for the person to continue receipt of medical rehabilitation services hereinafter.

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114. If the condition of the person becomes stable (according to the opinion of the doctor of rehabilitation and physical medicine or the psychiatrist, paediatric psychiatrist, or narcologist), the dynamic observation of medical rehabilitation may be revoked upon initiative of the person or upon person moving to a long-term social care and social rehabilitation institution.

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3.12. Emergency Medical Assistance

115. Emergency medical assistance shall be provided to a person:

115.1. by a medical treatment institution;

115.2. by the State Emergency Medical Service.

116. Medical treatment institutions which ensure the operation of the reception ward in accordance with Annex 6 to this Regulation shall provide emergency medical assistance throughout the day and night. Other medical treatment institutions shall ensure the provision of emergency medical assistance during the working hours of the institution.

117. If a person requires emergency medical assistance or it is necessary to determine or clarify a diagnosis, the team of the State Emergency Medical Service shall deliver the person to the nearest corresponding medical treatment institution, taking into account the health condition of the person and the conditions referred to in the contracts of the Service with medical treatment institutions.

118. The team of the State Emergency Medical Service shall provide emergency medical assistance to a victim (sick person) who is in a condition that is critical to life and health on-scene as well as during transportation to a medical treatment institution in the following cases:

118.1. accidents, traffic accidents, disasters, severe mechanical, thermal, chemical, and combined injuries, electrical injuries, foreign bodies in airways, drowning, choking, poisoning;

118.2. sudden disease or exacerbation of chronic diseases which endangers the life of the person:

118.2.1. a cardiovascular disease characterised by pain, choking fits or shortness of breath, cold sweat, irregular heartbeat, loss of consciousness;

118.2.2. peripheral vascular disease characterised by sudden pain in arms or legs, coldness of arms or legs, pallor;

118.2.3. diseases of the central or peripheral nervous system characterised by sudden cognitive loss, cramps, fainting fit, headache or backache, disorders of sensation or movement;

118.2.4. a gastrointestinal disease characterised by sudden pain in the stomach, vomiting, cold sweat, continuous diarrhoea;

118.2.5. a urologic disease characterised by sudden pain in the lumbar and sacral region or acute urinary disorders;

118.2.6. acute mental disorders characterised by aggressive behaviour or an attempted suicide;

118.2.7. bleeding of any origin that endangers life;

118.2.8. allergic reactions of any origin that endanger life;

118.2.9. a seizure of bronchial asthma;

118.3. emergency movement of the victim (sick person) (the person shall be transported with the ambulance emergency response vehicle under supervision of the team of the State Emergency Medical Service according to the referral issued by the attending physician) as well as delivery of a woman giving birth according to the health condition:

118.3.1. from the location of the person to the nearest corresponding medical treatment institution;

118.3.2. from a medical treatment institution to an inpatient medical treatment institution or an inpatient medical treatment institution of higher level.

119. The medical practitioner who applies movement has an obligation to ensure the provision of emergency medical assistance or health care of another type to the victim (sick person) until the moment of arrival of the team of the State Emergency Medical Service.

120. The State Emergency Medical Service shall provide specialised emergency medical assistance:

120.1. during disasters or in emergency medical situations upon request of rescue services or a medical practitioner authorised by the head of the medical treatment institution;

120.2. upon request of a medical practitioner authorised by the head of an inpatient medical treatment institution if the necessary amount of medical assistance exceeds the possibilities of the available medical assistance at the medical treatment institution in the following cases:

120.2.1. severe head traumas and spontaneous intracranial haemorrhage;

120.2.2. trauma to the spine with damages to spinal cord;

120.2.3. severe polytraumas;

120.2.4. severe or extensive burn and corrosion, frostbite;

120.2.5. injury to or acute closure of the major blood vessels;

120.2.6. traumatic amputations where replantation is possible;

120.2.7. serious acute surgical diseases or serious complications of a surgical operation;

120.2.8. severe internal bleeding;

120.2.9. severe myocardial infarction, acute irregular heartbeat;

120.2.10. severe, complex obstruction of upper airways;

120.2.11. severe poisoning;

120.2.12. unclear contagious disease or massive outbreak of infectious disease in a short period of time as well as justified suspicions regarding an especially dangerous infectious disease;

120.2.13. the victim (sick person) is in a condition that is critical to health and life and he or she requires a consultation (council), medical transportation or medical evacuation by air transport to an inpatient medical treatment institution of the corresponding profile in the territory of Latvia;

120.3. upon request of a medical practitioner authorised by the head of the medical treatment institution, if it is necessary to transport a child who is in a condition critical to life and who has received, in accordance with the procedures laid down in this Regulation, the S2 form "Authorisation to Obtain Planned Health Treatment" to a medical treatment institution of a EU Member State, EEA state or Switzerland or to transport such child from a medical treatment institution of a EU Member State, EEA state or Switzerland if medical transportation is required according to his or her health condition.

121. The medical practitioner on duty of the State Emergency Medical Service shall register all calls for emergency medical assistance, including emergency movement applications, and, where necessary, inform the caller for emergency assistance that a visit will possibly be a paid service, and also provide information regarding other possibilities of receipt of health care services.

122. Teams of the State Emergency Medical Service shall be placed in the relevant territory, taking into account the density of inhabitants and the size of the zone to be serviced, and also other factors influencing the time of provision of assistance (for example, poor quality of roads) so that in 75 % of cases emergency medical assistance is provided within the following period of time after receipt of emergency call:

122.1. in republic cities - not later than within 12 minutes from the time of receipt of the call;

122.2. in municipality towns - not later than within 15 minutes from the time of receipt of the call;

122.3. in other territories - not later than within 25 minutes from the time of receipt of the call.

3.13. Receipt of Health Care Services in Another EU Member State, EEA State, and Switzerland

123. The Service shall cooperate with the cross-border healthcare contact points of EU Member States, EEA states, and Switzerland in issues regarding the receipt of health care services in foreign states and the compensation of expenses for health care services received in foreign states, and also, upon request of a person, shall provide the contact details of the contact points of the EU, EEA, and Switzerland.

124. The Service shall, in accordance with the conditions of Regulation No 883/2004 and Regulation No 987/2009, issue the following documents certifying the right of the person to receive State paid health care services in another EU Member State, EEA state, or Switzerland:

124.1. S1 form "Certificate of Entitlement to Health Care" (hereinafter - the S1 form) ensuring the person with the right to receive the health care services in the state indicated in the form which are guaranteed in the relevant state;

124.2. S2 form "Authorisation to Obtain Planned Health Treatment" (hereinafter - the S2 form) ensuring the right to receive the planned health care service indicated in the form in the state and within the time period indicated in the form;

124.3. S3 form "Certificate of Entitlement to Health Care to a Retired Cross-border Employee in the Former Country of Employment" (hereinafter - the S3 form) ensuring a retired cross-border employee with the right to complete the medical treatment indicated in the form in the country indicated in the form;

124.4. the European health insurance card (hereinafter - the insurance card) or a copy of the certificate replacing the European health insurance card (hereinafter - the certificate replacing the insurance card) which ensures the right to receive emergency medical assistance or the necessary medical assistance during temporary stay in a EU Member State, EEA state, or Switzerland;

124.5. form E104 and its equivalent form S040 certifying the periods of insurance, employment, or stay of a person in the Republic of Latvia.

[7 May 2019; 10 December 2019]

125. The Service shall evaluate the right of a person to receive an S form, the insurance card, or the certificate replacing the insurance card if a submission of the person or a request of the competent authority for the issue of the relevant document has been received.

126. The State Revenue Service and the State Social Insurance Agency shall provide the information necessary to the Service for the coordination of the social security system in online mode in conformity with the following procedures:

126.1. the State Revenue Service shall provide the current information regarding the employment status of the person;

126.2. the State Social Insurance Agency shall provide information:

126.2.1. on the social insurance periods of the person in Latvia since 1996;

126.2.2. on the pension granted, including information on the type of pension, length of period of insurance, and restriction on the time period for disbursement of pension if such has been specified;

126.2.3. on the term of validity of the A1 form "Statement of Social Security Legislation Applicable to the Recipient of the Certificate" and U2 form "Authorisation to Continue Receiving Unemployment Benefits" issued to the person.

[10 December 2019]

127. The S1 form shall be issued to an insured person who complies with any of the following criteria:

127.1. the person is registered in Latvia in the status of an employed person or self-employed person and performs essential part of his or her activity being physically present in Latvia but his or her place of residence is in another EU Member State, EEA state or Switzerland, and the person regularly returns there;

127.2. the person is temporarily (for not more than 24 months) sent to the state of residence which is in the EU, EEA, or to Switzerland and he or she has a valid A1 form "Statement of Social Security Legislation Applicable to the Recipient of the Certificate";

127.3. the person is temporarily (for not more than 24 months) going to the state of residence - another EU Member State, EEA state or to Switzerland in order to perform activity in the status of a self-employed person, and he or she has a valid A1 form "Statement of Social Security Legislation Applicable to the Recipient of the Certificate";

127.4. the person is receiving a pension of the Republic of Latvia and is not employed but his or her place of residence is in another EU Member State, EEA state or Switzerland;

127.5. the person is an unemployed person who, for the purpose of finding a job, wishes to go to the state of residence which is located in a EU Member State, EEA state or Switzerland and who has a valid U2 form "Authorisation to Continue Receiving Unemployment Benefits".

[7 May 2019]

128. In order for the Service to assess the right of a person to receive the S1 form, the person shall submit an application to the Service for the receipt of S1 (E106, E109, E121) form. The following shall be indicated in the application:

128.1. basic information on the person:

128.1.1. the given name, surname, nationality, date of birth, personal identity number of Latvia or the taxpayer registration number assigned by the State Revenue Service if the person is not registered in the Population Register, and telephone number or electronic mail address;

128.1.2. information as to whether the person is insured in the social security system of another EU Member State, EEA state or Switzerland;

128.1.3. information as to whether the person is registered in the status of an employed person or self-employed person in another EU Member State, EEA state or Switzerland;

128.1.4. if the person is registered in the status of an employed person in Latvia, the name, registration number, and legal address of the place of work shall be indicated;

128.1.5. if the person is registered in the status of a self-employed person in Latvia, the registration number, address of the performance of activity, and type of occupation shall be indicated;

128.1.6. if the person is receiving pension from Latvia, the type of pension (old-age, loss of provider, disability, service) shall be indicated, including regarding pension from another EU Member State, EEA state or Switzerland;

128.2. additional information on the person according to the criteria on the basis of which the person wishes to receive the S1 form:

128.2.1. if the person is going to or has been sent to the state of residence - a EU Member State, EEA state or Switzerland, the address in Latvia and the address in the foreign state to which the person is going shall be indicated;

128.2.2. if the status of an unemployed person has been granted to the person, the address of stay in the state to which he or she wishes to go for the purpose of finding a job shall be indicated;

128.2.3. if the person has a place of residence in another EU Member State, EEA state or Switzerland, the identification number assigned in the state of the place of residence and the registered address of the place of residence for which the S1 form is being requested shall be indicated.

129. In order for a family member dependent on the insured person (spouse, person under guardianship or trusteeship) to receive the S1 form, information according to the conditions applying to the insured person shall be submitted to the Service.

130. In order for the Service to assess the right of the person to receive the insurance card, the person shall submit an application to the Service for the receipt of the insurance card. The following information shall be indicated in the application:

130.1. the given name, surname, date of birth, personal identity number of Latvia or the taxpayer registration number assigned by the State Revenue Service and the identification number assigned in another state if such has been assigned, and telephone number or electronic mail address;

130.2. address (if the person wishes to receive the insurance card by post);

130.3. information on the state of citizenship and place of residence;

130.4. information as to whether the person is insured in the social security system of another EU Member State, EEA state or Switzerland.

131. If an application for the receipt of the insurance card is submitted in the unified electronic information system of health sector, the person shall fill in the form posted therein.

132. If the person has the right to receive the insurance card, the Service shall issue it or send it by post to the address indicated by the person or to the address of the declared place of residence of the person.

133. The insurance card shall be issued for a period of three years or a shorter period of time conforming to the period during which it is possible to establish that the person has the right to receive health care services paid from the State budget resources.

134. The Service shall issue the insurance card to the person on the day of receipt of the application or send it by post, except for the case if the Service establishes that the person does not have the right to receive the insurance card. In such case the Service shall prepare a written decision on refusal to issue the insurance card and shall notify the abovementioned decision to the person in accordance with the procedures laid down in the Law on Notification.

135. The person shall pay according to the price list of paid services of the Service for making of the insurance card if it has been requested more than a month before expiry of the term of validity of the valid card.

136. If a person, upon temporary stay in any EU Member State, EEA state or Switzerland, wishes to receive emergency medical assistance or necessary medical assistance and the person cannot present the insurance card, the Service shall, on the basis of the application of the person for the issuance of the replacing certificate or upon request of the competent authority of such state in which the person is located, issue the certificate replacing the insurance card to the person or the competent authority of the relevant state.

137. The Service shall issue the S2 form to an insured person who wishes to receive a planned health care service in another EU Member State, EEA state or Switzerland if the following conditions are met concurrently:

137.1. the health care service is part of the range of State paid health care services;

137.2. during examination of the application there is no medical treatment institution providing State paid health care services which could ensure the necessary health care service to the person, and a justified opinion of the medical treatment institution has been received thereon;

137.3. the person requires the service in order to prevent irreversible deterioration of vital functions or health condition, taking into account the health condition of the person at the moment of assessment and the predictable development of the disease.

138. The Service shall not issue the S2 form if health care services are provided within the scope of clinical trials or an experimental technology of medical treatment is used for them.

139. In order for the Service to assess the right of a person to receive the S2 form, the person shall submit the following documents to the Service:

139.1. an application for the receipt of S2 (E112) form. The following information shall be indicated in the application:

139.1.1. the given name, surname, date of birth, personal identity number of Latvia or the taxpayer registration number assigned by the State Revenue Service if the person is not registered in the Population Register, address, telephone number or electronic mail address;

139.1.2. the health care service necessary for the person according to an opinion of the doctors' council;

139.1.3. the state of receipt of the health care service and the service provider;

139.1.4. the time period of receipt of the health care service (period from/to);

139.1.5. the state of employment if the person is employed in another EU Member State, EEA state or Switzerland;

139.1.6. the state in which pension/benefit is received and the type of pension/benefit if the person is receiving pension/benefit in the field of social security in another EU Member State, EEA state or Switzerland;

139.1.7. information as to whether the person is insured in the social security system of another EU Member State, EEA state or Switzerland;

139.2. an opinion of the doctors' council of the relevant field of medical treatment of a medical treatment institution providing State paid health care services in which the necessary service is indicated, and also a justification whether such service is necessary for the person in order to prevent irreversible deterioration of vital functions or health condition, taking into account the health condition of the person at the moment of assessment and the predictable development of the disease, and medically justified reasons due to which the person needs to receive the relevant health care service in another state, and also information whether the relevant health care service is to be provided within the scope of clinical trials or an experimental technology of medical treatment will be used for it.

140. The Service has the right to request that the person submits a confirmation of the medical treatment institution that the health care service planned to be received at the relevant medical treatment institution will be ensured on the basis of the S2 form.

141. The Service has the right to request the following opinions from medical treatment institutions:

141.1. on whether the medical treatment institution can ensure the necessary health care service to the person and whether the health care service can be provided within a time period that is medically justified, taking into account the health condition of the person at the moment of assessment and the predictable development of the disease;

141.2. on the possibilities of providing the necessary health care service in Latvia by inviting a medical practitioner of another state in the relevant field of medical treatment, and the costs of providing such health care service in Latvia, comparing them to the costs arising if the person would be sent to another EU Member State, EEA state or Switzerland for the receipt of the necessary health care service, and also indicating whether the medical technology which must be used for the provision of the health care service has been approved in the state of the medical practitioner invited.

142. If the Service receives an opinion of a medical treatment institution that it is possible to provide the necessary health care service to the person in Latvia by inviting a medical practitioner of another state in the relevant field of medical treatment, the Service shall, upon assessment of the considerations of economic viability and other circumstances which might affect the health condition of the person, take the decision to issue the S2 form or to refuse to issue it, indicating that the person may receive the necessary health care service in Latvia, and enter into a contract with the relevant medical treatment institution, providing for the procedures by which the necessary health care service will be provided and payment for it shall be made.

143. Upon taking the decision to issue the S2 form, the Service has the right to specify the Member State and the health care service provider, taking into account the considerations of economic viability, if the Service has such information at its disposal. If the person refuses to receive services with the service provider selected by the Service, the Service has the right to take the decision to refuse to issue the S2 form.

144. The Service has the right to take a decision in the cases specified in Regulation No 883/2004 and Regulation No 987/2009 on behalf of the competent authority of another EU Member State, EEA state or Switzerland to issue the S2 form to a person who is subject to the social security system of another EU Member State, EEA state or Switzerland.

145. If the person has not exercised the right granted by the decision of the Service within one calendar year after the day of entering into effect of the decision to issue the S2 form, the decision to issue the S2 form shall cease to be in effect.

146. In order to receive the S3 form, the person shall submit the following documents to the Service:

146.1. an application for the receipt of the S3 form. The following information shall be indicated in the application:

146.1.1. the given name, surname, date of birth, personal identity number of Latvia or the taxpayer registration number assigned by the State Revenue Service if the person is not registered in the Population Register, address, telephone number or electronic mail address;

146.1.2. the previously commenced health care service;

146.1.3. the provider of the health care service;

146.2. an opinion of the doctors' council of the relevant sector of medical treatment on the health care service necessary for the person which must be completed. The health care service, medically justified reasons due to which the relevant health care service should be considered a continuation of a previously commenced health care service shall be indicated in the opinion.

147. The person is not entitled to receive and use the S form, the insurance card, or the certificate replacing the insurance card issued by the Service in order to receive health care services paid from the State budget resources in another EU Member State, EEA state or Switzerland if the person is considered insured:

147.1. within the scope of another social security system in accordance with Regulation No 883/2004;

147.2. within the scope of the social security system of any institution of the European Union or within the scope of the health insurance scheme in accordance with Regulation (EEC, Euratom, ECSC) No 259/68 of the Council of 29 February 1968 laying down the Staff Regulations of Officials and the Conditions of Employment of Other Servants of the European Communities, except for the case referred to in Article 15 of Regulation No 883/2004;

147.3. within the scope of the social security system of an international organisation;

147.4. within the scope of the social security system of students.

148. A person who has been issued any of the S forms, the insurance card or the certificate replacing the insurance card has an obligation, without delay but not later than within five working days, to inform the Service in writing if:

148.1. the person becomes an insured person within the scope of another social security system;

148.2. information submitted by the person to the Service within the scope of the administrative case changes.

149. The Service shall take the decision to cancel the S form, the insurance card or the certificate replacing the insurance card issued if it establishes that, upon application of Regulation No 883/2004 and Regulation No 987/2009, the person is not entitled to receive health care services paid from the State budget resources in another EU Member State, EEA state or Switzerland.

149.¹ The data referred to in this Sub-chapter which is necessary to specify the right of the person to receive health care in the EU, EEA, and Switzerland is processed in the international cooperation information system under management of the Service, and exchange of such data among the competent authorities of the EU Member States shall take place using the access point referred to in Article 4 of Regulation No 987/2009 laying down the procedure for implementing Regulation (EC) No 883/2004.

[10 December 2019]

4. Payment for the Health Care Services Included in the State Paid Medical Assistance Minimum and State Mandatory Health Insurance

4.1. General Provisions

150. It shall not be paid from the State budget resources intended for payment for health care services:

150.1. for services which are not health care services, including it shall not be paid for transport and residence expenses of the person or the person accompanying him or her which are related to movement in order to receive a health care service;

150.2. for health care services which have been received without the referral of such doctor who has the right to refer for the receipt of State paid health care services, except for emergency medical assistance provided by a medical treatment institution which is in contractual relations with the Service and other cases referred to in this Regulation;

150.3. for secondary health care services if the person has refused in writing from waiting for a planned health care service and he himself or she herself or a third person has made payments for the relevant health care service;

150.4. for medical treatment on an inpatient basis of such persons whose disease or trauma may be treated on an outpatient basis;

150.5. for similar examinations or examinations equivalent on an information basis in secondary health care which have been performed repeatedly within a month from the day when an examination with a referral of a general practitioner or specialist was performed, except for cases if the person is provided emergency medical assistance at a medical treatment institution which is in contractual relations with the Service or control of therapy results is ensured;

150.6. for ensuring of medical assistance at public events.

151.¹ The estimate of fixed payments and tariffs for bed days shall include a payment for work during night, on weekends, on holidays, and for overtime work.

[7 May 2019]

151. The Service shall pay, in accordance with the procedures laid down in this Regulation, to medical treatment institutions for the health care services included in the list of State paid health care services using the following types of payment:

151.1. a fixed payment;

151.2. an estimate payment;

151.3. actual costs according to invoices;

151.4. a payment of capitation;

151.5. a tariff for a care episode;

151.6. a tariff for a manipulation;

151.7. a tariff for a bed day;

151.8. a tariff for medical treatment of one patient.

152. Tariffs for health care services, including tariffs for the manipulations included in the list of manipulations, shall be calculated using the following formula:

TC = VC (D + S + M + E) + FC (U + A + N) where

TC - tariff for a health care service;

VC - variable costs (direct costs):

D - work remuneration;

S - mandatory State social insurance contributions;

M - means of medical treatment;

E - expenses related to the catering of patients;

FC - fixed costs (indirect costs):

U - indirect manufacturing costs to be added (expenses related to the maintenance of patients for payment for services, for making of risk payments, for purchase of materials, energy resources, water, and inventory);

A - administrative expenses;

N - depreciation.

153. The work remuneration (D) referred to in Paragraph 152 of this Regulation, and also other payments for a health care service shall be calculated taking into account that the average work remuneration per month is specified in the following amount:

153.1. for doctors and functional specialists - EUR 1 485.00;

153.2. for medical practitioners, patient care persons, and assistants of functional specialists - EUR 891.00;

153.3. for support persons of medical treatment and patient care - EUR 594.00.

[10 December 2019]

154. The amount of payment for health care services referred to in this Regulation shall be determined taking into account:

154.1. the amount of the tariff for a care episode referred to in Annex 4 to this Regulation;

154.2. the amount of capitation referred to in Annex 11 to this Regulation;

154.3. the amount of the fixed monthly payment (supplement) for consulting rooms of medical specialists and units referred to in Annex 10 to this Regulation;

154.4. the services of emergency medical assistance and the health care services provided at the reception ward of an inpatient medical treatment institution in accordance with Annexes 6 and 10 to this Regulation;

154.5. the conditions referred to in Annex 6 to this Regulation for observation of patients for up to 24 hours;

154.6. the medical treatment of patients at a hospital in conformity with the conditions referred to in Annex 6 to this Regulation;

154.7. the manipulations of health care services referred to in the list of manipulations and the payment conditions for such manipulations to be reviewed by the Service not more than once in a calendar quarter, coordinating changes with the Ministry of Health;

154.8. the planning territories of secondary outpatient health care services specified in Annex 12 to this Regulation.

155. Prior to introduction of a new health care service payment model, in order to check the operation of the planned payment model, the Service is entitled, after coordination with the Ministry of Health and the relevant health care service provider, to specify in the contract the financing procedures corresponding to the conditions of the planned payment model.

156. Upon receipt of health care services paid from the State budget, a person shall make the patient co-payment in the amount specified in Annex 13 to this Regulation in conformity with the conditions referred to in the list of manipulations in relation to the patient co-payment.

157. Upon providing inpatient health care services, a medical treatment institution may collect additional fee in the amount of not more than EUR 31.00 for surgical operations performed in the operating room per admission which have been indicated as major surgical operations in the list of manipulations. This additional fee shall not be collected from persons who are exempted from co-payments and from persons who present the statement referred to in Paragraph 162 of this Regulation.

[10 December 2019]

158. The additional fee of a patient for the surgical operations performed in the operating room per admission shall not be covered from the State budget resources, except for the case if the surgery has been performed for a poor person who has been recognised as such in accordance with the laws and regulations regarding the procedures by which a family or a person living separately shall be recognised as poor, or for an employee of the State Medical Emergency Service, or in case if a person has requested a statement from the Service certifying that the amount of co-payment for the outpatient and inpatient health care services received in the calendar year has reached the maximum amount.

[10 December 2019]

159. A person may pay the patient co-payment within 15 days after receipt of the health care service or at another time if a written agreement thereon has been reached with the medical treatment institution.

160. The total amount of the patient co-payment for each time of admission in one inpatient medical treatment institution may not exceed EUR 355.00.

161. The amount of the patient co-payment for the outpatient and inpatient health care services received in the calendar year may not exceed EUR 570.00.

162. A statement that the person has received health care services during the calendar year and made the patient co-payment (including that covered by the insurer or another person) in the amount of EUR 570.00 shall be issued by the Service according to the payment documents presented by the person.

163. The Service shall cover the patient co-payment for a medical treatment institution from the State budget resources:

163.1. for persons who are exempted from it;

163.2. for persons whose patient co-payment has reached the maximum amount in one case of admission;

163.3. for persons who have received a statement regarding the maximum amount of annual co-payment reached;

163.4. in case of death of a patient at a medical treatment institution or in case if the general practitioner establishes the fact of death of a person who has died in domestic environment;

163.5. the difference forming between the amount of co-payment specified in Sub-paragraph 5.1 of Annex 13 to this Regulation for medical treatment at a day and night hospital and the amount of co-payment specified in Sub-paragraph 5.3 of Annex 13 to this Regulation for persons with specific diagnoses;

163.6. the difference forming between the amount of co-payment specified in Sub-paragraph 5.1 of Annex 13 to this Regulation for medical treatment at a day and night hospital and the amount of co-payment specified in Sub-paragraph 5.4 of Annex 13 to this Regulation upon undergoing medical treatment in beds of rehabilitation profile.

[7 May 2019]

164. The infectious diseases in case of which a person is exempted from the patient co-payment are indicated in Annex 3 to this Regulation.

165. Persons who, in accordance with the conditions referred to in Annex 6 to this Regulation, receive inpatient health care services within the scope of the programme of inpatient health care services "Palliative Care" shall be exempted from the patient co-payment.

166. The Ministry of Defence, the Ministry of Justice, and the Ministry of the Interior shall cover the fee for the following health care services for the following persons:

166.1. the Ministry of Defence:

166.1.1. for soldiers of professional service and national guardsmen - the patient co-payment, including the patient co-payment for the reimbursable medicinal products and medical devices in accordance with the laws and regulations regarding the procedures for reimbursement of expenditures for the acquisition of medicinal products and medical devices intended for the outpatient medical treatment, and also the fee for health care services which such persons have the right to receive in accordance with the laws and regulations regarding the conditions for the receipt of health care and social rehabilitation services, the types of services to be paid, and the procedures for payment of expenses;

166.1.2. for retired soldiers and former national guardsmen - health care services in accordance with the laws and regulations regarding health care services to be paid, and also the amount of expenses and payment procedures;

166.1.3. for soldiers of the armed forces of member states to the North Atlantic Treaty Organisation and the states participating in the programme "Partnership for Peace" - for health care services in accordance with the Status of Forces Agreement of member states to the National Atlantic Treaty Organisation;

166.1.4. for candidates of professional service, reserve soldiers, and reservists which are conscripted in the active service, for citizens of Latvia who have voluntarily enlisted for the service into reserve, and for candidates for national guardsmen - expenses for the medical examinations performed within the scope of a medical examination with an appointment of the medical commission and for the opinions of doctors (including expenses for paid services of health care) in accordance with the laws and regulations regarding the conditions for the receipt of health care and social rehabilitation services, the types of services to be paid, and the procedures for payment of expenses;

166.1.5. for the participants of the movement "Youth Guard" - expenses for health care services in accordance with the Cabinet regulations determining health care services to be paid for youth guards, the conditions for the receipt thereof, and the payment procedures;

166.2. the Ministry of Justice shall cover the health care services provided by a medical practitioner working at a place of imprisonment, and also the patient co-payment for prisoners who are receiving health care outside the place of imprisonment and the patient co-payment for the reimbursable medicinal products and medical devices in accordance with the laws and regulations regarding the procedures for reimbursement of expenditures for the acquisition of medicinal products and medical devices intended for the outpatient medical treatment;

166.3. the Ministry of the Interior shall cover the fee for health care services and the patient co-payment in the following amount:

166.3.1. for foreigners who have been detained in accordance with the procedures laid down in the Immigration Law - for health care services which are necessary during and at the place of their accommodation and are guaranteed to such persons in accordance with the laws and regulations (except for emergency assistance, birth assistance, and the cases specified in the Epidemiological Safety Law, and also the medicinal products necessary for medical treatment of tuberculosis which are paid from the State budget resources intended for health care). If health care of such persons is insured, the health care expenses shall be covered by the insurer;

166.3.2. for outpatient health care services which are provided to persons placed in the temporary place of detention of the State Police (except for emergency medical assistance and the cases specified in the Epidemiological Safety Law if health care services are paid from the State budget resources intended for health care);

166.3.3. for the initial health examination performed for asylum seekers at a general practitioner which has been provided in the premises of an accommodation centre for asylum seekers and at a psychiatrist, for rapid tests for determination of HIV and Hepatitis B;

166.3.4. for asylum seekers who have been detained in accordance with the procedures laid down in the Asylum Law - for examinations of the health condition and sanitary treatment, and also for such health care services which are necessary during and at the place of their accommodation and have been specified in the laws and regulations governing the field of health care and the interior;

166.3.5. for officials with special service ranks of the institutions of the system of the Ministry of the Interior and the Prisons Administration of the Ministry of Justice, and also for officials retired from service who, in accordance with the laws and regulations, have been granted the right to receive paid health care, the fee for health care services and the patient co-payment shall be covered in accordance with the laws and regulations governing the field of the interior and the field of remuneration of the State administration.

167. The requester of a forensic medical expert-examination shall pay for consultations, clinical and paraclinical diagnostic examinations which are conducted for victims of unlawful offences upon assignment from a forensic medical expert.

168. The Service shall make payment for the health care services specified in this Regulation on the basis of the contracts referred to in Paragraph 5 of this Regulation and in conformity with the conditions referred to in Annex 14 to this Regulation.

4.2. Payment for Primary Health Care

169. The Service shall plan the resources for payment for primary health care services in accordance with Annex 11 to this Regulation.

170. The Service shall cover the following for a general practitioner for the provision of State paid health care services in accordance with the conditions referred to in Annex 11 to this Regulation:

170.1. the payment (including payment for carrying out of the functions of a receptionist) which is calculated taking into account the number of persons registered in the list of patients of the general practitioner (capitation);

170.2. expenses for the manipulations carried out at the practice of the general practitioner which have been indicated in the list of manipulations as the manipulations to be paid additionally to the general practitioner in accordance with the conditions of payment for such manipulations;

170.3. the fixed payments and supplements;

170.4. the average work remuneration of a nurse, a doctor's assistant (feldsher), and a midwife per month specified in this Regulation (Paragraph 153 of this Regulation);

170.5. the payment for substitution of another general practitioner if he or she is substituted for a time period exceeding two months - according to the estimate of monthly revenue of the practice to be substituted;

170.6. the compensation of the patient co-payment for persons who have been exempted from the patient co-payment.

[10 December 2019]

171. The Service, upon calculating the capitation, fixed payments, and supplements of the general practitioner as well as the work remuneration of a nurse and a doctor's assistant (feldsher), shall not take into account the information on such persons whose registration with the general practitioner has been blocked. The Service shall pay for the health care services provided to such persons as for temporary patient care.

172. The general practitioner shall be paid for the care for a temporary patient according to the tariffs for care episodes of a general practitioner and the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations. If the temporary patient is registered with the general practitioner, then the care episode shall be paid from the monetary funds of such general practitioner with whom the person is registered but in the amount of not more than 50 % from the payment of the monthly capitation of such general practitioner calculated in accordance with the procedures laid down in this Regulation.

173. The primary health care services provided to a person who has registered with a general practitioner but is receiving health care services with another general practitioner and does not meet the criteria of a temporary patient referred to in this Regulation shall be paid services.

174. The number of medical practitioners necessary for ensuring patient care at a practice of a general practitioner and the conditions for financing such persons shall be included in the contract entered into by the general practitioner with the Service. The general practitioner has an obligation to pay the payment made by the Service for the work of the medical practitioners employed at the practice of the general practitioner to such persons in full amount, making the tax payments specified in the laws and regulations.

175. In case of death of a general practitioner or in case if a court judgment or a decision precluding a general practitioner from providing primary health care services has entered into effect, the Service may, for a time period not exceeding one month, enter into a contract with the medical treatment institution in which the general practitioner had been working or with the medical practitioner employed at the practice of the general practitioner and, in accordance with the procedures laid down in Annex 11 to this Regulation, cover expenses related to the performance of the following activities:

175.1. arranging of the medical documentation at the practice, carrying out complete accounting thereof;

175.2. issuing of the information accumulated in the medical documentation regarding the patient upon request of the patient;

175.3. handing over of the medical documentation to the subsequent general practitioner chosen by the patient;

175.4. maintaining of the premises leased by the general practitioner;

175.5. handing over of the medical documentation to the general practitioner who enters into a contract with the Service regarding provision of health care services in the basic area of operation of the previous (deceased) general practitioner.

176. If a general practitioner terminates the contractual relations with the Service in relation to retirement of the general practitioner, the Service shall disburse a compensation payment calculated in accordance with the procedures laid down in Annex 11 to this Regulation to the practice of the general practitioner for the redundancy benefit disbursed to the medical practitioners employed at the practice, in conformity with the following conditions:

176.1. the general practitioner has attained the age when old-age pension is granted in accordance with the laws and regulations;

176.2. a general practitioner who is in the waiting list of general practitioners or a general practitioner who is taking over the practice of the general practitioner in another case in accordance with the procedures laid down in this Regulation has agreed to enter into a contract regarding the provision of health care services in the basic area of operation of the general practitioner.

[7 May 2019]

177. The general practitioner has the right to receive a payment of the performance evaluation of a general practitioner which is calculated on the basis of the evaluation of performance indicators of the general practitioner in accordance with Annex 15 to this Regulation.

178. The newly opened practices of general practitioners are disbursed a monthly fixed payment until the moment when the number of persons registered in the list of patients of the general practitioner reaches 600 but not longer than for nine months after entering into the contract with the Service, and such payment consists of:

178.1. the average work remuneration specified in this Regulation for a doctor per month (Paragraph 153 of this Regulation) and State social insurance contributions;

178.2. the average work remuneration specified in this Regulation for medical practitioners and patient care persons per month (Paragraph 153 of this Regulation) and State social insurance contributions;

178.3. the monthly fixed payment indicated in Paragraph 7 of Annex 11 to this Regulation to the practice of the general practitioner;

178.4. the fee for the manipulations performed at the practice of the general practitioner according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations;

178.5. the compensation of the patient co-payment for persons who have been exempted from the patient co-payment.

[10 December 2019]

179. The Service shall evaluate the number of persons registered in the list of patients of the newly opened practice of general practitioners once a month.

180. A doctor on duty who is providing services outside the working hours of general practitioners shall be paid for work according to the monthly fixed payment indicated in Annex 11 to this Regulation.

181. Medical treatment institutions which are providing State paid dental services shall be paid for work according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations.

182. The Service shall pay to medical practitioners who are carrying out health care at home in accordance with Sub-chapter 3.4 of this Regulation according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations.

183. The Service shall pay to doctor's assistants (feldshers) who are employed at the feldsher station owned by the local government with which the Service has entered into a contract, in accordance with Annex 11 to this Regulation.

4.3. Payment for Secondary Outpatient Health Care

184. The Service shall perform payment for the secondary outpatient health care services provided by specialists, except for the health care services provided at a day hospital:

184.1. according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations and the tariffs for care episodes indicated in Annex 4 to this Regulation;

184.2. by performing a fixed monthly payment the calculation of which shall include:

184.2.1. the average work remuneration of doctors and nurses specified in this Regulation per month (Paragraph 153 of this Regulation);

184.2.2. the mandatory social insurance contributions of the employer;

184.2.3. the resources necessary for ensuring the operation in accordance with the conditions indicated in Annex 10 to this Regulation;

184.3. by covering expenses for individual secondary outpatient health care services which are referred to in Annex 7 to this Regulation - on the basis of the invoices of the medical treatment institution.

185. The fixed monthly payment shall be performed for the following specialists or units of medical treatment institutions:

185.1. for a pneumonologist who is providing health care services to persons suffering from tuberculosis (in accordance with the ICD-10, diagnosis codes A15-A19, B90, J65, P37.0, R76.1, Y58.0, Y60.3, Z03.0, Z20.1);

185.2. for the consulting room of diabetic foot care;

185.3. for the palliative care consulting room;

185.4. for the consulting room of chronic obstructive pulmonary diseases which is providing health care services to persons suffering from asthma or another chronic obstructive pulmonary diseases (in accordance with the ICD-10, diagnosis codes J44-J45);

185.5. for the stoma consulting room;

185.6. for the consulting room of a psychologist/psychotherapist;

185.7. for the consulting room of methadone maintenance treatment;

185.8. for the consulting room of rare diseases at the State limited liability company Children's Clinical University Hospital which provides health care services:

185.8.1. to patients with metabolic disorders (in accordance with the ICD-10, diagnosis codes E70-E90) or rare diseases (ORPHA codes);

185.8.2. to patients with congenital anomalies;

185.8.3. to pregnant women for whom a congenital developmental anomaly of the foetus has been detected;

185.8.4. to children who are registered with the palliative care consulting room of the State limited liability company Children's Clinical University Hospital and who require a consultation of a dietician;

185.9. for the training room of diabetes mellitus patients upon providing health care services to persons with diabetes mellitus (in accordance with the ICD-10, diagnosis codes E10-E14, O24);

185.10. for the HIV compliance room;

185.11. for the consulting room of a psychiatrist;

185.12. for the consulting room of functional specialists upon providing psychiatric assistance;

185.13. for the consulting room of a nurse upon providing psychiatric assistance;

185.14. for the consulting room of a paediatrician upon providing health care services to children in case of acute diseases at inpatient medical treatment institutions of Level III, IV, and V;

185.15. for the consulting room of an arrhythmologist.

[7 May 2019; 10 December 2019]

186. The Service shall additionally pay to a medical treatment institution which receives the fixed monthly payment for the work of the palliative care consulting room and the consulting room of rare diseases for ensuring of the food intended for special medical purposes:

186.1. to children who are registered with the palliative care consulting room, including after attaining 18 years of age if it is necessary to ensure successive medical treatment until such necessity ceases to exist according to medical indications;

186.2. to patients of cystic fibrosis and children in case of severe protein intolerance or explicit malabsorption syndrome according to the payment conditions for the service specified in the contract with the Service.

187. The Service shall perform the monthly fixed payment for the operation of the training room of diabetes mellitus patients to university hospitals, regional multi-functional hospitals, and medical treatment institutions which ensure the largest amount of endocrinology services to inhabitants in planning units and in which the service may be ensured by a diabetes nurse.

[7 May 2019]

4.4. Payment for the Health Care Services Provided at a Day Hospital

188. The Service shall perform payment for the secondary outpatient health care services provided at a day hospital according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations.

189. The Service shall not pay for medical treatment at a day hospital if any of the surgical operations which, according to the payment conditions indicated in the list of manipulations has been referred to as the major surgical operation, has been performed during such medical treatment, except for the surgical operations referred to in Annex 5 to this Regulation.

4.5. Payment for the Health Care Services Provided at an Emergency Room and the Reception Ward

190. The Service shall pay for the services provided at an emergency room:

190.1. by performing the fixed monthly payment the calculation of which shall include:

190.1.1. the average work remuneration of doctors and doctor's assistants (feldshers)/nurses specified in this Regulation (Paragraph 153 of this Regulation);

190.1.2. the mandatory social insurance contributions of the employer;

190.1.3. the resources necessary for ensuring the operation in accordance with the conditions indicated in Annex 10 to this Regulation;

190.2. according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations - for the diagnostic examinations performed for the person.

191. The Service shall pay for the outpatient health care services provided at the reception ward of an inpatient medical treatment institution:

191.1. by performing the fixed monthly supplement for the operation of the reception ward;

191.2. according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations and the tariffs for care episodes indicated in Annex 4 to this Regulation if the medical treatment institution does not receive the fixed monthly supplement for the operation of the reception ward;

191.3. by covering expenses for the performed diagnostic examinations according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations.

192. The fixed monthly supplement for the operation of the reception ward of a hospital shall include expenses for ensuring the being on 24-hour duty of the specialists referred to in Paragraph 1 of Annex 6 to this Regulation. The medical treatment institutions which receive the fixed monthly supplement for the operation of the reception ward have an obligation to ensure that the necessary specialists are on a 24-hour duty. If the medical treatment institution fails to ensure that specialists are on a 24-hour duty in accordance with the procedures laid down in this Regulation, the Service may reduce the fixed monthly supplement for the operation of the reception ward of a hospital as well as agree with the medical treatment institution which has been granted the first level regarding another time for ensuring a surgeon being on duty.

193. If a person has turned to the reception ward of an inpatient medical treatment institution and the person does have a trauma, acute disease, or exacerbation of a chronic disease when urgent intervention of medical practitioners is required or the necessary assistance does not exceed the competence of the primary health care practitioner, the person shall pay for the outpatient health care services received according to the price list of paid services of the medical treatment institution.

4.6. Financing of Outpatient Laboratory Services

194. The Service shall, in accordance with the procedures laid down in Annex 16 to this Regulation, plan the amount of resources intended for a general practitioner and a specialist of secondary outpatient health care within the scope of which the general practitioner and the specialist of secondary outpatient health care shall appoint a person for the receipt of outpatient laboratory services, and also the amount of payment for the providers of outpatient laboratory services.

195. The general practitioner and the specialist of secondary outpatient health care have an obligation, upon referring a person for the receipt of outpatient laboratory services, to supervise the utilisation of the amount of resources intended for payment for outpatient laboratory services.

196. A doctor of a medical treatment institution of a place of imprisonment, a long-term social care and social rehabilitation institution, or a medical treatment institution of the National Armed Forces shall, upon referring a person for the receipt of outpatient laboratory services, conform to the amount of financial resources stipulated by the Service regarding which the relevant medical treatment institution is informed according to the procedures specified in the memorandum of understanding.

197. The Service shall, each month, post information on the website regarding the utilisation of the financial resources intended for payment for laboratory services in the previous month, indicating how they have been utilised:

197.1. by general practitioners with whom patients are registered;

197.2. by medical treatment institutions with which the Service has entered into a contract regarding payment for secondary outpatient health care services;

197.3. at medical treatment institutions of a place of imprisonment;

197.4. by the bodies of a long-term social care and social rehabilitation institution;

197.5. by medical treatment institutions of the National Armed Forces.

198. If a general practitioner or a medical treatment institution providing outpatient health care services has turned to the Service in the first half of the relevant year regarding increase in the amount of the resources intended for payment for outpatient laboratory services, the Service shall increase the amount of the resources to such general practitioner or medical treatment institution intended for payment for outpatient laboratory services calculated for the second half of the relevant year if resources are available to the Service and if:

198.1. the number of persons registered with the general practitioner in the first half of the relevant year has increased by more than 25 %;

198.2. the general practitioner receives, in the first half of the relevant year, the supplement specified in this Regulation for care for chronic patients in such amount which exceeds the supplement for care for chronic patients calculated on average per general practitioner by more than 25 %;

198.3. the total number of episodes in the medical treatment institution in which a specialist of secondary outpatient health care is employed has increased, in the first half of the relevant year, by more than 25 % from the planned number of episodes.

199. The Service shall perform payment for the outpatient laboratory services according to the tariffs for manipulations indicated in the list of manipulations and the payment conditions for manipulations.

200. If the provider of outpatient laboratory services has performed examinations to an extent the amount of resources intended for payment for which is more than EUR 7114.36 (excluding from the calculation the payment for performance of histological examinations), then, upon performing payment for outpatient laboratory services to such service provider, the Service shall apply the coefficient 0.9 to all the amount of services provided in the relevant month.

4.7. Financing of Inpatient Health Care

201. The following shall be included in the payment performed by the Service for inpatient health care services:

201.1. the payment for the services included in the programmes of inpatient health care services for which the tariff of medical treatment of one patient (hereinafter - the marked services) has been specified in accordance with Paragraph 2 of Annex 6 to this Regulation - according to the relevant tariff of medical treatment of one patient;

201.2. the fixed monthly payment for the services included in the programmes of inpatient health care services which are included in the calculation of the Diagnosis Related Groups (hereinafter - the DRG services);

201.3. the fixed monthly supplement for the operation of the reception ward to inpatient medical treatment institutions providing emergency medical assistance 24 hours a day;

201.4. the fixed monthly supplement for the observation of patients up to 24 hours;

201.5. the fixed monthly payment for the DRG services and the marked services to the State limited liability company Children's Clinical University Hospital according to the conditions specified in the contract with the Service;

201.6. the payment according to the number of actual bed days and the tariff for a bed day to care for a patient who requires long-term mechanical ventilation of lungs;

201.7. the payment according to the estimate financing determined in the contract with the medical treatment institution, forecasting the number of patients who will receive the necessary medical treatment within the scope of the estimate in the following cases:

201.7.1. for involuntary psychiatric medical treatment at an inpatient medical treatment institution with security guard;

201.7.2. for long-term psychiatric medical treatment of children or adults at an inpatient medical treatment institution, including according to a court decision;

201.8. the payment according to the number of actual bed days, the tariff for a bed day of the relevant medical treatment institution, and tariffs for the performed manipulations for manipulations which have been marked with an asterisk (*) in the list in the following cases:

201.8.1. for health care services provided to the persons insured within the scope of the social security system of the EU Member States, EEA states, and Switzerland with the insurance card or the certificate replacing the insurance card in accordance with the requirements laid down in the international agreements governing the field of health care;

201.8.2. the payment for health care services provided to a person with a predicable disability according to the individual rehabilitation plan approved by the State Medical Commission for the Assessment of Health Condition and Working Ability;

201.8.3. for the health care services provided to persons who have been ill for a protracted period of time and who are of the working age according to the conditions specified in the contract with the Service;

201.9. the payment according to the tariffs for manipulations for the manipulations which are marked in the list with two asterisks (**);

201.10. the payment for individual inpatient health care services referred to in Annex 7 to this Regulation - on the basis of invoices of the medical treatment institution;

201.11. the payment for the subacute rehabilitation, long-term rehabilitation/dynamic observation, and rehabilitation of the conditions which had occurred during perinatal period according to the number of actual bed days, the tariff for bed days specified for the relevant programme, and the tariffs for the performed manipulations for the manipulations which have been indicated in the contract with the medical treatment institution in the payment conditions as the manipulations binding for the programme.

[7 May 2019]

202. Upon calculating the number of bed days spent in a hospital (the duration of medical treatment), the day of entering and the day of discharging a person shall be considered one day.

203. The Service shall not pay for the secondary outpatient health care services received at an inpatient medical treatment institution during admission of a person, except for the organised screening examinations and microbiological examinations for determination of tuberculosis, if the sample was taken prior to the placement of the person in the inpatient medical treatment institution.

204. The Service shall not pay for medical treatment of a person on an inpatient basis if the person has stayed at the inpatient medical treatment institution for one day, except for the case if death of the person has set in during the period of medical treatment, the person has received birth assistance, the person has been transported to another medical treatment institution or services have been provided to a person who has been brought for medical treatment from a place of imprisonment. If the person leaves the inpatient medical treatment institution on the first day disregarding instructions of a medical practitioner, the medical treatment institution is entitled to request payment from the person for the inpatient health care services provided on the first day.

4.8. Procedures for the Reimbursement of Expenses for the Health Care Services Received in Another EU Member State, EEA State, and Switzerland and International Settlement of Accounts

205. The Service shall reimburse the expenses to an insured person covered from personal funds for the health care services received in another EU Member State, EEA state, or Switzerland:

205.1. on the basis of the provisions of Regulation No 883/2004 and Regulation No 987/2009, and also in accordance with the conditions of such state regarding costs of health care services in which health care services were provided to the person according to the information provided by the competent authority of the EU Member State, EEA state, or Switzerland regarding the amount to be reimbursed to the person if:

205.1.1. during temporary stay the person has received emergency medical assistance or the necessary medical assistance and the relevant health care services are part of the range of State paid health care services in the state in which they were received;

205.1.2. the Service has taken a decision to issue the S2 form to the person but the person has paid for the received health care service from personal funds;

205.2. according to the tariffs of health care services in the Republic of Latvia specified at the moment of receipt of the health care service or according to the amount of compensation specified in the laws and regulations regarding the procedures for reimbursement of expenditures for the acquisition of medicinal products and medical devices intended for the outpatient medical treatment at the moment when the medicinal products and medical devices were acquired if:

205.2.1. the person has received a planned health care service, except for the case referred to in Sub-paragraph 205.1.2 of this Regulation, and such health care service is paid in the Republic of Latvia from the State budget resources in accordance with the procedures laid down in this Regulation;

205.2.2. the person has received emergency or necessary health care and it was ensured by a health care service provider which does not participate in the social security system of such state, and such health care service is paid in the Republic of Latvia from the State budget resources;

205.2.3. the person has not received a planned health care service for the provision of which the Service has issued the S2 form in the state or with the health care service provider indicated in the S2 form issued by the Service.

206. In order to receive reimbursement of expenses for health care services received in another EU Member State, EEA state, or Switzerland, the person shall, within a year from the day when he or she has stopped receiving health care services, submit the following documents to the Service:

206.1. an application for the reimbursement of expenses. The following information shall be indicated in the application:

206.1.1. the given name, surname, date of birth, personal identity number of Latvia or the taxpayer registration number assigned by the State Revenue Service if the person is not registered in the Population Register, telephone number or electronic mail address;

206.1.2. the state in which health care services have been received;

206.1.3. [7 May 2019];

206.1.4. a description regarding the reason for receipt of the health care service in another EU Member State, EEA state or Switzerland;

206.1.5. the details of the settlement account of the person;

206.2. a document certifying the payment in which information identifying the recipient of the service is indicated;

206.3. a document of the provider of the health care service in which the following information is indicated:

206.3.1. the health care services provided to the person;

206.3.2. the period of provision of the health care services;

206.3.3. the price of the health care services provided to the person for each service individually;

206.3.4. a certification regarding payment for the health care services provided;

206.3.5. the diagnosis on the basis of which the health care service was provided to the person;

206.4. [7 May 2019];

206.5. if the person is requesting to perform reimbursement of expenses in accordance with Sub-paragraph 205.2.1 of this Regulation - a prescription or a referral issued by a general practitioner or specialist for the receipt of the relevant health care service or information regarding the number, date of issuance of the prescription or referral, the medical treatment institution, and the medical practitioner who issued the prescription or referral, if the person does not have the prescription or referral at his or her disposal anymore, except for the case if, in accordance with the procedures laid down in this Regulation, a referral is not necessary for the receipt of the relevant health care service, and also other documents certifying that the requirements for the receipt of health care services laid down in the laws and regulations governing the field of health care have been met;

206.6. information as to whether the person was not considered insured within the scope of another social security system at the time of receipt of the health care service.

[7 May 2019]

207. Upon performing reimbursement of expenses for the health care services received in another EU Member State, EEA state, or Switzerland, the amount of reimbursement of expenses in euro is specified on the basis of the currency rate published by the European Central Bank which was specified in accordance with Regulation No 987/2009 on the day when the Service received an application of the person for reimbursement of expenses.

208. The Service shall perform mutual settlement of accounts with EU Member States, EEA states, and Switzerland for the persons insured within the scope of the social security system of such states in conformity with the following conditions:

208.1. for the outpatient health care services provided by State administration institutions and medical treatment institutions - according to the tariffs for health care services indicated in the list of manipulations and the tariffs for care episodes indicated in Annex 4 to this Regulation;

208.2. for a call of a team of emergency medical assistance - according to the price of the call in accordance with the price list of paid services of the State Emergency Medical Service;

208.3. for inpatient health care services - according to the number of actual bed days, the tariff for a bed day of the relevant medical treatment institution specified in Annex 6 to this Regulation, and tariffs for the performed manipulations marked in the list of manipulations with an asterisk (*), and also in case if payment to the medical treatment institution for the service provided has been performed in accordance with Annex 7 to this Regulation - according to the amount of the invoice paid.

5. Closing Provisions

209. The following are repealed:

209.1. Cabinet Regulation No. 113 of 27 February 2018, Procedures for the Provision of Health Care Services at a Day Hospital (Latvijas Vēstnesis, 2018, Nos. 42, 66);

209.2. Cabinet Regulation No. 311 of 29 May 2018, Regulations Regarding Health Care Services in the Field of Rare Diseases (Latvijas Vēstnesis, 2018, No. 107);

209.3. Cabinet Regulation No. 450 of 24 July 2018, Procedures for the Provision of Health Care Services to Patients with Chronic Diseases at an Inpatient Medical Treatment Institution (Latvijas Vēstnesis, 2018, No. 150);

209.4. Cabinet Regulation No. 452 of 24 July 2018, Procedures for the Provision of Health Care Services for the Prevention of Cardiovascular Diseases (Latvijas Vēstnesis, 2018, No. 150).

210. Sub-paragraph 6.3 of this Regulation shall come into force on 1 July 2019.

211. The requirement referred to in Sub-paragraph 185.10 of this Regulation in relation to the HIV compliance room and Sub-paragraph 3.15 of Annex 10 shall come into force on 1 April 2019.

212. The institutions referred to in Paragraph 126 of this Regulation shall hand over the data necessary to the Service in online mode starting with 1 January 2020.

213. The Service shall perform reimbursement of expenses for the health care services referred to in Sub-paragraph 205.2.1 of this Regulation if the health care services were received after 25 October 2013.

214. The Service shall pay the fixed supplement for the operation of the reception ward to the medical treatment institutions referred to in Sub-paragraphs 1.7.9, 1.5, 1.7.5, 1.7.6, and 1.7.7 of Annex 6 to this Regulation from 1 April 2019 if the medical treatment institutions ensure that the relevant specialists are on 24-hour duty in the reception wards.

[7 May 2019]

215. The Service shall apply the procedures laid down in Annex 14 to this Regulation for the determination of the amount of finances for the provision of inpatient health care services from 1 January 2019.

216. The Service shall, by way of subrogation, recover the expenses for inpatient health care services, which have been paid from the State budget resources and, until 31 December 2013, provided to a person upon whose health harm has been inflicted as a result of illegal act, failure to act or criminal offence, in accordance with the tariff for bed days, the tariffs for the performed manipulations, and the number of actual bed days specified in the laws and regulations regarding the procedures for the organisation and financing of health care in force at the time of receipt of the health care service.

217. The functions of a general practitioner referred to in this Regulation shall also be carried out by primary health care paediatricians and primary health care internists with whom the Service has a contract entered into as on the day of coming into force of this Regulation regarding the provision of and payment for primary health care services.

218. If the Service has entered into a contract with the local government regarding the operation of a feldsher station but the relevant area does not conform to the condition referred to in Paragraph 19 of this Regulation anymore, the Service may continue the contractual relations with the local government for not more than three years from the day when a non-conformity with any of the abovementioned conditions has been detected.

219. Medical treatment institutions which until 31 August 2018 have been specified the right, in the contract with the Service, to provide State paid health care services at emergency rooms shall provide such services according to the conditions indicated in the contract until 31 March 2019. From 1 April 2019 such medical treatment institutions shall provide State paid services at emergency rooms or in the reception wards in accordance with the procedures laid down in Paragraph 92 of, Annex 6 and Annex 10 to this Regulation.

220. The Service shall include the profiles indicated in Paragraph 1 and the programmes of inpatient services indicated in Paragraph 2 of Annex 6 to this Regulation in contracts with medical treatment institutions in conformity with the following conditions:

220.1. sabiedrība ar ierobežotu atbildību "Jēkabpils slimnīca" [limited liability company Jēkabpils Hospital] shall commence the provision of inpatient health care services in the profile "Stroke Unit" and in the programme of inpatient services "Neurology (Stroke Unit)" indicated in Sub-paragraph 2.7.1 of Annex 6 to this Regulation from 1 April 2019;

220.2. sabiedrība ar ierobežotu atbildību "Siguldas slimnīca" [limited liability company Sigulda Hospital] shall commence the provision of inpatient health care services in the profile of therapy, surgery, gynaecology, paediatrics, and traumatology from 1 April 2019;

220.3. the State limited liability company Pauls Stradiņš Clinical University Hospital shall commence the provision of inpatient health care services in the programme of inpatient services "Palliative Care" indicated in Sub-paragraph 2.17.2 of Annex 6 to this Regulation from 1 April 2019;

220.4. the first level inpatient medical treatment institutions shall commence the provision of inpatient health care services in the programme of inpatient services "Other Therapeutic Services" indicated in Sub-paragraph 2.21 of Annex 6 to this Regulation from 1 April 2019.

221. The Service is entitled, until 31 December 2018 on the basis of an application of a medical treatment institution, to make changes in the amount of financing specified in the contract which is intended for payment for the surgical operations performed at a day hospital and for the services that are part of the programme of inpatient services "Planned Temporary Surgery", without taking into account the restrictions referred to in Annex 14 to this Regulation for the amount of the financial resources to be diverted.

222. Medical treatment institutions shall ensure the use of parenteral medicinal products purchased in accordance with the procedures laid down in this Regulation for medical treatment of oncological diseases and the Service shall pay for them from 1 January 2019.

223. The E106, E109, E120, and E121 forms, the insurance cards issued for the use in the EU Member States and by 15 August 2010 shall be valid until expiry of the term of validity of such document, except for the cases when the relevant document has been cancelled.

224. Contracts regarding the provision of State paid health care services which have been entered into by and between the health care service provider and the Service prior to coming into force of this Regulation shall be in effect until expiry of the time period specified in the contract.

225. The Regulation shall be applied from 1 September 2018.

226. The condition referred to in Sub-paragraph 4.1.3 of this Regulation regarding payment for dental assistance from the State budget resources for asylum seekers who have attained 18 years of age and are more than 18 years old shall be in force until 31 December 2018.

227. [7 May 2019]

228. The Service shall, in accordance with the conditions referred to in Sub-chapter 4.8 of this Regulation, reimburse expenses for health care services which have been received in the United Kingdom of Great Britain and Northern Ireland or their receipt has been commenced until the day when the United Kingdom of Great Britain and Northern Ireland has withdrawn from the European Union in accordance with Article 50 of the Treaty on the European Union.

[26 March 2019]

229. The medicinal products referred to in Sub-paragraph 4.4 of Annex 7 to this Regulation for medical treatment of children with oncological and oncohaematological diseases in case of invasive mycoses after chemotherapy shall be paid as for medical treatment performed on an inpatient basis also if medical treatment was performed in the time period from 1 September 2018 to 1 April 2019.

[7 May 2019]

230. The payment indicated in Paragraph 8.¹ of Annex 11 to this Regulation shall be EUR 142.29 until 30 June 2019.

[7 May 2019]

231. The Service shall disburse the payment referred to in Paragraph 16 of Annex 11 to this Regulation in the amount of EUR 75.00 to general practitioners for cancer discovered in a timely manner in 2018 until 1 September 2019.

[7 May 2019]

232. The rights specified in Paragraph 13 of this Regulation for the doctors working at long-term social care and social rehabilitation institutions which provide long-term social care and social rehabilitation services financed by the local government shall be applied from 1 January 2020.

[7 May 2019]

233. In 2019 and 2020 the Service shall, in addition to the payment referred to in Sub-paragraph 201.2 of this Regulation, pay a compensation payment for introduction of the programmes of DRG services, determining it in the amount of the previous year and additionally taking into account the financing necessary for ensuring the planned increase in remuneration for such medical treatment institutions the total contractual amount of which is less than the contractual amount of the previous year.

[10 December 2019]

234. The compensation payment referred to in Paragraph 232 of this Regulation for the introduction of the programmes of DRG services for medical treatment institutions of Level V is made in addition to the payment referred to in Sub-paragraph 201.2 of this Regulation by 31 March 2019, but starting from 1 April 2019 the compensation payment is covered by applying the base coefficient in the calculation of the payment of DRG services in accordance with Sub-paragraph 3.3.1 of Annex 14 to this Regulation.

[7 May 2019]

235. The tariffs for medical treatment of one patient specified in Sub-paragraph 2.4 of Annex 6 to this Regulation shall be as follows until 30 June 2019:

235.1. for the programme "Birth in Case of Birth Pathology" - EUR 667.11;

235.2. for the programme "Physiological Birth" - EUR 476.29;

235.3. for the programme "Caesarean Section" - EUR 866.53.

[7 May 2019]

236. The requirement referred to in Sub-paragraph 1.1.1.4 of Annex 1 to this Regulation for enzymatic determination of biotinidase activity in a newborn, for the determination of 17-OF-progesterone with the fluorescence enzyme immunoassay (FEIA) in a newborn, for the quantitative fluorometric determination of the total galactose in a newborn, for the determination of immunoreactive trypsinogen (IRT) with the fluorescence enzyme immunoassay (FEIA) shall come into force on 1 July 2019.

[7 May 2019]

237. Sub-paragraph 8.7 and Paragraph 9.¹ of this Regulation shall come into force on 1 January 2022.

[10 December 2019; the abovementioned Paragraphs shall be included in the wording of the Law as of 1 January 2022]

238. The coefficients to be included in the calculation of work remuneration referred to in Note 2 of Annex 10 to this Regulation shall be applied from 2020 to the average work remuneration which was in force until 31 December 2019 (for doctors and functional specialists - EUR 1 350.00, for medical practitioners, patient care persons, and assistants of functional specialists - EUR 810.00).

[10 December 2019]

239. The Service shall apply the evaluation of the execution of the quality indicators specified in Sub-paragraph 3.1.1 of Annex 14 to this Regulation from 1 January 2021. Until 1 January 2021 the Service shall determine the number of patients planned in programmes of DRG services for a medical treatment institution according to the number of patients actually treated but not more than 10 % from the number of patients planned for the medical treatment institution in the contract in the previous year.

[10 December 2019]

Informative Reference to European Union Directives

This Regulation contains legal norms arising from:

1) Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients' rights in cross-border healthcare;

2) Commission Implementing Directive 2012/52/EU of 20 December 2012 laying down measures to facilitate the recognition of medical prescriptions issued in another Member State;

3) Directive 2011/92/EU of the European Parliament and of the Council of 13 December 2011 on combating the sexual abuse and sexual exploitation of children and child pornography, and replacing Council Framework Decision 2004/68/JHA.

Prime Minister Māris Kučinskis

Minister for Health Anda Čakša

Translation © 2020 Valsts valodas centrs (State Language Centre)