Health Insurance and Europe

Hungary’s example

Peter Ötvös, National Health Insurance Fund, Hungary

Brief Outline

• Overview of the European Legislation

• Co-ordination of Social Security as a Tool for the Free Movement of Persons

• Freedom to Provide Health Care Services – Questions related to Financing

• Planned Directive on Cross-Border Health Care

• Cross-Border Co-operations

Rules Related to Health Insurance

• Council of Europe (Strasbourg): • European Social Code – basic principles• European Social Charter – basic standards• Model-agreement for co-ordination

• EC-Treaty:• Free movement of persons• Free movement of services

• Co-ordination-regulations: • 1408/71, from 2010: 883/04

• Planned directive on health services

Co-ordination of Social Security in the

EU

Co-ordination = Harmonisation

Means:

•EC-Treaty (Art. 42)

• Regulation (EC) 1408/71 and 883/04

• Jurisprudence of the European Court of Justice

• Decisions of the Administrative Commission

Mandatory

application !

Principles of Co-ordination

• Single State of insurance• Equal treatment (no discrimination, equal rights

and access to services)• Aggregation of periods of insurance

(consideration of insurance periods in other Member States)

• Export of benefits (payment to other Member States)

AIMEnsuring that persons are not disadvantaged

in terms of social security when they move from one Member State to the other

Applicable legislation – a single State

the State where the person is employed

a single State is responsible for insurance

Legislation of

Special rules - posting

Currently 12+12 months, from 2010: 24 months

Hungarian company

Company in another

Member State

Sending State

State of employment

Sickness and maternity

EQUAL TREATMENT

• Care which becomes medically necessary during the temporary stay (as of 1/06/2004)

Also: dialysis, oxygen therapy, chemotherapy

• Right to all services (residence in other Member State)

• Authorised treatment in another Member State

Temporary Stay

Competent institution

Insured person Health care provider

Institution of the place of stay

Authorisation for treatment in other

Member State

This procedure applies for

Tourists

Posted workers, workers in international transport, posted civil servants

Students

Unemployed seeking employment in the other Member State („unemployment tourists”)

their family members

Use of the EHIC

• the entitled person can directly consult a service provider with the EHIC or the replacement form (no former administration)

• most of the Hungarian service providers are contracted with the NHIF

• practically no co-payment exists

In case of lack of entitlement certificate

• the service provider can issue a bill – the exact costs of the medical treatments in these cases are fixed in a protocol, which might be different for each providerConditions:- no discrimination, same price for the same service,- the price has been made public

• at home: reimbursement the treatment costs at the tariff used in the country where the care has been provided

Planned medical care and rehabilitation

• authorization of the competent authority at home

• pre-check by the service provider is necessary

• without form the doctors are not obliged to provide the treatments or no reimbursement is due

• Spa is only available upon referral• Dental treatment to a very limited

extent!

Entitlement of residents

• insured persons with residence outside the competent state, e.g. diplomats, frontier workers and the members of their families

• pensioners and the members of their families

• entitled to all benefits in kind

=

Use of the entitlement forms

• the forms are issued by the competent authority

• and answered by the health insurance institution

• the forms are not directly applicable at the service provider

• An insurance number/certificate will be issued for the entitled personCompetent institution Institution of the place

of residence

examination; registration

Example: Health Care for Residents in

Hungary

entitled person

Hungarian health care

provider

NHIF

Pharmacy

TAJ

From May 2010 (?) New Regulations

What changes?

• Modernized and Simplified Regulations‘simplification’ would not necessarily make the

procedures easier• Expected for 1st May 2010 – with a

transitional period of 2 yearsAlways the more favorable provisions apply

• Dynamic Process – Electronic Exchange of Information: SED

• Making Citizens’ Rights More Effective – Efficient Service and Information

EESSI Network – Exchange of ‘SEDs’

Source: European Commission

MemberState 1

MemberState 2

CI

CI

MemberState 4

CI

CI

CI

CI

CI CICI CICI

CI

CI

Member State 3

CI

CI

CI

MemberState “n”

CI

CI

CI

CoordinationNode CI Competent

InstitutionAccessPoint

NationalNetwork

NationalNetwork

NationalNetwork

NationalNetwork

sTESTA

EESSIInternational Network

NationalNetwork

NationalNetwork

EESSI information flows

Member State A

Institution

InstitutionInstitution

Member State B

Institution

Institution

Access Point

Access Point

Institution

Institution

Access Point

NationalDirectory

NationalDirectory

Member State A

Institution

Institution

Institution

Institution

Access Point

NationalDirectory

NationalDirectory

Access Point

CentralMessage Relay

MasterDirectory Service

Messages Flow

Directory information flow

Legend

Freedom to Provide Services

• Legal Basis: EC-Treaty• Interpreted by judgments of the European

Court of Justice• Health Care = Service (with some

limitations)Consequence: all obstacles shall be eliminated• Difference to the co-ordination: no equal

treatment but the services shall be regarded as if they were provided in the home country

• Reimbursement at domestic tariffs

Most important ECJ-Judgments

• 1998: Mr. Kohll and Mr. Decker (LU): Health care provided in another Member State is to

be reimbursed according domestic tariffs• 2001: Ms. Geraets-Smits and Mr. Peerbooms

(NL): Prior authorization may restrict the freedom of services only if necessary and proportionate

• Ms. Vanbraekel (BE): The highest possible amount shall be reimbursed

• 2003: Ms. Müller-Fauré (NL): No authorization for out-patient treatment

• 2006: Ms. Watts (UK): Reimbursement is due even if there are no domestic tariffs (rate: 100%)

A Planned Directive on Cross-Border Health Care

Aims:- Transposition of the Court judgments- Guaranteeing the freedom to provide health care

services (guidelines and standards)- Enhance patients’ rights (non-discrimination,

correct price setting, information, medical records)- Reimbursement of planned treatment (at

domestic rates)- Recognition of prescriptions- European Reference Network- Co-operation in eHealth and Technology Assessment

How to Seek Health Care in Europe?

Unexpected

treatment

Planned treatment

Out-patient

In-patient

Authorization

Working Cross-Border Co-operations

Current Situation (Survey by HOPE)

– Provision of health care in border regions

(Belgium-Netherlands-Germany, Northern Countries, UK-Ireland);

– Co-operation between providers

Thank you for your attention