MY HEALTH INSURANCE RIGHTS IN THE EU

We often receive inquiries about the health insurance rights of Bulgarian citizens in EU, EEA countries, and the Swiss Confederation. This is why I decided to write this article, which will be very brief. Information on the topic can be found on the NHIF website. There is also a lot of information on many other issues on the NHIF website. Therefore, I will simply publish selected excerpts from already described procedures with a few comments from my side.

To begin with, there are different possibilities for providing medical care in EU, EEA countries, and Switzerland, namely emergency medical care, planned treatment, medical assistance during a short stay, or when the person is residing there long-term (please do not confuse residence with habitation and permanent or long-term residence status, which are different things). What is the difference between all these things—the emergency medical care is for emergencies. A short-term stay might be, for example, a holiday or a short business trip up to 30 days. When we talk about a long-term business trip, it refers to a posting within the meaning of Regulation 883 (with A1 certificate) or when the person has gone for training purposes. In the last two cases, one should apply to the NHIF for a C1 (S1) certificate, which allows the insured individual to obtain the medical care they need in the host country without the necessity of a European Health Card, medical insurance, or another additional alternative. The insured person—a Bulgarian citizen with a C1 certificate is equated with the insured persons—citizens of the host country. This concludes my comments, see the quoted information below.

HOW BULGARIAN CITIZENS CAN USE

MEDICAL ASSISTANCE DURING STAY OR RESIDENCE

IN THE COUNTRIES OF UNIFIED EUROPE

From January 1, 2007, for Bulgaria, the provisions of European regulations that regulate the issues of social and health insurance—are directly applicable within the context of the right to free movement of people within Unified Europe.

In the event of a conflict between national and European legislation in the social and health insurance sphere, the provisions of European law apply.

Bulgarian citizens with continuous health insurance rights according to Bulgarian law can use medical assistance when necessary in countries of the European Community—when they are residing on a different basis in the other countries of the European Union (EU), the countries from the European Economic Area (EEA), and the Swiss Confederation: short-term (temporary stay) or long-term (residence).

The right to medical assistance in the EU depends on the continuous health insurance rights acquired in the competent state. Determining the competent state for social and health insurance of citizens is carried out in accordance with the provisions of Regulation (EC) No. 883/2004 on the coordination of social security systems and its implementing regulation No. 987/2009. In the territory of the Republic of Bulgaria, the determination of applicable legislation is carried out by the National Revenue Agency (NRA)—www.nap.bg.

The basic rule for determining the competent state is that it is the country of primary employment—whether employed or self-employed. Into these categories fall:

- all citizens who have performed (active population), or have performed (pensioners) any work activity in the territory of any of the countries of Unified Europe;

- persons in non-working age or condition (minors, students, regular PhD students on state support);

- unemployed citizens in the process of seeking work (for up to 3 months).

All citizens are subject to mandatory health insurance in only one (competent) state. If the rights of health insurance are continuous in the competent state, citizens are entitled when necessary to use medical assistance from the public health system package (basic health services package) from the country of their stay or residence.

During a temporary stay in another EU country, medical assistance at the expense of the National Health Insurance Fund (NHIF) can be obtained from foreign medical institutions or doctors only after presenting a valid certifying document (document confirming continuous rights in Bulgaria—a European Health Insurance Card (EHIC) or a Certificate replacing the EHIC (CR EHIC)).

The right is realized in the following way:

 

TEMPORARY STAY: TOURISM - SHORT-TERM BUSINESS TRIP – VISIT

During a temporary stay (tourism, short-term business trip, visit, etc.) of Bulgarian insured citizens in the EU/EEA/Switzerland:

• Bulgarian citizens should possess a valid European Health Insurance Card (EHIC), issued by the competent Bulgarian health insurance institution (NHIF). In the event of an urgent need for medical care, Bulgarian citizens should present their EHIC to the attending doctor/healthcare facility and should be treated equally with local insured persons. The purpose of this assistance is not to interrupt the previously planned temporary stay in the respective country for medical reasons. If the local health insurance system envisages co-payment for certain medical services or a legally regulated user fee, it is paid by Bulgarian citizens, and the paid amount is not refundable upon returning to Bulgaria;
• When the Bulgarian insured person needs to be admitted urgently to a hospital but does not carry their EHIC, the respective hospital (or insurance institution in the place of stay) can contact the NHIF or the RHIF in Bulgaria with a request (by letter or with a suitable form) to send a Certificate replacing the EHIC. The validity period of the certificate is for the duration of the necessary urgent treatment, but not more than two months. The Regional Health Insurance Fund (RHIF), or NHIF, should send the requested certificate to the hospital (or insurance institution), confirming that the treatment will be at the expense of the NHIF—only in cases where the patient has continuous health insurance rights in Bulgaria. If the patient does not have the coordinates of their RHIF, they can find them on the official NHIF website www.nhif.bg or contact the Bulgarian contact point on health insurance issues—Headquarters of the NHIF (on the information phone 00359 2 965 91 16).
• When the legislation of the country of temporary stay requires that local insured persons pay in advance to the doctor or medical institution, and after receiving the necessary assistance, apply to the local issuer for reimbursement of the incurred costs (e.g., in France or Belgium), the same provisions apply to Bulgarian insured persons temporarily residing in this the country. Bulgarian citizens can apply for reimbursement of the incurred expenses at the local health fund, or upon return to Bulgaria, they can apply to the NHIF for reimbursement of expenses - against the presentation of original financial and medical documents from abroad. Information on the procedure for reimbursement of paid expenses for necessary medical assistance in the EU is published on the NHIF website www.nhif.bg, menu "International Cooperation," submenu "European integration," article for reimbursement of expenses.

RESIDENCE IN THE EU: WORK – LONG-TERM POSTING – FAMILY MEMBERS - PENSIONERS

Here I will supplement the article with a preliminary comment—the person on whom the S1 will be issued applies in person, presenting a copy of their ID card, a copy of their passport, and a copy of the posting order together with a copy of the A1 posting certificate.

Long-term residence of Bulgarian insured citizens in the EU/EEA/Switzerland (registration forms for benefits in kind S1/S072):

• When a working Bulgarian insured citizen is posted by a Bulgarian employer to perform certain work for the account of their employer in another EU member state (MS), they can be registered with the local health insurance system using the European form S1/S072. The posted citizen and accompanying family members (with continuous health insurance rights) are registered with the foreign health insurance system for the duration of the posting. A separate registration form is issued for each accompanying family member of the posted person.

Family members are: husband, wife, children up to 18 years of age, and if they continue their education - up to 26 years of age, and if they are incapacitated or permanently disabled - regardless of age.

These individuals use medical care to the full extent, guaranteed also to local insured persons in the country of residence. If the posted Bulgarian and their family temporarily go to a third country, urgent and necessary medical assistance there can be obtained by presenting valid EHICs issued by the NHIF.

The posted person should submit documents to the National Revenue Agency (NRA)—www.nap.bg for issuing A1 certificate for the applicable legislation. A copy of this form should be attached to the application before the RHIF (by place of residence) for issuing a registration form for the right to benefits in kind - S1/S072. An application in the NHIF sample is filled out at the RHIF, a copy of the ID card or passport of the applicant is attached and a copy of the posting order to the other country.

∙ Form S1/S072 is also used in the following cases:

- for frontier workers when the condition for a frontier worker is present, which is considered as any person exercising activities as an employed or self-employed person in one member state and who resides (lives) in another member state, to which they principally return daily or at least once a week;

- for diplomats and consular officers, and for members of their families, posted to another MS (with a copy of the posting order or an official note from the Ministry of Foreign Affairs);

- for seamen living in one EU country but sailing under the flag of a ship registered in another EU country (with A1 form from the NRA);

- for state officials posted by a Bulgarian state institution to work in another European country (with a copy of the posting order);

- for registration in the health insurance system of another EU country of family members of a working person, who live in a member state different from that of the insured person's insurance. Since in Bulgaria health insurance rights are personal, family members must not interrupt their health contributions in Bulgaria. Otherwise, upon losing their rights here, RHIF issues a form for the termination of registration in the foreign Health Insurance system;

- for the registration of pensioners and accompanying family members into the health insurance systems of the EU/EEA/Switzerland states. The form is personal and is issued for each accompanying family member of the pensioner, if with continuous health insurance rights.

- for the registration of individuals claiming/applying for pension benefit.

It should be noted that the independent right to benefits in kind based on member state legislation (i.e., personal health insurance rights) has priority over derivative benefit rights for family members.

SCHEDULED TREATMENT IN THE EU (TREATMENT BY PLAN)

Bulgarian citizens wishing to receive scheduled inpatient treatment in the EU, should present to the foreign hospital (which has previously confirmed acceptance for scheduled treatment) form S2, issued by the competent Bulgarian health insurance institution NHIF. With this form, the NHIF confirms its approval for conducting the treatment specified in the form abroad—at its expense.

Only treatment activity expenses are subject to payment by the health insurance institutions. The patient shall pay user fees, fees of some doctors, additional unplanned tests, the patient's accommodation outside the hospital (if applicable), transport expenses, as well as all the additional unplanned procedures not covered by the mandatory health insurance in the other country, and which are paid by local insured persons (or covered by their additional/voluntary health insurance). If the medical assistance in the other country was received from a doctor or hospital not working with the local health insurance fund, the cost of the received assistance shall be borne by the patient.

Permission to receive treatment in the territory of another EU member country on behalf of the NHIF is granted when the said treatment is among the benefits covered by the law provisions of the Republic of Bulgaria and payable through the system of mandatory health insurance, and when the person cannot receive treatment within the customary necessary time to obtain it in the Republic of Bulgaria, given the current state of health and potential disease progression. The assessment for the above is carried out by national consultants for the respective diseases and by chairpersons of the respective scientific societies, who provide written opinions on the justification of the submitted requests—according to their expert medical judgment of each patient's condition and the possibility/impossibility to perform the treatment within a reasonable medical term in Bulgaria.

Information about the process for applying and the necessary documents for a form for scheduled treatment in the EU is published on the NHIF website www.nhif.bg, menu "International Cooperation," submenu "European integration," article for scheduled treatment abroad.

EDUCATION – TRAINING IN THE EU

Use of medical assistance in the EU/EEA/Switzerland by Bulgarian students, regular PhD students on state support:

• Medical assistance is used upon presentation of a valid Bulgarian EHIC. For this purpose, students should not interrupt their health insurance in Bulgaria. If they are regular students up to 26 years of age, minors or school students (until completing secondary education), their health contributions are paid by the Bulgarian state budget. It is necessary for regular students up to 26 years of age to regularly present an enrollment certificate from the foreign educational institution (with a certified translation in Bulgarian) to the National Revenue Agency for the payment of their health contributions by the state budget;
• For regular students over 26 years of age, a requirement for monthly self-insurance to the NRA - through health insurance accounts.
• If a Bulgarian student in an EU, EEA state, or Switzerland starts legal work there (apart from temporary student part-time occupation), they are subject to insurance in the country of the work activity. Then the competent state for their health insurance and for issuing the necessary European documents is the country of employment;
• If the student has a valid Bulgarian EHIC, it can serve as receipt of necessary medical care in the other country—during their period of education there.

MEDICAL ASSISTANCE IN THE EU/EEA/SWITZERLAND IN CASES OF PREGNANCY AND CHILDBIRTH

According to Administrative Commission decisions for coordination of social security systems (AC), pregnancy, and childbirth (before the determined childbirth term) falls within the scope of necessary urgent medical care. During stay in another MS, needed medical assistance related to sudden pregnancy problems (consultations for complaints or functional disorders, tests, etc.) is provided upon presentation of a valid EHIC and identity document—without restrictions on the type of needed assistance.

For necessary medical assistance during a stay in Bulgaria, the pregnant woman, with a valid EHIC from another MS, should contact a GP contracted with the NHIF, who assesses the type and volume of necessary consultations, investigations, etc., and issues relevant medical referrals for them. Reporting to the RHIF is done in the established EHIC manner with copies of the EHIC and a declaration filled by the patient that their stay in Bulgaria is not for medical purposes.

Regular student women from other MS, studying in a Bulgarian higher education institution expecting pregnancy and birth monitoring in Bulgaria should make a temporary choice of a personal doctor—for the duration of their studies in our country. After their inclusion in the GP's patient list, they use necessary medical care under the Motherhood Healthcare program—as Bulgarian insured persons. EHIC also covers medical care related to the childbirth itself (under the respective Clinical Pathway). In cases where newborn monitoring is needed (e.g., placement in an incubator), a Certificate replacing the EHIC from the country where the mother is insured is required for the child.

BACK TO BULGARIA

Certification of health insurance periods acquired in another EU/EEA country - for Bulgarian citizens returning to Bulgaria:

• With form E 104 or S041 the respective insurance system certifies to the Bulgarian system (before the territorial directorate of the National Revenue Agency—by place of residence in Bulgaria) what the periods of employment or residence in a specific MS are, during which the person was socially or health insured there. Thus, the periods of health insurance from the EU/EEA/Switzerland are recognized, and the person re-enters the Bulgarian health insurance system.

CHANGE IN CIRCUMSTANCES OR INSURANCE STATUS

• If the insured person was registered abroad with S1/S072, upon their final return to Bulgaria they should contact the RHIF by place of residence and certify that the issued form should be terminated.
• During a temporary stay in Bulgaria (leave, holiday, visit to relatives, etc.), Bulgarian citizens insured in other EU/EEA/Switzerland countries, may only receive urgent and necessary medical assistance within the package of mandatory health insurance—upon presentation of a valid EHIC or a Certificate replacing the EHIC, issued by the other state of insurance.
• Bulgarian citizens insured in another member state desiring to receive scheduled inpatient treatment in Bulgaria should present to the Bulgarian medical facility (which has previously confirmed their admission for scheduled treatment and the period of scheduled admission) form S2, issued by the competent foreign insurance institution. This form confirms the institution's agreement to conduct the specified scheduled treatment in Bulgaria—at its expense.

IMPORTANT TO KNOW:

• According to Regulation (EC) No. 883/2004, all health-insured citizens in Unified Europe are obliged to inform competent health insurance institutions of any change in their condition (insurance, health, family) and changes of residence.
• If in the state of residence of stay the local legislation requires insured citizens to pay a certain use fee, or there is regulated co-payment for medical assistance, it applies to citizens from the other nations of the EO. These sums are at the insured person's expense.
• If in the state of temporary stay it is required to use medical assistance from the public health insurance package against payment (when it is not possible to present EHIC or certificate replacing it on time, or for other objective reasons), subsequently, NHIF can make reimbursement of the expense incurred abroad after the person's return to Bulgaria. In Bulgaria, this is submitted through documents in the NHIF HQ. The sums subject to reimbursement are agreed between the NHIF and the local health institution abroad. The reimbursement procedure is lengthy and time-consuming due to information exchange between health insurance institutions in the EU.
• In the event there is a requirement for urgent or authorized scheduled inpatient assistance, the competent health insurance institution covers only the cost of medical care within the health insurance package.

Useful contact points:

 

NHIF:

Website: www.nhif.bg, menu "International Cooperation," submenu "European integration"

Tel.: 00359 2 965 91 16; fax: 00359 2 965 91 24

Information phone for the entire country: 0800 14 800

 

NRA

(applicable insurance legislation)

Website: www.nap.bg

Information phone for the entire country: 0700 18 700

 

NSSI (National Social Security Institute)

(pension benefits, compensation for illness and maternity, compensation for work accidents and occupational diseases, compensation for unemployment)

Website: www.noi.bg

Information phone for the entire country: 02/926 10 10

 

Ministry of Health (MH)

Website: www.mh.govenment.bg

Information phones: 02 / 9301 152; 02 / 9301 253; 02 / 9301 259