1. Health Insurance and Europe Hungary’s example
Peter Ötvös, National Health Insurance Fund, Hungary

2. 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

3. 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
mandatory only
for ratified articles

4. 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 !

5. 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)
AIM
Ensuring that persons are not disadvantaged in terms of social security when they move from one Member State to the other

6. Applicable legislation – a single State
Legislation of
the State where the person is employed
a single State is responsible for insurance

7. Special rules - posting
Company in another Member State
Hungarian company
State of employment
Sending State
Currently months, from 2010: 24 months

8. 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

9. Competent institution Institution of the place of stay
Temporary Stay
Competent institution
Authorisation for treatment in other Member State
Health care provider
Insured person
Institution of the place of stay

10. 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

11. 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

12. 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 provider
Conditions:
- 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

13. 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!

14. 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 =

15. 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 person
Institution of the place of residence
Competent institution
examination; registration

16. Example: Health Care for Residents in Hungary
entitled person
 Hungarian health care provider
TAJ 
NHIF 
 Pharmacy

17. 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 years
Always the more favorable provisions apply
Dynamic Process – Electronic Exchange of Information: SED
Making Citizens’ Rights More Effective – Efficient Service and Information

18. EESSI Network – Exchange of ‘SEDs’CI CI CI CI CI
National Network
Member State 2 CI
National Network CI CI
Member State 1
EESSI
International Network
sTESTA CI
National Network
Member State 3 CI
National Network
Member State “n” CI CI CI
National Network CI
National Network
Member State 4 CI CI CI CI CI
Coordination Node CI
Competent Institution
Access Point
Source: European Commission 18

19. EESSI information flows
What a Mess!
God Save the Health
Insurance Administrations!
Portable Forms &
Paper SEDs

20. 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

21. 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%)

22. 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
still debated

23. How to Seek Health Care in Europe?
Planned treatment
Unexpected treatment
Out-patient
In-patient
Authorization
Domestic
tariffs
Full reimbursement NO
refund

24. 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

25. Thank you for your attention