NHSiS guidance manual for overseas visitors

NHSiS Manual of Guidance: Overseas Visitors

Chapter 12: European Economic Area Health Care Arrangements	Statutory/Manual References
Member States 1. EEA member states, including dependent territories bound by EC Regulations, are as follows:
Austria Belgium Denmark - for EEA purposes, Denmark *excludes* the Faroe Islands and Greenland. However, a reciprocal health care agreement between the UK and Denmark allows residents of the *Faroe Islands* visiting the UK to receive emergency health care under the NHS. A reciprocal health care agreement between the EEA and *Greenland* allows Danish nationals resident in Greenland to receive immediately necessary NHS treatment. Finland France - for EEA purposes includes, French Guiana, Guadeloupe, Martinque and Reunion. Germany Greece Iceland Irish Republic - there are no special arrangements with the Irish Republic. Italy Liechenstein Luxembourg Netherlands Norway Portugal - for EEA purposes includes, the Azores and Madeira Spain - for EEA purposes includes, the Balearic Islands, Canary Islands, Ceuta and Melilla Sweden "UK" - for EEA purposes includes Gibraltar. Excludes Cannel Islands, Isle of Man and the UK sovereign base areas in Cyprus.
Note: 1 Only countries, including those dependent territories listed above are currently within the EEA. 2 The UK - Gibraltar arrangements are governed by a separate reciprocal health care agreement, as are the agreements with the Channel Islands, the Isle of Man and other UK dependencies.	Chapter 2 Chapter 13
EC Regulations
2. On production of the following EC forms overseas visitors will be entitled to hospital services without NHS charge:
E111D - Request for renal dialysis treatment during a stay in a EEA member state.	Paragraph 5 Appendix H1
E112 - Certificate concerning retention of the right to Sickness or Maternity Benefits currently being provided. (This EC form is used under specific arrangements where an overseas patient is referred to the UK by the home health or benefits authority for NHS treatment.)	Paragraph 10 Appendix H2
E119 - Certificate concerning the entitlement of Unemployed Persons and members of their family to sickness and Maternity Insurance Benefits.	Paragraph 9 Appendix H3
E123 - Certificate of entitlement to Benefits in kind under insurance against Accidents at Work and Occupational Diseases. (This EC form is used under specific arrangements where an overseas patient is referred to the UK by the home health or benefits authority for NHS treatment.)	Paragraph 10 Appendix H4
E128 - Certificate of entitlement to necessary Benefits in kind during a stay in a Member State. (*This EC form applies to 2 groups of EEA nationals only*: workers posted temporarily to another member state and any members of their family who accompany them and students temporarily in another member state to study and any members of their family who accompany them.	Paragraph 22 Appendix H5
Note: Specimen EC exemption forms are attached at Appendix H(1-5). Some EEA nationals and their families may offer a EC form E111. However, the EC form E111 is *not* needed for an overseas patient to access NHS emergency treatment. The EC form E111 is sufficient evidence of entitlement to exemption from NHS charges for "treatment the need for which arose during the visit", but is *not* acceptable as evidence of authorisation to come to the UK specifically for treatment. This would require EC forms E112 or E123. An unemployed EEA national seeking work should have a EC form E119 for him/herself and for any accompanying family member. EC form E128 is required for posted workers and students temporarily in the UK and their family members. Those holding form E128 are entitled to NHS care without charge for immediately necessary treatment *and for known pre-conditions*. This entitlement extends only in respect of the period of work or study.
Extent of exemption from NHS charges
3. Nationals of any EEA member state, including stateless persons or refugees residing within the territory of one of the member states as well as family members and their survivors irrespective of their nationality are exempt from NHS charges for "treatment the need for which arose during the visit" to the UK.	1989 Reg 5(a) & Chapter 2
4. This exemption from NHS charges applies equally to maternity care where a woman from EEA member state becomes pregnant or aware of pregnancy after arrival in for the UK or the NHS treatment needed is other than for a planned delivery.
Partial exemption from NHS charges - Renal Dialysis
5. Treatment for renal dialysis is also exempt from NHS charges provided:	SHHD DS (1985)31
i. the patient has a EC form E111D (Renal Dialysis) authorised by his/her home health or benefits authority; ii. advance arrangements have been made with the care unit and the unit has spare capacity on the dates requested; and iii. the purpose of the patient’s visit is for *non*-medical purposes (for example, a holiday or visit on business).	Paragraph 2
Note: Other than Australia (see Chapter 13 paragraph 15) overseas visitors from *non*-EEA countries requiring renal dialysis, as well as visitors from countries with which there is no reciprocal health care agreement, should be subject to NHS charges or treated privately.
Exemption from NHS charges - Oxygen Therapy
6. Visitors coming to the UK from other EEA member states on *non*-medical grounds (for example, on holiday or on a business trip) who need oxygen therapy should be provided with supplies through the NHS during their visit on the same terms as apply for UK residents. There is no requirement to bring with them EC form E112 in relation to oxygen therapy treatment or related supplies.
7. The UK provide oxygen therapy as a domiciliary service to which access is obtained generally via a GP. No advance arrangements to have supplies of oxygen available immediately on arrival are necessary. Once here, however, the patient is entitled to be prescribed oxygen therapy on the same terms as a UK resident.
8. Visitors who wish to make private arrangements in advance of their arrival will be responsible for any costs incurred.
Exemption from NHS charges when the patient has not come to the UK expressly for NHS treatment
9. The following patients are exempt from NHS charges - nationals of EEA member states, refugees or stateless persons who are unemployed (if authorised to seek employment in the UK), who should have with them a EC form E119 (Unemployed entitlement to Sickness and Maternity Benefits).	1989 Reg 4(m) & Paragraph 2

Note: Where the patient is exempt from NHS charges, so also are their dependants.
Exemption from NHS charges when the patient has come to the UK expressly for treatment
10. For people who want to come to the UK expressly for NHS treatment, including second opinions and diagnostic tests, and planned ante-natal and post-natal care, there are separate arrangements.	1989 Reg 4(m)
i. patients must have the prior authorisation of their home health or benefits authority, which will in principle bear the costs of NHS treatment. Under these arrangements patients are required to bring with them a EC form E112 (Entitlement to Sickness and Maternity Benefits). Note: The EC form E112 is *not* a private health insurance document. Where patients are in doubt, they must have the difference between private health care and NHS charged care explained to them. ii. those authorised to come for NHS treatment of an industrial injury or occupational disease must have a EC form E123 (Accidents at Work and Occupational Diseases).	Paragraph 2 Paragraph 2 Paragraph 2
11. Someone from another EEA member state, who seeks treatment in the UK with the permission of his or her home health or benefits authority, is exempt from NHS charges for that treatment. The treatment must be provided as NHS care and *not* as private treatment.
Note: Advance notice is required by the receiving NHS Trust or DMU before a patient can be accepted under these arrangements. Such patients must be treated in every respect no differently than a resident of the UK.
Validity of EC forms E112 and E123
12. A patient holding the relevant EC form is authorised to receive NHS treatment only during the period of validity entered in E112 box 3 or E123 box 4 on the relevant form. If the treatment is expected to extend beyond this period the patient should be advised in good time to seek another EC form extending the authorised period from their home health or benefits authority. The alternative is that the patient would be liable to NHS charges or private care if they so choose for their continuing care after the expiry date on the relevant form.
13. In the event that a relevant EC form *cannot* be produced, NHS charges may be made under the NHS (Charges to Overseas Visitors) (Scotland) Regulations 1989. A refund should be made if the relevant EC form extending the qualified period is later produced.
14. When asked to accept the referral of a patient from another EEA member state, clarification should be sought on whether the NHS treatment required is to be paid by the patient’s home health or benefits authority under E112 arrangements, or at the patient’s own expense (NHS charged care or private care).
15. When the patient is discharged the NHS hospital finance department should forward the relevant form to: Benefits Agency Pensions and Overseas Benefits Directorate Medical Benefits Section Tyneview Park Whitley Road *Newcastle* NE98 1BA
16. The DSS should then write to the NHS hospital finance department requesting that they complete a questionnaire (form CF(N)956) on the level of NHS care provided to the EEA patient, so that the costs may be claimed from the visitor’s home health or benefits authority. It is essential that patient returns should be made promptly and on an individual basis.
17. Patients coming to the UK specifically for health care are also exempt from NHS charges under the EEA arrangements for any other unrelated medical requirement "treatment the need for which arose during the visit."
18. If there is doubt that a patient is a national of an EEA member state, he or she can be asked to produce a passport or identity card or (for refugees and stateless persons) a travel document.	Chapter 2
19. There are people belonging to other EEA member states but employed overseas by HM Government (for example, some locally employed staff for whom the UK has accepted responsibility). In each case appropriate documentation is provided by the FCO, entitling the bearer to treatment without NHS charge.
Visitors from EEA member states carrying form E128 20. The E128 form applies to 2 groups of EEA nationals only - workers posted temporarily to another member state and any members of their family who accompany them; and - students temporarily in another member state to study and any accompanying members of their family.
21. For people in these 2 groups who come to the UK, form E128 gives entitlement under the NHS to necessary treatment for any condition, that is, entitlement is not restricted to treatment that is immediately required. Routine treatment for on-going conditions existing before arrival in the UK cannot be excluded, and such patients should, in effect, receive full health-care under the NHS on the same terms as UK residents. They may either be accepted by the GP of their choice, or be assigned to a GP by the local Health Board. As an NHS patient, the overseas visitor carrying form E128 should not be treated on a private, paying basis.
22. A few points about the form may be of help:
(i) The relevant legislation come into effect for posted workers on 1.1.1996 and for students on 4.10.1997 (ii) The names of the people covered by the form will be entered by the issuing country. (iii) The sole country in which the form is valid will be entered, together with a time-limited period of validity. This will be linked to the period of the posting or the length of study. (iv) Instructions on the form tell the holder to present the form to the doctor, dentist, hospital etc. when seeking treatment to prove their eligibility to NHS treatment. (v) We would expect the information on the form to be verified and the form handed back to the holder for retention.	EC Reg 1408/71, Art. 22b & 22c
23. In verifying the form, the GP or receptionist should confirm that: (i) The patient is named on the form, at either item 1.1 or item 2.1; (ii) The UK is named on the form as the country in which the person is temporarily posted or is studying - item 3 (first entry); (iii) The form is valid on the date on which treatment is sought, ie it falls within the period entered on the form - item 3 (second and third entries); (iv) The form bears an official stamp and signature at item 4. It is impossible because of the huge number of different sickness insurance institutions throughout the EEA, to attempt to list their names. They will have to be taken at face value.
24. It should not be necessary to seek corroborating evidence of identity, dates of birth, name of employer/college etc unless there are suspicions that the person is trying to make use of a form fraudulently.
25. Posted workers or students on holiday visits to the UK from their posting or state of study, who present a form E128 issued by a third country, should be told the form is not valid in the UK. (In other words, Form E128 is only valid where the holder is studying or working in the UK.) Without E128 they are entitled under EC law only to immediately necessary treatment, on the same terms as for any other visitor from an EEA country, unless they produce a form E112. Similarly, family members of posted workers or students who do not accompany them to the UK for the period of the posting or study may nevertheless visit the UK from time to time. Their entitlement also extends only to immediately necessary treatment, unless they produce a form E112.
Patients without relevant EC forms
26. When a GP, NHS Trust or DMU has agreed to accept a patient under the arrangements set out at paragraphs 10, 11 or 20 (above) but on arrival the patient cannot produce the relevant EC form, he or she may be liable for NHS charges under the NHS (Charges to Overseas Visitors) (Scotland) Regulations 1989 but *not* as a private patient.
27. Where the relevant EC form is produced in retrospect the patient will be refunded; the patient should be asked to give an address to which any refund can be sent. If an EC form is *not* produced by the time the patient is discharged from care, he or she should be advised to take the matter up with their home health or benefits authority.