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Provision and reimbursement of cross-border healthcare for a Slovak insured person in another Member State of the European Union
Insured persons have the right to the entitlements to cross-border healthcare guaranteed in the Directive and the national law of the Member State in which healthcare is provided to be respected.
Cross-border healthcare is healthcare provided or prescribed for an insured person in another Member State of the European Union (other than the State of residence), the costs of which the insured person must pay directly to the healthcare provider in the other Member State and then requests reimbursement from his/her health insurance company. The provided healthcare must fall within the material scope of the Directive. The Ministry of Health of the Slovak Republic defines the types of cross-border healthcare that require prior authorisation from the patient’s health insurance company in its regulation. The list of procedures affected can be found in Decree of the Ministry of Health No. 341/2013 Z. z.
The competent health insurance company may refuse authorisation for the provision of cross-border healthcare if
a) the illness involves treatments presenting a particular risk for the patient or the population, taking into account the potential benefit for the patient of the sought cross-border healthcare,
b) it is provided by a healthcare provider in another Member State that could give rise to serious and specific concerns relating to the quality or safety of the healthcare,
c) the planned healthcare can be provided in Slovakia within a time limit which is medically justifiable, taking into account the current state of health and the probable course of the illness of the patient concerned.
Apart from the above reasons, a health insurance company cannot refuse to grant prior authorisation if the insured person and the planned healthcare satisfy the conditions laid down in the coordination regulations and
a) the illness cannot be treated in Slovakia within a reasonable time period taking into account the current state of health and the probable course of the illness of the insured person,
b) the requested treatment or the equivalent treatment with comparable effectiveness and safety is not provided in Slovakia,
c) all potential treatment options in Slovakia have been exhausted and treatment in another Member State can be expected to lead to a significant improvement in the patient’s health or prevent it from its worsening,
d) the patient has residence in another EU Member State and wishes to continue treatment that began in Slovakia in his/her place of residence or
e) the illness requires the use of highly specialised and cost-intensive medical infrastructure or medical equipment that is not available in Slovakia.
and if this healthcare cannot be provided in Slovakia in a time limit which is medically justifiable, based on an objective medical assessment of the patient’s state of health, the history and probable course of the patient’s illness, the degree of the patient’s pain and/or the nature of the patient’s disability at the time when the request for authorisation was made.
The provision of cross-border healthcare also applies to rare diseases.
Proceedings on prior authorisation
Insured persons shall submit request for prior authorisation to the competent health insurance company before healthcare is provided. A form of the request is stipulated by Decree of the Ministry of Health No. 232/2014 Z. z.
The request must include:
- the insured person’s name, surname, date of birth and birth ID number, if assigned,
- the address of the insured person’s place of residence,
- the insured person’s diagnosis,
- justification of the need for planned healthcare by the healthcare provider,
- confirmation of the prescription and justification of the need to provide the proposed treatment by a clinical facility with the relevant specialisation,
- a calculation of expected costs for the planned healthcare abroad prepared by the foreign healthcare provider which will provide healthcare – vide a form of the calculation in Decree of the Ministry of Health No. 232/2014 Z. z.,
- confirmation of possible admission by the foreign healthcare provider after a positive decision of the health insurance company – vide a form of the confirmation in Decree of the Ministry of Health No. 232/2014 Z. z.
In proceedings on prior authorisation the competent health insurance company checks if the conditions laid down in the coordination regulations for prior authorisation are met. If the conditions for authorisation are satisfied in accordance with the coordination regulations, the health insurance company shall grant authorisation under the coordination regulations. Costs for healthcare whose provision was authorised by the health insurance company under the provisions of the coordination regulations will be settled between the competent institutions of the State of insurance and the State where healthcare was provided according to the rates of the State where healthcare was provided. This procedure is not applied if the insured person insists on authorisation in accordance with the Directive, in such a case he/she is entitled only to reimbursement at the rates of the State of insurance.
The health insurance company will decide on a request within 15 days of receipt. In case of a serious illness that could seriously damage the patient’s health, the health insurance company will decide without delay. An insured person can submit an appeal against a decision of his/her health insurance company up to 20 working days from the date of decision’s delivery.
The health insurance company may decide on the appeal itself, if it accepts the appeal in full; if it does not decide within 15 working days of receiving the appeal, it must submit the appeal and the results of additional proceedings and all documentation on file to the Health Care Surveillance Authority by the end of the period the Health Care Surveillance Authority will decide on the appeal within 15 working days of receiving the appeal, the results of additional proceedings and all documentation on file. The Health Care Surveillance Authority’s decision is subject to judicial review and proceedings of subjects regarding prior authorisation are subject to the Code of Administrative Procedure.
In the case of a Slovak insured person – a family member of an employee or self-employed person who does not live in the same Member State as the insured person and who has residence in a State that applies fixed amounts (CY, ES, IE, NO, PT, SE, UK), prior authorisation is granted under the Directive by the institution in the place of residence, i.e. the health insurance company in that State, in accordance with its legislation. This institution likewise reimburses costs for cross-border healthcare at its own rates.
In the case of a Slovak insured person submits to pharmacy or medical device supplier medical prescription or prescription for medical device issued in another Member State of the European Union, he/she is entitled to get medicine, medical device or dietetic food from the authorized person for medicine under the same condition as if the medical prescription or prescription for medical device was issued in the Slovak Republic by non-contracting healthcare provider pursuant to the Act No. 362/2011 Z. z. as amended. The price of medicine is paid in full by the insured person on spot.