European cross border healthcare: Information for commissioners

Transcription

1 European cross border healthcare: Information for commissioners Published: June

2 2

3 European Cross Border Healthcare Information for Commissioners First published: July 2013 Updated: June

4 Contents Equality statement... 5 Background... 6 Refresh of roles and responsibilities... 6 Patient applications... 9 Financial flows EU Directive route only Information on entitlements Interaction with Individual Funding Request (IFR) processes Emergency treatment National Contact Point Contact information

5 Equality statement Equality and diversity are at the heart of the NHS strategy. Due regard to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited in under the Equality Act 2010) and those who do not share it, has been given throughout the development of the policies and processes cited in this document. 5

6 Background 1. This document sets out the implications for commissioners of the European Union (EU) Directive on patients rights in cross-border healthcare, which became UK law on 25 October It also provides a refresh of the roles and responsibilities of commissioning organisations in European Cross Border healthcare and supersedes the original European cross border healthcare: Information for commissioners document, which was published in July This document does not, however, provide details of the eligibility criteria that apply to applications for funding for European cross border healthcare. More information about these principles can be found on the NHS Choices website. 3. The scope of this document is limited to treatment within the European Economic Area (EEA) that is funded under the S2 (formerly E112 ) route 1 and the EU Directive route. These are explained in more detail here: 4. Arrangements that are out of the scope of this guidance include: those that govern healthcare across borders within the UK ; reciprocal arrangements with other non-eea countries; the European Health Insurance Card (EHIC) and applications for S2s relating to maternity care, which are managed separately by the Department of Work and Pensions (DWP) Overseas Healthcare Team (OHT) Refresh of roles and responsibilities 5. NHS England is responsible for administering and determining applications made under the S2 route and the EU Directive route. A central team (the European team ) operates within NHS England s Leicestershire and Lincolnshire Area Team, to manage this process on behalf of the whole of England. 6. Whilst the European team is responsible for administering the application process and determining the outcome of applications, CCGs (and in some cases CSUs) are often involved in supporting the decision making process. 7. Under the EU Directive route, NHS England is responsible for reimbursing patients in line with legislation, whilst the responsible commissioner 2 in each case is required to refund NHS England for the reimbursements they have made to individual patients. 1 The S2 route covers Switzerland too, which is not part of the EEA 2 As determined through the principles outlined in the Who pays guidance, available here: 6

7 8. In summary, NHS commissioners are responsible for: Providing information on patient entitlements within 7 working days of the request (which may come directly from a patient or from the European Team); Publishing information on patient entitlements (see Information on entitlements below for more details); Refunding NHS England s Leicestershire and Lincolnshire area team for reimbursements made to patients under the Directive route, when identified as the responsible commissioner. 7

8 9. The detailed roles and responsibilities of the organisations involved in European cross border healthcare are collated below: 1 2 Area of responsibility Manage S2 and EU Directive application process (including assessing, approving / rejecting requests) and appeals Provide information on patient entitlements within 7 working days of request (either from patient directly, or European Team) European Team NHS England Direct commissioning CCGs CSUs DWP OHT 3 3 Inform applicants of S2 and EU Directive decisions Reimburse applicants for expenditure under the EU Directive, according to entitlement Ultimately pay for treatment under the Directive route, when identified as the responsible commissioner 3 Publish information on patient entitlements (including any clinical criteria or access thresholds), where relevant Publish information on those services subject to prior authorisation as a condition of funding 4 8 Data collection on activity 9 Run the National Contact Point (NCP) 10 Enquiries and applications for maternity S2s, reimbursement of co-payments, EHIC retrospective claims and PRCs This function is managed centrally by NHS England 3 As determined through the principles outlined in the Who pays guidance, available here: 4 If the CSU is acting on behalf of a CCG 8

9 Patient applications 10. Based on the above roles and responsibilities, the flow chart below outlines the overall process that patient applications should follow: Patient applies for funding, sending a completed application form to the European team within NHS England (either pre or post treatment, depending on the funding route and the treatment in question) The European team assesses the application, liaising with the responsible commissioner to clarify patient entitlement to the specific treatment The European team informs the patient of the outcome of their application If the application has been successful, the European team authorises the issuing of a reimbursement or an S2 form The European team issues any reimbursement due directly to the patient, and claims the money back from the responsible commissioner* *Please note that treatment approved under the S2 route is not funded by the responsible commissioner, but is paid for via a state to state transfer. 11. In the majority of cases the European Team will not need to provide detailed information about the patient when liaising with the responsible commissioner about a patient s entitlement. Rather, it should be possible to determine entitlement by understanding the patient s diagnosis, the treatment received (or requested) and any relevant commissioning policy that applies. The European Team will only share patient identifiable information in exceptional circumstances and when consent has been given. 12. The standard application form can be found within the following section of NHS Choices: 9

10 Financial flows EU Directive route only 13. In line with legislation 5, any reimbursements issued to patients will be limited to either the amount paid for the treatment or the cost to the NHS of providing the same treatment, whichever is the lowest. 14. Reimbursements are calculated using the following information: Where possible, reimbursements are calculated using the NHS tariff and a national average Market Forces Factor (MFF) For dentistry, reimbursements are calculated using the relevant number of Units of Dental Activity (UDA) and a national average UDA price. The relevant patient co-payment for the band of treatment received is deducted from this value The reimbursement value for GP consultations will be capped in line with the estimated cost of providing this service, as provided in the Personal Social Services research Unit (PSSRU) Unit Costs of Health and Social Care document 6 Where possible, reimbursements for prescriptions are calculated using the drug tariff, with the patient charge deducted (if applicable) 15. As the above flow chart outlines, once the reimbursement has been issued to the patient, NHS England s Leicestershire and Lincolnshire area team (Finance Department) will recover the costs from the responsible commissioner, as set out in legislation. For area teams, this will be done using the journal feature of the Integrated Single Finance Environment (ISFE). For CCGs, this will be done through invoicing. 16. Reimbursements issued to patients that are below 25 will not be reclaimed from the responsible commissioner by NHS England. This is because it is not efficient to do so, due to the administration costs involved. Information on entitlements 17. Under the EU Directive route, patients are only entitled to receive funding for healthcare in another European Economic Area (EEA) country if it is the same as, or equivalent to, treatment that they would be entitled to receive under their home healthcare system, in their circumstances. However, this restriction is dependent on information being clearly available to patients on what they are, or are not entitled to. This is to ensure that patients can freely exercise their right to access treatment across European borders

11 18. Poor quality or inaccessible patient information, including a lack of clarity on patient entitlements, is perceived to be an obstacle to that freedom. Therefore, unless the NHS provides appropriate clarity on the services that are, or are not, available to patients under the NHS, it is possible that funding would have to be approved, even for treatments that are not available here. 19. To minimise this risk, NHS England Area Teams and CCGs (or CSUs if acting on their behalf) will need to ensure that there is clear, published information available to patients on the treatments that are, or are not available, to them under the NHS, and any qualifying criteria or access thresholds that apply. 20. The NHS does not have a single defined set of treatments that are unavailable to patients, so it is vital that individual commissioners clearly describe any restrictions in place locally. 21. Unless there is clear information to the contrary, only providing information on the thresholds or restrictions relating to a specific set of treatments will lead to the assumption that other treatments are generally available to patients. 22. The Department of Health (DH) has published Directions to NHS England and CCGs, providing more specific details on the requirement to ensure clarity on patient entitlements. The Directions can be found in Annex B of the following document: /252940/Cross_Border_Healthcare_Information.pdf Interaction with Individual Funding Request (IFR) processes 23. NHS England will not normally approve funding for treatment to which a patient is not entitled under the NHS, if this is clearly set out in information published by the responsible commissioner (be that NHS England, a CCG, or, a CSU acting on a CCG s behalf). 24. NHS England and CCGs (or CSUs acting on their behalf) have IFR processes designed to consider situations where the patient has a medical condition for which the commissioner has responsibility and a commissioning position, and where the patient s particular clinical circumstances fall outside the criteria set out in an existing commissioning policy for funding the requested treatment. 25. In these circumstances, whilst the patient may not be eligible for reimbursement under the EU Directive route, an application via the relevant IFR process may be appropriate, if applying in advance of treatment. 26. If the treatment relates to the commissioning responsibility of NHS England, the patient will be referred to NHS England s published information on IFRs 11

12 (available here: If the treatment is the commissioning responsibility of a CCG, the patient will be referred to the relevant CCG or CSU. IFR applications are considered for exceptional clinical cases and must be supported and made by the relevant clinician. 27. If a patient is applying for funding following treatment and does not meet the criteria as set out in a commissioning policy, reimbursement will not normally be granted, nor will an IFR be appropriate (as IFRs should be made prior to treatment). 28. Approved IFR applications should not be passed to the European team, even if the treatment is taking place in another European country. Emergency treatment 29. The EU Directive route covers emergency treatment in addition to planned care. In most emergency cases, it is anticipated that a patient will use their European Health Insurance Card (EHIC). The EHIC should be the first resort for emergency or immediately necessary treatment and if the individual requiring such treatment does not have an EHIC, the patient should obtain a Provisional Replacement Certificate (PRC) from the OHT, which provides temporary cover. 30. Possible reasons for the EHIC or PRC not being used include: a. the patient not having a valid EHIC at the point of treatment and not obtaining a PRC; b. the EHIC or PRC not being accepted due to the provider being in the private sector (the EHIC is only valid in the state funded sector); and c. the EHIC or PRC not being accepted for another reason. 31. In circumstances a or c, the patient may be entitled to reimbursement under the rules that govern the EHIC. This would be administered by the DWP OHT, in line with their other associated roles. 32. The rules that govern the EHIC only apply to treatment provided in the state sector. Therefore, if a patient has accessed emergency or medically necessary treatment in the private sector (as in scenario b above), the only reimbursement option available to them is via the EU Directive route. In these circumstances, the patient would have to pay for their treatment and seek reimbursement for any eligible costs. The responsible commissioner would be required to ultimately fund the reimbursement, up to the cost of the equivalent treatment under the NHS. 12

13 33. NHS England will administer the reimbursement process for patients claiming under these circumstances (scenario b ). In many cases, the claim will be straightforward, as the patient s entitlement to receive the equivalent emergency treatment under the NHS will not vary according to the commissioner. Therefore, to facilitate an efficient service, an individual patient s entitlement to a specific treatment will not always be checked with the responsible commissioner. In cases where entitlement is unclear, checks will continue to be made with the responsible commissioner, in line with the process already established for other funding requests under the Directive route. National Contact Point 34. One of the requirements of the EU Directive on cross border healthcare is for EU member states to set up National Contact Points (NCPs). The primary role of the NCP in England is the provision of information to prospective European patients coming to England for treatment ( incoming patients ) and English residents seeking funding for healthcare in the EEA ( outgoing patients ). The NCP is required to provide this information in easily accessible formats, electronically and for people with disabilities. The second major role of the NCP is to liaise with NCPs from other member states, as necessary. 35. NHS England is responsible for providing the NCP for England and is doing so through its customer contact centre and a dedicated area on NHS Choices ( 36. The objectives of the NCP are discrete from the operational functions of the European Team. Specifically, the NCP is required to provide information in the following areas: For Incoming patients (from other EU member states) Quality and safety standards in England Regulation of healthcare professionals Hospital accessibility Rights of providers to provide services / any restrictions on its practice For Outgoing patients accessing Healthcare elsewhere in the EU Contact details of other NCPs in the EU Rights, entitlements, reimbursement principles and appeals processes The different rights and rules governing the S2 and Directive routes Ensure the above is accessible to people with disabilities and electronically Rights and complaints procedures for patients accessing NHS services 13

14 Contact information 37. Taking into account the new role of the NCP, the following table describes which team a patient or applicant should contact in a number of scenarios. Who Type of enquiry How to contact NHS England European Team Specific enquiry about an application for funding under the S2 (excluding maternity care) or Directive route e.g.: application progress clarity on level of reimbursement Phone england.europeanhealthcare@nhs. net National Contact Point General enquiries from incoming patients about the NHS including: information on providers charging and exemptions how the NHS works regulation of healthcare and healthcare professionals General enquiries from outgoing patients, including: how to apply for funding different funding routes information on entitlements Phone Web england.contactus@nhs.net DWP Overseas Healthcare Team Enquiries regarding the following: maternity S2s retrospective emergency treatment claims in the state sector EHICs and Provisional Replacement Certificates (PRCs) Phone overseas.healthcare@dwp.gsi.gov. uk 14

15 Annex A - Frequently Asked Questions (FAQs) The following FAQs combine a number of relevant FAQs from the previous iteration of this document with more recent questions that have arisen. 1. Our CCG/CSU has received an application for funding for healthcare in another EEA country. What should we do with it? Please ask the patient to apply directly to NHS England s European team, using the application form available on the NHS Choices website: Specific enquiries can be addressed to: england.europeanhealthcare@nhs.net 2. How can our CCG be assured that patients are not receiving funding under the Directive route for treatment in Europe that we would not fund locally? NHS England s European team will contact the responsible commissioner as required, to determine a patient s entitlement to specific treatments. The EU Directive requires the NHS to ensure that patients are able to understand their rights and entitlements to treatment in Europe. Therefore, any relevant commissioning policies (and qualifying criteria or access thresholds) should be made publically available in a format that is understandable to patients. The European Team will use these to inform their decisions and liaise with you as appropriate. 3. A patient in our area has contacted us regarding funding for treatment in Wales/Scotland/Northern Ireland. Should we refer the patient to the European team? No the arrangements for cross border treatment within the United Kingdom are different. Please refer to the Who Pays guidance, available at: 4. Treatments in other EEA countries may cost significantly more than they would within the NHS. Will funding / reimbursements be capped at NHS costs under the Directive route? Yes. Where it is possible to identify the NHS cost for a particular treatment this will be used as the funding limit. For costs calculated using the Payments by Results (PbR) Tariff, a national average Market Forces Factor will be applied. Where the treatment cost abroad is lower than the NHS cost, the funding will be limited to the actual cost incurred. 5. Do the principles of the EU Directive apply to emergency care? Yes. A patient can claim reimbursement for expenditure on emergency care in another EEA country. However, in most circumstances the EHIC will have been used and therefore reimbursement (by NHS England, on behalf of the 15

16 responsible commissioner) will not be required. If someone has accessed emergency care in the private sector of another EEA country, they may be eligible for reimbursement and the responsible commissioner would ultimately be required to fund this (limited to the equivalent NHS cost). This is because the EHIC is not accepted by private providers, but emergency care is covered by the EU Directive. 6. What happens if a patient is advised that treatment is not appropriate by an NHS clinician and then seeks the same treatment abroad? To be eligible for an S2, the patient would need to have the explicit recommendation of a UK NHS Consultant. Therefore, in this scenario an S2 would be refused. However, the patient may be entitled to reimbursement under the Directive if a clinician within the EEA determines that they have a medical need for it and it is treatment that would be available to them within the NHS. This is because the EU Directive on the Mutual Recognition of Professional Qualifications requires the team to accept the medical opinion of a health professional of another European country. 7. The treatment is available to the patient under the NHS why do they need to go abroad? The EU Directive on cross border healthcare is based on the principle of freedom of movement across the EU and this is an extension of patient choice. Therefore, if the treatment is available to the patient under the NHS, the principle is that the patient should be able to choose to receive funding (via reimbursement) to access that treatment in another EEA country. Our experience is that patients make this choice for a range of reasons. 8. Is dialysis on cruise ships covered by the European cross border Directive route? No. Treatment required during a cruise is not covered under any healthcare agreement that the UK has with other countries in the world, including EEA countries. 9. How do I know that the European Team has identified the correct responsible commissioner? The application form requires a patient to provide their registered GP and NHS number, which enables NHS England, and where necessary the CCG, to confirm the responsible commissioner. 10. How do the principles of European cross border healthcare apply to visitors from other EEA countries accessing NHS treatment? Patients ordinarily resident in another EEA country, but accessing emergency or immediately necessary treatment under the NHS can use their EHIC or 16

17 Provisional Replacement Certificate (PRC) to ensure they are not charged. (Please note that standard NHS charges, such as prescription charges still apply). For planned treatment, patients who have an S2 issued by their country of residence may use this to ensure no charge is made for their treatment. The NHS provider should enter the details of the EHIC or S2 on the DWP portal to ensure that the cost of the treatment is recouped from the patient s country of residence. If a patient does not have an EHIC, PRC or an S2, the NHS provider is able to charge the patient at the appropriate tariff rate. Depending on their circumstances, the patient may be able to claim a refund for this under the EU Directive, on return to their country of residence. For further information on provider responsibilities under the EU Directive please see: ross_border_healthcare_information.pdf 11. I have specific questions about treatment in other EEA countries that are not covered by this guidance. How do I find out more? Further information can be found on the NHS Choices website: 17