Ad-Hoc Query on Compulsory Health Insurance. Requested by UK EMN NCP on 16 th February Compilation produced on 14 th March 2012

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1 Ad-Hoc Query on Compulsory Health Insurance Requested by UK EMN NCP on 16 th February 2012 Compilation produced on 14 th March 2012 Responses from Austria, Belgium, Czech Republic, Estonia, Finland, France, Germany, Hungary, Italy, Latvia, Lithuania, Luxembourg, Netherlands, Portugal, Romania, Slovak Republic, Sweden, United Kingdom plus Norway (19 in Total) Disclaimer: The following responses have been provided primarily for the purpose of information exchange among EMN NCPs in the framework of the EMN. The contributing EMN NCPs have provided, to the best of their knowledge, information that is up-to-date, objective and reliable. Note, however, that the information provided does 1. Background Information The UK Government is considering various policy options regarding compulsory health insurance for migrants. Information from other EU countries is required urgently for an internal briefing paper to inform the discussions. The questions are as follows: 1. Could you provide a brief overview of the compulsory health insurance system in respect of migrants? 2. Do your border officers and entry clearance staff ask to see visa applicants and passengers insurance policies and check their validity and, if so, when? 1 of 11

2 3. Do you have a system of approved insurance providers? 4. How well does the system work e.g. are there many problems regarding compliance, cancelled policies or non disclosure of pre existing conditions? Please can you inform us about the total costs estimated for 2012 for the reception of asylum seekers? If available please provide a breakdown of these costs, this would be welcomed. Grateful for responses by 21 st February if possible, as information is required for urgent Ministerial briefing. However, we will still be happy to accept responses received as soon as possible after this date. 2. Responses Wider Dissemination? Austria No This EMN NCP has provided a response to the requesting EMN NCP. However, they have requested that it is not disseminated further. Belgium No This EMN NCP has provided a response to the requesting EMN NCP. However, they have requested that it is not disseminated further. Czech Republic Yes 1. Permanent residents, long-term residents employed by a firm whose place of business is in the Czech Republic (both EU/EEC citizens and their family members and third country nationals) and retired EU/EEC citizens who are long-term residents as well as their family members take part in public health insurance. Other EU/EEC citizens shall be provided free indispensable healthcare as EHIC holders. Other third country nationals must have private travel health insurance covering healthcare up to EUR. Outside public healthcare system, nationals of several third countries enjoy some extent of free healthcare provided for in bilateral agreements. 2. The officers of Department for Asylum and Migration Policy who decide on the applications are able to check with the insurance providers whether the contract is valid. 3. Yes. The registration of insurance providers can be checked on the website of the Czech National Bank. 4. According to advocates of inclusion of third country nationals in public health insurance, the major problem of private health insurance is the existence of several exclusions from coverage (such as chronic diseases, infections, congenital defects of newborn children). Estonia Yes 1. An alien staying in Estonia temporarily (up to 3 months within a 6 month period) and applying for an extension of stay has to possess health insurance contract, which will guarantee payment of his or her expenses related to illness or injury sustained during stay in Estonia. 2 of 11

3 Following aliens do not have to possess health insurance contract: 1) if she or he is a person insured under the compulsory health insurance according to the Health Insurance Act; 2) if she or he has an insurance contract that will cover his or her costs of treatment that arise from illness or injury in the same amount as in case of a person who has health insurance; 3) if such a clause is derived from an international agreement; 4) if treatment costs that arise from illness or injury are covered by another state or an international organisation. An airport transit and short-stay visa may be issued to an alien in accordance with the Visa Code. Article 15 of the Visa Code states that visa applicant shall prove that he or she is in a possession of adequate and valid travel medical insurance to cover any expenses which might arise in connection with repatriation for medical reasons, urgent medical attention and/or emergency hospital treatment or death, during his or her stay on the territory of the Member States. Long-stay visa may be issued to an alien who has a valid health insurance contract that will cover his or her treatment costs in case of illness or injury during the validity of the visa, in case of a multiple visa until the end of the first planned stay. If the alien is a person insured under the compulsory health insurance according to the Health Insurance Act or if treatment costs are covered by another state or an international organisation then the alien does not have to possess such health insurance contract. Temporary residence permit may be issued to an alien if the alien has insurance protection, which would cover costs arising from illness or injury. The insurance contract for the entire validity of the temporary residence permit has to be such that it would cover medical costs arising from injury or illness in an amount corresponding to that of a person with health insurance. Alien, who is a person insured under the compulsory health insurance according to the Health Insurance Act or if stated so in an international agreement, does not have to be in a possession of a said insurance contract. 2. At the request of a police officer a third country national has to present the health insurance contract when crossing the state border, if obligation to possess such a contract is laid out in a legal act. In practice, health insurance is checked in cases of random checks or there is a concrete reason/doubt. In a standard border crossing health insurance is not checked, but it is assumed that the alien has it, since it is one of the conditions when applying for a visa. 3. There is no such system. During different proceedings presented health insurance is evaluated whether it matched set criteria or not. In practice a list of accepted health insurances has evolved, but it isn t complete. 4. There are cases where an alien ends his or her insurance contract after receiving a residence permit, but Estonia s largest insurance companies inform the Police and Border Guard Board of aliens ending their insurance contracts. In such cases the Police and Border Guard Board have grounds to start proceedings for invalidating the residence permit. Finland Yes 1. According to Finnish Aliens Act issuing a residence permit requires that the alien has taken out insurance with a solvent and reliable company or institution covering health care services. If the estimated duration of the course of study is at least two years, it is sufficient for the insurance to cover the costs of medicines. 3 of 11

4 Students must attach details of their comprehensive health insurance cover to their application. Comprehensive insurance cover means insurance which includes the types of treatment and costs that are covered by municipal health care services and the health insurance system. For studies of less than two years in duration, a student must have private insurance which primarily covers the costs of medical treatment up to 100,000 Euros (cost level in 2007). Where the duration of the studies is two years or more, a student will usually have a home municipality in Finland and is therefore entitled to municipal health care services. In such cases, it is sufficient for the insurance to primarily cover the cost of medicines (in practice the cover extends to doctor s fees and costs of treatment and examination), up to 30,000 Euros (cost level in 2007). A student must have insurance cover when applying for a residence permit as without it a residence permit cannot be granted. In principle a residence permit cannot be issued for a period exceeding the period of the insurance cover. The student him- or herself is responsible for taking care of the health insurance being valid during the whole residence time in Finland 2. The Finnish Border Guard may ask to see whether the visa applicant or the passenger has a valid health insurance. If the health insurance is no longer valid, entry into Finland may be rejected since the grounds for issuing a visa are no longer met. 3. No, though some international insurance companies are mentioned as an example. Finnish Immigration Service utilises the knowledge of Finnish embassies abroad in order to approve new insurance providers. 4. So far Finnish Immigration Service has detected misuse only in few cases. Immigration Service finds it difficult to determine the content and cover of the health insurance provided by different insurance providers, since the certificates differ by their quality and information. It is possible that there are cases in which the insurance has been cancelled once the residence permit has been issued. After the first residence permit has been issued there is no check on the validity of the health insurance before extension of the residence permit becomes at stake. France Yes 1. For third country nationals, French authorities require a valid health insurance certificate as a prerequisite to obtaining a visa (except for students long term visa). Health insurance plan must be valid for the first three months of their stay in France and must comply with minimum coverage for health expenses of 30,000. In France, third country national are covered by the general laws on social and health insurance after three months of residence if they are in a regular situation as regards residence and work. The social insurance system is held by the French government (Social security). A third country national who regularly lives in France and who has not sufficient financial resources can apply for free health care for people on low incomes (CMU and supplementary CMU). Third country nationals who do not have a valid residence permit and sufficient resources and who can give proof of their presence on 4 of 11

5 French territory for a period exceeding three months can benefit from the free State Medical Aid (AME = Aide médicale d Etat) If a third country national is temporarily in France (less than 3 months), only emergency treatment and hospitalization will be covered by French Social Security. Third country nationals aged under 28 who study in an education institution in France are automatically affiliated to the student social security. Students aged over 28 have to be affiliated to the 'Caisse primaire d'assurance maladie' (local sickness insurance fund). Others are required to take out personal insurance with voluntary private insurance in France. 2. Yes. Border officers can ask to see visa applicants insurance policies and check their validity when they arrive in France. 3. Yes. Germany Yes 1. Asylum seekers, foreigners who are obliged to leave the country and foreigners whose stay in the country is due to a temporary purpose and who therefore receive the needed benefits for livelihood and accommodation in accordance with the Asylum Seeker Benefits Law (AsylbLG) receive the needed health care services also on this basis. All other migrants are insured by the general health insurance system. 2. Proof of the existence of the required health insurance must be provided prior to the granting of a visa abroad to the German mission in the respective country or prior to the granting of a residence title to the competent local foreigners authority in Germany. The visa checked at the immigration control hence proves that all required prerequisites, including the proof of a health insurance cover, are fulfilled. 3. In the visa procedure, the travel medical insurance must comply with requirements stipulated in Article 15 of Regulation (EC) No. 810/2009, dated 13 July 2009 (code on visas). According to this, the visa applicant always has to take out the insurance in his or her country of domicile; the consulates, however, check whether claims against the insurance company can be recovered in a Member State (Article 15 (4) and (5) of the code on visas). In the federal territory a health insurance can be taken out with every approved insurance company, whereas the only difference could be made by the question if a foreigner (normally as employee up to a specific salary limit) is insured by a compulsory health insurance or if he or she has to take out a private insurance. 4. Sometimes it can turn out to be difficult to ascertain if the insurance cover of a private health insurance provides the same benefits like those of a compulsory health insurance, which is a prerequisite for its recognition. In individual cases there might be problems with the provision of health insurance services, for example in case a foreigner possessing a private insurance stops paying the contributions upon having been granted his or her residence permit, which causes the loss of his or her insurance cover. However, fundamental or frequently occurring problems of a certain kind with the health insurance cover of migrants cannot be observed. Hungary Yes 1. One of the fundamental objectives of the Hungarian sickness insurance scheme is to include into the mandatory health system possibly all persons residing in Hungary. The mandatory health insurance scheme is perceived as a solidarity-based system of persons who reside in Hungary for longer periods. Those who form part of this risk-sharing mechanism are obliged to get affiliated. Those who are residing 5 of 11

6 here for shorter periods or those who are exempted from affiliation (e.g. members of international organisations and of diplomatic services) can join the system voluntarily. Secondly, affiliation to the system is always coupled with the payment of some kind of contributions. Affiliation is possible in more ways, however, the underlying logic requires the existence of financial coverage in every case, be it the insured person, the employer, a person resident in Hungary or a person who qualifies a foreigner but wishes to enter into a contract for health care benefits. The system is characterised by possibly aiming at the avoidance of discrimination based on nationality, because it links the right to benefits to the insured status. However, in case of foreigners several exceptional, differing rules are in place depending upon the length of stay of the foreigner in Hungary. These differences gain grounds partly in the membership of Hungary to the EU, partly in the existence of bilateral social policy and social security agreements, on the other hand in the application of provisions of aliens laws that determine the length of stay and possibility of migrants to create residence. The rights and obligations of migrants in social insurance, in particular in sickness insurance are fundamentally determined by the fact whether the migrant qualifies as insured or entitled person during his / her stay in Hungary. The insured and entitled persons are entitled to the same sickness benefits as Hungarian nationals. Migrants who do not fall under the ambit of Hungarian social insurance are in a different situation. In this case, at the first place, they are not entitled to sickness benefits and are required to finance their medical treatment on their own. In several cases migrants who are not insured in Hungary can have access to certain benefits (e.g. if an international agreement gives the right to benefits in Hungary or if the insurer of the persons has given prior authorisation for the benefit). The Act on social insurance (Act LXXX of Tbj) distinguishes basically three main categories from the point of view of eligibility to benefits: I. The insured persons fall within the first category, who, based on their economic activity and the related payment of contributions, are entitled to all sickness insurance benefits, including both in kind (medical) and cash benefits (Tbj. 5. ); II. The so-called entitled persons belong to the second category, who, based on their former insurance (e.g. pensioners) or on their actual status (e.g. minors or students), are entitled to in kind benefits, without being obliged to pay the health service contribution, these persons must have a residence in Hungary (Tbj. 16. ); o The persons who are not insured and not entitled persons in the main group II but are resident are obliged to pay the health service contribution and can only have access to in kind benefits, based on individual contribution payment (Tbj. 39. (2) paragraph); and finally III. Persons who enter into agreement with the Health Insurance Fund, based on their discretionary decision, belong to the third category, who are entitled to in kind benefits with the parallel application of some restrictive rules. The fee payable is 50 % of the minimum wage for adults and 30% of the minimum wage for minors. These persons are usually foreigners who are not resident (Tbj. 37. ). Several facts influence the decision as regards which category the migrant falls into. One of these is the purpose of stay of the migrant in Hungary, another whether he /she pursues an economic activity or not, moreover, his / her nationality is also important and whether he / 6 of 11

7 she has a residence in one of the EEA (European Economic Area) Member States. It is important to note that EEA nationals can access the resident status on the basis of Directive 2004/38/EC and thereby they can access the Hungarian health system in the I. and II. Categories while other migrants can access resident status in longer procedures. For migrants who are not EEA nationals a longer waiting period is foreseen to become residents. 2. Application for a visa at the border: The border guard poured out the visa application with the applicant and shall examine whether the applicant meets the requirements and whether the applicant can enter the country, after this the border quad checks the applicant in the SIS system as well as the validity of the travel document, the financial resources and grounds for refusal of entry, and citations the visa application to ION, who decides on the authorization. Travel valid visa: The border guard checks the passengers validity visa, valid travel document, sufficient means of subsistence and financial resources to cover their accommodation costs for the duration of the intended stay and for the return to their country of origin or transit to a third country. If the passengers have letter of invitation the guar may call the defendant in order to check the validity of the letter of invitation as well that the conditions are available. Health insurances: In the case of visas for a validity period not exceeding three months the entry cannot be denied if the passenger is not entitled to emergency treatment or the financial resources not covered the return to country of origin or transit to a third country. The guard can check EU-registered insurance. In Hungary 1000HUF (~3 ) / entry is the relevant requirement, if the passenger has not health insurance which is checked together with financial resources, difference is possible. 3. No. 4. No, at present there are no real problems with migrants in general. Italy Yes 1. The entry visa to Italy is not released if the applicant cannot prove to be in possession of a valid health insurance. 2. The entry to Italy is denied at the border if the applicant is not able to show to the police his/her insurance policy. 3. The local diplomatic site is responsible to establish whether the insurance providers really exist and provide adequate services. 4. The enrolment to the National Health Service is compulsory for regularly staying migrants who are employed or self-employed as well as to migrants who have applied for the stay permit renewal. In such cases, keeping the private insurance policy is an individual choice. Latvia Yes 1. All third-country nationals (unless they are family members of EU citizens) are required to provide a health insurance policy for all intended period of stay in Latvia. Family members of EU citizens should obtain a health insurance only in cases stipulated in Directive 2004/38 (if a sponsor is a student or person with sufficient financial means). 7 of 11

8 2. Yes. Visa applicants should show this document when receiving a visa sticker. Holders of residence permit - when they receive a residence permit. Health insurance policy may be checked at border control point. 3. No. Any health insurance policy valid in Latvia and if it covers medical expenses in amount at least EUR is accepted. 4. No. Office of Citizenship and Migration Affairs has non-written agreement with biggest insurance companies regarding information on cases when third-country citizen cancels insurance policy after s/he has been issued a residence permit. Such cases are exceptionally rare. There are problems with acquiring a health insurance for elderly people cost of insurance is very high. There are many complaints on inadequate services provided by insurance companies but mostly from people who have chosen the cheapest offers. Lithuania Yes 1. All foreigners who arrive to Lithuania for short stays or for residence (expect those who do not need a visa if they arrive for a short stay) must possess a private health insurance covering the period of their stay in Lithuania. In some exceptional cases the requirement to possess a health insurance may be not applicable (e.g. for older people if the insurance company declines to sell a health insurance due to old age and if a Lithuanian residents guarantees to cover medical expenses if such arise. Foreigners who come to work or study are covered by the state health insurance. 2. No. Health insurance is checked when issuing visa or residence permit. 3. No. A health insurance must be valid in Lithuania. 4. It works quite well. No major problems are identified. Problems sometimes arise with visa-free travellers who are not required to have health insurance. Luxembourg Yes 1. In Luxembourg any foreigner has to have a health insurance for entry and stay in the territory. Article 6 (1) 2 of the Law of 29 August 2008 on free movement of persons and immigration requires that if a EU citizen wants to stay more than three months and to obtain a registration certificate he has to probe that he has a valid health insurance for himself and his/her family (art. 6 (1) 2) 3), art. 8(2)). The EEA nationals and Swiss citizens are assimilated to EU nationals. In relation with third country nationals article 34 (2) 5 specifically state that the third country national has to probe for a stay below 3 months that he disposes of a valid health insurance covering all the potential risks in the territory. If the person wants to stay less than three months for family or private reasons a financial responsibility certificate made by the Luxembourgish resident, that has to be validate by the Passport and Visa Office, must also guarantee the financial responsibility for health insurance or to cover any health related expenses (art.34(3)). It is important to mention that if a third country national has the intention to stay more than three months he has to obtain before entering the territory an authorisation to stay (and if required a D-visa). Once he is on the territory he/she has to pass a compulsory medical examination (article 41) and a Lung X-ray in order to obtain the residence permit as a salaried worker he must produce an employment contract. In consequence the salaried worker is immediately affiliated to the Social Security agency. For obtaining the authorisation of stay as sportsman (art. 54 (1) 3), students and trainees (article 56 (1) 4, 60 (1) 7, 61 (1) 4), researchers (art. 66 (1) c) and for the authorisation of stay for private reasons (art. 78 (1) and 8 of 11

9 long term residency (art. 81 (1) 3), the third country national has to probe that he has a valid health insurance. In case of family reunification, the Luxemburgish resident must ask the National Health Fund, co-insurance of the family member (s). The border officers can ask a third country national at the external border to show the proof of health insurance and they can verify it before let the third country national inside the country. However, Luxembourg has only one external border (the International Airport) and there are very few flights that come outside the Schengen area so the third country national control is limited in this sense. 2. There are not approved insurance providers. 3. There are not statistics on the subject. The minister can proceed to make controls to verify if the fixed conditions for the entry and residency of foreigners are fulfilled (art. 133(1)) and to access by a direct informatics interface the files of the Social Security (Centre Commun de la Sécurite Sociale) related to the affiliations salaried workers, independent workers, and of the employers (art.138d) Also when the residence permit has to be renewed the requirement of a valid health insurance has to be fulfilled. It is important to mention that the Directorate of Immigration, the Inspectorate of Labour and Mines and the Grand-Ducal police acting at the request of the Minister can demand at any moment the probe of a valid health insurance. Portugal Yes 1. One of the requisites for granting visas, namely Temporary Stay Visas and Residence Visas for students is that the applicant must be covered by a Social Protection System which maintains its validity in national territory. 2. No. Without prejudice to specific checks performed in exceptional cases, as a rule, border control only covers the legal requirements related to the admission, including the existence of an adequate visa but disregarding the conditions that grounded the granting of that visa (visa requirements are analysed by consulates during visa granting procedure). However, upon the entry in national territory, lack of Health Insurance valid for Portugal or contracted with Insurance Companies based in our Country constitutes grounds for refusing extension of a Temporary Stay Visa, as well as to refuse the issuance of a residence permit for holders of a Residence Visa. 3. No. 4. Globally, one may say that this system works properly, and have no further remarks to be made. Romania Yes 1. A medical or a health insurance is compulsory when applying for a visa or for the granting or extension of the stay right 2. The existence of the medical/health insurance is checked when the application is submitted 3. In case the aliens are applying for a short stay visa they must provide for an international insurance In case the aliens are applying for granting/extending the stay right they must provide for an insurance issued by the National Health Insurance Office 4. Romanian authorities hasn t faced problems in this area. 9 of 11

10 Slovak Republic Yes 1. Generally, every individual with permanent residence in the Slovak Republic must have mandatory public health insurance. A thirdcountry national (outside EU/EEA) becomes mandatorily insured after obtaining permanent residence permit in Slovakia and fulfilling conditions stipulated by the Act on Health Insurance. An individual who does not have permanent residence in Slovakia must also have mandatory public health insurance (if he/she is not covered by health insurance in another EU/EEC member state), if such person is: Employed with an employer whose seat or permanent establishment is in Slovakia; A self-employed person in Slovakia; A student from another EU member state or a foreign student studying in Slovakia according to an international treaty; An asylum holder A minor foreigner staying in the territory of the Slovak Republic without a legal guardian or person responsible for his/her upbringing and is provided with care in a facility where he/she is placed on the basis of a court decision; A foreigner detained in Slovakia; In detention or serving a prison sentence; A dependent family member who was born to the insured person in another EU member state. Aside from others, the state pays compulsory public health insurance for a: Foreigner detained in the territory of the Slovak Republic Foreign student (in order to guarantee commitments from international treaties binding for the Slovak Republic) Asylum seeker However, the state guarantees health care (outside the framework of health insurance) also to the following categories of foreigners: Asylum seeker Applicant for temporary shelter Foreigner who was provided with temporary shelter Foreigner who was provided with additional protection (in certain cases). More detailed information about this topic can be found on the following website. 2. No. 3. No. 4. Sweden Yes 1. Students and other migrants intending to stay in Sweden less than a year, have to have a valid health insurance. This is to be shown at the time of application which is done at a Swedish foreign mission. Since they have to show it to migration authorities before a decision is 10 of 11

11 made there are no checks at the border. All this is in line with EU regulations. Those staying more than a year are regarded as settled in Sweden and are not obliged to have a health insurance since they are covered by the Swedish national health care system. Those applying for visa have to show a medical health insurance in line with the Schengen Visa Codex art Checks can be done by border authorities at the Schengen borders. The frequency of these checks is not known. 3. No. 4. Sweden does not face any problems. United Kingdom Yes 1. EEA nationals wishing to reside in the UK as a student or a self sufficient person and accession nations subject to transitional arrangements are required to have a comprehensive insurance policy or a valid European Health Insurance Card (EHIC) in line with EU Regulations. There are no requirements on other migrants to have compulsory medical insurance. 2. No checks are made by border officers or entry clearance officers. Those applying in the UK for documentation confirming their right to reside in the UK as a student or self-sufficient person or as nationals of new accession nations subject to transitional controls must provide the UK Border Agency with the compulsory insurance policy or EHIC. Where necessary, the validity of these documents will be checked. 3. No. 4. There is evidence that a number of policies are cancelled a short time after being obtained. Norway Yes 1. EU/EFTA nationals wishing to reside as a self sufficient person are required to have an adequate medical insurance covering all contingencies during their stay. Furthermore, medical insurance is a condition for being granted residence permit as an au pair. There are no requirements for other migrants to have compulsory medical insurance. 2. No. 3. No. Within the Local Schengen Cooperation the Member States share experiences regarding insurance providers who fail to comply with their financial obligations. Insurances from such companies are not accepted. 4. Non disclosure of pre existing conditions or insurance companies failing to comply with their obligations does occur from time to time, but is not regarded a serious problem. ************************ 11 of 11