Prior-authorization for planned treatments abroad

Rules and procedures of planned medical treatments abroad.

Kulcsszavak: application for treatment abroad; institution proposed by the applicant for medical treatment abroad; medical details; S2 form; expert opinion; Health Care College (Egészségügyi Szakmai Kollégium), treatment not available in Hungary; medical justification

Prior approval is required for planned medical treatments in another EEA Member State at the expense of the social security scheme. Applications are made by filling in the specific form which can be downloaded from the website of the National Institute of Health Insurance Fund Management (Hungarian acronym: NEAK). The completed form should be posted, with the relevant documentation, a confirmation of admission, treatment and budget plan from the host hospital.

The form is an Annex to Government Decree 340/2013 (IX.25) and can be downloaded from the following link:

http://neak.gov.hu/nyomtatvanytar/temp_sc_532993.html

These proceedings are governed by the rules on administrative authority procedures and may take a maximum of 60 days from the receipt of the application (not including requests for expert assistance (8 to 21 days) and any corrective actions (15 to 45 days). Subsequent reimbursement is also governed by administrative authority procedures with deadlines of 8 or 60 days.

Annex 2 of Government Decree 340/2013 (IX.25.) laying down detailed rules on medical treatment abroad; relevant documentation; a confirmation of admission, a detailed treatment plan, and a quote from the host health care institution.

The procedure is free of charge.

The National Institute of Health Insurance Fund Management (Hungarian acronym: NEAK) has exclusive competence for this case type.

http://neak.gov.hu/felso_menu/lakossagnak/ellatas_kulfoldon/tervezett_kulfoldi_gyogykezeles

 

As a general rule, decisions specified in EU regulations and directives may be challenged by appeal. However, decisions may also be made based on considerations of equity and such decisions may be contested before a court on the grounds of infringement, within 30 days from the communication thereof.

In each case, the acting authority will inform applicants of the appeal procedure in its decision.

 

The different procedures via the regulation, directive and equity ‘path’ are described in detail on the NEAK website under the link mentioned above. In brief, when a requested benefit (treatment) is not admitted or accepted in Hungary that is where the ‘equity path’ becomes relevant. The next question could be the definition of ‘admitted treatment’ and whether there is an exhaustive list somewhere and how can an ‘admitted treatment’ be ‘not accepted’. If our purpose is to give the party a brief and concise description, it is recommended to avoid such explanations. The decisions of NEAK always emphasise in the operative part whether appeals are possible and, if so, how they should be submitted.

 

In each case, it is common practice that:

In procedures initiated on request, the form in Annex 2 of the Government Decree is completed with the applicant’s personal and medical details and submitted by the applicant (i.e. the patient, the practitioner or a family member of the patient) in each case, together with the relevant medical documentation. If the application is incomplete, NEAK will ask the applicant to correct the deficiencies. Two outcomes are possible if the time limit for correcting deficiencies elapses without any result: NEAK will terminate the procedure, or it will give a decision based on the documents available. NEAK will examine the application against both the formal and substantive requirements. It will assess whether the applicant has Hungarian social insurance coverage, and whether the treatment being sought abroad qualifies as one admitted and financed by the Hungarian social security scheme.

If so, the procedure will continue on the regulation or directive ‘path’.

If the treatment is not admitted in Hungary, or the application involves treatment that is not available in Hungary, assessment of the application will take the equity ‘path’. (In the latter case, the applicant also has to justify a so-called ‘reasonable health gain’.)

If the assessment focus is on whether a treatment abroad under a regulation or a directive is necessary, a medically-based treatment period will be established for the applicant after an admissibility check. NEAK will engage external experts to determine a medically-based treatment period. The experts will conduct an examination and submit their findings with documentation to NEAK.

 

In order to protect the National Health Insurance Fund, NEAK will look for – relying on expert opinion – a Hungarian public health care provider to treat the applicant within the medically-based treatment period, and outside the scope of the performance volume limit (Hungarian acronym: TVK) and the obligation to provide in-area (regional) care (Hungarian acronym: TEK). If an eligible health care provider is available, the application for treatment abroad will be rejected. At the same time, confirmation is sent about the provider who can offer treatment in Hungary.

If no public health care provider is available to perform the treatment within the medically-based period, NEAK may verify the eligibility of the public EU health care provider proposed by the applicant.

 

If an applicant opts for the ‘regulation path’ (i.e. by choosing full compensation for treatment on the S2 form), NEAK will have the right to explore other public EU health care providers, if the provider proposed by the applicant offers to treat the applicant for a sum that exceeds the price in Hungary by 30%.

 

If applicants prefer the ‘directive path’, they may propose and choose a private health care provider within the EU. However, they will be compensated for Hungarian costs and only after the treatment.

 

In procedures based on equity considerations, medical justification of a treatment unavailable in Hungary will be assessed by the competent branch of the national Health Care College (Egészségügyi Szakmai Kollégium). As a general rule, preferred health care providers must be a public EU institutions.

 

Reimbursement by NEAK will cover treatment costs to the extent of the appropriation.  Accommodation and interpreter costs will not be reimbursed. Reimbursement of travel expenses is available on request and granted based on equity considerations.

 

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