Reimbursement of expenses representing cross-border healthcare
PRESS RELEASE regarding the amendments made by the GD no.304 / 16.04.2014 regarding the reimbursement of expenses representing cross-border healthcare
The reimbursement of the value of the medical services benefited by the insured persons from the health insurance system in Romania who have moved to a Member State of the European Union in order to receive medical treatment is solved on the basis of a written request of the insured or a persons empowered by it, accompanied by supporting documents:
- copy the identity document of the person;
- medical document, including the admission ticket, the medical prescription for medicines and medical devices – in copy, from which it follows that the insured person has benefited from medical services, medicines and medical devices, dated and assumed by the medical framework that granted it (EU Member State);
- payment documents stating that the medical services, medicines and medical devices were paid in full by the insured, by a family member (parent, spouse, son / daughter) or by a person empowered by it;
- detailed invoices that include the level of the prices / prices separately for each medical service, medicine, medical device, including the date of their payment;
- eligibility documents if applicable *
- proof of prior authorization if applicable **
The translation into Romanian of the supporting documents by an authorized translator is the responsibility of the health insurance company.
After verifying the submitted documentation, the reimbursement will be made at the level of the Romanian tariffs provided in the Framework Contract regarding the conditions of the provision of medical assistance within the social health insurance system.
* The following eligibility criteria are respected cf GD 304/2014:
- hospital medical services were provided in another EU member state, following a medical evaluation performed by a medical professional providing medical services in the Romanian social insurance system, finalized by issuing an admission ticket, except for the situations provided in art. 1 no. crt. 2 and of the situations that fall within the criteria that allow the hospitalization without admission ticket provided in the Framework Contract regarding the conditions of the medical assistance in the social insurance system;
- the medicines for the outpatient treatment were granted in another member state of the European Union, as a result of a medical evaluation performed by a medical professional who provides medical services in the Romanian social insurance system, finalized by issuing a medical prescription in the conditions set out in the Framework Contract regarding the conditions for the provision of medical assistance within the social health insurance system and in the Technical Norms for the implementation of the national curative health programs;
- the medical devices in the outpatient treatment were granted in another Member State of the European Union, following a medical evaluation performed by a medical professional who provides medical services in the Romanian social insurance system, finalized by issuing a medical prescription and for which the health insurance house has issued an approval decision, under the conditions stipulated in the Framework Contract regarding the conditions of the provision of the medical assistance within the health insurance system;
** The type of medical care that is subject to prior authorization and the criteria that must be met in order to obtain prior authorization:
| Nr. crt. | The type of healthcare that is subject to prior authorization | Criteria to be met for obtaining prior authorization |
|---|---|---|
| 1. | PET-CT in ambulatory regime | Referral note accompanied by the approval decision issued by the committee of experts at the level of the National Health Insurance House according to the provisions of the Technical Norms for the realization of the national curative health programs |
| 2. |
Hospital medical services provided under continuous hospitalization - more than 24 hours hospitalization - for the following types of treatment:
|
It cannot be granted by any health unit with beds within a period that is medically reasonable, taking into account the current state of health and the probable evolution of the insured's illness, and the displacement of the requesting person does not prejudice the state of his health or the receipt of medical treatment. In this case, a medical report will be presented prepared by a doctor from a clinical hospital or, as the case may be, a county in contractual relations with a health insurance company in Romania. The model of the patient's medical report requesting the prior authorization for reimbursement of the value of the cross-border healthcare is provided in annex no. 1. |
Footnote:
- LAW 95/2006 Art. 913
- In case the health insurance companies do not approve the requests of the insured persons regarding the reimbursement of the value of the cross-border healthcare, they are obliged to communicate this in writing, indicating the legal basis, within the term provided in the methodological norms approved by Government decision.
- Insurers can appeal for the situation provided in par. (1) or against the level of the value of the reimbursed cross-border healthcare, at the health insurance house at which the insured person under the conditions of the Administrative Litigation Law no. 554/2004, as subsequently amended and supplemented.
- After the communication of the response to the appeal or the expiration of the term of response, the insured can address the administrative litigation court according to the provisions of Law no. 554/2004, as subsequently amended and supplemented.