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Expat Briefing Editorial Team
14 May, 2014
There remains much confusion over exactly who will have to pay the National Health Service’s new migrant levy, what they will have to pay for and how much they will have to pay. However, it seems that for expats originating from the UK, the situation with regard to NHS charging may be about to improve.
The Current Rules
According to existing guidance on entitlements to NHS care published by Public Health England (confusingly, different rules apply in Scotland and Wales), whether or not somebody is entitled to free hospital treatment depends on whether they are “ordinarily resident” in the UK, rather than on nationality, the amount of UK tax and national insurance contributions paid, or if they are registered with or referred by a general practitioner in the UK.
In this case, ordinary residence is broadly defined as living in the UK “on a lawful and properly settled basis”, although the principle is open to interpretation (see our previous weekly Expat Briefing on the new UK statutory residence test for an explanation of the UK’s residence rules).
Some people who are not considered ordinarily resident in the UK ('overseas visitors') are exempt from charges for NHS hospital treatment under the current Regulations, but all other patients are charged for treatment, except for treatment that is 'free to all'.
‘Free to all’ services include: treatment provided by a GP (including temporary patients who can register for between 24 hours and three months); emergency treatment at an Accident and Emergency department; family planning services; treatment for communicable and sexually transmitted diseases; diagnosis, treatment and counselling in relation to HIV; and those detained under the Mental Health Act or treatment for mental problems under the aegis of a court order.
As regards an individual taking up permanent residence in the UK and needing hospital treatment, they are normally exempt from any charge. However, they may be required to provide proof that they are legally entitled to remain in the UK and that they intended to live in the country on a permanent basis, as opposed to just visiting.
If the person does not have an automatic right to take up permanent residence but has applied to the Home Office for leave to enter/remain on a settled basis, they will be charged for any hospital treatment up to the point their application is granted or until they accrue 12 months lawful residence in the UK or are considered ordinarily, except for treatment that is ‘free to all’.
People who are visiting the UK from a country which has a bilateral healthcare agreement with the UK are exempt from charges for NHS hospital treatment in England, if the treatment is needed promptly for a condition that arose, or acutely worsened, after their arrival in the UK.
People from European Economic Area member states and Switzerland are also exempt from charge for treatment for chronic conditions, including routine monitoring, but must show a valid European Health Insurance Card (EHIC) or a Provisional Replacement Certificate. In neither case is pre-planned treatment included free of charge without special, prior arrangement.
In the UK, the EHIC provides access to free medical treatment which is seen, by a medical professional in the UK, to be clinically necessary and needed before the patient’s planned return to their home country. Visitors are also covered, with an EHIC, for the treatment and routine monitoring of pre-existing conditions.
In July 2013, the Government launched a consultation into plans to "tighten up on who is entitled to free NHS treatment" by introducing a "migrant health levy" on temporary migrants from outside the European Economic Area (EEA), and in December new proposals were outlined by the Government which included the following:
The good news for expats in all of this is that, according to the proposal document, all expatriates who return to reside in the UK will resume automatic qualification to free NHS services, while those returning on a visit will be entitled to NHS treatment if they have amassed a certain amount of national insurance contributions.
The paper explains: “Some but not all will benefit from exemptions if they return on a visit. We intend to extend this entitlement to any expatriate or former UK residents who have an extensive record of National Insurance contribution, and for this to cover their full medical needs.”
It goes on to state that: “Expatriate UK citizens who move to reside abroad currently lose their entitlement to free NHS treatment. They regain this if they return to live in the UK permanently but usually not when returning to visit. In line with the principle that everybody makes a fair contribution, we propose to confirm the entitlement of any person who has previously paid at least seven years of National Insurance contributions.”
The Government reckons that by deterring ‘health tourists’ the NHS will save around GBP500m per year.
“Having a universal health service free at the point of use rightly makes us the envy of the world, but we must make sure the system is fair to the hardworking British taxpayers who fund it,” said health minister Lord Howe. “We know that we need to make changes across the NHS to better identify and charge visitors and migrants. Introducing charging at primary care is the first step to achieving this.”
The Government was supposed to reveal further details of its proposals in March 2014 ready for introduction in April. However, the legislation needed to bring these new rules into force is contained in the Immigration Bill, which is still in the final stages of passage in parliament, so many aspects of the new regime remain unclear. And although a politically popular move, the new NHS charging scheme is not loved by many doctors themselves, who say it will be difficult to administer and hard to enforce.
Dr Mark Porter, Chair of British Medical Association Council, says that the proposals “could create unintended drawbacks for the NHS and patients”.
“They are likely to create a complex patchwork of charging and access entitlements where some services remain free, such as GP appointments, while others will be chargeable, including A&E visits and other services provided via many GP practices, such as physiotherapy”, he cautioned.
“There remains a real risk that some migrants and short term visitors who desperately need care could be discouraged from approaching the NHS if they cannot pay the proposed charges”, Dr Porter added. “There is particular confusion over access entitlements to emergency care services, given the proposals introduce charging for A&E visits yet say no patient will be turned away if they need care”.
Of course, the insurance industry says that the steady tightening of the rules determining who is and isn’t entitled to free care on the NHS merely underlines the necessity of health insurance for Britons living, or intending to live, abroad.
Research suggests that around 50% of those who leave the UK to live and work abroad do not take out international private medical insurance, thinking instead that they will automatically qualify for free NHS treatment, should an emergency arise.
Underlining the increasing cost of medical treatment at home and abroad for even the most apparently mundane complaints, Debbie Purser, managing director of Medicare International highlights two recent examples of on-going claims that MediCare International has settled on behalf of policyholders.
In the first, a 53 year old British male living and working aboard a luxury yacht went to a doctor in the USA complaining of chest pains. Extensive testing revealed a blocked artery which required an emergency stent to be fitted. The client continues to make a steady recovery, but obviously requires costly regular monitoring, with the result that medical bills of nearly GBP20,000 have been paid out over the last six months. The client is expected to make a good recovery.
In a second case, a 34 year old British male suffered a broken wrist following a fall whilst in Turkey. Although a full recovery is forecast, to date the costs of medical treatment and rehabilitation are nearly GBP13,000.
Such cases are a constant reminder of the everyday value and importance of having international private medical insurance, but it is the cost of treating cancers which can produce medical bills running into the tens of thousands of pounds, especially where a patient is moved between countries to access treatment. Two clients of MediCare with cancers who are currently being treated have so far run up bills over GBP65,000 and GBP262,000 respectively. In one case, having taken out worldwide cover, the client elected to be flown from Europe and treated in the USA in order to be able to access the highest standards of care. In the other, chemotherapy was started in Hong Kong, with the client being flown to London to complete the treatment.
“Cancers are now far more treatable than was the case 20 years ago,” said Purser. “However the cost of that treatment can be very high. At MediCare International, we will meet the cost of cancer diagnosis and treatment, both today and into the future, giving clients immense peace of mind.”
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