Benefits provided under cross-border healthcare

What you are entitled to

• If you are entitled to receive free healthcare benefits in Poland, the Cross-Border Directive (CBD) allows you to claim reimbursement of medical expenses incurred in another European Union (EU) or European Economic Area (EEA) Member State.
• Detailed regulations on the use of cross-border healthcare can be found in the Act on healthcare benefits (art. 42b-h).
• You can take advantage of services provided by both public and private healthcare operating in a EU/EEA Member State.
• You will be reimbursed only for guaranteed benefits, i.e. for healthcare benefits that people covered by general health insurance in Poland are eligible for.
• Your reimbursement:

• • might not exceed the amount of the actual expenses incurred
  • might not exceed the amount of funding for the same guaranteed benefit applied in settlements between the National Health Fund (Narodowy Fundusz Zdrowia - NFZ) and healthcare providers under contracts for the provision of healthcare benefits in Poland.

Exclusions - you will not be reimbursed for the following benefits:

• mandatory vaccinations
• long-term care the purpose of which is to support people in need of assistance in carrying out routine, everyday tasks
• allocation of and access to organs for the purpose of organ transplants.

Documents you need to obtain before taking advantage of benefits provided under cross-border healthcare

When you intend to use medical treatment

• a proper referral, when you intend to seek:
  • diagnostic tests and examinations
  • long term nursing care
  • specialist outpatient care, except in cases when a referral is not required for equivalent consultation sought in Poland
  • hospital treatment
  • therapeutic rehabilitation

• a proper referral for sanatorium resort treatment and the approval of the referral as to the advisability of the treatment
• a proper order for sanitary transport, including air transport
  • a referral or an order for sanitary transport may also be issued by a healthcare professional practising in another EU/EEA Member State.

• prior authorisation granted by the President of the NFZ in the case of healthcare services included in the list issued in pursuance to art. 42e(1) of the Act on healthcare benefits. See: Ordinance of the Minister of Health on the list of healthcare services requiring prior authorisation.

When you intend to buy medicines, foodstuffs intended for particular nutritional uses and medical devices

• a prescription or an order for the supply or maintenance of a medical device issued in another EU/EEA Member State
• a cross-border prescription or an order for the supply or maintenance of a medical device, issued in Poland by a healthcare professional who is authorised within the meaning of the Reimbursement Act, upon request of a patient who intends to have it filled in another EU/EEA Member State

You can also be reimbursed for medicines, foodstuffs intended for particular nutritional uses and medical devices if you were issued a prescription or an order for the supply or maintenance of a medical device in another EU/EEA Member State and you had it filled in Poland at full retail cost, as long as they have a status of guaranteed benefits in Poland.

When you intend to participate in a drug program or a health program

• confirmation of enrolment in the program.

In the case of benefits obtained within the scope of drug and health programs, reimbursement is also dependent on meeting the inclusion criteria for participation in the particular program.
If exclusion criteria emerge in the course of treatment under a drug program, the reimbursement shall cover the cost of the healthcare obtained prior to the occurrence of these circumstances.

Where you can get information on the approximate amount of reimbursement

Before you take advantage of a particular healthcare benefit in another EU/EEA Member State, you can seek information on the approximate amount of reimbursement you might be granted.

• You can seek information at the competent Regional Branch of the NFZ.
• You can use a dedicated form: Enquiry about the approximate amount of reimbursement.

The reimbursement amount estimated prior to receiving healthcare is for guidance only. The final amount will be calculated based on the documentation you submit with your request.

How you can claim reimbursement

• You can claim reimbursement by filing a request with the NFZ.
• If the recipient of the healthcare was a minor, file a request on their behalf acting as their statutory representative.
• You must pay the medical bill before filing the request for reimbursement.
• You can file your request within a maximum period of 6 months from the issuance of the medical bill.
• Your request will be considered under administrative procedure in accordance with the provisions of the Act on healthcare benefits (art. 42b-h).

Request for reimbursement

1. Fill out the reimbursement request form Downloadable and printable blank form (PDF format)
2. Compile the required documents

• the original medical bill containing:
  • the issuance date
  • the details of the bill issuer
  • the details of the recipient of the healthcare
  • information necessary to identify the benefit for which reimbursement is claimed - if this information is not on the bill, it should be included in the documentation submitted with the request.

Information necessary to identify the benefit for which reimbursement is claimed includes:

- information allowing to identify the codes of the International Classification of Medical Procedures ICD-9 and the International Statistical Classification of Diseases and Health Problems ICD-10

or

- details of the dispensed medicine, foodstuff intended for particular nutritional uses or medical device.

Upon request the healthcare provider is obliged to enter the required information in the documentation.

If you file your request electronically, attach a copy of the bill.

• the original payment receipt confirming that the healthcare was fully paid for - when this is not apparent from the attached bill
• the original or a copy (as appropriate) of:
  • the referral (or a printout of the e-referral) – only when you were not granted prior authorisation by the President of the NFZ
  • the order for sanitary transport – only when you were not granted prior authorisation by the President of the NFZ
  • the prescription/cross-border prescription
  • the order for the supply or maintenance of a medical device
• a confirmation of enrolment in a health program/drug program and a copy of your medical records – only when you were not granted prior authorisation by the President of the NFZ
• a copy of medical documentation demonstrating medical necessity for the prescribed medicine, foodstuff intended for particular nutritional uses or medical device – when the filled prescription was issued in another EU/EEA Member State
• translation into Polish of all the documents attached to the reimbursement request (including the bill) – when they were drawn up in a foreign language. It is not required that the translation be certified.

3. File the request and the required documents with the competent Regional Branch of the NFZ having jurisdiction over your place of residence:

• in person or by post

or

• in the form of an electronic document with a qualified electronic signature, personal signature or trusted signature; in that case, the required attachments can be submitted in the form of a digital copy.

Processing time

Reimbursement requests are processed in the order that they are received by the NFZ:

• within 30 days – when the request is complete
• within 60 days – when it is necessary to conduct explanatory proceedings

The time limits do not include:

– the period starting on the day the NFZ demands that the claimant remedy formal defects and ending on the day the defects are remedied, or on the day the deadline for doing so expires

– the period starting on the day the NFZ sends an enquiry to a national institution and ending on the day the response is received

• within 6 months – when it is necessary to conduct explanatory proceedings in cooperation with a national contact point for cross-border healthcare operating in another EU/EEA Member State.

If, in the course of the proceedings, the NFZ fails to unequivocally determine the due amount of reimbursement, reimbursement shall be made immediately after expiration of this deadline. In such case, the amount of reimbursement shall be equivalent to the amount deemed to be the most likely basis for reimbursement. Any doubts shall be resolved in favour of the claimant.

Decision on reimbursement

• If the filed request is complete and admissible in accordance with the applicable regulations, the President of the NFZ will issue a decision on reimbursement.
• The administrative proceedings will be conducted by the Director of the Regional Branch of the NFZ acting as the administrative body authorized to decide matters on behalf of the President of the NFZ.
• Your request will be refused in the following situations:
  • the healthcare you received is not a guaranteed benefit in Poland or it is excluded from the scope of the Directive
  • you failed to submit the required documents (referrals, orders, prescriptions) or you failed to comply with other formal requirements (for drug and health programs)
  • you were not granted prior authorization by the President of the NFZ for healthcare subject to such requirement
  • you failed to submit documents containing information allowing to identify the healthcare you had received
  • you failed to submit evidence that the received healthcare was fully paid for
  • the request was filed more than 6 months after the issuance of the bill
  • the healthcare for which reimbursement is sought was qualified by the NFZ for settlement under the coordination provisions set out in the Act on healthcare benefits

Find out about the differences between receiving treatment under the provisions of the Cross-Border Directive and under the coordination provisions.

• The decision of the President of the NFZ on granting or refusing reimbursement is final.
• If you disagree with the decision, you can challenge it by filing a complaint with the administrative court.
• A complaint against the decision of the President of the NFZ is lodged via the Director of the Regional Branch of the NFZ who issued the decision on his behalf.

Payment of the reimbursement

• The granted reimbursement will be paid out within 7 days of receipt by the NFZ of confirmation that the decision determining the due amount of reimbursement has been received by the claimant.
• The reimbursement will be paid out in PLN.
• The payment will be made according to the preferred method indicated in the request form. It can be:
  • a transfer to a bank account

or

• • a postal money order

What amount will be reimbursed

• The amount of reimbursement is calculated based on national rates, i.e. it will be equivalent to the amount of financing of the corresponding guaranteed benefit in Poland. Usually, the amount matches the price applied in settlements between the NFZ and the Polish healthcare providers.
• Your reimbursement might not exceed the amount of the actual expenses you incurred. This amount is calculated by converting the amount from the bill into PLN applying the average exchange rate of the given currency announced by the National Bank of Poland as of the day the bill was issued.

The rules for calculating the due amount of reimbursement are set out in art. 42c f the Act on healthcare benefits.