UK launches Global Health Insurance Card

The UK has announced that a Global Health Insurance Card (GHIC) will replace the existing European Health Insurance Cards (EHIC). The sheer complexity of the rules and the still emerging details creates a confusing picture. Ian Youngman reports on the current state of play for UK cross-border healthcare and possible impact on medical travel flows.

The UK’s new Global Health Insurance Card (GHIC) has recently been launched, but like much of the UK-EU deal, once beyond the headlines, the reality is more complex than what it replaced. Detailed guidance notes have been published, with new notes coming out daily.

Broadly, the new agreement ensures that the rights of UK residents to access emergency and medically necessary care when travelling in the EU will continue. This includes medically necessary treatment for a pre-existing or chronic condition. The specifics include the following:

EHICs still apply

UK residents and EHICs
Current EHICs are valid as long as they are in date and UK citizens can continue to use these when travelling to the EU.

EU residents and EHICs
Current EHICs are valid as long as they are in date and EU residents can continue to use these when travelling from the EU to the UK.

People visiting the UK from an EU country who fall ill or have a medical emergency during a temporary stay in England, can also still use a valid EHIC issued by their home country to access healthcare from the NHS.

The EHIC also still covers the treatment of pre-existing medical conditions and for routine maternity care, providing the reason for the visit is not specifically to give birth or receive treatment.

However, EU residents without an EHIC will be charged at 150% of the national NHS rate.

EU students
EU residents who are students at an accredited UK higher education institute in the UK on or before 31 December 2020, may use an EHIC for medically necessary healthcare until the end of the course, irrespective of nationality.

They must however apply to the EU Settlement Scheme if the course extends beyond 30 June 2021.

If a course of study in the UK begins after 1 January 2021 and lasts for more than 6 months, students will need to pay the immigration health surcharge as a part of the student visa application.

GHICs cover fewer countries

UK residents and GHICs
UK residents will now be able to apply for a UK GHIC, although they only need to apply for their new GHIC when their current EHIC expires.

The new GHIC card is free to obtain from the official GHIC website. People should apply at least two weeks before they plan to travel to ensure their card arrives on time.

Like the EHIC, the GHIC will offer equivalent protection for emergency and medically necessary healthcare needs when in the EU on a temporary stay, which includes holiday, study and business travel. The state-provided healthcare will be provided at a reduced cost or, in many cases, free of charge, until planned return home.

Necessary healthcare means healthcare that becomes medically necessary during the stay and for which they cannot reasonably wait until back in the UK to get. This includes medically necessary treatment for a pre-existing or chronic condition. Some treatments need to be pre-arranged with the relevant healthcare provider in the country being visited, for example kidney dialysis, oxygen therapy or chemotherapy.

EHIC and GHIC only apply to state healthcare, not private healthcare, although in some countries the difference between state and private healthcare is not as clear cut as in the UK.

GHIC covers fewer countries and for UK residents, neither the EHIC nor GHIC now apply in Switzerland, Liechtenstein, Norway or Iceland.

Like the advice on EHICs, the UK government continues to stress that anyone travelling overseas, whether to the EU or elsewhere in the world, should take out comprehensive travel insurance.

Cross border healthcare continues with Ireland

Under existing Common Travel Area arrangements with Ireland, UK residents will continue to be able to access necessary healthcare in Ireland by showing proof of residency documentation, such as a UK driving licence, a biometric residence permit, a Northern Irish medical card, or an EHIC or GHIC.

In line with longstanding commitments under the Common Travel Area, Irish citizens do not need to apply to the EU Settlement Scheme for treatment in the UK, although they may do so if they wish.

Irish citizens living in the UK will continue to access healthcare in the UK on the same terms as a UK resident.

EU settlement scheme

Any EU, EEA or Swiss citizen living in the UK can apply under the EU Settlement Scheme to continue living in the UK after 30 June 2021. With many caveats, they can then be regarded as a UK citizen for free NHS treatment.

UK expatriates

Because the NHS is a residency-based system, under NHS rules UK nationals who move abroad on a permanent basis lose their entitlement to free NHS healthcare.

UK nationals living and working in EU countries, Norway, Iceland, Liechtenstein or Switzerland on or before 31 December 2020 and their family members may be eligible to use NHS services without charge. They may be asked to provide evidence of residency.

Any UK national who moves to the EU on or after 1 January 2021, should not expect to be able to use NHS services for free when visiting the UK unless they have an EHIC, PRC or S2 to show healthcare costs are funded by the EU country in which they now live, or another exemption applies.

Some former UK residents do not have to pay for NHS treatment when visiting England. This includes UK war pensioners, UK government employees, and UK nationals living in the EU on or before 31 December 2020.

Will this impact UK medical tourism?

The definition of ‘necessary healthcare’ does not include healthcare where people travel specifically to receive medical treatment, so neither EHIC or GHIC cards cover planned medical tourism or going abroad to give birth.

Individuals who want to seek planned treatment in a member state may be covered under the broader healthcare arrangements with the EU. But from 2021 this now excludes UK citizens resident in the UK.

Some people may be able to request UK funding for planned treatment under the S2 route in Norway, Iceland, Liechtenstein or Switzerland (as well as EU countries) if they are:

• An EU, Swiss, Norwegian, Icelandic or Liechtenstein national, and have been living in the UK since before 1 January 2021.
• A UK State Pensioner living in the EEA or Switzerland since before 1 January 2021.
• A frontier worker who works in one state and lives in another, and have been one since before 1 January 2021, for as long only as they continue to be a frontier worker in the host state.
• A family member or dependant of one of the above.

For inbound medical treatment, different rules apply in England, Scotland, Wales and Northern Ireland. In England, for example, NHS England will need to be satisfied that the following eligibility criteria are met:

• The person is ordinarily resident in England and entitled to treatment on the NHS.
• The requested treatment would normally be provided on the NHS to that individual.
• The patient has provided written evidence that they have had a full clinical assessment by a clinician in either the UK, any EEA country, or Switzerland. The clinician’s statement must clearly state why the treatment sought is needed, and what the clinician considers to be a medically justifiable time period within which they should be treated again.
• The requested treatment is available under the treating country’s state healthcare scheme.
• NHS England has determined that the same or equivalent treatment cannot be provided on the NHS within a time period that’s medically justifiable.
• The requested treatment is not experimental or part of a drug trial.
• The requested treatment is not emergency treatment.

If the application under the S2 route is approved, the treatment will be provided under the same conditions of care and payment that would apply to residents of the country being treated in. This could mean they have to pay a percentage of the costs personally (a co-payment charge), as well as travel and accommodation costs.

In some countries, patients cover 25% of the costs of their state-provided treatment while the state covers the other 75%. If the patient received treatment under such a healthcare system, they would be expected to pay the same co-payment charge as a patient from that country.

Future developments

The UK is seeking to conclude new agreements on reciprocal healthcare, with the EEA EFTA States and with Switzerland.

Temporary deals
Until a new agreement is in place, the UK and Norway will apply, on a temporary basis, an amended version of the 1991 Convention on Social Security and Protocol on Medical Treatment between the governments of the UK and Norway. This includes medically necessary healthcare.

Reciprocal healthcare
The rest-of-the-world countries that the UK currently has reciprocal healthcare agreements with are Australia, New Zealand, some Crown Dependencies and overseas territories (such as Isle of Man, Jersey, Gibraltar), and some Balkan states (Bosnia, Serbia, Montenegro, Kosovo). Different proofs of eligibility are required under these agreements.

The following European countries do not accept the EHIC or GHIC:

• The Channel Islands, including Guernsey, Alderney and Sark
• The Isle of Man
• Monaco
• San Marino
• The Vatican

Travel bans

As no longer part of the EU, the UK is not part of travel deals agreed with all EU countries. This means that individual countries such as Spain and Portugal can apply travel bans to the UK without reference to EU partners, and have done so.

These changes may take some time to filter through the healthcare systems. With so many UK and EU hospitals franticly busy with the pandemic and vaccinations, it would be surprising if hospital managers or doctors have the bandwidth to process a fraction of the above.