Foreign nationals’ entitlement to healthcare and health insurance status

A duo of Bulgarian statutes govern the healthcare entitlement of foreign natonals - the Health Insurance Act and Public Health Act. These acts provide that foreign citizens, who have obtained the right to permanently reside in Bulgaria are entitled to the same scope of healthcare services as Bulgarians and to all services that are normally covered by the Bulgarian National Health Insurance Fund. On the other hand, possession of permanent residence obligates foreign nationals to make health insurance contributions in essentially the same way as Bulgarian citizens would.

Foreign nationals with the right to long-term residence, as well as stateless persons, refugees, persons to whom a humanitarian status has been conceded, and persons with the right of asylum in Bulgaria, are also entitled to medical services, paid for by the Bulgarian National Health Insurance Fund (NHIF). Persons in the process of applying for refugee or asylum-seeker status are, statutorily, to be health-insured by provision in the national budget.

Foreign nationals employed in Bulgaria are insured in the same manner as Bulgarians since by being employed in Bulgaria, foreign citizens obtain a work permit and residence permit. Having the entitlements goes hand in hand with the respective obligations to insure.

On the other hand, foreign citizens with only the right to short-term residence (90 days in a 6-months period), as well as persons with dual Bulgarian and foreign citizenship, and for whom there is no special provisions in an international agreement, are expected to pay the cost of the medical services provided.

The payment for medical services provided to foreign citizens who are only short-term residents is governed by the Regulations for Applying the Public Health Act, and, by the 2001 Regulation for the Medical Treatment of Foreigners on the Bulgarian Territory. As per these, foreigners entitled to short-term residence, as well as persons with dual Bulgarian and foreign citizenship, who are not paying health insurance contributions to the NHIF, shall pay for the cost of medical services they have been provided with, unless otherwise provided in an international agreement to which Bulgaria is a signatory.

The 2001 Regulation provides that medical costs for services rendered by the Centres for Blood Transfusion or by the Centres for In-patient Psychiatric Care are fixed (arranged in a schedule to the same regulation). The respective costs of all other types of medical service are not fixed and are determined by each medical institution by reference to the market. As per the 2001 Regulation, medical institutions can independently determine the means and time-limits for payment for the medical services they provide, and are obliged to exhibit in the reception area of their facility the following information:

- the prices of all medical services offered;
- the instances in which patients are required to pay for the treatment;
- the time-limits and method of payment for the services provided.

In addition, a physician who admits a foreign national to a hospital, has a duty to inform the foreign national of the above, as well as about the type of treatment to be applied, and the duration of the treatment. At the inception of treatment in the hospital, an estimate account of the cost of medical treatment has to be provided to the foreign national. Such an estimate of account becomes final at the end of the treatment after including any additional services. An invoice for the cost of the services is produced in three separate copies – one for the patient and two for the hospital.

The cost of out-patient medical services is payable in advance since the cost of these services can be determined preliminarily. Again, an invoice for the services has to be produced and presented to the patient.

But how far can foreign citizens rely on guaranteed admission, even where they are happy to pay? As per art. 92, para. 5 of the Law on Medical Institutions, state and municipal hospitals can accept for treatment paying patients but such patients cannot exceed 10% of their bed capacity. In cases when the provision of medical services are governed by a contract between the hospital and the NHIF, the hospital can determine freely the price of its services. Any income a hospital receives this way becomes part of its general profit.

Short-term residence foreign citizens and stateless persons who enter or transit Bulgaria must have purchased medical insurance. In case emergency medical treatment has been rendered, the manager of the medical institution informs the foreigner’s insurance company or the intermediary insurance company about the identity of the foreign patient, the diagnosis, the intensity of the treatment and the cost of the treatment.

Foreign states’ embassies in Bulgaria are obliged by Bulgarian law to provide for the medical treatment of foreign citizens, who do not possess medical insurance and do not have the means to pay for the cost of the treatment.

Finally, the Health Insurance Act provides that private Bulgarian health insurance companies can enter into agreements with foreign-based national health and insurance companies to assure the medical treatment of foreign citizens during their stay on the territory of Bulgaria. Thus, the foreign nationals would not pay directly for the cost of treatment, which is reimbursed by their home country’s national insurance scheme. The function of the Bulgarian health insurance company is as an intermediary between the foreign citizens’ health insurance funds and the Bulgarian medical institutions.