2. Directive 2011/24/EU
Obligatory prior approval
Under the provisions of the Directive 2011/24/EU, transposed into the Compulsory Health Insurance Act, based on the fulfilment of all the prescribed provision, the insured persons are entitled to receive scheduled treatment even in private practices in other Member State of the European Union (EU) or the European Economic Area countries (EEA - Iceland, Liechtenstein and Norway).
• The exception are Switzerland and the United Kingdom of Great Britain and Northern Ireland as those countries are exempted from provisions of the Directive 2011/24/EU
Persons insured by the CHIF planning to undergo treatment at the private healthcare providers in EU/EEA countries need to request prior approval from the CHIF.
The CHIF is always obliged to check whether the person submitting the request for approval complies with the requirements for issuing the prior approval under Article 20 of the Regulation 883/04. If these Regulation requirements have been fulfilled, the prior approval is issued in accordance with the Regulation Uredbi 883/04, unless otherwise required by the insured person (Article 28 of the Compulsory Health Insurance Act).
Request for issuing prior approval
A written request for issuing the prior approval shall be submitted at the competent CHIF regional or branch office, according to your place of residence.
The request needs include the following:
-medical indication for the solicited treatment (medical history and other medical documentation from which the established indication for the requested healthcare service is evident),
-the scheduled date for the appointment in the contracted healthcare institution or conctracted private practice physician or contracted supplier of orthopaedic and other prostheses in the Republic of Croatia, as well as the
-dates available for the appointment, or the possible date of admittance to the healthcare provider in another Member State of the EU/EEA countries (Article 27 Compulsory Health Insurance Act).
Compulsory Health Insurance Act Article 28 stipulates the scenarios in which the insured person is obliged to acquire the prior approval.
This includes:
- when the treatment includes the accommodation of the insured person in a healthcare institution overnight, for the minimum of one night
- when the treatment includes utilising highly specialised and expensive medical infrastructure or medical equipment
- when the treatment in question presents a special risk for the insured person or the population, or
- when the healthcare service provider in another Member state might cause serious and special concern regarding the quality and safety of healthcare services provided, with the exception of healthcare ensuring the minimum level of safety and quality in its territory under the legislation of the European Union.
The list of the highly specialised and expensive medical infrastructure or medical equipment is established by the Decision on the list of treatment procedures provided as part of cross-border healthcare (Official Gazette, No. 133/13.).
Planned treatment approval
The treatment shall be approved providing it has been envisaged by the Croatian system of the compulsory health insurance and providing that the mentioned treatment cannot be received at the territory of Croatia within the medically justifiable time limit, taking into account your health condition and the expected course of your illness.
Reimbursement of the costs covered
In case that the approval is issued in accordance with the Directive 2011/24/EU, or Article 28 of the Compulsory Health Insurance Act, the insured person in another EU/EEA countries will always need to cover personally the cost of it in full.
In contrast to it, for the scheduled treatment carried out under Regulation 883/04, solely the amount for participation needs to be paid.
Upon the return to Croatia, the insured person has a right to submit a written request for the reimbursement of costs. The request is to be submitted with the regional or branch office that issued the approval for the planned treatment, and the person is entitled to reimbursement of costs in accordance with the Croatian tariff for the equivalent service (Croatian price).
The request needs to include the medical documentation on the healthcare services rendered, as well as the original invoice in the name of the insured person stipulating which healthcare services were rendered and that the invoice had been paid in full.
Request refusal
In accordance with Article 29 of the Compulsory Health Insurance Act, the CHIF retains the right to refuse to issue the prior approval issued for cross-border healthcare, if:
– the insured person will, according to clinical assessment, without a doubt be exposed to a risk that cannot be considered acceptable, taking into account the potential benefit of the cross-border healthcare solicited for the insured person,
– citizens of Croatia will unequivocally be exposed to a substantial security risk because of the requested cross-border healthcare service,
– the healthcare can be provided by contracted entities of the CHIF within the time-limit that is medically justifiable, taking into account the current health state and the expected course of the insured person’s illness.
Undergoing the treatment without prior approval
If the planned medical treatment under Directive 2011/24/EU is carried out in another EU/EEA countries without receiving prior approval from the CHIF, there are no grounds on which the CHIF can reimburse the insured person for the received treatment.
