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Update on Medical Insurance

Since Bulgaria joined the European Union many questions were raised in relation to the scope of medical care, to which EU citizens are entitled during their stay in Bulgaria. Put another way, are EU citizens entitled to Bulgarian medical care and if they are, is it free or is there a charge?

It is not possible to cover thoroughly in the present article this boundless matter regulated by both the European Community Law and the Bulgarian legislation. We believe this is even not necessary, since it is a relatively new issue to most of the Bulgarians, but not to most of the British and Irish citizens, who live within the legal limits of the EU for a much longer period of time and know the basics in respect of your medical insurance rights and obligations throughout the European continent. We are hereby aim to explain some more practical issues and to try to answer specific questions, posed by Quest Bulgariamembers.

The European Community Law does not entirely harmonise the medical insurance systems of all member states, it does not impose mandatory obligations to the countries on what internal health insurance rules to create and how to organize their respective national medical insurance systems. The two Regulations in this field – No. 1408/71 and No. 574/72 are only designed to co-ordinate the operation of the different social and medical insurance systems and thus synchronize them and help them to co-operate for the benefit of the EU citizens who have the fundamental right to move freely within the borders of the EU. The main goals of this synchronization are:

1. To avoid unnecessary double insurance;

2. To eliminate unequal treatment of citizens of different countries within the territory of one EU country;

3. To overcome possible omissions in the medical insurance where one and the same person has paid insurance in several different countries within the EU.

In addition to the said two Regulations, the Bulgarian Medical Insurance Act is the third main piece of national legislation, which determines the field of application, the pre-conditions and terms of medical insurance and the scope of the medical care available.

It appears that the main differences in treatment come from the residential status of the person in question.

1. If you have a short term or long term permit to stay in Bulgaria (not a permanent residency), you are then not obliged to pay medical insurance in Bulgaria. Even more – the Bulgarian law does not provide for a procedure that would allow you to pay medical insurance in Bulgaria upon your own will and decision, if you are not a permanent resident. EU citizens that do not have permanent residence in a given EU country (including Bulgaria) are entitled, on the basis of their medical insurance in their state of permanent residence, to all medical treatment in any other EU country, as long as it is emergency treatment. Long-term stay in Bulgaria is granted by the authorities for a stay in the country of up to five years. Although, many readers have lived in Bulgaria for a fairly long period of time, most have not yet stayed five years here, which would allow you to obtain permanent residence. However, you still may wish to know, whether you would be able to obtain cheap medical treatment not only as a matter of emergency, but also in cases that are not urgent, e.g. dental care. Most dental services are not conducted in an emergency situation and can be quite expensive. This may make more attractive to you paying medical insurance in Bulgaria and getting full medical treatment in the country.

Unfortunately, the applicable rules and regulations in Bulgaria do not provide a straightforward answer. Led by your inquiries, we asked both at the National Revenue Agency and the National Health Insurance Fund, whether it is possible for an EU citizen to choose paying medical insurance in Bulgaria, although he/she does not reside here permanently. The answer came and it was a bit surprising: we simply do not know. The employees in these institutions are still trying to catch up with the increasing number of new sets of rules and procedures. No matter that they take special training courses, they are still not able to provide all answers in respect of medical insurance and they are not shy to admit it. Since the law also fails to provide any rules, we need to give an answer derived from application of other rules and general principle of law though analogy. Unfortunately, we have to conclude that, if you are not permanent resident in Bulgaria, not only you are not obliged to pay medical insurance, but you also may not do so, even if you wished. We hope that the Revenue and the Health Insurance authorities will be able to develop a practice that would provide for legislative changes to the contrary.

Our conclusion: EU citizens who are not residing permanently can make use of their medical insurance in their state of permanent residence by obtaining the well-known European Health Insurance Card. It is considered that apart from emergency medical care, this Card also allows for treatment of chronic conditions and diseases. You have to bear in mind that the European Health Insurance Card comes to replace the old form E-111, which is no longer valid. If you have the old one, you must obtain its replacement.

2. If you are residing permanently in Bulgaria and do not pay medical insurances elsewhere, then you will be obliged to pay medical insurance in Bulgaria. The basis is your income – the monthly instalment is currently equal to 6 % of your total income. If you have medical insurance in another country however, then all you need to do is obtain Form E-106, which will allow you to get the full package of medical treatment (not only emergency medical care) as any other Bulgarian citizen.

With regard to the EU citizens permanently residing in Bulgaria, the issue with changing their place of medical insurance is easily addressed – as soon as they stop paying their medical insurance elsewhere – they will (and are obliged to) start paying medical insurances in Bulgaria. Another question, important to us, which got the “We do not know” answer in both institutions quoted above, was: If you have income in another country, in which you are medically insured, but you also have income in Bulgaria, will you still be obliged to pay medical and all other insurances on that income? Two established legal principles conflict in this case – the principle for avoidance of being medically insured in two different EU countries, and the principle that all income is subjected to medical insurance and social security charges. We would rather suggest that you will have to pay medical insurance in as many EU countries, in which you have income, but neither the law nor the established practice of the competent authorities has provided the real answer yet.

A similar approach we would suggest also in respect of EU citizens, who are shareholders or directors in Bulgarian limited liability companies. If the company is “non-active” (dormant) and the shareholders and/or directors do not derive any income from it, they are not obliged to pay medical insurance. Medical insurance is definitely due by the shareholders and/or directors of Bulgarian limited liability companies, if the company provides income for them, if the shareholders and/or directors are permanently resident in the country. If they are only long-term residents, the question still remains in the ‘grey’ area of the law.

In respect of pensioners it is much more straightforward. All that a retired EU citizen, living in Bulgaria, has to do, is to get Form E-121 from their country of medical insurance, which will provide them full medical care, identical to the one provided to Bulgarians.

Finally, some hints on the level of medical treatment in Bulgaria may help you choose whether to bother trying to get free medical care in Bulgaria at all, or just make sure you pay when you are obliged to and observe the law:

  • Even if your country of medical insurance is Bulgaria, in order to obtain the right for free examination by a medical expert or for some more specific tests (in fact almost everything that cannot be provided by your GP), you need to prove to your GP that you really need it. GPs get a very limited number of the so-called “directions” for their registered patients and will not give you one, unless it is not really necessary. Otherwise, you have to go to the relevant specialist of your own will and pay for that.
  • Being medically insured in Bulgaria does not mean that all your medicines will be provided for free. There is a certain list of free medicines, determined by the Ministry of Health every year, but they relate to serious medical conditions only. In the most common case you are required to pay for your medicines.
  • The free dental care covers only the taking out of one tooth (as if you need it every year!) and two fillings (metal ones!) per year. In practice, these three free procedures are totally useless, so you normally always go to a private dentist – no one wants iron in his teeth in the 21st century.
  • To get to your GP for examination or for a free “direction”, most times you need to queue together with at least 10 pensioners, which may be quite annoying for an active and busy person.

Roumen V. Petrov
Asya Mandjukova
GPNG Law Firm