There is a legal duty on the Trust to identify and charge patients who are not eligible for free NHS treatment under the National Health Service (Charges to Overseas Visitors) Regulations 2015.

The standard test is whether a patient is ‘ordinarily resident in the UK’ – but the rules regarding eligibility are complex and ultimately set by Government and there are many exemptions. For example, a patient may have paid the immigration health surcharge as part of their visa application or they may come from a country with reciprocal charging arrangements such as European Health Insurance cards (EHIC) – both of which means they would be exempt from charging.

Other exemption categories include asylum seekers and victims of modern slavery.

Asylum seekers (and their dependants) are individuals who have made a formal application to the Home Office to be granted asylum. Asylum seekers can be Identified by a green banner on their patient record when viewed through the National Care Record Service (NCRS) or confirmation from the Home Office.

Refugees (and their dependants) are individuals who have been granted asylum, temporary protection or humanitarian protection under the Immigration Rules. Refugees can be identified by a green banner on their patient record when viewed through the NCRS or confirmation of status by the Home Office

The process for determining whether an overseas patient is chargeable for NHS treatment can be complex, as chargeable status depends on the individual patient's circumstances, including their immigration status, ordinary residence and whether they meet any applicable exemption from NHS charges.

At the point of assessment, reasonable enquiries and supporting evidence are used to establish the patient's status. Where appropriate, the NHS may use Home Office systems to verify immigration status. Where the available information is unclear or contradictory, a Home Office status check may be requested.

Where a patient initially appears to be chargeable but subsequently provides evidence, or information is received from the Home Office, confirming that they are no longer chargeable, the patient's charging status should be updated. Any charges affected by the change in status should then be reviewed and, where appropriate, withdrawn or cancelled in accordance with the charging regulations and current guidance

In addition, some services in themselves are not charged for such as A&E and family planning services.

NHS Organisations do not have the power to waive or cancel charges, and the Secretary of State for Health and Social Care can only do so in certain situations where there are exceptional humanitarian reasons.

If chargeable, and if treatment is ‘immediately necessary’ or ‘urgent’ NHS providers must not withhold or delay treatment in order to establish charging status or obtain payment. The patient may still be charged afterwards, but treatment must proceed first.

So the Trust will provide treatment without asking for payment in advance but will provide the patient with an estimate of their treatment costs.

As maternity care is considered as immediately necessary it should not be delayed or withheld based on the patient’s chargeable status. Women must continue to be encouraged to access antenatal, intrapartum and postnatal care regardless of any potential charging status. While overseas visitors who require maternity services should be informed of possible charges and interim payments accepted if offered, no charges should be made and no debt collection should take place until after delivery or, if they leave the UK, prior to delivery. Concerns regarding charging must never create barriers to accessing maternity services

If patients do not have the means to pay, an assessment of affordability is conducted by the Trust, which may result in a payment plan to settle the debt over an extended period. The Trust has a legal duty to share the details of all patients with outstanding debt with the Home Office, information which may be taken into account in future immigration applications.

This guidance gives advice on charging overseas visitors for some NHS services, as required by law under the National Health Services (Charges to Overseas Visitors) Regulations 2015 . NHS Organisations do not have the power to waive or cancel charges, and the Secretary of State for Health and Social Care can only do so in certain situations where there are exceptional humanitarian reasons.

Some relevant NHS services are free at the point of delivery for everyone, either because they exempt from the charging regulations or because they are covered by a specific legal exemption in the charging regulations.  Overseas visitors are required to pay for NHS services unless they or the services they receive are exempt. An overseas visitor is defined as someone who is not ‘ordinarily resident’ in the UK.

Some overseas visitors are exempt from paying for relevant services, including asylum seekers and victims of modern slavery.

In some cases, an overseas visitor will be exempt because:

  • they have paid the immigration health surcharge (IHS) as part of their visa application. This gives them access to all NHS services on the same basis as an ordinary resident, except for assisted conception services, while their visa is valid.
  • they are covered by international healthcare arrangements. In such cases, the overseas visitor cannot be charged directly for most relevant services (subject to some limitations), but the NHS Organisation may still be able to claim back the cost of the patient’s care from the contracting state where a European Health Insurance Card (EHIC) A Provisional Replacement Certificate (PRC) is issued to qualifying EU or Swiss visitors in cases where an EHIC cannot be produced or certificate of entitlement to scheduled treatment (S2) has been used, depending on the nature of the arrangement.

The following relevant services are exempt, which means that an overseas visitor must not be charged for using them.

  • Accident and emergency services, providing the purpose of the visit was not for seeking treatment. This includes emergency ambulance services and all accident and emergency services provided at an NHS hospital - for example, those provided at an accident and emergency department, walk-in centre, minor injuries unit or urgent care centre. It does not include those emergency services provided after the overseas visitor has been accepted as an inpatient (for example, once a patient has been formally transferred from the care of accident and emergency and admitted to a hospital) or at a follow-up outpatient appointment, for which charges must be levied unless an exemption applies. services that are provided as part of the NHS 111 or telephone advice line commissioned by an ICB or NHS England, providing the purpose of the visit was not for seeking these services

 

  • Palliative care services provided by a registered palliative care charity or a community interest company, providing the purpose of the visit was not for seeking treatment

 

  • Treatment required as a result of specified types of violence, provided the patient has not travelled to the UK for the purposes of seeking such treatment. The exemption covers care for any physical or mental condition (whether acute or chronic) that a clinician determines has been caused by torture, FGM, domestic abuse or sexual violence.

 

  • Family planning services, which means services that supply contraceptive products and devices to prevent pregnancy, provided that the patient has not travelled to the UK for the purpose of seeking such treatment. This does not include termination of an established pregnancy

 

 

  • Diagnosis and treatment of sexually transmitted infections, including routine screening and vaccinations, provided that the patient has not travelled to the UK for the purpose of seeking such treatment

 

  • The diagnosis and treatment of specified diseases set out in schedule 1 of the charging regulations, providing the purpose of the visit was not for seeking treatment, unless it is by means of a form of transport which has been agreed with or funded by the Secretary of State. This includes routine screening and vaccinations, and any services required in the opinion of a clinician for the diagnosis and treatment of a suspected specified condition, up until the point that it is negatively diagnosed. The exemption does not extend to any secondary illness that may be present even if treatment is necessary to successfully treat the condition. The list of exempt diseases can be found in schedule 1 of the charging regulations  SCHEDULE 1.docx

The UK is party to several international reciprocal agreements patients who are covered by an international agreement are likely to be entitled to some services without charge. Overseas visitors will need to provide valid documentation to demonstrate that they are covered by a reciprocal healthcare arrangement. For the arrangements with the EU and EFTA   this will be an EHIC or PRC, S1 or S2. For countries outside of the EU and EFTA countries, the usual documentation is a passport issued by the relevant country and, often, other documents which prove residence in that territory.

If a visitor shows a valid EHIC or PRC, S2 or registered S1, the UK can claim back the cost of their treatment from that country.

If the patient cannot provide valid documentation and is not covered under another exemption category under the charging regulations, they must be charged for relevant services at 150% of the NHS Payment Scheme in the same way that other non-exempt overseas visitors are.

Patients can also take out travel insurance privately and depending on their policy may be able to recoup some or all of the charges.

Urgent or immediately necessary care must never be withheld or delayed because of charging issues. Failure to provide urgent or immediately necessary treatment may be unlawful under the Human Rights Act 1998. This means that treatment must go ahead even if the patient has not yet been informed of possible charges, or there are ongoing investigations into a patient’s charging status, or the patient has indicated that they are unable or unwilling to pay.

This does not mean that the charging regulations cease to apply in cases where urgent or immediately necessary care is required.

NHS Organisations must still charge overseas visitors (unless exempt) and obtain upfront payment if it is possible and appropriate to do so without causing a delay and should continue to inform patients of potential charges at the earliest possible opportunity.

Immediately necessary treatment

Immediately necessary treatment (which must include all maternity services) is any treatment which, in the opinion of a clinician, is needed to:

  • save a patient’s life
  • prevent a condition from becoming immediately life-threatening
  • prevent permanent serious damage from occurring

While urgency of treatment is a matter of clinical judgement, this does not mean that treatment should be unlimited; In many cases, a patient undergoing immediately necessary treatment may be able to be stabilised, allowing them to be safely discharged and giving them time to return home for further treatment rather than incurring further avoidable charges. 

Urgent treatment

Urgent treatment is any treatment which, in the opinion of a clinician, cannot wait until the person can be reasonably expected to leave the UK. If a patient requires urgent treatment, NHS Organisations are strongly advised to make every effort, taking account of the individual’s circumstances, to secure payment in the time before treatment is scheduled. However, if that proves impossible, treatment must not be delayed or withheld.

Consideration of the following 2 aspects when determining whether treatment is urgent: 

  • clinical considerations - for example:
  • the pain or disability a particular condition is causing
  • the risk that delay might mean a more involved or expensive medical intervention being required
  • the likelihood of a substantial and potentially life-threatening deterioration occurring in the patient’s condition if treatment is delayed until they leave the UK

Non-urgent treatment

Non-urgent treatment is treatment that can wait until the date a patient can reasonably be expected to leave the UK. NHS Organisations must not provide non-urgent treatment until the estimated full cost of treatment has been paid in advance of receiving treatment.

Maternity services include all antenatal, intrapartum and postnatal services provided to a pregnant women or person, a woman or person who has recently given birth, or a baby. While overseas visitors who require maternity services should be informed of possible charges and interim payments accepted if offered, no charges should be made and no debt collection should take place until after delivery or, if they leave the UK, prior to delivery.

Maternity services are chargeable but must be treated as being ‘immediately necessary’, with no patient having them denied or delayed based on their status as an overseas visitor or due to charging-related issues. If a maternity patient needs other treatment in addition to their maternity care, a separate assessment will need to be made as to whether it is immediately necessary, urgent or non-urgent.

These patients should also be made aware that accident and emergency services and primary medical services remain free to all.

The process for determining whether an overseas patient is chargeable for NHS treatment can be complex, as chargeable status depends on the individual patient's circumstances, including their immigration status, ordinary residence and whether they meet any applicable exemption from NHS charges.

At the point of assessment, reasonable enquiries and supporting evidence are used to establish the patient's status. Where appropriate, the NHS may use Home Office systems to verify immigration status. Where the available information is unclear or contradictory, a Home Office status check may be requested. The Home Office provides information about the individual's immigration status; the NHS is responsible for determining how that information affects the patient's liability for NHS charges.

A patient's chargeable status is not necessarily permanent. It must be kept under review because a patient's circumstances or immigration status may change during or after an episode of care. The current guidance specifically states that where a patient already has a chargeable status recorded, relevant bodies should still satisfy themselves that the status remains correct and up to date.

Where a patient initially appears to be chargeable but subsequently provides evidence, or information is received from the Home Office, confirming that they are no longer chargeable, the patient's charging status should be updated. Any charges affected by the change in status should then be reviewed and, where appropriate, withdrawn or cancelled in accordance with the charging regulations and current guidance.