Healthcare abroad: Countries without agreements with Italy

When travelling abroad, even for work reasons, one cannot take for granted his/her right to freely access state-provided healthcare. This becomes especially true when travelling in Countries outside the EU that have not signed any bilateral agreement with Italy. Let us see what the scenario is when this happens.

Healthcare abroad

Systems aimed at ensuring access to state-provided healthcare to temporarily residing foreign individuals, are in place all over the world. The European Union has regulated this subject so that its citizens, who are regularly insured in one of the Member States, can access necessary medical treatment during a temporary stay in another Country of the Union.

In addition to that, Countries all over the world have drafted and signed bilateral agreements, in order to foster access to healthcare for their respective citizens that temporarily resides in one Country, while remaining insured in the other one.

Despite all that, it is highly likely that an individual temporarily residing in a foreign Country, in which he does not benefit from an insurance, will not have access to state-provided healthcare. This is due to the absence of bilateral or multilateral agreements between the two Countries.

Healthcare abroad in Third Countries: the Italian regulation

As previously stated, in the context of Countries outside the European Union, one must separate two different scenarios. On the one hand, there is the matter of health cover in Countries with which a bilateral agreement is in force. On the other, the opposite case of Countries with which no agreement is in force.

The perspective of Italian citizens reflects this situation. In the eventuality of the former, it is agreement between the two Countries that regulates the access to healthcare for Italian citizens.

To understand what applies in case of the latter, instead, one must refer to Article 1 of Presidential Decree n. 618 of 1980, which reads as follows:

Health assistance to Italian citizens abroad, and to their entitled family members, for the entire duration of their stay outside Italian territory in connection with a work-related activity, is the responsibility of the State, which provides it in the modalities indicated in this Decree […].

Beneficiaries of the healthcare abroad

Article 1 of Presidential Decree n.618, 1980 narrows down the spectrum of the beneficiaries to the State assistance to those who are staying abroad for work reasons. Therefore, this already excludes tourists. However, it is Article 2 of that same Decree that better specifies who the beneficiaries are. It states, above all, that the state-provided assistance is granted to Italian citizens who are regularly insured in the National Health Care system, known as Servizio Sanitario Nazionale (SSN).

It then moves on to further specify the categories of insured citizens covered by this regulation. Excluding civil servants, and focusing on the private sector, here they are:

1. Nationals temporarily working abroad, employed or in a joint or associative relationship with enterprises or employers […];
2. Self-employed persons, including freelancers who work abroad for a limited period of time;
3. Holders of scholarships at foreign universities or foundations;
4. Workers abroad, temporarily unemployed, provided that this status is proven by certificates issued by the competent employment offices of the foreign State;
5. Citizens temporarily abroad in receipt of a pension paid by the State or by Italian social security institutions;
6. Family members of the persons referred to in the preceding numbers who follow the worker abroad or join him or her even for short periods.

What kind of healthcare is granted

The assistance granted to individuals matching the aforementioned criteria is an indirect one. An indirect assistance means that such individuals can receive healthcare in the foreign Country they are in, if necessary. However, they would have to pay in advance for it. Afterwards, they will be able claim their reimbursement through the Italian diplomatic mission in the Country where they received healthcare. This claim must happen within three months from the last expense borne for each sanitary necessity, following a specific procedure.

Reimbursement procedure: before departure

The first step to carry out in order to claim reimbursement of the healthcare expenses borne abroad is the request of the Attestation for healthcare abroad (ex Art. 15, Presidential Decree July 31st, 1980, N. 618). This request must be done before departure from Italy, at the competent Local Health Office (ASL).

This is necessary because such attestation is part of a long series of documents, which are necessary to present, either in person or digitally, to the Italian diplomatic mission in the Country where one received health care.

Reimbursement procedure: after having received healthcare

Here are the other documents one needs to present, should he/she incur in medical costs:

• indication of residence in Italy and of the territorially relevant ASL.
• application for reimbursement drawn up by the assistance beneficiary with the date of presentation and the stamp of the diplomatic representation.
• copy of the aforementioned Attestation for healthcare abroad (ex Art. 15, Presidential Decree July 31st, 1980, N. 618).
• reasoned opinion of the head of the diplomatic mission regarding the congruity of the prices, tariffs, local fees. It must also specify whether the assisted person was forced to go to a private facility in the absence/inadequacy of public facilities.
• tax code of the assistance beneficiary.
• medical certificate with diagnosis and/or medical report.
• in case of hospitalisation, a declaration by the health facility of its cost of general care in force.
• original expense documentation. This must be issued in accordance with the tax regulations in force in the country (invoices, payment receipts). It must also show the breakdown of the individual costs of the services.
• Italian translation of the documentation (except if this is in English or French).
• the holder’s domicile or bank account in Italy, with the relevant ABI/CAB and IBAN codes, as coordinates for the reimbursement.

After having checked the documentation, the Italian diplomatic mission sends it to the competent ASL. This Office, in turn, after another check, will set up the reimbursement of the medical costs.
However, should the Local Health Office judge the request as non-compliant, it will reject it.

Conclusion

In conclusion, workers temporarily sent abroad to a Third Country with no agreements in force with Italy, can still benefit from an indirect form of healthcare, following the procedure described above.

In the organization of work travels, it necessary to evaluate the convenience of this solution, compared or in addition to the acquisition of a direct assistance, through a private travel insurance, for instance.

The conditions of the public healthcare system abroad, in the Countries of one’sinterest, are vital in this decision. In fact, it is important to remember that the state-provided, indirect assistance discussed here, can only be obtained if the treatments are received in a public facility. If the one receives healthcare in a private facility, on the contrary, he/she will not obtain full reimbursement, except in case of inaccessibility or inadequacy of local public facilities, which  the Italian diplomatic mission in the Country must attest.