Hongrie : information sur le système de soins de santé, y compris les exigences et la marche à suivre pour obtenir une assurance maladie, les populations couvertes et les services offerts; information indiquant si une contribution personnelle est exigée pour les services de soins de santé (2015-août 2017)

Research Directorate, Immigration and Refugee Board of Canada, Ottawa

In correspondence with the Research Directorate, an official from the Embassy of Hungary in Ottawa provided information obtained from the Hungarian Ministry of Human Capacities (HMHC), which indicated that the Hungarian healthcare system is based on "the right to benefits in exchange for contributions" (Hungary 8 Sept. 2017). Both health insurance contributions and "direct" government transfers fund the healthcare system (ibid.). The same source adds that healthcare membership is compulsory for all residents of Hungary (ibid.).

1. Services Provided by the Hungarian Healthcare System

According to the information provided by the official from the Embassy, the Hungarian healthcare system provides both for benefits in kind and for benefits in cash (Hungary 8 Sept. 2017). According to the website of the National Health Insurance Fund (Országos Egészségbiztosítási Pénztár, OEP) of Hungary,

benefits in kind [include] cost-free healthcare services such as preventive examinations, primary healthcare, specialised inpatient care, specialised outpatient care, certain dental care, rehabilitation, the ambulance service, patient transport and accident-related benefits, drug reimbursement, reimbursement for medical aids, medical spa services, reimbursement of travel expenses and benefits granted on the grounds of equity.

Cash benefits … include sickness benefit, prenatal allowance, child care fee and accident-related benefits. (Hungary n.d.)

The Embassy official indicated that healthcare beneficiaries are either "holders of the right" or "entitled beneficiaries" (Hungary 8 Sept. 2017). Holders of the right are individuals who have a "statutory" obligation to pay contributions and they are entitled to the full range of health benefits, i.e. "cash benefits, benefits in kind and accident allowances" (ibid.). They include:

general employees, civil servants, public service employees, service providers and people with other legal working arrangements, the self-employed working alone or in collective organizations, ecclesiastical personnel and members of associations. … [They also include] people receiving assistance while looking for work, who pay pension contributions on their benefits although they are not entitled to cash benefits. (ibid.)

According to the same source, entitled beneficiaries are not entitled to cash benefits (ibid.). They are:

minors, schoolchildren, students studying during the day, pensioners, people on low incomes who have reached retirement age, those receiving cash maternity and social protection benefits, person placed in residential institutions providing personal care and those required to pay flat rate contributions. (ibid.)

An individual's contribution to health insurance is 7 percent of the individual's gross salary, namely 3 percent for cash benefits and 4 percent for benefits in kind (ibid.). For individuals who are entitled beneficiaries, a monthly contribution of 5,790 Hungarian forints (HUF) [C$28] per person is paid by the "central budget" to the OEP (ibid.).

The information in the remainder of this section is taken from a factsheet on health insurance in Hungary published on the website of the European Commission 's Directorate-General on Employment, Social Affairs & Inclusion:

Medical care services provided in Hungary are, "as a general rule, free of charge." Should the treatment not be prescribed, or should the treatment not be provided in the "normal hospital system," or should the patient choose a doctor other than the one designated by the healthcare system, fees may be required by the care provider and they have to be paid by patients.

Dental treatments are free of charge up to the age of 18, but each individual pays for the technical costs associated with dental treatment. Students, seniors who are at least 60 years old, and pregnant women ("from the determination of pregnancy until 90 days after childbirth") are entitled to dental services free of charge, but they still have to pay for the technical fees. "According to the [OEP]", dental treatments are covered by "the social security system" in emergency cases.

Home care is covered for the same length of time as the same treatment would require in a hospital setting, provided that the practitioner signed a contract with the OEP and is prescribed by a specialist.

"[M]ost" preventive care is provided by the patient's doctor. Early detection and screening tests are, "with certain exceptions[,]" voluntary, but can be recommended by nurses, school doctors or by appropriate specialists and "may in some cases" be a necessary requirement for "some" medical treatments to be free; patients who fail to take advantage of screening or early detection tests may be charged for treatments they need.

Inpatient specialized care is provided in hospitals, national institutions for "highly" specialized care, university clinics, day-care hospitals and other institutions "for chronic, rehabilitation or nursing care". Without providing further information, the same source further states that

• [p]atients being treated in hospitals receive the following services for the flat-rate daily charge:
• diagnostic examinations related to the illness;
• the treatment prescribed by a doctor, including surgical operations, therapeutic equipment used during these and prosthetic appliances;
• medicines, blood tests, dressings and curative accessories;
• therapeutic care;
• dietary advice and healthy living advice;
• food, as part of a diet prescribed by the doctor;
• care in a convalescent home, for as long as required by their condition, depending on availability and the ethical and professional considerations involved. (EU n.d.)

1.1. Out-of-Pocket Expenses

The World Health Organization (WHO) indicates that, in 2014, the out-of-pocket expenditure as a percentage of total expenditure on healthcare in Hungary amounted to 26.59 percent (UN 11 July 2017a). According to the same source, the out-of-pocket expenditure as a percentage of total spending on healthcare in Canada is 13.60 percent for 2014 (ibid. 11 July 2017b).

The information provided by the official from the Hungarian Embassy indicated, without providing further details, that

[p]artial reimbursement fees must be paid by the insured persons in the following cases:

interventions to alter external sex characteristics, unless the purpose is to develop genetically defined non-exterior portions due to a developmental disorder;

[t]ooth restoration to restore mastication;

[o]rthodontic device[s] under the age of 18.

Supplementary fees must be paid for the following benefits:

other comfort services provided on [the basis of] the patient's own initiative, and

if justified by the condition of the patient, care in the nursing department on the basis of medical referral ([which includes] medicines and meals as well). (Hungary 8 Sept. 2017)

The same source stated that healthcare facilities must clearly indicate the service they provide and the fees associated with them, and that patients should be informed before receiving treatments (ibid.).

The European Commission factsheet indicates that in order to be reimbursed, medical appliances must be prescribed by a doctor (EU n.d.). The amount covered is a percentage of the price of the appliance and for appliances in the "highest reimbursement category, any co-payment for appliances in excess of 5,000 HUF [C$24.50]" is paid by the OEP (ibid.).

2. Population Covered

The Organisation for Economic Co-Operation and Development (OECD)'s online statistical platform indicates that, in 2015, an estimated 95 percent of the population of Hungary had healthcare coverage, which represents approximately 9.3 million individuals (OECD n.d.). In 2010, an estimated 97 percent had healthcare coverage, which then amounted to approximately 9.6 million individuals (ibid.). According to the same source, 100 percent of Canada's population had healthcare coverage in 2016 and in 2010 (ibid.). However, the information provided by the official from the Hungarian Embassy indicated that "virtually" the entire population of Hungary is covered for healthcare and that less than 1 percent of the population is not covered (Hungary 8 Sept. 2017).

The same source further stated that every employed individual is "automatically affiliated with the health insurance scheme" as soon as employment begins (ibid.). According to the same source, self-employed individuals register themselves for health insurance, while employers register their employees (ibid.). The European Commission's factsheet further explains that employers register their employees with the bureau of taxation and finance or with the competent social insurance organisations (EU n.d.). The information provided by the Embassy official noted that employers "should take care of the necessary paperwork," but that it can be requested by individuals at "all government offices" (Hungary 8 Sept. 2017).

According to the same source, self-employed individuals "who perform activities in a complementary way or their joint ventures," or any person not insured or not entitled to healthcare insurance must pay a contribution, which amounts to 7,110 HUF (C$34) a month in cases where the person continuously resides in Hungary for a year (ibid.).

2.1 Healthcare by Agreement

According to the information provided to the Embassy official, individuals who are either not insured or not entitled to healthcare coverage may enter into "contractual arrangements" with the National Health Insurance Office (Hungary 8 Sept. 2017). The website of the OEP further explains that individuals not entitled [translation] "by any other laws" to receive healthcare services for themselves, or for their children living with them, can enter into an agreement to receive services (Hungary 23 Feb. 2017). The same source notes that an agreement can be signed by a third party who accepts to pay for the patient's healthcare services (ibid.).

Individuals who enter into a contractual arrangement are entitled only to benefits in kind (Hungary 8 Sept. 2017). In that case, a "special certificate" proves an individual's entitlement to emergency care (ibid.). Other benefits in kind are available to the individual who enter into a contractual arrangement once the monthly fees for 24 months have been paid (ibid.). The OEP further explains that individuals entitled to healthcare services through an agreement can only avail themselves of emergency dental treatment with a subsidy, they cannot be covered for medical treatments offered in another country which are not also offered in Hungary, and they are not entitled to healthcare services in the European Economic Area (EEA) member States or in a federal State, which means that they cannot be [translation] "put on a transplantation waiting list" (Hungary 23 Feb. 2017).

The information in the remainder of this section is taken from the OEP website:

The procedure to enter into an agreement for healthcare services requires providing and verifying the following documents:

[translation]

• verification of identity: ID card (including temporary ID), valid passport, driver's licence (the beneficiary in the agreement must also be verified),
• document verifying the address, residence or accommodation of the beneficiary,
• in the case of a foreign citizen, the document permitting the residency issued by the authorities responsible for foreigners (not including the residency permit for the purpose of medical treatment and the local border traffic permit), and
• in the case of full-time students, the certificate of school attendance.

If the person entering into an agreement to receive healthcare services is an adult, then 50 percent of the minimum wage [127,500 HUF (C$607) in 2017], must be paid monthly from the day the agreement is signed, which amounts to 63,750 HUF (C$304). Should the person be under the age of 18, the monthly contribution is 30 percent of the minimum wage, approximately 38,250 HUF (C$182). Foreign citizens who are attending a [translation] "regular, full-time program" in an educational institution in Hungary must also make a monthly contribution of 30 percent of the minimum wage. In all cases, the first 3 months must be paid at the time of signing the agreement, and monthly payments are due thereafter by the 12th of the month preceding the one for which payment is due.

The agreement [translation] "ceases to exist" if monthly contributions are not paid by the patient. Should the patient not pay a monthly contribution, the agreement ends on the last day of the month for which the patient missed a payment. The agreement can be terminated with a written notice by either party. The patient does not need to provide any reason, whereas the health insurance provider is allowed to terminate the agreement if a change in the patient's legal status would prevent the patient from entering into the agreement. After the contractual arrangement has ended, patients are not entitled to healthcare services for the 45-day "entitlement based on passive rights." (Hungary 23 Feb. 2017).

3. Health Insurance Card (TAJ Card)

According to information provided to the Embassy official, national health insurance card ("TAJ card"), together with a health insurance number ("TAJ number"), are issued to insured individuals (Hungary 8 Sept. 2017). The OEP states that the TAJ card is issued at birth to Hungarian citizens or when an eligible individual applies for it, and that it is used to identify the cardholder in the health, and social insurance registries (Hungary 16 Feb. 2017a). According to the same source, any individual eligible to social insurance, unemployment or social benefits who does not have a TAJ number can apply for a TAJ card in person or through the mail at any district office operating in the [translation] "chief town" of the county, and at the District XIII office in Budapest and Pest County (ibid.). Without providing further details, the official from the Hungarian Embassy in Ottawa indicated that the following documents are required to apply for health insurance:

• ID card or passport
• Address card
• Residency permit
• Proof that the health insurance contribution has been paid. (Hungary 8 Sept 2017)

According to the OEP, in case the application is made through the mail, all documents attached to the application form must be signed by the applicant (Hungary 16 Feb. 2017a).

The same source states that citizens of the EEA, or members of their families from non-EEA States, must also provide a Hungarian registration card or residence permit (ibid.). According to the same source, in case an individual's healthcare is covered by the insurance agency of an EEA member State or by Switzerland, a form or official certificate concerning the insurance period must be provided (ibid.). For further information on access to healthcare by citizens of the EEA members States, see Response ZZZ105194 of July 2015.

The OEP indicates that immigrants or permanent residents must provide resident permits confirming their status, while refugees and stateless person must provide documents certifying their refugee or statelessness statuses (ibid.). According to the same source, where applicable, a document certifying the [translation] "legal status as an insured person[,]" such as a work contract or certificate of employment, must also be provided in order to apply for a TAJ card, together with a "certification" issued by the tax authority that proves that payment were made by those who have an obligation to make payments (ibid.).

The same source adds that no application is required for new-borns, since their personal information and address is automatically transferred to the OEP at the time the birth is registered (Hungary 16 Feb. 2017a). Parents of Hungarian infants born abroad must first obtain a Hungarian domicile card for their child before applying for the TAJ card (ibid.). According to the same source, parents of non-Hungarian infants born in Hungary must register them in the country of the child's citizenship, then apply for a Hungarian domicile card before applying for the child's TAJ card (ibid.). Should the mother of a non-Hungarian new-born baby be insured in Hungary, then the mother's own TAJ card entitles the newly born child to receive healthcare services up to two months after birth (ibid.).

The OEP indicates that TAJ cards are ready within 21 days after the application is received by the district office, including applications for replacing a lost, stolen or damaged TAJ card (ibid.). The same source further states that the TAJ card will be issued immediately or within a maximum of eight days if all documents are provided [translation] "without any deficiency" (ibid.). The cards are issued within 21 days for Hungarian infants abroad (ibid.). The first TAJ card and any replacement due to a stolen card are issued free of charge (ibid.). According to the same source, although modifications to the name and data on the card is also free of charge, a fee of 3,000 HUF [C$ 14.69] is required in order to replace a lost, destroyed or damaged TAJ card (ibid.).

3.1 Verification of Coverage

The information provided to the Embassy official states that healthcare service providers verify the eligibility of a patient electronically, and that eligibility can also be ascertained by the patient through an "internet client interface" (Hungary 8 Sept. 2017).

The information in the following paragraph was provided by the OEP:

The system used for the verification of eligibility can return a [translation] "green light," which means that the patient's TAJ number is valid and the legal status is in good order. A "red light" means that the TAJ number is valid, but the legal status is "unsettled;" in that case, the practitioner cannot refuse to provide care, but the patient must contact a district office, or the District XIII office in Budapest or the Pest County, to settle the "legal status". A "blue light" signifies that the patient is insured abroad and that the TAJ card is temporarily invalid. A "brown light" signifies that the TAJ card is "invalid for other reasons," and in this case, the patient must pay a fee in order to receive healthcare services. A "yellow light" indicates that the TAJ card is valid, but that the patient is eligible only for limited medical services; in that case, the patient is entitled to medical care through an agreement with the health insurer and the patient is not entitled to dental care unless it is deemed urgent, nor can they be placed on a waiting list for a transplant (Hungary 16 Feb. 2017b).

The OEP states that patients who signed an agreement to receive healthcare have their entitlements indicated by a yellow light during the [translation] "legal status check" (Hungary 23 Feb. 2017). Furthermore, the TAJ card is issued to patients who receive healthcare through an agreement only after they pay the contribution for 24 months, which can also be paid in one lump-sum in order to avoid the 24-month waiting period (ibid.).

The European Commission indicates that patients have to register with one general practitioner wherever they wish in the country, and that they can change their doctor once a year (EU n.d.). Patients can consult any doctor contracted by the OEP for basic healthcare, while designated specialists or institutions serving the patients' declared places of residence provide secondary level care (ibid.).

This Response was prepared after researching publicly accessible information currently available to the Research Directorate within time constraints. This Response is not, and does not purport to be, conclusive as to the merit of any particular claim for refugee protection. Please find below the list of sources consulted in researching this Information Request.

References

European Union (EU). N.d. European Commission, Employment, Social Affairs and Inclusion. "Hungary - Health Insurance in Hungary." [Accessed 3 Aug. 2017]

Hungary. 8 September 2017. Embassy of Hungary in Ottawa. Correspondence with the Research Directorate.

Hungary. 23 February 2017. Nemzeti Egészségbiztosítási Alapkezelő. " Megállapodáson alapuló jogosultság" (Entitlement Based on Agreement). Translated by the Translation Bureau, Public Works and Government Services Canada. [Accessed 20 Sept. 2017]

Hungary. 16 February 2017a. Nemzeti Egészségbiztosítási Alapkezelő. "Ellátásra való jogosultság igazolása" (Proof of Eligibility for Benefits). Translated by the Translation Bureau, Public Works and Government Services Canada. [Accessed 20 Sept. 2017]

Hungary. 16 February 2017b. Nemzeti Egészségbiztosítási Alapkezelő. "TAJ kártya igénylés, kiadás" (TAJ card application, issuing). Translated by the Translation Bureau, Public Works and Government Services Canada. [Accessed 20 Sept. 2017]

Hungary. N.d. Nemzeti Egészségbiztosítási Alapkezelő. "Tasks of the National Health Insurance Fund of Hungary (Hungarian acronym: OEP)." Translated by the Translation Bureau, Public Works and Government Services Canada. [Accessed 20 Sept. 2017]

Organisation for Economic Co-operation and Development (OECD). N.d. OECD.Stat. "Social Protection." [Accessed 20 Sept. 2017]

United Nations (UN). World Health Organization (WHO). 11 July 2016a. Global Health Observatory Data Repository. "Hungary". "Health Expenditure Ratios, by Country, 1995-2014." [Accessed 27 Sept. 2017]

United Nations (UN).World Health Organization (WHO). 11 July 2016b. Global Health Observatory Data Repository. "Canada". "Health Expenditure Ratios, by Country, 1995-2014." [Accessed 27 Sept. 2017]

Additional Sources Consulted

Internet sites, including: Amnesty International; ecoi.net; European Observatory on Health Systems and Policies; Freedom House; Human Rights Watch; UN – Refworld, Office of the High Commissioner for Human Rights; US – Department of State, Department of Commerce.