The Consolidated Text of the Law on Social Security of the Armed Forces, approved by Royal Legislative Decree 1/2000 of 9 June, establishes in its article 13 the content of the health care of this special regime, which is developed in chapter V of its General Regulations, approved by Royal Decree 1726/2007 of 21 December.

Article 66 of the aforementioned General Regulations on the Social Security of the Armed Forces provides for the coverage of health care outside the national territory, in certain cases, by empowering the ISFAS Managing Secretary-General to develop regulatory standards in this area and, in response to this forecast, by Resolution 4B0/06269/2010 of 20 April of the Management of the Social Institute of the Armed Forces, health care was regulated outside the national territory.

Directive 2011/24/EU of the European Parliament and of the Council of 9 March on the application of patient rights in cross-border health care sets out rules to facilitate access to safe and high-quality cross-border assistance, with full respect for national competencies in the organization and provision of health care.

Royal Decree 81/2014 of 7 February, which establishes rules to ensure cross-border health care, and amending Royal Decree 1718/2010 of 17 December, on medical prescription and dispensation orders, supplements the transfer of the aforementioned Directive to the Spanish legal system, determining that the ISFAS will be competent exclusively in the procedures relating to cross-border assistance of the holders and beneficiaries signed with the Military Entity.

The regulation of the health care of ISFAS holders and beneficiaries outside the national territory must be adapted to this new context and, for this purpose, in the exercise of the competences assigned by article 18 of the General Regulations of the Social Security of the Armed Forces, approved by Royal Decree 1726/2007 of 21 December, I provide:

1. General rules. Object

The increasing mobility of the ISFAS holders and beneficiaries outside the national territory, justifies a system of benefits to attend to the health care they may need during their stay abroad, whose extension and content must take into account the territorial area of displacement, as well as the reasons or circumstances that motivate them, personal or professional, thus considering the following assumptions:

(a) Destination or service commission abroad.

(b) Temporary displacement abroad for private reasons.

(c) habitual residence abroad, for private reasons.

This Resolution is intended to regulate the benefits of ISFAS for health care outside the national territory, according to the specificities of the collective protected by the Special Social Security Regime of the Armed Forces.

At the same time, the procedures relating to cross-border assistance of the holders and beneficiaries under the modality of cooperation with the Insurance Entities and the system of cooperation with the Military Health, unique in which the ISFAS will be competent, as provided for in the Third Additional Provision of the Royal Decree 81/2014 of 7 February, establishing rules to ensure cross-border health assistance, and amending the Royal Decree 1718 of 17 December 2010.

In accordance with the fifth additional provision of Law 39/2007, of 18 March, of the military career, and in Article 96 of Law 42/1999, of 19 November, of the Civil Guard Staff Regime, is excluded from the scope of coverage regulated in this Resolution, the health care provided to Spanish military contingents in international missions, forming part of the expeditionary forces or thus participating in any other military exercises,

In addition, long-term care, organ assignment and transplantation, as well as vaccination programmes in the field of public health programmes in the country of stay, are excluded from the scope of this Resolution.

2. Destination or service commission abroad

2.1 General delivery content.

The incumbents and their beneficiaries shall be entitled to the coverage of the health care they require during their stay in the country of destination or in which the commission of service is carried out for reasons of illness, accident, pregnancy or childbirth, with the freedom of choice of services and, in general, for the procedure of reimbursement of expenses, as provided for in this Resolution.

Health care will have a content similar to that given in the national territory, defined by the Common Portfolio of Services of the National Health System, provided for in article 8 of Law 16/2003 of 28 May, of cohesion and quality of the National Health System, in its regulatory development and in the specific provisions applicable in the Special Regime of the Armed Forces and shall include:

A) Primary care services and specialized care, on an outpatient and hospital basis, including hospital emergency services, with a similar content to that contained in the Basic Common Portfolio of Assistance Services of the National Health System, including urgent health transport.

B) The dispensation of medicines and other pharmaceuticals applied in hospital placement.

C) The cost of medicines and other pharmaceuticals that are financed by the National Health System in Spain and dispensed on an outpatient basis, less the amount that would have been paid to the holder according to the regime of the pharmaceutical benefit in the national territory which, in general, is 30% of the amount paid.

D) The provision with dietary products for the treatment of patients on an outpatient basis, within the limits and conditions established within the National Health System, therefore the cost invoiced for products subject to the benefit will be met.

E) Non-emergency health transport, when an indication has been established by a doctor and its purpose is to receive health care at the nearest centre where the beneficiary can be treated.

In no case will international transfers or accompanying expenses be covered.

F) Economic aids corresponding to prosthesis, osteosis and other complementary health benefits, with the content and limits set out in their specific regulation.

G) Vaccinations in all age groups and, where appropriate, risk groups, according to the National Health System vaccination schedule.

Other vaccinations included in prevention or public health programmes in the country of stay will not be covered.

However, when the holder has any insurance or protection system whose coverage reaches health care, only the refund of the expenses not covered by it will be provided.

For health care in Spain, the incumbents for or for service abroad shall maintain the services assigned to them, depending on the type of assistance to which they are attached prior to their departure from the national territory, with the exception provided for in paragraph 2.3.2.

2.2 Destination or Commission of Services in member countries of the European Union and the European Economic Area (EEA) and Switzerland.

In the event of a stay in member countries of the European Union and the European Economic Area (Island, Liechtenstein and Norway) and in Switzerland, the holders and their beneficiaries may choose to avail themselves of the benefit regime developed in paragraph 2.1 above, during the time the destination or service commission is extended, or request the European Health Card and use it.

In the latter case, when the social security system of the country of stay requires co-payments, it may be requested to be reimbursed by the ISFAS solely for primary assistance, specialized care, emergency services, ortho-protésic benefits and supplementary benefits provided in the national territory, within the limits and conditions established in its regulatory regulations.

The conditions of issuance and use of the European Sanitary Card shall be in accordance with paragraph 8.

2.3 Destination or Service Commission outside the European Union.

2.3.1 General conditions.

During the first five years of stay in countries that are not members of the European Union, the European Economic Area or Switzerland, the provisions of paragraph 2.1 will apply.

When the destination extends for more than five years, the incumbents shall sign a health-care insurance for their protection and that of their beneficiaries, with a similar extension and content, as far as possible, to those of the protection system enjoyed by the general population of the country of destination or, where appropriate, the staff employed in the service of the Ministry of Defence in that country. In this case, ISFAS benefits for the assistance of the incumbent and its beneficiaries in the country of destination shall be limited to the payment of assessed contributions under the insurance policy.

If the holder does not subscribe to a health-care insurance, from the date of the end of the period indicated for this purpose, only the costs arising from the benefits detailed in paragraph 2.1 shall be met, with a limit of Euro5,520 per person.

In addition, the holder and its beneficiaries will be attached to the D0 modality, "without adscription".

However, when a beneficiary stays in Spain, for reasons of studies or other exceptional circumstances, to be accredited, at the request of the holder, he may be authorized to enter another form of assistance, for a period of up to 12 months, extended. The request will result in an extraordinary change procedure for Assistance Modality.

2.3.2 Procedure for the effectiveness of the benefit.

A) When the stay outside the designated area exceeds five years, the ISFAS will notify the holder of this circumstance, in order that within six months it will subscribe to a health insurance policy, warning him that, once this period has been concluded, only the expenses that could be incurred by his assistance or that of his beneficiaries will be paid up to a limit of 5,520 euros per person every natural year, and that his or her assistance modality will be paid in Spain.

The calculation of the period of stay shall be valued, taking into account the date of the provision by which the holder was assigned in a State outside the European Union, the European Economic Area (Island, Liechtenstein and Norway) or Switzerland.

B) For the formalization of the insurance, the support of the Ministry of Defence or the Economic-Administrative Section (SEA) to which the holder depends may be sought.

Once the health care insurance has been completed, a copy of the contract will be forwarded to the ISFAS Subdirectorate. If the contract was not written in English, English or French, it should be accompanied by the simple translation of the sections in which the benefits covered and the contributions to be paid are regulated.

The maximum amount to be paid for this benefit will be 460 euros per person per month for the United States and 350 euros per person per month for other countries. In the event that the holder has a beneficiary in his or her office, with an age exceeding 65, the maximum amount of the benefit will be increased by 30%.

The established limits may be updated by Resolution of the ISFAS Management.

C) The holder may request the refund of the monthly fees previously paid by the Insurance, by means of written form to which the corresponding invoices or receipts will be attached (original documents).

In cases of prolonged stays where a health insurance has not been signed, the holder may apply for compensation for assistance costs, within the limits set, in accordance with the general procedure set out in paragraph 7.

2.3.3 Assistance on national territory.

When the holders and beneficiaries in this situation and attached to the D0 modality are temporarily moved to the national territory, the necessary assistance will be provided through the health services of the Autonomous Communities. To this end, the ISFAS delegation for the place of stay will provide a displaced document that will enable the accreditation of the right to the coverage of the ISFAS assistance.

Also, the holders and beneficiaries will have access to the rest of the benefits included in the ISFAS Service Portfolio for contingencies that occurred during the stay in Spain.

3. Temporary deferral abroad for private reasons

3.1 General conditions.

A) Generally speaking, the coverage of emergency or immediate health care during travel abroad, free of choice of services, except in the following cases:

Where an intentional purpose of circumventing the means of the ISFAS is deemed to have existed, making or taking advantage of the displacement to use means other than those corresponding to the current regulations, taking into account the pathology and the circumstances involved.

When assistance is covered by insurance of any kind.

B) Health care benefits will be covered, which are required, from a medical point of view, to prevent an insured person from being forced to return before the end of the expected stay, in order to undergo the necessary treatment, including:

Medical assistance, surgical and non-surgical hospitalizations and any other service of stay and treatment in Centro Sanitario with a content equivalent to that provided in Spain, including urgent health transport.

Non-emergency health transport, with the limits and conditions provided for in paragraph 2.1.E).

The total cost of medicines and other pharmaceutical products applied in hospitalization.

70% of the cost of medicines and other pharmaceutical products that are the subject of the pharmaceutical benefit of the National Health System in Spain, dispensed on an outpatient basis.

Economic aid for ortho-protein benefits and other complementary health benefits included in the ISFAS Service Portfolio, with the content and limits set out in its specific regulation.

C) The coverage period will extend to a maximum of six months. However, in the event of temporary travel to study, at the request of the holder, the extension of the period of coverage may be authorized, the reason for the stay must be documented at the time of request for the refund of the expenses.

3.2 Temporary displacement to member countries of the European Union, the EEA or Switzerland.

In the event of displacement to member countries of the European Union, the European Economic Area (Island, Liechtenstein and Norway) or Switzerland, the holders and their beneficiaries may opt for the benefit regime managed directly by the ISFAS, under the conditions set out in paragraph 3.1, or make use of the European Health Card that will allow them to access the necessary health care through the public health system of the country of stay.

The conditions of issuance and use of the European Sanitary Card shall be in accordance with paragraph 8.

Where co-payments are required in the social security system of the country of stay, reimbursement may be requested from ISFAS, only in the case of primary assistance benefits, specialized care and emergency services.

3.3 Temporary displacement to countries outside the European Union.

In the case of temporary displacements outside the European Union, the payment of the expenses that are made for urgent or immediate medical assistance provided to the beneficiary shall be provided if the amount is less than 30,000 euros. When the cost invoiced for all concepts is higher, a benefit will be recognized for this amount or for which the reimbursement rates collected in Annex 3 are applied, if any, greater.

3.4 Displacement by grouping.

When a holder moves to the country where the spouse, or person with whom he/she maintains a stable partner, is intended or in service, and provided that he/she has in turn the status of holder of the ISFAS, the provisions of paragraph 2, assimilating his/her situation to that of the intended holder or in service commission, will apply.

4. Repatriation costs

Exceptionally, in the event of illness or accidents arising during the stay abroad, requiring prolonged hospitalization, more than 30 days, the coverage of the transfer of the beneficiary, by health transport, to hospital services assigned in national territory may be provided.

The request will be accompanied by a medical report from the hospital, which will show that the patient's situation is stable and allows the transfer.

5. habitual residence abroad

5.1 General considerations.

The insured persons who establish their habitual residence abroad shall notify the delegation of the appropriate ISFAS, their new domicile, in order to make it necessary to modify their Assistance Modality in Spain that will become D0 "without adscription". The right to the corresponding benefits shall be born on the date of such notification.

When the holder or its beneficiaries temporarily move to national territory, the necessary health care will be provided through the health services of the Autonomous Communities. The ISFAS delegation for the place of stay will provide the person concerned with the document that will allow him to credit his right to the coverage of the assistance provided by the ISFAS, as a beneficiary in a situation of displacement.

5.2 Regular residence in European Union countries.

In cases where the holder and its beneficiaries establish their residence in a member country of the European Union, the European Economic Area (Island, Liechtenstein and Norway) or Switzerland, health care will be provided for illness, accident and maternity in the country of residence, with the content detailed in paragraph 2.1.

5.3 Regular residence outside the European Union.

Insured persons who set their residence outside the scope specified in the preceding section shall be entitled to receive financial assistance to cover the health-care benefits they may require by signing a health insurance policy, without any other benefit costs of any kind.

The amount of such aid will have a limit equivalent to the price that the ISFAS should pay to the insurance entities that have signed a concert for the assistance of holders and beneficiaries of the ISFAS in Spain.

In cases where, exceptionally, it is not possible to formalize a health insurance policy, an economic aid may be recognized to offset the costs of any provision of health care provided to the holder or its beneficiaries, provided that it is included in the ISFAS Health Care Service Portfolio. The amount of aid may not exceed the limit per person referred to in the preceding paragraph.

The right to economic benefit regulated in this section shall arise from the first day of the month following the date on which the affiliate has made known the ISFAS delegation its new residence abroad and is attached to the D0 modality.

From one January of each year, the holder may request the payment of the assistance for the months of the year ended 31 December immediately prior.

6. Cross-border health care

6.1 General considerations.

Directive 2011/24/EU, of the European Parliament and of the Council of 9 March, on the application of the rights of patients in cross-border health care, regulates the reimbursement of expenses incurred in receiving care or treatment in another member State of the European Union, establishing in Royal Decree 81/2014 of 7 February, establishing rules for guaranteeing cross-border health care, and amending the Royal Decree 1718/2010, provides for the provision of effective orders.

All forecasts regarding cross-border health care in the member States of the European Union shall be deemed applicable to the States parties to the Agreement on the European Economic Area, from the time the corresponding legal instruments are adopted for the implementation of Directive 2011/24/EU in this area.

Expenditures resulting from health care provided in another Member State shall be charged by the holder or beneficiary, and may be reimbursed in accordance with the conditions and requirements provided for in this Resolution.

6.2 Scope of application.

The ISFAS shall be competent exclusively in the procedures relating to cross-border assistance of the holders and beneficiaries under the modality of cooperation with the Insurance Entities or the arrangements for cooperation with the Military Health.

As set out in the Third Additional Provision of the aforementioned Royal Decree 81/2014 of 7 February, the Autonomous Communities and INGESA shall be the competent administrations in the procedures relating to the cross-border assistance of the holders or beneficiaries of the Special Social Security Regime of the Armed Forces attached to their health services by the established procedure.

Therefore, in these cases, both the right to reimbursement for cross-border health care and, where appropriate, the corresponding prior authorization shall be requested from the Health Service of the corresponding Autonomous Community or INGESA in Ceuta and Melilla, subject to the rules established for the rest of the insured and beneficiaries of the National Social Security Institute, the provisions on this matter are not applicable in the present Resolution.

6.3 Content.

Cross-border health care is the one received when the beneficiary decides to go to services located in another member State of the European Union. Therefore, it does not include the assumptions of destination or temporary stay in which, for medical reasons, the beneficiary has received health care.

Where a beneficiary decides to go to services located in another member State of the European Union to receive cross-border health assistance, he shall be entitled to reimbursement of the expenses incurred by such assistance, with the limits, conditions and exclusions provided for in paragraph 6.4.

In accordance with Directive 2011/24/EU of the European Parliament and the Council of 9 March 2011, the Member State of the European Union in which the assistance is carried out must ensure that professional liability insurance systems or similar guarantees are available that are equivalent or essentially comparable to their purpose and appropriate to the nature and scope of the risk, for the treatments provided in its territory, so that the liability derived from cross-border assistance shall not be granted to the relevant entity.

6.4 Conditions, requirements and limits.

6.4.1 General conditions.

Reimbursement of costs incurred by a beneficiary who has received cross-border health care shall be ensured, provided that such assistance is included in the common service portfolio of the National Health System, with the extent and requirements established for such health care or a similar provision for the services allocated in Spain.

The beneficiary requesting reimbursement of costs arising from cross-border health care must comply with the same conditions applicable to access to health care provided on national territory through the corresponding services allocated.

In the event that health care is received in another member State, where required in the area of concerted ISFAS assistance or in the National Health System, a prior assessment will be required to justify the indication of the health benefit to be provided to the patient.

6.4.2 Additional requirements: Prior authorization.

In the cases provided for in paragraph 6.5.1, the ISFAS Subdirectorate of Benefits shall be authorized, on a pre-transboundary basis, to which the right to reimbursement is conditioned.

The authorization may be refused in the following cases:

(a) In the case of a non-inclusive provision in the common service portfolio of the National Health System or the ISFAS, or does not meet the conditions under which it is provided.

(b) Where there is a reasonable degree of certainty that the patient, according to a clinical evaluation, will be exposed to a risk that cannot be considered acceptable, taking into account the potential benefit of the requested transboundary health care.

(c) Where there is a reasonable degree of certainty that the general population may be exposed to a substantial risk as a result of cross-border health care.

(d) Where health care is to be provided by a health care provider that raises serious and specific concerns regarding the standards and guidelines for patient quality and safety.

(e) Where health care can be provided in the national territory within a medically justifiable period, taking into account the health condition of each patient and the possible evolution of their illness and other criteria provided for in article 17 of Royal Decree 81/2014 of 7 February.

6.4.3 Refund limit.

Reimbursement for each service or procedure shall limit the amount that is set out in each case in Annex 3, the prices of which shall be considered as reimbursement rates for the purposes of the application of community instruments in respect of reimbursement for cross-border health care, without exceeding the actual cost of effective health care and without considering the related costs that, as provided in paragraph 6.4, are excluded from the provision.

Therefore, the total amount of the refund may not exceed the amount invoiced for the assistance, without considering the related costs, at which time this amount would be refunded.

6.4.4 Exclusions.

The right to reimbursement for transboundary health care is excluded:

(a) Services in the area of long-term care whose purpose is to help people who need assistance in performing routine and daily tasks;

(b) Allocation of organs and access to organs for the purpose of organ transplantation;

(c) Public vaccination programmes against infectious diseases, which are exclusively aimed at protecting the health of the population in the territory of a member State and subject to specific planning and implementation measures.

(d) Related or complementary costs such as health and non-health transport and maintenance and stay of patients and companions whose help may be required.

6.5 Amount subject to prior authorization.

6.5.1 Provisions subject to prior authorization.

All health benefits detailed in Annex II of Royal Decree 81/2014 of 7 February are subject to prior authorization, including the following:

(a) Any kind of care that involves the patient having to stay in the hospital at least one night.

(b) Regardless of what is stated in subparagraph (a), those techniques, technologies or procedures included in the common portfolio of services of the National Health System that have been selected on the basis of the requirement of the use of highly specialized medical procedures or equipment, the need to care for patients with complex problems, or their high economic cost:

Postitron emission tomography (PET), and combined with TC (PET-TC) and SPECT.

Assisted human reproduction.

Dialysis.

More outpatient surgery that requires the use of a surgical implant.

Radiation therapy treatments.

Pharmacological or biological treatments, the monthly amount of which is more than 1,500 euros.

Radiosurgery.

Genetic analysis aimed at diagnosis of complex cases, including prenatal and pre-plantation diagnosis, pre-symptomatic and carrier genetic analysis, pharmacogenetic and pharmacogenemic analysis.

Disability treatments that require for correction or improvement: electric wheelchairs, superior limb prosthesis except partial hand prosthesis, lower limb prosthesis except partial foot prosthesis, hearing aids and bitutores.

Treatments with complete formulas for homeless enteral nutrition and nutritional formulas and modules for congenital disorders of the metabolism of carbohydrates, amino acids and lipids.

Attention to pathologies and procedures for which reference services have been designated, in accordance with Royal Decree 1302/2006 of 10 November, establishing the basis for the procedure for the designation and accreditation of the centres, services and reference units of the National Health System, included in Annex III of Royal Decree 1207/2006 of 20 October, regulating the management of the Sanitary Cohesion Fund, or have been established in Europe.

6.5.2 Procedure for obtaining prior authorization.

The request for authorization shall be made in the established form, to which the medical report shall be joined with the indication of the assistance or treatment required, and shall be submitted through the Electronic Headquarters or any Delegation of the ISFAS where it shall be sent immediately, by telematic procedures or by FAX, to the Subdirectorate of Benefits. This will replace the Insurance Entity to which the beneficiary or the General Defence Health Inspectorate is attached, if the beneficiary is in the form of a partnership with the Military Health system, with the aim that, within a maximum of 10 days, the beneficiary issue a report stating:

(a) If the assistance required by the beneficiary can be carried out in the national territory, in the terms stipulated in the Concert or in Ministerial Order 52/2004, regulating the collaboration with the Military Health, specifying in this case the specific means or services assigned to the effect.

(b) The time limit on which assistance could be initiated.

(c) Objections to cross-border patient health care, duly substantiated.

In the light of the report issued, or after the ten-day period has not been received, the ISFAS will proceed to issue a motivated resolution on the beneficiary ' s request, authorizing or denying assistance.

In any event, the maximum time limit for notification of the decision to grant or refuse prior authorization shall be 45 days from the date of receipt of the request. After such a period of time without express resolution, the request for administrative silence may be considered, as provided for in article 43 of Law 30/1992 of 26 November, on the Legal Regime of Public Administrations and the Common Administrative Procedure.

The authorisation may be refused in the cases and cases set out in paragraph 6.4.2, in accordance with article 17 of Royal Decree 81/2014 of 7 February. If the authorization is denied because health care can be provided on the national territory, as stipulated in the Concert or Ministerial Order 52/2004 of 18 March, which regulates the concerted collaboration of the Social Institute of the Armed Forces with Military Health, within a medically justifiable period, the resolution will indicate the means allocated for the provision of the requested assistance.

6.6 Procedure for reimbursement.

The request for reimbursement shall be made in the form established within three months of the date of payment of the assistance received and, as provided for in paragraph 7.2.1, shall be accompanied by the documents included in paragraph 4 of Annex 2.

Upon receipt of the request and the required documentation, after the necessary checks are made to determine the right to reimbursement and the corresponding amount, a resolution shall be issued which shall be notified to the person concerned and, in the case of beneficiaries attached to a Insurance Entity, to the corresponding Entity, in accordance with Law 30/1992 of 26 November, within a maximum of three months, from the date of receipt of the application.

When the right to reimbursement is recognized, the payment shall be materialized directly by the ISFAS through bank transfer, in the account designated by the person concerned, without prejudice to its subsequent impact on the Insurance Entity to which the beneficiary is attached for health care in Spain, in accordance with the forecasts established in the Concerts that are signed by the ISFAS for the health care of the holders and beneficiaries.

6.7 Refund rates.

Annex 3 determines the amounts for assistance services, medical procedures or treatments that will be applicable in cross-border assistance cases, which will have the consideration of reimbursement rates for the purposes of the application of community instruments for reimbursement of cross-border health care costs, pending the establishment of reimbursement rates at the state level.

In accordance with paragraph 6.4.3, the amount resulting from the application of the fees may not exceed the actual cost of the actual provision of health care, and in such case the amount invoiced for the assistance would be met, without considering the related costs.

7. Procedure for implementing benefits

7.1 Applications and documentation.

Applications for health care benefits abroad may be made in the standardized form to be obtained in the ISFAS Delegations, the Defence Attachments or Administrative Economic Sections abroad or through the website of this Institute. In any case, the application shall reflect the data of the holder and the beneficiary, the address indicated for the notifications, the benefits involved and the data from the bank account in which the amount of the benefit must be entered.

7.1.2 Documentation required on a general basis

In any case, requests should be accompanied by the documents detailed in Annex 2.

The decision-making body may require interested parties to submit documents that may be appropriate to clarify the right to the benefit, health care received, actual cost, valuation or amount of the refund.

In all cases it will be understood that the person concerned voluntarily cedes the clinical reports and documents with health information that are required, for the valuation and, if necessary, for the recognition of the benefits that he or she requests.

7.2 Recognition of benefits.

7.2.1 Modality of reimbursement or refund of expenses.

Applications for health-care benefits abroad will give rise to an express resolution in which, where appropriate, the recognized benefit and the procedure for implementing it will be realized.

In general, the recognized benefits will be made effective for reimbursement or refund of expenses to be made by the ISFAS by transferring to the designated bank account the holder to be a financial entity based on national territory.

The payment will be made in euros, applying, where appropriate, the official change set at the time of the assistance given to the benefit.

The procedure for recognition of cross-border health care benefits will be in line with the provisions of paragraph 6.6.

7.2.2 Special modalities.

A) Direct payment: Upon express request of the person concerned, the direct payment may be authorized to hospital centres, by transfer, provided that the cost of the benefits is deemed to be high. To perform this direct abono, the hospital center must show its conformity with the procedure. The amount of the invoice should also be consistent with the amount of the benefits that are recognized, without any costs that correspond to services other than strictly health care. In the case of invoices issued in currency other than the euro, for the valuation of the equivalence the current change will apply on the date on which the payment of the invoice is made.

B) Payments on account: Where direct payment to hospital centres is not possible, in the terms provided for in the preceding paragraph, insured persons who are or who are serving abroad may apply to the ISFAS for the formalization of a payment on account or advance through the corresponding SEA or Agregaduría de Defensa. The request shall be provided exclusively for the payment of invoices in excess of 500 euros or equivalent amount.

Subsequently, the person concerned shall submit the invoices and proof of payment within three months. If the corresponding requirement is not met, the procedure for claiming unduly perceived benefits shall be initiated, in accordance with article 47 of the General Regulations on Social Security of the Armed Forces, approved by Royal Decree 1726/2007 of 21 December.

C) Collaboration agreements: When assistance is provided in centres with which the ISFAS has entered into collaboration agreements, the procedure for the processing of the files will be assimilated to the corresponding one for assistance benefits in established centres.

(d) Banking costs: In all cases indicated, the amount of aids that are recognized may never exceed that of expenses that may arise from the assistance provided, with the ISFAS meeting bank expenses that may arise in cases of direct payment to hospital centres and formalization of payments to account or advances.

8. European Health Card

8.1 Health care through the European Health Card.

The European Health Card (TSE) is individual and certifies the right of its holder to receive the necessary health benefits from a medical point of view, during a stay in any of the countries of the European Union, the European Economic Area (Island, Liechtenstein, Norway) or Switzerland, taking into account the nature of the benefits and the expected duration of the stay.

The European Sanitary Card or a substitute certificate must be presented at the Foreign Centre where health care is requested, which certifies the right to benefits, and the proof of the identity of the card holder (DNI, NIE, passport, etc.).

If you do not have the card or the substitute certificate, the institution of the place of stay, at the request of the interested party, will be addressed to the ISFAS, as a competent institution, to obtain it.

The health care required by the European Health Card includes the necessary health care in the public health system of the country of stay. Any medical treatment related to pregnancy, including childbirth, shall also be covered, not giving the right to repatriation or transportation to the country of origin or habitual residence.

In general, the institutions of the member state of stay will facilitate health care benefits, which are required, from a medical point of view, to prevent an insured person from being forced to return before the end of the expected stay, in order to undergo the necessary treatment, in accordance with their legislation.

The European Sanitary Card is not valid if the reason for displacement to another State is to receive a specific medical treatment for a disease or injury that the patient had before traveling. Nor does it provide access to private health care.

The benefits to which the European Sanitary Card gives access will be the same to which the citizens of the country where the person concerned is entitled, taking into account that each country has its own rules so that, in some, the assistance is free, but in others a portion of the costs may be required or the benefits of the reimbursement system may be met.

In the latter case, if the beneficiary had effectively paid the costs of the assistance, he or she may request reimbursement to the institution of the place of stay or to the ISFAS upon his return to Spain.

The European Health Card can only be used as long as it is discharged in the ISFAS. Therefore, even if the validity of the card is higher, if the person concerned passes to the situation of the person who has been discharged, he or she must communicate it and stop making use of the card, since otherwise the invoices arising from the treatment he or she receives will be paid, and the benefits that he or she has received may be claimed under article 47 of the General Regulations on Social Security of the Armed Forces approved by Royal Decree 1726/2007 of 21 December.

8.2 European Sanitary Card Expedition.

The holders and beneficiaries of the ISFAS in a high situation may obtain the European Health Card for stay in member countries of the European Union, the European Economic Area (Island, Liechtenstein and Norway) or Switzerland. The period of validity shall be found in the European Health Card and shall be adjusted according to the reason for the displacement and other circumstances of affiliation.

The European Sanitary Card may be requested through the Electronic Office or the ISFAS Delegations and will be received at the address assigned to the effect within an approximate period of 15 days, which is why it must be requested in advance.

In the event of urgency or diversion, the provisional substitute certificate will be issued, which is equivalent to the European Sanitary Card and which will allow, under the same conditions, access to health care and an assumption of it during a temporary stay in another member State. The provisional substitute certificate may also be requested from the country of stay in case of oblivion or diversion.

The certificate is individual and certifies the right of the holder to receive health benefits under the same conditions as the European Health Card, from the start date to the end of its validity, which will be included in the certificate.

9. Derogation

At the entry into force of this Resolution, Resolution 4B0/06269/2010 of 20 April 2010 of the Management of the Social Institute of the Armed Forces, regulating health care outside the national territory and any provision or internal rule that would have been dictated by any organ of the ISFAS, which opposes the provisions of this Resolution.

10. Final provision

This Resolution will enter into force the day after its publication.

Madrid, February 19, 2014. – Secretary General Manager, María Soledad Álvarez de Miranda Delgado.

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Annex 2

Documentation for the application of health care benefits outside the national territory

1. Documentation required on a general basis

In any case, the following documents and their translation shall be attached to the applications unless they are written in English, French or Spanish.

1.1 Autoliquidation, which will conform to the model contained in Annex 1.

When the application is made through the corresponding standardized form, the self-liquidation included in the application will be completed, with the bank account data indicated for payment.

1.2 Bills.

They will be original (not proform or photocopies), having to be included in them, necessarily:

Patient identification.

The name and address of the natural or legal person issuing the invoices.

The various concepts invoiced with their amount. In its case, the name of the medication, health product or dietary food, the number of containers dispensed and the amount paid by the patient.

Place and date of issuance and other requirements required in the applicable regulation.

1.3 Documents or justifications that credit the payment of invoices in all refund or refund procedures.

1.4 Copy of the medical prescription or clinical report of the care given to the beneficiary in the following cases:

(a) Where assistance benefits are requested with hospital placement.

(b) When applying for rehabilitation treatments, tests or diagnostic studies of high technology, pharmaceutical benefits or orthoprothesic benefits.

(c) In all requests for cross-border health care benefits, provided for in paragraph 6.

(d) Where it is expressly required by the ISFAS as necessary for the proper resolution of the procedure, as provided for in paragraph 7.1.2.

2. Additional documentation required for assistance from residents outside the European Union, the European Economic Area or Switzerland

In the case of applications for health care benefits for residents outside the European Union, EEA or Switzerland, the following will be provided:

2.1 Document that credits the formalization of a health insurance policy in the country of residence.

2.2 Where exceptionally it would not have been possible to formalize a health insurance policy, and economic aid is requested for compensation for expenses derived from care or treatments provided to the holder or its beneficiaries, a responsible statement which states that the insurance policy cannot be subscribed, indicating the reasons.

3. Additional documentation required in the special procedures provided for in paragraph 7.2

3.1 Direct payment to hospital centres: Declaration of the conformity of the hospital with the direct payment procedure, by bank transfer.

3.2 Formalization of advance or payment through the Defence Addition or the corresponding Administrative and Economic Section.

Express request.

Budget or documentation based on which an approximate cost estimate can be made.

4. Documentation required for reimbursement for transboundary health care

In accordance with the provisions of Annex I to Royal Decree 81/2014 of 7 February, requests for reimbursement for cross-border health care shall be made through the corresponding form, to which they shall be joined:

4.1 Invoices, which will include the identification data of the professional responsible for cross-border health care and other requirements provided for in paragraph 1.2 above, should be credited.

4.2 Copy of the medical prescription or clinical report of care to the beneficiary, including:

(a) Clinical reason for providing cross-border health care.

(b) Diagnostic procedures or main and secondary therapeutic procedures performed for cross-border health care (indicating, whenever possible, homologated identification code, such as CIE9-MC or similar).

(c) Revisions to be made and approximate time for them.

(d) Any other data deemed appropriate to review in order to clarify the health care received or its actual cost, provided that it is strictly necessary for the assessment of the origin and amount of the refund.

4.3 In the case of cross-border health care benefits and treatments, included in paragraph 6.5.1, authorization by the ISFAS Subdirectorate.

Annex 3

Reimbursement rates for cross-border health care

1. General considerations

1.1 Table 1 includes those benefits, techniques and procedures which may result in the reimbursement of the cost paid by the beneficiary, with the limit fixed, without requiring the prior authorization referred to in paragraph 6.5. of the present Resolution, provided that they are carried out on an outpatient basis, without the patient staying in a hospital.

1.2 However, only the reimbursement of the costs of the benefits, techniques and procedures included in Table 2, if the authorization of the ISFAS had been obtained, will be met in advance of its realization.

1.3 Prices set as a reimbursable limit include medicines, contrasts and other health products that are required for diagnostic and treatment procedures.

2. Specifications for reimbursement valuation

2.1 First consultation.

The initial visit consisting of the medical act performed in a consultation facility will be considered for the first consultation, for the diagnosis, treatment or follow-up of a patient based on anamnesis and physical exploration.

2.2 Consult successively.

It is the one that derives from a first consultation and all that are generated as a review or follow-up of an earlier consultation. Therefore, all revisions determined by a doctor ' s decision shall be considered for consultation and follow-up to the same process, regardless of the time between them.

2.3 Consultation with supplementary evidence.

It is understood by consultation with complementary tests that raise the need for non-complex and non-scheduled auxiliary techniques.

The price assigned to the consultation includes, therefore, that of all the basic diagnostic tests that may have been required, such as analytics, basic cytology, simple radiology, ECG, ultrasound, optical prognosis, etc, regardless of whether they are performed at another date and at a different specific center.

2.4 Home care.

It is understood by home care, care by a doctor or nurse who needs to be transferred to the patient ' s home.

2.5 Unentryed ERs.

The amount fixed as a reimbursable limit includes all the actions performed by the Emergency Service and those basic diagnostic tests (analytics, simple radiology, ultrasound, ECG, etc.).

2.6 Ambulatory hemodialysis.

For treatments to patients with chronic kidney failure, undergoing outpatient or day hospital dialysis programs, the amount set as a reimbursable limit includes basic diagnostic procedures, as well as necessary transfusions and the cost of erythropoietin.

2.7 Radiation therapy and brachytherapy.

The limit of the refundable amount includes the entire process, from the first consultation to the patient's discharge or completion of the treatment, including the first visit, treatment planning, physical dosimetrics and treatment verification.

Radiation therapy treatments consider 5 levels of complexity based on the indications of treatment, predictable consumption of resources and technological equipment required, for which different maximum reimbursable amounts are fixed.

The following guiding considerations will be taken into account in the assessment of the level of complexity of the treatment:

(a) Level I:

Simple technique, usually with palliative intent, of few sessions and with simple dosimetry.

Symptom mom.

Symptomatic stomagus.

Pancreas, symptomatic bile pathways.

Symptom esophagus.

Straight, colon, symptomatic sigma.

SNC prophylaxis.

Symptom liver.

Symptomatic SNC Metastasis.

Symptom ORL.

Symptom thyroids.

Vejiga, symptomatic prostate.

Bone metastases (1 location).

Symptomatic cervix.

Symptom endometrial.

Symptom ovary.

Symptom Vagine.

Symptom valve.

Symptom lung.

Symptom trachea.

Splenic radiation therapy.

Radiocastration.

Other palliative treatments up to a dose of 30 Gy.

Hemoderivates and biological samples.

(b) Level II:

Intermediate technique. In most cases, complementary to surgery, with generally radical intention, of about 20-25 sessions and with non-complex dosimetry.

Complementary lung.

Palliative, preoperative (Dosis of 30-60 Gy), includes radical relief.

Esophagus, complimentary trachea.

Complementary stomagus.

Pancreas, complementary bile tracks.

Recto, complementary sigma or preoperative.

Vejiga, complementary prostate.

Seminoma.

Kidney, complementary ureter.

Irradiated metastases (≥ 2 locations).

Complementary breast (technical 2 fields).

Palliative, preoperative (dose 45-50 Gy).

Lymphomas, treatment of affectionate fields (IF).

Skin, electron treatment up to 60 Gy.

Other complementary processes, up to 60 Gy.

Complementary cervix (posthisterectomy).

Palliative cervix, preoperative (dose 45-50 Gy).

Supplementary endometry (posthisterectomy).

Palliative endometrium, preoperative (dose 45-50 Gy).

Complementary vagine (postsurgery).

Complementary valve (postsurgery).

(c) Level III:

Complex technique. Costly treatment. Many sessions, usually always with radical intent and that requires a complex dosimetric.

Radical hypophysis.

Eye melanoma.

Orbitary tumors.

Head and neck tumors.

Parotida, breasts, radical.

Cavum, cervical primary tumor of unknown origin.

Complementary ORL, radical.

Complementary oral cavity, radical.

Vejiga, radical prostate.

Complementary, radical soft parts sarcoma.

Radical breast, postmastomy (≥ 3 fields).

Complementary, radical bone tumors.

Leather, treatment with electrons  60 Gy.

Radical lung.

Esophagus, radical trachea.

Radical stomagus.

Straight, radical sigma.

Lymphomas (Mantle, And Inverted).

Radical complementary ovary.

Other treatments with radiation therapy with  60 Gy.

Conservative mom with overprint with external RT.

Radical cervix.

Radical endometry.

Radical vagina.

Radical Vulva.

Radical anus.

Complementary, radical astrocytoma.

(d) Level IV:

Great Complexity Technique.

Irradiation of the skull.

Medulloblastoma.

Retinoblastoma.

Wilms Tumor.

Neuroblastoma.

Other pediatric tumors.

Treatment of young children, up to 7 years, due to difficulty immobilization, with anesthesia.

(e) Level V:

Special techniques.

Total Hemicorporal Irradiation: 70 URV

Total Corporal Irradiation with Photons: 140 URV

Total Corporal Irradiation with Electrons: 180 URV

Intraoperative RT: 170 URV

Radiosurgery (one fraction): 170 URV

Stereotaxic radiation therapy (multiple fractions): 180 URV

Modulated Intensity Radiation: 180 URV

(f) Brachytherapy: interstitial and endocvital.

2.8 Hospitalization: Hospital assistance with placement.

Hospitalization assistance will be considered to be provided on a placement basis or to imply that the patient has to stay in the hospital, on the order of entry of the responsible physician.

To determine the reimbursable limit the number of stays caused will be taken into account.

For this purpose it will be understood by "day of stay", the overnight in the health center when one of the main meals ( lunch or dinner) is also made effective by the admitted patient.

2.9 Surgical procedures. Major surgery.

These are procedures performed in the O.R., indistinctly of the type of anesthesia applied, and which can be carried out in an outpatient or hospital setting.

When performed on an outpatient basis, the limit for reimbursement will be set for the corresponding Surgical Procedure, which includes medical care, nursing care, cures, medication, food, any diagnostic or therapeutic procedure and surgical prosthesis or implants (with the exception of vascular prosthesis). If the patient's hospitalization is required, the reimbursable limit will be determined taking into account the one fixed for the procedure plus that of the hospital stays caused to the hospital discharge.

3. Outpatient pharmacy allowance subject to beneficiary ' s contribution

The limit of reimbursement for the dispensation of medicines and other health products included in the pharmaceutical benefit of the National Health System, for outpatient treatments, shall be the invoiced amount, less the corresponding contribution to the beneficiary, established at each time in the specific regulation of this benefit.

4. Supplementary benefits of ISFAS

They will be provided with the limits and requirements provided for in Annex 5 of Resolution 4B0/38008/2014 of 15 January of the Social Institute of the Armed Forces on the ISFAS Sanitary Assistance Portfolio.

Table 1

Table 2