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Resolution Of 7 February 2012, Of The Judicial General Mutual Insurance Company, Which Publishes Circular No. 80 Regulator Of The Health Care Outside The National Territory.

Original Language Title: Resoluci├│n de 7 de febrero de 2012, de la Mutualidad General Judicial, por la que se publica la Circular n.┬║ 80 reguladora de la asistencia sanitaria fuera del territorio nacional.

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TEXT

The General Judicial Mutuality (MUGEJU), as an entity that is in charge of the administration of the Special Social Security System of the staff of the Administration of Justice, provides its mutual and beneficial owners with assistance In accordance with the provisions of the Royal Legislative Decree 3/2000 of 23 June, which approves the recast text of the Legal Provisions in force on the Special Regime for the Social Security of Personnel to the Service of the Administration of Justice. The Mutuality of State Officials (MUFACE) and the Social Institute of the Armed Forces (ISFAS) have the same task with their mutualists.

It is therefore essential to publish those circulars which concern the system of granting of benefits and which have not been published previously, for general knowledge of the beneficiaries of the scheme. Special Social Security managed by the Judicial General Mutuality.

For all of the above, this Management resolves the publication in the "Official State Bulletin" of the following circular: Circular No. 80.

Madrid, February 7, 2012. -Manager, Celima Gallego Alonso.

CIRCULAR NO 80 HEALTH CARE REGULATOR OUTSIDE THE NATIONAL TERRITORY

JUSTIFICATION

The Royal Decree 1026/2011 of July 15, which approves the Judicial Mutualism Regulation, regulates for the first time health care outside national territory, defining in Article 73 the basic principles of the Provision: The use of health services abroad by a mutualist entitled to them is provided under conditions of equivalence with health care within the national territory, and will entitle them to cover expenditure (a) on the grounds of such assistance, under the terms, conditions and forms of management which are establish by the General Judicial Mutuality.

Articles 74 and 75 distinguish the cases for which the General Judicial Mutuality must establish the terms, conditions and forms of healthcare abroad: Healthcare to the mutual societies abroad, which can be extended to other cases of mutualists and beneficiaries with residence abroad and the assistance of mutualists and beneficiaries who move abroad for any reason.

The present circular is dictated by the Regulation of the Judicial Mutualism in order to regulate the situations and the terms of the health care outside the national territory, taking into consideration the experience practice that the General Judicial Mutuality has in the management of this benefit.

1. Health care in the cases of destination or residence in countries outside the national territory.

1.1 This healthcare mode is provided to the collective that is in any of the following assumptions:

(a) mutualists who have their destination outside the national territory and the beneficiaries who move with them.

(b) Mutualists who are in the commission of services in countries outside the national territory, for a period of more than four months and beneficiaries who move with them.

(c) Mutualists who, finding themselves destined in a foreign country cause low in the active service by retirement, remain without formal interruption residing in the country in which the retirement has occurred and retain the conditions to be eligible for healthcare in MUGEJU, as well as the beneficiaries of such mutualists.

(d) Mutualists and beneficiaries who establish their domicile in a country of the European Union.

1.2 These mutualists and beneficiaries who move with the holder abroad shall be entitled to health care with similar content to that provided on national territory. Assistance shall be provided outside the national territory, in the form and conditions laid down in the contract concluded between MUGEJU and the relevant insurance company. In the national territory, these mutualists and their beneficiaries shall receive healthcare through a concerted medical entity or the public health service of the Autonomous Community.

1.3 In order to benefit from this type of health care outside the national territory, it is essential to have formally requested it from MUGEJU, which will proceed to authorize it, processing the high of the mutualist and su/s beneficiaries on the contract policy with the insurance company. To this end, the mutualist must complete the corresponding application form, accompanied by the supporting documentation of the appointment in cases of posting on account of the professional destination or the supporting documentation residence. MUGEJU shall not address any request for payment or reimbursement of health expenses in countries outside the national territory, if the mutualist has not requested in advance discharge in this health mode.

1.4 The assistance referred to in point 1.2 shall be provided through the direct drawback system by the contracted insurance company and shall cover at least the following concepts:

(A) Expenditure arising from healthcare: primary care, specialised in outpatient and inpatient treatment, including emergency services, as well as expenses arising from stay-at-home services healthcare facilities.

B) Expenditure on medicinal products and other medical devices, dietoterapics and enteral formulas, administered as an internment, and if they are dispensed on an outpatient basis, 70 per 100 of their total amount, or with the percentage to be applied to medicines or medical devices financed by the Spanish National Health System.

C) Expenses derived from the acquisition and implantation of surgical prostheses, external prostheses, orthotheses and orthoprostheses, equipment, apparatus and other medical supplies necessary for the treatment of pathologies.

D) Health transport costs when a medical cause prevents movement by ordinary means for health care, health transport costs between different countries when in the country of residence, work or stay is not available for adequate care, health evacuation costs in case of terminal illness or repatriation of the body or ashes of the insured in case of death.

1.5 In the event that healthcare costs exceed the limit covered by the contract with the insurance company or are due to health benefits not included in the contract, MUGEJU will reinstate the amount not covered by the contract. the contract referred to, provided that the services are included in its portfolio of services and with the same content and coverage as the general rule for the MUGEJU collective. For the refund application, the procedure referred to in paragraph 4 of this circular shall be followed.

2. Healthcare on temporary displacements to countries outside the national territory.

2.1 When a mutualist or beneficiary moves to a foreign country for any cause, the General Judicial Mutuality must be informed of the conditions and procedures to be followed in order to receive the health care that might need it, in accordance with the terms, conditions, and forms of management that are established by MUGEJU.

2.2 Temporary displacements are considered outside the national health coverage territory through MUGEJU, through this mode:

A) Displacements of the mutualist and the beneficiaries who are transferred with him, which are carried out under a service commission of less than four months.

B) Displacements of the mutualist and the beneficiaries, for non-work reasons, with a maximum duration of four months.

C) Displacement by studies.

2.3 In the previous three scenarios, healthcare is provided through the collective insurance policy contract signed by MUGEJU with the relevant insurer and with the following limits:

(A) In the case of displacements made on the occasion of a professional destination in the event that the health costs exceed the limit covered by the contract with the insurer or are due to health benefits not included In the same way, MUGEJU will refund the amount not covered by the above mentioned contract, provided that it is services included in its portfolio of services and with the same content and coverage as the general established for the collective of MUGEJU. For the refund application, the procedure referred to in paragraph 4 of this circular shall be followed.

B) In the case of displacements for non-work reasons, health care is covered for a maximum period of four months from the start of the posting, with the coverage limits determined in the contract mentioned by Mugeju. After that period, no payment shall be made or reimbursement shall be made.

C) In case of travel by study, assistance is covered under the terms of the contract mentioned and with the time limit set by MUGEJU.

2.4 MUGEJU will not reinstate the health costs of the mutualists or their beneficiaries when it is appreciated, in the light of the pathology and any other concurrent circumstances in the case, that the displacement with an intended purpose of circumventing the use of the health services agreed with the MUGEJU on national territory, and of using means other than those.

3. European Health Card (TSE).

3.1 In addition to the coverage referred to in point 2, on temporary displacements to European Union countries, European Economic Area (Iceland, Liechtenstein and Norway) and Switzerland, mutualists may make use of the card European Health (TSE), which provides the right to receive health benefits through public health systems, with the extension and content laid down by the legislation of the State of residence providing health care, in identical conditions to the nationals of the country you are visiting.

3.2 The benefits to which the TSE gives access will be the same as the citizens of the country where the person concerned is located, the TSE does not give the right to repatriation or transport to the country of origin or habitual residence and in no case, gives access to private healthcare.

When the public health system of the country of stay in which the TSE is used, is subject to some kind of partial financing by the user (copay system), may request the refund of the co-payment through of MUGEJU, exclusively in the case of benefits of primary care, specialised care, emergency services, orthopaedic services and supplementary benefits covered by the national territory, with the limits and conditions of their regulatory regulations. The drawback procedure shall be as set out in paragraph 4 of this circular.

3.3 The mutualists may apply for the TSE for themselves and their beneficiaries, in the Mujeju provincial delegations or in the central services, by filling the form to the effect if the trip is imminent and does not You can expect to obtain a TSE, the mutualist must address the provincial delegation of MUGEJU and apply for a temporary replacement certificate (CPS), which temporarily replaces the European health card and has the same validity.

3.4 In the health centre where health care is requested, the TSE or the PSC, which credits the right to benefits, and the document certifying the identity of the holder of the card (DNI, passport, etc.).

3.5 The TSE and the CPS will not be valid when the displacement is intended to receive medical treatment for an injury or illness that the patient had before traveling.

3.6 The use of the TSE and the PSC, during its period of validity, is conditional on the holder's continuing discharge as an affiliate at MUGEJU. In another case, the costs incurred shall be regarded as being of undue benefit.

4. Procedure for reimbursement of expenses.

For the reimbursement of expenditure in paragraphs 1.5, 2.3 (a) and 3.2 of this circular, the holder shall make the application by completing the standard form corresponding to the facts and to which he shall attach, the following documents:

A) In the case of medical-ambulatory care and/or dispensing of medicinal products and other pharmaceutical products on an outpatient basis: Medical report of the care at least, patient, date and place of the patient care, diagnosis and treatment prescribed.

B) In case of medical-hospital care: High-profile clinical report, patient data, date and place of attendance, date of admission and discharge, diagnosis and treatment prescribed.

C) In all cases, original health center invoices, containing all legal requirements for their validity.

In any case, medical reports, prescriptions and invoices must have been issued outside the national territory.

(D) Supporting documentation of the professional destination or residence in a country outside the national territory, in the case of not being included in MUGEJU.

5. Special medical treatments in countries outside the national territory.

5.1 In the case of a technique, test and/or treatment which, being financed by the National Health System, cannot be provided through the public or private medical means in Spain, Mugeju may authorize the reimbursement of certain expenses arising from the assistance required in a country outside the national territory.

5.2 The procedure should be initiated at the request of the person concerned, on the basis of the treatment or intervention concerned, by completing the corresponding application form, in which he must state the facts and to which you must accompany the following documents:

1. Detailed medical report issued by the Hospital Service of the Autonomous Community or medical entity to which the applicant is attached, indicating:

a. The reason and the need to be cared for in a country outside the national territory.

b. The center and service where you can perform the technique, test and/or treatment.

c. Estimated duration of the same.

2. Budget of the health centre where intervention or treatment is to be carried out.

Requests for payment or reimbursement of expenses for techniques, tests, and/or treatments for which the authorization of MUGEJU is not previously available shall not be processed.

5.3 In view of the contributed reports, MUGEJU will perform as many checks as required and will request as many reports as it deems necessary. The case will be resolved by the MUGEJU Management Agreement.

5.4 In the case of authorisation, the reimbursement shall be limited to the health costs and the displacement of the patient and an accompanying person, calculated as provided for in Royal Decree 462/2002 of 24 May and in their subsequent amendments, on compensation for the service, referred to group 2 listed in Annex I.

5.5 Exceptionally, taking into account the special circumstances of the case, MUGEJU will analyse the possibility of making the payment directly to the foreign healthcare provider.

6. Final disposition.

6.1. All the standard forms required to apply for the above-regulated benefits will be available from the Central Services, the Provincial Delegations and the General Judicial Mutual website (www.Mugeju.es).

6.2. This circular shall enter into force on the day following that of its publication.

7. Repeal provision.

Point 13 of Circular 77 of the General Judicial Mutuality ("BOE" 29 November 2005) is hereby repealed.

Madrid, February 7, 2012.-The Manager of the Judicial Mutual General, Celima Gallego Alonso.