Impact of Brexit on Healthcare
After intense negotiations, the European Union (EU) and the United Kingdom opened a new chapter in their relations with the agreement reached on 24 December 2020.
The Trade and Cooperation Agreement (Partnership Agreement) negotiated by the EU and the United Kingdom entered into force provisionally on 1 January 2021 after all 27 member states approved the Agreement and its provisional application. On 27 April 2021, the European Parliament also voiced its approval meaning the Agreement was able to enter into force fully on 1 May 2021. Additional up-to-date information on the agreement can be found on the website of the Federal Foreign Office.
1) How will the Partnership Agreement affect the health sector from 1 January 2021? An overview.
a) The rights of citizens with regard to health and long-term care insurance
Guidance on Brexit for all those affected can be found on the website of the German Liaison Agency Health Insurance – International (Deutsche Verbindungsstelle Krankenversicherung – Ausland) (for example, for tourists, pensioners, students, posted employees). Since the specifics of each case and the questions vary, we recommend that citizens contact their health insurance fund or health insurance carrier in Germany directly.
Fortunately, in a separate protocol on the coordination of the social security systems, the Partnership Agreement essentially adopts the provisions of Regulations (EC) Nos. 883/2004 and 987/2009 that have applied within the EU to date and also due to the transition period of the Withdrawal Agreement. According to this protocol, the social insurance agencies can continue to apply EU law as if the United Kingdom were still a member state. What can no longer be continued under the Partnership Agreement, however, is the export of long-term care services for new cases, in other words, for situations starting from 1 January 2021 where no cross-border relationship had previously existed between an EU member state and the United Kingdom. Such cases are subject to the new Partnership Agreement, which excludes coordination of long-term care insurance benefits. However, use of the European Health Insurance Card (EHIC) and the Provisional Replacement Certificate (PEB) will still be possible. The recognition of insurance periods will also still be possible. Nevertheless, in some cases, it will be necessary to make healthcare contributions from 1 January 2021 in order to obtain full access to the health care system in the United Kingdom. Persons who are domiciled in the United Kingdom but insured in another country, and students, can under certain circumstances have their contributions reimbursed in part or in full by the United Kingdom. Answers to and tips on health and long-term care insurance can be found in the “FAQs”.
b) Recognition of professional qualifications in healthcare
The Partnership Agreement envisages regulations for the recognition of foreign professional qualifications that will apply to applications for recognition from 1 January 2021. These envisage, in particular, that professional organisations of both contractual partners can propose easing recognition regulations for specific professions if this is in the economic interest of both sides. However, the automatic recognition through the previously valid EU Professional Qualification Directive, will no longer apply. In the absence of eased recognition regulations based on the agreement, from January 2021 EU citizens with qualifications acquired in the United Kingdom must have these recognised based on the regulations valid in Germany for qualifications acquired in third countries. The same applies to British citizens who have not obtained their qualifications in a member state of the EU.
Further information on the recognition procedure can be found at the Information portal of the German government for the recognition of foreign professional qualifications.
c) Movement of medicinal products and medical devices
In principle, the United Kingdom leaves the regulatory system of the EU for medicinal products and medical devices on 1 January 2021. However, the Partnership Agreement establishes, among other things, a foundation for comprehensive economic partnership. At its core, this is based on a free trade agreement that envisages neither customs nor quotas and, as a result, avoids significant barriers to trade. The Partnership Agreement therefore significantly contributes toward ensuring the population's uninterrupted supply of medicinal products, vaccines and medical devices, which remains the Federal Government’s utmost priority. The Partnership Agreement envisages regulations to avoid technical barriers to trade with regard to standardisation and conformity assessment procedures, including medical devices. A highly welcome point, in addition, is the special annex providing possibilities for recognising inspection results in order to certify compliance with Good Manufacturing Practice (GMP certificate) by medicinal products and active substances. On their websites Germany's higher federal authorities draw attention to the potential impact of Brexit and provide information for pharmaceutical companies (BfArM and PEI) Furthermore, on its website EMA provides information for businesses.
d) Health Security
From 1 January 2021, cooperation between the EU and the United Kingdom in the area of health security will take place as with a third country, in other words, only event-driven and on a temporary basis during an acute threat situation – without permanent membership in European structures, as is the case with EU member states or states with a permanent observer status, such as Norway or Liechtenstein. In acute threat situations such as the current pandemic, crisis management corporation with the United Kingdom will continue within the Health Security Committee (HSC) and through the Early Warning and Response System (EWRS) at the European Centre for Disease Prevention and Control (ECDC).
In the area of preparedness planning and crisis prevention, it was possible to secure future collaboration by means of a memorandum of understanding (MoU) with the ECDC, as is the case with other third countries.
2) What applied up to 31 December 2020 during the transition phase?
The transition phase, during which EU legislation on social law coordination and the recognition of professional qualifications in principle still applied, lasted until the end of 2020. As the United Kingdom continued to remain within the EU’s Single Market and the customs union during this time, there were also no changes to the movement of medicinal products and medical devices until the end of 2020.
a) Health and long-term-care insurance
Health coverage, the uptake and billing of health and long-term care insurance services in the respective other country, as well as the recognition of insurance periods, all stayed the same until the end of 2020.
The European health insurance card (EHIC) or the Provisional Replacement Certificate (PRC) for instance, remained valid over this period. Additionally, the Withdrawal Agreement stipulated that people who had already commenced or applied for planned care in the United Kingdom or in Germany before the end of the transition period, would continue to possess the right to pursue that treatment.
From Germany's perspective, health insurance contracts with German private health insurers (substitute health and long-term care insurance as well as state-subsidised supplementary long-term care insurance) signed before the end of the transition period can continue as before if the relevant person was already resident in the United Kingdom on 31 December 2020. The prerequisite for the continuation of a supplementary long-term care insurance with state funding is, however, the eligibility for benefits, in other words, basically, the person to be insured must be a member of the statutory or private long-term care (compulsory) insurance. However, a person can lose this membership if the obligation to be insured ends after 31 December 2020, for example in the wake of a stay abroad without continuation of the insurance or in the case of a “special agreement”, or the insured person cancels his/her private long-term insurance contract, for instance because he/she wishes to switch to the insurance system of the United Kingdom or to a private insurance there. At best, there exists the possibility of signing an entitlement insurance, as long as no need for long-term care and no insurance case has yet occurred. Since individual cases can differ greatly, particularly with long-term care insurance, it is recommended that insured persons consult their insurance companies for further advice.
b) Recognition of professional qualifications
Until the end of 2020, there were no changes with regard to the recognition of professional qualifications in healthcare. Until then, an application for recognition of professional qualifications filed by an EU or UK citizen to a competent authority in the receiving country or country of employment was still determined according to EU rules. The citizens concerned were therefore urged to apply for recognition of their professional qualifications as early as possible and in good time before the end of the transition period. Professional qualifications recognised before the end of the transition period retain their validity within the other country, including the right to exercise the profession on the same terms as nationals.
c) Medicinal products and medical devices
Goods, therefore also medicinal products and medical devices, which were legally placed on the market before the end of the transition period, will retain the right to be traded in the markets of the EU and the United Kingdom after the transition phase until they reach their end consumers, without requiring product changes or renewed labelling.
Depending on the risk class of a medical device or an in vitro diagnostic medical device, manufacturers must work together with a Notified Body when pursuing the conformity assessment of their device. During the transition period, British Notified Bodies were able, in principle, to continue to issue certificates for medical devices and in vitro diagnostic medical devices.
3) Frequently Asked Questions on topics related to health care and long-term care
Questions on the regulations contained in the Partnership Agreement
The Withdrawal Agreement will continue to apply to old cases.
Since the long-term care insurance and the private compulsory long-term care insurance are not covered by the Partnership Agreement, the previous regulations do not apply to new cases. For example, if a person’s domicile or usual place of residence is transferred to Great Britain from 1 January 2021, this person will no longer be subject to the long-term care insurance obligation in Germany (exceptions may exist for cases of posting to Great Britain Kingdom or ordinary gainful employment in Germany and Great Britain). However, it will be possible to apply for voluntary continuing insurance (subject to contributions) so as to maintain already acquired insurance claims in the event of a return to the country, and to avoid any potentially detrimental interruptions in insurance periods. The application is to be submitted at the latest one month after termination of the insurance obligation to the long-term care insurance fund where you were last insured. The continued insurance covers all of the family members or life partners hitherto insured who transfer their registered or usual place of residence abroad together with the insured member. If a member transfers his/her registered or usual place of residence abroad, family members or life partners who remain in the country will cease to be entitled to this family insurance. Along the same lines, persons who had been privately insured until that point and who transfer their registered or usual place of residence to Great Britain from 1 January 2021, will have the option of concluding a so-called “special agreement” corresponding to the insurance and contractual conditions to secure their insurance coverage in case they return to the country. It should be borne in mind that state-subsidised supplementary long-term-care insurance funds are tied to the continuation of the statutory long-term care insurance. With respect to long-term care insurance law, for new cases from 1 January 2021, domestic insurance coverage will generally be upheld for short-term stays abroad (for example, holidays) in Great Britain. However, claims to benefits will be suspended for as long as the insured person remains abroad. In cases of a purely temporary stay abroad, the nursing care benefit or proportional care allowance will be paid for a maximum of up to six weeks per calendar year.
You are advised to check whether taking out a travel or international health insurance would be useful.
The provisions of the European regulations on coordination of social security will essentially continue to be applicable with the provisions of the Partnership Agreement from 1 January 2021. In so far as members of the statutory health insurance stay in the United Kingdom temporarily, they may make use of the services there. Under the provisions of the Partnership Agreement, this can continue based on the European health insurance card (EHIC) or the Provisional Replacement Certificate (PRC).
The same applies to people temporarily staying in Germany, who are insured in the United Kingdom. They, too, can take advantage of benefits and services on the basis of the European health insurance card (EHIC) or the Provisional Replacement Certificate (PRC).
For students in Germany, who are subject to compulsory insurance via Student Health Insurance (KVdS) or insured with the statutory health insurance under the family benefits scheme, their existing insurance status will apply for as long as the remaining conditions continue to be met. Treatment costs incurred in the United Kingdom will be reimbursed by the German health insurance.
Under specific conditions, students can have any healthcare contributions, required by the United Kingdom at the start of their studies from 1 January 2021 for them to obtain full access to the healthcare system, reimbursed in part or in full by the United Kingdom.
Students registered in Germany are, in principle, obliged to have mandatory health insurance unless they can prove sufficient health insurance coverage through a foreign-based health insurance carrier. Where students continue to have the centre of their life in the United Kingdom and remain insured with their health insurance carrier in the United Kingdom, they will generally not be covered by the German compulsory health insurance and can prove their claim to benefits using the European health insurance card (EHIC) or a Provisional Replacement Certificate (PRC).
In order to be eligible for pensioners’ health insurance (KVdR), among other things the pre-insurance period must be met (it must be shown that a person made payments to the statutory health insurance for nine-tenths of the latter half of their working life). According to the Partnership Agreement, from 1 January 2021 the insured periods completed in the United Kingdom will continue to be counted towards the pre-insurance period.
Pensioners who reside in the United Kingdom and receive a pension from the German statutory pension insurance or old-age financial security for farmers and who were insured with the German statutory health insurance as pensioners at the end of the transition phase, will remain covered by the statutory health insurance after the transition phase ends. Those who remain insured with the statutory health insurance are also insured with the social long-term care insurance. Furthermore, according to the Partnership Agreement, German pensioners who move their registered place of residence to the United Kingdom from 1 January 2021 will retain the option of remaining with their German health insurance fund if they fulfil the other requirements.
In the area of long-term care insurance, for new cases there is no obligation to obtain insurance, as the long-term care insurance is not covered by the Partnership Agreement. However, it will be possible to apply for voluntary continuing insurance (subject to contributions) so as to maintain acquired insurance claims, in the event of a return to the country, and to avoid any possible detrimental interruptions in insurance periods. The application is to be submitted to the long-term care insurance fund where you were last insured at the latest one month after termination of the insurance obligation. The continued insurance will cover all of the family members or life partners hitherto insured who are transferring their registered or usual place of residence abroad, together with the insured member. On the day that the member transfers his/her registered or usual place of residence abroad, family members or life partners who remain in the country will cease to have the family insurance to which they were entitled up to that point. Along the same lines, persons who had been privately insured until that point and who transfer their registered or usual place of residence to Great Britain from 1 January 2021, will have the option of concluding a so-called “special agreement” corresponding to the insurance and contractual conditions to secure their insurance protection coverage in case they return to the country.
According to section 2 (1a) of the Ordinance on the Prescription of Medicinal Products (Arzneimittelverschreibungsverordnung, AMVV), only medical or dental prescriptions from member states of the European Union, the European Economic Area and from Switzerland are deemed equivalent to prescriptions issued in Germany (implementation of Directive 2011/24/EU on the application of patients’ rights in cross-border healthcare). Therefore, since 1 January 2021, prescriptions from the United Kingdom may no longer be dispensed in Germany due to the withdrawal of the United Kingdom from the European Union and the expiry of the transition phase by the end of 2020.
Questions regarding the Withdrawal Agreement/Old cases
No, you do not need to do anything. If, on 31 December 2020, you were the holder of an S1 form, the United Kingdom will continue to finance your healthcare and the benefits-in-kind in case of a temporary stay in the territory of the other state, should you need long-term care, even after the transition period comes to an end. Pensions and other benefits can be exported. This applies as long as you continue to live in Germany and are covered by the regulations contained in the Withdrawal Agreement.
Yes, if you fall under the Withdrawal Agreement (for example, you have a legal right of stay in Germany on 31 December 2020, or a general cross-border situation simultaneously involving the United Kingdom and a member state of the EU), the rules on the coordination of social security systems, and consequently also your European health insurance card for holidays, will continue to apply even after the end of the transition period and beyond. This applies to travel to the United Kingdom as well as to trips to other EU member states.
Yes, you have the right to apply for a portable S1 document as soon as you have applied for your state pension in the United Kingdom and have proven that, at the end of the transition period, you were lawfully resident in Germany and continue to live in the country and/or a general cross-border situation applies simultaneously involving the United Kingdom and a member state of the EU. Through the S1 form, you will have access to the same health insurance benefits and services as German pensioners and to benefits-in-kind in case of a temporary stay in the territory of the other state, in the event of a need for long-term care, but at the expense of the United Kingdom.
Good to know
Guidance on Brexit for all those affected can be found on the website of the German Liaison Agency Health Insurance – International (Deutsche Verbindungsstelle Krankenversicherung – Ausland).
Since the specifics of each case and the questions asked frequently vary, we recommend that affected citizens contact their health insurance fund or health insurance carrier in Germany directly.
For general information related to health insurance, please contact the citizens’ hotline of the Federal Ministry of Health at: +49 (0)30 3406066 01. A contact form is also available.
Current information, questionnaires and link collections can be found on the website of the Federal Foreign Office.
An overview of Brexit preparations by the Federal Government, the EU Commission and trade associations can be found on the website of the Federal Government.
The EU Commission publishes Questions and answers on the Partnership Agreement.
In addition, the EU Commission has published Guidelines on citizens’ rights in the context of the Agreement on the Withdrawal of the United Kingdom from the EU that, among other things, explain the rules on the coordination of social security systems and the recognition of professional qualifications.
Furthermore, the EU Commission has published a communication as well as, in the meantime, over 80 so-called Readiness Notes in preparation for the ending of the transition periord at the close of 2020. The documents describe legal amendments that stakeholders will have to cater for and which will be necessary in any case at the end of the transition period, irrespective of the outcome of the ongoing negotiations between the EU and the United Kingdom on a future partnership. This applies, among other things, to amendments governing travelling in relation to medical treatment and medical prescriptions, clinical trials, medicinal products, substances of human origin, drug precursors and industrial products including medical devices as well as the area of data protection.