An overseas visitor is any individual who is not “ordinarily resident” in the UK. Being ordinarily resident means living in the UK on a lawful, voluntary, and settled basis. The NHS is a residency-based healthcare system. Therefore, the primary qualifying requirement for free NHS care (relevant services) is residency status, regardless of nationality, ethnicity, possession of a British/European Economic Area (EEA) passport, an NHS number, GP registration, past residence in the UK and previous tax/National Insurance contributions. 

Chargeable overseas visitors are charged at 150% of the NHS tariff. However, Accident and Emergency services and GP services are free for everyone, including overseas visitors. This does not include any inpatient care or outpatient/community services following the A&E or GP treatment.

This list includes, but is not limited to: 

• Individuals who have paid the Immigration Health Surcharge (IHS) or are IHS exempt. This may include but not limited to professionals working under a valid work visa (e.g. skilled worker visa) and students studying full-time in the UK. Please note, IHS payment does not cover assisted conception or other non-relevant services.
• Citizens of European Economic Area (EEA) countries or Switzerland who have a valid European Health Insurance Card (EHIC). Please note, an EHIC does not cover all NHS services and is not a substitute for travel insurance.
• Refugees and their dependents or individuals who have applied for asylum and are awaiting a decision from the Home Office. In the latter case, patients may be expected to provide documentary evidence such as an Application Registration Card (ARC).
• Individuals receiving support under section 95 of the Immigration and Asylum Act 1999 are also exempt from charges. 

This list includes, but is not limited to: 

• Short-term visitors who are visiting the UK for less than six months, e.g., tourists
• Individuals without a Valid Immigration Status
• British citizens who have been living abroad and are not currently residing in the UK.

Overseas visitors should be given information on how to raise any complaints or concerns they may have about decisions made regarding their chargeable status. For instance, if a patient considers that they have been charged incorrectly, they should liaise with the Overseas visitor’s team to discuss on what basis they have been found to be chargeable and whether further documentary evidence is required. 

In cases where disagreement persists about how the charging regulations have been applied to a particular patient, the patient may want to seek the services of the Trust's patient advice and liaison service (PALS) or follow the NHS Complaints procedure.

Clinicians play a pivotal role in ensuring that the charging regulations work effectively and have four key responsibilities under the Charging Regulations: 

• To take the final decision in determining whether treatment is immediately necessary, urgent or non-urgent.
• To confirm that a patient is receiving treatment which falls under the exemption category (Referred to in the exempt services section).
• To confirm that a patient is a victim of specified types of violence, such as torture, female genital mutilation, sexual or domestic violence, as well as modern slavery. Although it is not expected that the clinician will be able to provide confirmation in all cases.
• To advise that the patient is fit to travel to return home for further treatment.

Can services refuse treatment to patients? 
No! Immediately necessary treatment or urgent treatment must never be delayed or withheld due to charging considerations, even if the patient indicates that they cannot afford to pay or unwilling to pay. Refusing patients access to immediately necessary or urgent treatment could be a breach of the Human Rights Act 1998. 

Can a patient be asked to pay for treatment upfront before the treatment commences? 
Yes! This is where the clinician has determined that the patient’s treatment is non-urgent treatment. In this case, the patient’s total treatment costs should be estimated, and the patient should be asked to pay before the treatment commences. 

Can a patient be interviewed? 
Yes! Especially, if it has not been possible to determine a patient’s chargeable status through the various checks that had been carried out and/or where chargeable status is disputed. 

Who is exempt from charges for NHS services? 
Exempt Services:

A charge cannot be made or recovered from any overseas visitor for:

• Accident and Emergency Services/ Primary Care, like GP visits
• Services that are provided as part of the NHS 111 or telephone advice line
• Palliative care services are provided by a registered palliative care charity or a community interest company
• Family planning services, which means services that supply contraceptive products and devices to prevent pregnancies
• Diagnosis and treatment of specified infectious diseases
• Sexually transmitted diseases
• Treatment required for a physical or mental condition caused by:
  • Torture Female Genital Mutilation (FGM)
  • Modern Slavery
  • Domestic violence, or
  • Sexual violence
• Except where the overseas visitor has travelled to the UK for the purpose of seeking that treatment. 

Exemptions for specified vulnerable groups

The charging regulations include legal exemptions for specified groups. The following categories of overseas visitors are exempt from charges: 

• Asylum seekers and their dependants.
• Failed asylum seekers receiving support under section 4(2) of the 1999 Act from the Home Office or those receiving support under section 21 of the National Assistance 1948 from a Local Authority.
• An individual receiving support under section 95 of the Immigration and Asylum Act 1999
• Refugees and their dependents.
• Residents of Ukraine, currently present in the UK lawfully.
• Children who are looked after by a Local Authority.
• Victims, and suspected victims, of human trafficking, as determined by the UK Human Trafficking Centre or the Home Office, plus their spouse/civil partner and any children under 18, provided they are lawfully present in the UK
• Victims of sexual violence, modern slavery, torture, FGM, and domestic violence
• Anyone receiving compulsory treatment under a court order or who is detained in an NHS hospital or deprived of their liberty (e.g. under Mental Health Act 1983 or the Mental Capacity Act 2005).
• Armed forces and war pensioners
• Those covered by reciprocal healthcare agreements or other international obligations. For more information on exemptions, please visit https://www.gov.uk/government/publications/nhs-cost-recovery-overseas-visitors/charging-overseas-visitors-in-england-guidance-for-providers-of-nhs-services#exemptions-for-specified-groups   

What if a patient fails to pay? 
If a patient has an outstanding debt of more than £500 which is not cleared within 2 months of invoicing, their future application to enter or remain in the UK may be impacted as the Trust has a legal obligation to inform the Home Office via the Department of Health and Social Care. Please note, clinical information is not shared with third parties. 

What if a patient states that they cannot afford to pay the invoice? 
If a patient states that they cannot afford to pay for their NHS care, an Income and Expenditure form or affordability assessment will be issued to them to be completed within 30 days. Information gathered in this form will be used by the Finance Senior team lead to determine whether a debt repayment plan can be agreed. 

Can a legitimate debt owed by a patient be cancelled or waived? 
No! Neither the Secretary of State for Health and Social Care nor ELFT as a Trust, have the power to cancel or waive debts, unless the charges are found to be incorrectly applied. 

What if a patient who has debt is destitute or is at risk of imminent destitution?
Following sets of criteria around the issue of destitution, the Trust may consider that debt collection is unlikely to be cost-effective and can choose not to pursue the debt for the time being. This is known as ‘writing off’ the debt in accounts. Although, the Trust may decide not to pursue a debt at that time, it does not mean it has chosen to cancel the debt and does not preclude pursuing that debt in the future if that individual’s circumstances change. 

What if a patient has an EHIC?
If a patient holds a valid European Health Insurance Card (EHIC) issued by an EEA country, they are entitled to receive medically urgent or necessary treatment, such as maternity care in the UK for no cost or reduced cost, based on circumstances. This does not cover planned treatment. 

What if a patient is from an EEA country but does not have an EHIC? 
In this case, a member of the Overseas Visitors Team can request a Provisional Replacement Certificate (PRC) on the patient’s behalf. If a patient is eligible for a PRC, it would normally provide the same cover as an EHIC. 

What if a patient does not have either EHIC or PRC? 
They will be charged for the cost of care received at 150% of standard tariffs. 

Can patient information be shared with the Home Office? 
Yes! Patient’s non-clinical information can be shared with the Home Office for the purpose of establishing immigration status.

Do we need to obtain patient consent before sharing their information for the purpose of submitting an SVEC form?
 No, but it is advisable to notify that their data is being shared, and how this data may or will be used. 

Can the patient SVEC report provided by the Home Office be shared with a third party? 
No! SVEC report provided by the Home Office, which contains patient immigration history, must never be shared with a third party, including the patient or their representative, without the Home Office's consent. 

What is the meaning of SVEC? 
Status Verification and Enquiries Checking. This can be used when other avenues of establishing a patient’s immigration status have been exhausted. 

SVEC can provide information about a patient’s immigration status, and why is SVEC used? 

• where fraud is suspected
• there is contradictory evidence regarding the patient’s status
• the patient has been unable or unwilling to provide evidence of status 

Can a patient prove their entitlement to free NHS care? 
Where a patient is claiming entitlement to free NHS care or an exemption from charges, it is their responsibility to prove they are entitled to that treatment without charge. This can be done by providing documentary evidence to support a claim for free treatment. If, in the light of the enquiries, ELFT decides that the person is not eligible for treatment without charge or that the person has not provided sufficient evidence to support their claim, then ELFT must levy a charge and take all reasonable measures to recover it from that person. 

Will a patient be charged for emergency treatment? 
Emergency treatment provided in Accident & Emergency (A&E) departments is free of charge for all patients, regardless of immigration or residency status. Charges may apply for treatment received beyond the emergency services. 

Can a patient receive treatment if they are not eligible for free NHS care? 
Yes, treatment, which, according to the clinician's opinion is deemed immediately necessary or urgent, will not be delayed or withheld due to charging considerations, even if the patient indicates that they cannot afford to pay. This does not imply that the treatment is free. Charges may follow later if not paid up front. However, if, as per the clinician’s opinion, the care is non-urgent, then it will proceed only once payment is made up front. 

Is the NHS Cost Recovery – overseas visitors charging regulations a legal obligation? 
Yes! It means that ELFT, as a relevant body (NHS provider), must comply with the regulations. 

What are baseline questions? 
Baseline questions are a set of initial questions for all patients to help determine their eligibility for free NHS Treatment, for example, “where have you lived in the last 12 months?”