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Following, as I have the same question! Thanks for asking it, Elaine.

The gov.uk site can be a little contradictory, and doesn't always make it clear if they're referring to people who move under the pre-Brexit rules or post-Brexit rules. So hearing from a Brit who got their retirement D visa in Bulgaria under the new rules will be hugely helpful!

@grumpyoldbird

Great question, healthcare is a very important topic!

The S1 allows you to enjoy the public healthcare system in any EU country, including Bulgaria.

In Bulgaria, I think that's free or nearly-free healthcare in public hospitals, similar to the UK's NHS. The difference is that it's a much smaller population here and there seems to be much less strain on the system. I doubt that there are long waits if you need something, unlike the UK.

Like the UK, there are both public and private hospitals here. However, the difference is that, in the UK, it's a different system so if you want private treatment you pay private prices. In Bulgaria, most of the private hospitals seem to be affiliated to the public system, so they receive the standard public payment for your treatment and you pay only the "upgrade" cost of your VIP treatment. Even the private hospitals are very affordable, so it's not a huge extra cost. If you prefer, you can take out a separate private medical insurance policy that would cover these additional costs. I doubt it's necessary, but if you want it I doubt it would be 90 euros per month!

Personally, I find this aspect of the BG health system very appealing and I routinely go to private hospitals near me (Medline, Pulmed). But I'm spending a lot of time in Plovdiv, a big city. In the village, I'd guess I'd have to figure out the public options.

Thanks, Gwyn! The problem Elaine is facing is that France is forcing people who have the long-stay visa under post Brexit rules to pay top up insurance as well as provide their S1. I know you have your Bg residency under the pre-Brexit rules. Do you know whether it works the same for those of us moving under the sunny uplands of the post-Brexit rules?

@janemulberry

I'm not sure France is "forcing people", I think it's simply that French healthcare isn't completely free. Instead, there are copayments by the patient. So if you think these costs might be significant then you can get a supplementary health insurance. (Yes, it's possible that if you're applying for a residence permit they might need to see this policy in place as most countries want to see that you have ALL your healthcare costs covered, not just most of it.) As most of your health costs ARE covered, this kind of insurance is much cheaper than a full policy would be if you were not enrolled in the public system. As @grumpyoldbird seems to be covered in France with her S1, it seems likely that it would also cover her in Bulgaria.

My understanding is that an S1 works throughout EU, even if you leave now. Indeed, it should be noted that an "S1" is an EU document, which the UK continues to issue, even post-Brexit. I think these pages are relevant, and confirm that (a) the UK continues to issue S1 forms to its state pensioners, and (b) this form continues to be valid in the EU.

Healthcare in France

Healthcare in Bulgaria

Where does my S1 form cover me for healthcare?

Am I entitled to state-provided medical care if I move abroad?

Separately, if someone is already resident somewhere in the EU, and has been for a couple of years, I always suggest they stay put (if they can) in order to reach 5 years and get their Permanent Residency there. 5 years is a bit of a magic number for non-EU citizens in the EU, and the PR status is much more useful (and durable) that the typical 1 or 2 year temporary residence. The PR doesn't have automatic rights to relocate elsewhere, but most EU countries do seem to make it much easier for an EU PR relocating vs. a brand-new entrant. (And there is - separate to the national PR - an EU Long Term Resident's Residence Permit which DOES have relocation rights, similar to EU passport holders.)

But, as a disclaimer, I don't have an S1, so I haven't flashed it around to see what happens. :-) I pay my 14 euros per month as "unemployed" in order to be in the system and get my BG EHIC.

I haven't been sick yet, so I don't have lots of first-hand data, but the Bulgarian system seems very inexpensive and very responsive, and I'm very confident that it's at least as good as the UK's NHS. Plus Bulgaria is definitely a significantly cheaper place to live than France.

I only know this second hand, but I suspect the "forcing people" part for France is making the supplemental health cover a requirement for residency. So in effect, If one wishes to remain in France as a post-Brexit applicant for residency, one is forced to have such insurance. The figures Elaine (grumpyoldbird) quotes are in addition to her S1, just to cover the 30% gap between what the S1 covers and what is charged.

So the question is whether Bulgaria has a similar requirement. Is the S1 on its own enough to meet the health insurance requirement for post-Brexit D visa applicants to Bulgaria? And if Bulgaria also requires top-up health cover as a condition to get a pensioner D visa and then apply for residency, what's the likely cost?

@janemulberry

You might think I'm splitting hairs (sorry), but "forcing" sounds too strong. All EU countries have a standard requirement that you have healthcare cover when applying for residence (so you are not a burden on the state). Bulgaria (and others) are a bit more relaxed and will accept your EHIC/GHIC card. France (and Spain and others) are insistent that you have a health insurance policy, and typically with no copay (i.e. 100% of your healthcare costs are met). A healthcare policy is obviously MUCH more expensive than an EHIC card, and such a policy is extra expensive if it has no deductible.

Arguably, France is being a bit naughty if they insist on this (but each country has some freedom when implementing EU Directives). That's because the EU says you should have "either" private or public health cover, and access to the public system (because you have an S1) is enough based on the EU guidelines (even if the public system doesn't pay 100%, but pays most of it).

As far as I know, all EU countries will accept your S1 (if you're a state pensioner elsewhere), and most of their immigration offices will accept the S1 instead of a health insurance policy. However, in the specific case of France, public healthcare has significant (30% ish) copays... and hence French immigration wants to see a policy just to cover this part of your treatment. It's much, much cheaper for this supplementary policy than a full policy.

Yes, in practical terms, you have to have the cover at the point that you apply for (and perhaps renew) your residence permit. But you don't apply for a permit very often, so once you have your permit you can cancel or reduce the policy, or find an alternative solution. In Spain, I used the "cooling off" period to apply for permit, then cancelled the policy after the permit was issued. In Bulgaria, once I got my first permit, I enrolled in the local system and pay my 14 euros per month as "unemployed".

I don't have a lot of case studies. :-) I have friends in VT district, and they have S1s, and they use the public system. They have an English-speaking doctor in their village, and when there's been an issue he has arranged it in the hospital within days. They think it's much better than the NHS, and they said the cost is peanuts.

I have friends in Plovdiv, and they also have S1s, and are entitled to public care. They always go to private hospitals (usually Medline, a very nice private hospital in Plovdiv), and they've both had multiple instances of requiring serious medical care. Everything they've needed they've received immediately. The public system pays its contribution, he pays the extra out-of-pocket (no insurance policy). He says the hospitals have been "amazing" and that they'd probably both be dead if they'd still been in the UK relying on the NHS.

I have a local GP in Plovdiv who is excellent, and speaks very decent English (recommended by the couple above). He's in a private hospital (Medline), but you can enroll as a public system patient (as I have), or see him privately (as I did before I enrolled). His private consult is 50 leva, which is very reasonable. If you have public cover it's 5 (I think). He has daily clinic hours, and I come 10 minutes early if I want to be first. Otherwise, there might be 2 or 3 people waiting. :-) He does not seem to clock-watch so NHS 10-minute GP appointments are a thing of the past! :-)

I'm not sure if the public system covers dentistry which @grumpyoldbird also mentions. I'd guess it probably does, but might be hard to track down a dentist who's happy to work like this! I found an excellent dentist in Plovdiv who is the best dentist I've ever had, anywhere. Usually it costs 100-150 leva. I spent a few hundred lv this year on a replacement crown made of zirconia, this kind of thing is pretty expensive in the UK.

Here, I do things that are unthinkable in the UK. A public hospital emergency room in UK is packed. Specialists (orthopedists, cardiologists, dermatologists, etc.) are always busy. Equipment (for MRIs, X-Rays, etc.) is always busy. This is true in both private and public hospitals, but even more so in public hospitals. Dentists won't do NHS. GP surgeries are packed, and it's hard to get an appointment, and if you get one it's very short. The GP is the gatekeeper, so you can't go direct to the hospital (unless you go private and pay a lot of money).

Here, I waltz in to Pulmed or Medline, and say "I want X", and I typically get it immediately, or later in the day, or next day. This applies to scans (MRI, X-ray, ultrasound) and tests (blood tests, blood pressure, EKG, echocardiogram). Medline has a bunch of specialists with set public clinic hours, so you go when they're in. They're usually 50 leva (private), but the dermatologist charged 100. I've even wandered into the Pulmed Emergency Room (I wanted a consult, and I didn't have a GP yet) and waited 5 minutes. It's easy, quick, and cheap. And good. Or "amazing", if you factor in the cost. :-)

@janemulberry

As to your specific questions...

Does Bulgaria has a similar requirement? Is the S1 on its own enough to meet the health insurance requirement for post-Brexit D visa applicants to Bulgaria?

They are similar in the sense that Bulgaria (like any EU country) ALSO requires healthcare cover! :-) But different in that Bulgaria (immigration) will accept either an EHIC/GHIC or an S1 as proof that you are entitled to public healthcare in Bulgaria. And, even though Bulgarian public healthcare isn't completely free, they're not concerned with this issue.

And if Bulgaria also requires top-up health cover as a condition to get a pensioner D visa and then apply for residency, what's the likely cost?

It doesn't require this. Your S1 (or EHIC/GHIC) is sufficient on its own.

Even if we forget our EHIC, or otherwise don't qualify for public healthcare, Bulgarian immigration accepts a Health Insurance for Foreigners policy which normally costs about 80 euros.

I agree with you that for @grumpyoldbird (and most of us) an extra annual cost of nearly 1,000 euros is a big deal. So Bulgaria's 0 euros should make a nice change. :-) And any required Bulgarian co-payment would be significantly less than for equivalent French treatment.

In general, it's pretty easy to get the D visa for UK pensioners. The S1 (or EHIC/GHIC) covers the healthcare requirement. Your pension covers the financial requirement. You'd have the cost of buying a house (or renting a property) for the proof of address.

In Bulgaria, if you purchased a healthcare insurance policy, it would either be the cheap one mentioned above for immigration (it covers emergencies, accidents, and repatriation) or it would be proper private medical insurance (like BUPA, etc.). Hence it would not be to cover the public system deductibles, but to obtain private health treatment. Because of the affiliation of private hospitals with the public system, the private hospital would receive the standard public system allowance (courtesy of your S1), and the insurance company pays the "top-up" amount due. Hence this is also much cheaper than a policy that needs to cover 100% because you're not in the public system. Like all medical insurance policies the cost depends on your age and pre-existing conditions, but the last quote I got was less than 400 euros per year.

Thank you for the comprehensive information on health costs, Gwyn! So it sounds as if indeed, the S1 should be adequate for immigration purposes in Bulgaria.

Splitting hairs - I said "forcing", you say "insisting". The result is the same. An extra 1000 EUR a year is required to obtain a pensioner D visa/ residency in France vs 0 EUR extra for Bulgaria.

@janemulberry

I agree "forcing" and "insisting" are much the same. The difference is that the "forcing" was in relation to a general requirement, something that's legally mandated for living in France. Whereas my "insisting" was in relation to a narrow requirement to have full health coverage at the point of applying for residence permits. Much of the discussion seemed to be about immigration requirements, so I thought that it was appropriate to treat this information more in relation to immigration, rather than simply living in France.

However, perhaps I've misinterpreted @grumpyoldbird's point. It's a long time since I lived in France, and I can barely remember it (except that it was very nice). I don't remember public health deductibles being a big deal, but perhaps things have changed over the years. I am presuming that as it's an NHS-type system, the co-pays aren't huge. If they are, and if everybody in France has a mutuelle, then that would be an unfortunate aspect of their public health system and living in France. And certainly an extra expense. And, yes, 30% does sound like it could, in some cases, be a large number. I'd guess that, perhaps, in practical terms, the young and healthy (or wealthy, or employed) might not worry about it, but it might be highly recommended as you get into your "sunset" years.

If we treat it as simply a fact of life in France, then, yes, it's an extra 1,000 euros per year. And Bulgaria's public system has smaller co-pays - and sufficiently small that I don't think top-up insurance to cover the co-pays even exists here.

On the other hand, my guess was that It is required to keep immigration happy at the point that you're applying for a residence permit. Which is annoying, and 1,000 euros is nothing to be sneezed at. But you don't apply for (or renew) residence permits very often, so it's not something you need every single year. Usually, in most EU countries, immediately upon first becoming a resident, you go straight to the social security office and find a way to register in the public health system and pay some monthly contribution to achieve this. Thereafter, for any residence renewal, you just flash the appropriate health card to show you're enrolled in their public system, and they typically accept this.

Additionally, most insurance policies can be cancelled, so you get it at the time of renewal, and then cancel immediately or shortly thereafter. So... 80 euros x 3 months (as a guestimate for cancelling), and done 3 times (first residence application and 2 renewals to get to PR status), is 720 euros. And once you're a permanent resident, immigration can't even ask you about your healthcare coverage.

This is looking at it more as a practical issue in relation to immigration only. Even in this aspect, Bulgaria is much easier and cheaper, as it has a very inexpensive health insurance specifically for immigration purposes, and it readily accepts EHIC, GHIC and S1.

Having lived in France (and three of its neighbours, Andorra, Spain, and Germany), I'd say that it's delightful to be able to live in this region. In terms of food, culture, architecture and history (and modern infrastructure and services) it seems rather unfair to compare little Bulgaria, the poorest country in the EU. If you have the option, like @grumpyoldbird, to live there, you're very lucky. However, Bulgaria doesn't look very poor these days, thanks to lots of EU funding for upgraded road and rail links and other projects. It's a lovely country, and nearly empty. :-) And the cost of living and cost of property (both buying and subsequently owning) is extremely affordable.

I'm entitled to a full UK state pension, I guess it will be around 900 euros per month. In the UK, I believe this counts as poverty-level income, and it would be a challenge to live well on it. Here, it's just over twice the minimum wage and goes a long way, especially if you own your own home (as most expats do). If I were choosing today between France and Bulgaria, it's a no-brainer to pick beautiful Bulgaria. But it's a much harder decision if you're already living in France as @grumpyoldbird is.

I'm Bulgaria all the way! And not because it's lower cost and I couldn't afford France, but because while I'm not blind to its faults, I still love the place. I'm glad and grateful that the S1 is all we need there, and top-up insurance will be an optional extra. Thanks for the information.

@grumpyoldbird @janemulberry

My wife is a registered GP in Bulgaria, but non practising. So I'm aware of what we can get.

You should register with a local GP, in order to register with the public health service, which you do separately, at the health service building.  You can only register for public health, once you're in possession of a longterm residency card!

If you pay your health contributions in Bulgaria, most GP visits, consultations, diagnostics and hospital admissions are free.

You can pay your contributions for an entire year. It costs around 230 Leva.

However...

You have to pay for prescribable medications, at the cost per medication. Each medication has a different price, some cheaper than others.  If you are going to be regularly taking medicine over a long period, even lifetime, you will get a discount, which your Bulgarian GP arranges. The discount is put against your id number, so that when you visit the pharmacy, they just look up your id and check whether you're due for your repeat prescriptions. The cost is around 40% less. So be prepared for this expense!

Hospitals can be run down, however, you can ask for a private room, if they have them. This will be a cost to you. Costs vary, depending on the hospital.

In Bulgaria, private hospitals are obliged to treat public patients. The rule of thumb, is that if you can't be treated for your condition in your own city or town, then you can access hospitals elsewhere, including private ones. I did this earlier this year and accessed a brand new private hospital in Burgas - the treatment, including medical procedures were free, but I paid 25 leva per night (3 nights) for the shared room (3 people).

You can, of course, choose to go private. This you can access without any GP referral - just walk into a clinic! I've done this countless times now, for X-ray , CT and MRI and to see various consultants in neurology , urology, cardiology and gastroenterology.

Private consultations are between 50 and 120 Leva. An x-ray is around 60 Leva, a CT scan 175 Leva, an MRI 275 Leva. But the scan cost will depend on which part of the body is scanned.

Blood tests are always done at private clinics and the cost is dependent on which type of tests are being done and how many. On average, I spend around 75 Leva for 6 tests.

But there are some tests which can be very expensive (most aren't).

In Bulgaria you, keep all your medical notes. Doctors and hospitals do not keep your notes. You are responsible for maintaining them and safekeeping them. You should take any relevant notes with you to appointments. This is a way better system, as only you are to blame if you lose them!

Public Ambulances are free, private are payable. Wait times for a public ambulance depends on where you live - if you're in a remote village, you can expect a long wait. In a city, around 10 to 20 minutes.

The emergency departments of big public hospitals can be chaotic and eye opening!

A few private hospitals also have emergency departments - the one in Burgas did.

@gwynj Wow! I've really opened a can of worms!

Can I just clarify? It is not compulsory to have the top up insurance in France, however if you don't have it and you need assistance, you have to pay 30% of the cost out of your own pocket. A friend had a coronary about 8 months ago and was airlifted to the hospital. I can't remember how many thousands of euros that was, but I remember it was an eye watering figure. So, whilst the top up insurance is not compulsory, on your own head be it. it. There are apparently discounts available for those in reduced circumstances, but I don't qualify.

My bad for misunderstanding!

It's been a helpful discussion with plenty of valuable information!