Cross-border healthcare

All persons assisted by the Health System of a European Union (EU) Member State can receive healthcare in another EU State at the expense of their own country. The way in which the costs are covered in the EU Member State are regulated by two legal instruments of the EU which mainly differ the way in which health care systems handle the payment. The coverage of healthcare expenses takes into consideration two forms of payment:

  • payment covered by the health system
  • reimbursement by the health system of expenses previously paid by the patient.

The general principles pertaining to the two legal instruments can be applied differently  in each  individual EU State, in addition to local regulations.


The Regulations (direct payment by the state of affiliation)

The first instrument derives from the Regulations (EC) of the European Parliament and of the Council on the coordination of Social Security systems No. 883 of 29 april 2004 and No. 987of 16 september 2009, and allows patients to receive treatment in another EU country, in other countries of the European Economic Area and in Switzerland, under the same level of healthcare generally available through the foreign National Health System.

The Regulations provide that:

The healthcare services provided by health professionals and health care centers , both public or private which have an agreement with the local health system, are paid directly by the patient’s health care system (direct payment by the state of affiliation); in most cases patient co-payment charges are not refundable. Cares provided by private health professionals and health care centers,  outside of the agreements with the local health system, are not refundable

In case of a planned treatment, i.e. a specific therapy which has been prescribed in advance, patient must obtain authorization by the relevant healthcare institution in his or her State of affiliation.

The authorization is granted if the planned cross-border treatment  fulfils the following criteria:

  1. is adequate and designed to ensure the health protection of the patient
  2. is provided by the patient’s healthcare benefit package but cannot be provided on its territory within a time limit which is medically justifiable, taking into account the current state of health and the probable course of the illness of each patient concerned

If permission is granted, a S2 certificate will be issued. This certificate must be presented to the health care providers (or institutions) so to have the cost covered.

Coverage of expenses for travel and assistance can also be authorized.

Direct access to emergency care when a citizen is temporarily in the territory of another Member State, having taken into consideration the specific health case scenario specifically regarding the type of care and stay, is granted to patients who own a European Health Insurance Card - EHIC (in Italy called Tessera Europea di Assicurazione Malattia - TEAM) or its replacement certificate.

The EHIC or its replacement certificate cannot be utilized to cover costs which are not classified as emergency care.

The Directive (reimbursement by the state of affiliation)

The Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 joins the Social Security Regulations providing further opportunities for cross-border healthcare treatments.

The Directive stipulates that:

  • The costs of health care (authorized under certain circumstances) are anticipated by the patients, who can request reimbursement by the Health System of their State of affiliation (indirect coverage).
  • The treatments which are deemed reimbursable are the ones provided by the health system in their State of affiliation , with the exception of long-term cares (the purpose of which is to support people in need of assistance in carrying out routine, everyday tasks), allocation of and access to organs for transplantation and public vaccination programs against infectious diseases.
  • The reimbursement for healthcare services is equal to the cost that the Health Care System would have incurred if the treatment had been provided in the State of affiliation, without exceeding the total cost of care. However, Member States may decide to reimburse the full cost of treatment, even if this exceeds the level of costs that the health system would have incurred if the treatment had been provided in its territory, and may reimburse expenses for travel and assistance.
  • Member States may restrict the application of the rules on reimbursement, based on overriding reasons of general interest.
  • As for incoming patients, the Directive states that Member States may restrict access to medical care on their own territory, based on overriding reasons of general interest.
  • Member States may introduce prior authorization, respecting criteria mandated by the Directive

Criteria for cross border health-care prior authorization

Healthcare that may be subject to prior authorization shall be limited to healthcare which:

  1. is made subject to planning requirements relating to the object of ensuring sufficient and permanent access to a balanced range of high-quality treatment in the Member State concerned or to the wish to control costs and avoid, as far as possible, any waste of financial, technical and human resources and (i) involves overnight hospital accommodation of the patient in question for at least one night or (ii) requires use of highly specialized and cost-intensive medical infrastructure or medical equipment;
  2. involves treatments presenting a particular risk for the patient or the population; or
  3. is provided by a healthcare provider that, on a case-by-case basis, could give rise to serious and specific concerns relating to the quality or safety of the care.

The Directive expressly states that, if a request for prior authorization satisfies the conditions for authorization under the Regulations section, the authorization is granted in accordance with the Regulations section, unless the patient requests otherwise.

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Data di pubblicazione: 4 aprile 2014, ultimo aggiornamento 4 aprile 2014

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