Scope of the directive and regulation1.
Why do we have both a Regulation and a Directive?
How do they differ?
Regulation (EC) No 883/2004 of 29 April 2004 and Directive 2011/24/EU of 9 March 2011 differ mainly in the following aspects:
Regulation (EC) No 883/2004 of 29 April 2004 is mainly based on direct healthcare: health services are provided, under the same conditions as for persons insured in the country of treatment, by public or NHS-affiliated private health facilities or professionals and are, as a rule, paid directly by your health system, except for any co-payment (e.g. the ‘ticket’ in Italy).
Directive 2011/24/EU of 9 March 2011, is mainly based on indirect healthcare: the patient pays upfront for the treatment abroad, authorised in the cases provided for, and subsequently claims reimbursement from his/her national health system. Reimbursement is normally equal to the cost that the patient’s healthcare system would have incurred if the treatment had been provided in the patient’s country, without exceeding the actual costs of healthcare received.
Regulation (EC) No 883/2004 of 29 April 2004 always requires prior authorisation.
Directive 2011/24/EU of 9 March 2011 provides that Member States may make reimbursement of costs of cross-border healthcare subject to prior authorisation for treatment which: 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 involves overnight hospital accommodation of the patient in question for at least one night or requires use of highly specialised and cost-intensive medical infrastructure or medical equipment; involves treatments presenting a particular risk for the patient or the population; 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.
Regulation (EC) No 883/2004 of 29 April 2004 provides that insured persons can obtain in an EU Member State, in one of the other EEA countries (Iceland, Liechtenstein, Norway) and in Switzerland, in addition to necessary and urgent treatment during temporary stays, treatment appropriate to their condition where the treatment in question is among the benefits provided for by the legislation in the Member State where the person concerned resides and where he/she cannot be given such treatment within a time limit which is medically justifiable, taking into account his/her current state of health and the probable course of his/her illness.
Directive 2011/24/EU of 9 March 2011 provides that insured persons can obtain, in one of the Member States of the European Union, the treatments provided by their health system, with the exception of: services in the field of long-term care, allocation of and access to organs for the purpose of organ transplants and public vaccination programmes against infectious diseases.
Regulation (EC) No 883/2004 of 29 April 2004 provides that health services are delivered by public or private health facilities or professionals affiliated with the health system of the country of treatment.
Directive 2011/24/EU of 9 March 2011 provides that reimbursable services may be provided by public and private healthcare providers, even not affiliated with the health system of the country of treatment.
Which of the two schemes is best for you?
In order to evaluate which of the two legal instruments best suits your needs, you should contact your competent institution (if you are registered with the Italian National Health Service, this is the Local Health Authority (ASL) to which you belong) or your National Contact Point which will be able to give you information appropriate to your medical condition.
Under the Directive, you can receive in another EU Member State the same health services that your health system offers you in your country, except for long-term care (the purpose of which is to support people in need of assistance in carrying out everyday and routine tasks), and except for access to and the allocation of organs for the purpose of organ transplants and public vaccination programmes against infectious diseases.
Contact your competent institution (if you are registered with the Italian National Health Service, the Local Health Authority (ASL) to which you belong) or your National Contact Point to find out exactly which types of treatment fall under the Directive and which of these require prior authorisation for reimbursement.
Can I seek healthcare abroad if the treatment is not promptly available in Italy?
You can seek healthcare abroad if it is not available promptly in your territory, but you must check with the competent institution (if you are registered in the Italian National Health Service, the ASL to which you belong) to find out if you need prior authorisation and if you will be reimbursed for the health services upon your return to your country.
EU Member States may limit the application of cross-border healthcare where this is justified by overriding reasons of general interest, such as planning requirements relating to the aim 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.
The limitations may concern both the reimbursement of costs incurred by patients treated in another Member State and access to healthcare by patients from other Member States.
Before leaving, check if there are any such restrictions, also through your National Contact Point.
In Italy, any restrictions are published on the portal of the Ministry of Health and on the websites of the Regions and Autonomous Provinces concerned.