Accessing Medical Care under the EU Cross Border Healthcare Directive

Nigel Whitfield is a 56 year old plant manager living in London’s west end. Two years ago he was diagnosed with severe osteoarthritis of the hip joint which, under Britain’s National Healthcare System (NHS), put him in a six-month queue for a hip replacement procedure. Within two months, however, Nigel’s pain was so severe that he began to look outside the NHS – and Great Britain, for a quicker solution to his healthcare dilemma. Fortunately, under the recently enacted EU Cross Border Healthcare Directive, Nigel has quite a few options. Unfortunately though, Nigel has little or no understanding of the practical implications of the directive in terms of his legal rights, getting reimbursed, or how it will help him to gauge the quality of care abroad.

What is the EU Cross Border Healthcare Directive and how does it impact your choice to seek healthcare outside your country?

Since 1971, citizens of the European Union have had the right to seek cross border healthcare. However, the administrative process was often long and cumbersome and only allowed patients to access cross border care under specific circumstances. Additionally, there were very few public resources available where patients could learn about their rights or about the quality of medical providers in other member states. While the introduction of the EU Cross Border Healthcare Directive did not remove all constraints, it has opened up new possibilities for patients seeking to access cross border healthcare.

What makes the EU Cross Border Healthcare Directive so important is that it recognized for the first time in EU law that patients have a right to cross-border healthcare and are entitled to be reimbursed for it. It also created a network of national contact points (NCP’s) to provide reliable and easily accessible information to patients considering cross border healthcare.

In general terms, the EU Cross Border Healthcare Directive establishes standard operating procedures and guidelines for EU citizens seeking to access cross border healthcare services in EU member states. While many of its provisions are optional or open to interpretation by each member state, the main goal of the directive is to clarify patients´ rights and the circumstances in which they can seek cross border healthcare.  In a nutshell, patients now have the right to access certain types of medical treatments in other EU countries on the same terms and at the same cost as people living in those countries.

Beginning your cross border healthcare journey

If you are considering seeking care in another EU country, the first thing you should do is discuss your plans with your doctor.  Your doctor can provide valuable advice about treatment options and whether or not they necessary. Your doctor should also oversee your aftercare so discuss with him or her how to transfer medical records to the member state where you plan to seek treatment.

Make sure you qualify for benefits under the directive

If you are a legal resident of the EU who holds public or private insurance in a member state of the European Economic Area (or Switzerland), you can access cross border healthcare and are entitled to the benefits outlined in the directive.

According to the EU Commission your rights as a EU resident include:

  • To be reimbursed for healthcare sought in another country
  • To receive information on safety and quality standards in EU countries
  • To be treated by qualified healthcare professionals
  • To get a copy of your medical records
  • To have your prescription recognized in all EU Countries
  • To receive appropriate medical follow-up in your home country

Research your options and information relating to cross border healthcare

Lack of information about cross border healthcare services has always been a problem for patients considering seeking care abroad. The directive addresses this issue by mandating the creation of national contact points (NCP’s) that provide information and assistance to the public.

The information provided by your NCP will include:

  • Information on your rights and entitlements relating to receiving cross border healthcare in a particular member state
  • Administrative procedures for accessing cross border healthcare
  • Information on treatment options and prices
  • Information on quality and safety standards of the healthcare providers
  • Information about cross border prescriptions
  • Procedures for filing complaints
  • How to seek remedies according to the legislation of the member state
  • Legal and administrative options to settle disputes

Check with your NCP´s (both domestic and abroad) to find out about your rights as a cross border patient, the quality of the facility and doctor you are considering, and the administrative procedures necessary to ensure you will be reimbursed for your treatment.  You should also contact the cross border provider directly to ask questions about your treatment and what types of tests you will need done.

To find a NCP in your country, visit: http://europa.eu/youreurope/citizens/health/planned-healthcare/get-more-info/index_en.htm

Types of treatments covered

Under the directive you can only access healthcare in another member state for treatments covered under your domestic insurance scheme.  So, for example, if IVF treatments are not covered under your home insurance scheme, you would be unable to get reimbursed for this treatment in another EU member state. A list of covered treatments can be accessed in each country through the national contact points (NCP’s) established by the directive.

Prior Authorization

In principal, you can seek cross border healthcare without prior authorization. However, provisions in the EU directive allow member states to require prior authorization in certain instances. These include treatments that:

  • require an overnight hospital stay of at least one night;
  • require use of highly specialized and cost-intensive medical infrastructure or medical equipment, and,
  • present a particular risk for the patient or the population.

In the UK, for example, prior authorization is required for most hospital treatments. Member States are required to publish a list of healthcare services that are subject to prior authorization. Therefore, it is important to check with your domestic insurance carrier prior to traveling abroad.

Costs and reimbursement

The directive provides that member states charge cross border patients the same fees as domestic patients for “comparable medical situations.”  This means that if you want to get a hip replacement in Poland you will pay the same fee as local patients and the cost will be covered by your domestic insurance carrier at whichever rate is higher – the State where you are insured or the State where you are receiving treatment.

To get a clearer picture, let’s take a look at the following example:

Elizabeth is insured in the UK but is seeking to have a hiatal hernia repaired in France. The cost of her treatment in France is €5,000. For a similar treatment in the UK, only €3,800 would be reimbursed, as compared with €4,200 in France. Under the cross border healthcare directive Sophie will enjoy the same terms as French citizens, meaning that she will be reimbursed €4,200 and will have to pay only the €800 difference.

If, on the other hand, the hiatal hernia repair is reimbursed at €4,500 in the UK, Elizabeth will receive not only reimbursement at the rate offered in France (€4,200), but also additional reimbursement of the difference between the two countries (€4,500-€4,200 =€300). The total amount reimbursed in this case would be €4,500, leaving Elizabeth to pay only €500.

Take note that you will have to pay the total cost of your treatment upfront and then claim reimbursement once you return home, up to the amount the treatment would have cost under your local insurance scheme. Travel costs will not usually be covered unless they are normally covered by your local insurance carrier. However, the directive provides that member states do have the freedom to cover these costs if they choose to do so.

How long will the administrative process take? 

The directive does not set specific time limits for requests for reimbursement to be processed; however, it states that they should be dealt with within “reasonable periods of time” and that time limits must be available to the public in advance.  Beware though, that it is up to national authorities to define these time limits.

Can care be refused?

The directive states that authorization cannot be refused where a patient is experiencing “undue delay” in receiving treatment under their own insurance system. And while the term “undue delay” is not specifically defined, the European Court has stated that judgments must rely on what is a medically acceptable based upon an objective clinical assessment of the patient and their individual circumstances.

Having said that, your request for cross border healthcare can be refused in very particular circumstances, these are:

  • after a clinical evaluation it is deemed “reasonably certain” that you will be exposed to an unacceptable safety risk;
  • within a reasonable degree of certainty the general public will be exposed to a safety hazard as a result of you traveling for care abroad;
  • there is serious concerns relating to the quality and safety standards of the healthcare provider; and,
  • the healthcare being sought can be provided in your own country within a time limit that is medically justifiable.

If your request is refused, the directive states that you have the right to appeal the decision within your country’s legal system.

Medical prescriptions

The lack of recognition of medical prescriptions between member states has always been a concern for patients seeking cross border care. No longer; the directive mandates that medical prescriptions must be recognized in other EU member states and that measures must be established enabling medical professionals to verify the authenticity of the prescription. To minimize the risk of confusion, medicines are to be referred to by their International Non-proprietary Name (INN) (e.g. the INN for Nexium is Esomeprazole).

Medical assistance back home

Continuity of care, or the lack thereof, is a primary concern for patients seeking medical care outside their borders. Under the directive you have a right to a copy of your medical records and, should you need follow-up assistance, you are entitled to receive the same follow-up care that would have been provided in your home country.

What if I have an adverse outcome?

If you have a bad treatment outcome you have the right to file a complaint and seek remedies according to the legislation of the member state where treatment was provided. It is important, therefore, that you contact the NCP of the country where you will be seeking treatment to clarify your rights and the legal and administrative options available to you to settle an eventual dispute.

Next steps…

If you are seriously considering seeking care in another European member state, be sure to consider your options very carefully.  Ask yourself the following questions:

How far am I willing to travel?

Am I comfortable with the doctor or doctors I have selected?

Does the hospital specialize in the procedure I am seeking?

What Accreditations and Affiliations does the medical provider possess?

Am I comfortable with the destination?

Am I allowing enough time for my recuperation before traveling home?

Do I need a travel companion?

Your primary reason to seek care abroad should be to improve your health, not embark on a vacation; so take the matter seriously and talk to your doctor prior to making a final decision.

Patient resources

Below are some links to patient resources regarding the EU Cross Border Healthcare Directive and your rights as a EU resident.

Planned Healthcare: http://europa.eu/youreurope/citizens/health/planned-healthcare/index_en.htm

Frequently asked questions: http://ec.europa.eu/social/main.jsp?catId=573&langId=en

Getting your costs met: http://ec.europa.eu/social/main.jsp?catId=570&langId=en

Summary of the Cross Border Directive: http://eurohealthnet.eu/sites/eurohealthnet.eu/files/publications/Cross-border%20Healthcare%20Directive.pdf

Posted in:

Leave a Reply

Your email address will not be published. Required fields are marked *

4 × two =