Q&A: Patients' Rights in Cross-Border Healthcare

• An elderly German man with diabetes brings extra prescriptions with him on a trip to Italy but will the pharmacist accept the prescription?
• A Polish woman would like to receive hip surgery in the country where her grandchildren live and work but how can she organize this from Poland?
• A Portuguese man seeks cataract surgery from a specialist in Spain but will he be reimbursed?

Directive 2011/24/EU clarifies patients’ rights to access safe and high-quality treatment throughout the EU and to be reimbursed for it. Patients who travel to another EU country for medical care will receive equal treatment to the citizens of the country where they are treated. If they are entitled to that medical treatment in their home country, they will be reimbursed by their home system. The reimbursement will correspond to the cost of the treatment in their own country. In certain cases, prior authorisation may be required before travelling for treatment, particularly if the treatment involves an overnight hospital stay or highly specialised and costly healthcare.

Directive 2011/24/EU and Regulation (EC) No 883/2004 provide significant benefits to patients across the European Union. Together, they facilitate access to healthcare in other EU countries by improving the availability of information and expanding patients’ treatment options.

Moreover, they strengthen cooperation among national health authorities by promoting the exchange of information on quality and safety standards in healthcare provision. They also support the establishment of European Reference Networks, which bring together, on a voluntary basis, recognised centres of expertise from across Europe.

Finally, they encourage collaboration between Member States in harnessing the potential of Health Technology Assessment and digital health (eHealth), contributing to a more effective, innovative, and interconnected healthcare delivery system.

What scale of Cross-Border healthcare are we talking about?

Patients prefer to receive healthcare in their own country. That is why the demand for cross-border healthcare represents only around 1% of public spending on healthcare, which is currently around €10 billion. This estimate includes cross-border healthcare which patients had not planned in advance (such as emergency care for tourists). This means that, at present, considerably less of that 1% of the expenditure and movement of patients is for planned cross-border healthcare, like hip and knee operations or cataract surgery.

What about the existing legislation in this area (Regulations on social security-Regulation (EC) No 883/2004)?

Citizens needing care (including emergency care) when temporarily abroad will continue to benefit from the existing Regulations and the European Health Insurance Card, and be provided with the care they need.

For planned care, under the Regulation, a patient can apply for prior authorization. This authorization cannot be refused if he/she cannot be treated in the home country within a time limit which is medically justifiable.

It is important to note that the Regulations do not cover all healthcare providers. Some private providers are excluded, for example. In addition, under these Regulations, patients are usually obliged to apply for authorization for all treatments, whereas under the Directive, authorization should be the exception rather than the rule.

What is the added benefit of the Directive 2011/24/EU?

The Directive will not affect the benefits already offered to citizens through the existing Regulations on social security, which have their basis in the EU Treaty article on free movement of people. However, it clarifies those patients' rights that have their basis in the free movement of services, and which have been set out in various European Court of Justice rulings. In the case of hospital care, one of the main achievements of this new Directive is that patients will be able to choose their healthcare provider.

Other advantages of the Directive 2011/24/EU are:

• More choice: the Directive covers all healthcare providers in the EU.

• Less red-tape for patients: under the Directive, seeking prior authorization should be the exception rather than the rule.

• Information to patients: patients will receive all the information they need to make an informed choice, for example on quality and safety of healthcare, through National Contact Points, which will be set up in all Member States. Moreover, the Directive introduces new measures to help all patients make the best use of their rights under both pieces of legislation.

• Procedural guarantees: all patients are entitled to properly reasoned decisions, and to appeal if they feel their rights have not been respected. All patients have the right to complain and to seek redress (and all treatment must be covered by liability insurance or a similar guarantee). And patients have the right to a copy of their medical record.

When would I need prior authorization from my national authority?

National authorities can introduce a system of "prior authorization" for going to another Member State for treatment in 3 cases:

• For healthcare which involves overnight hospital stay of at least one night.

• For highly specialized and cost-intensive healthcare.

• In serious and specific cases relating to the quality or safety of the care provided by the particular provider in question.

In these three cases, patients may need to ask for permission in advance from their national health authority in charge of reimbursement. Member States are required to set out publicly which treatments are subject to such authorization – you can find the list via your National Contact Point.

Can this authorization be refused?

National health authorities can refuse authorization if the treatment in question, or the healthcare provider in question, could present a risk for the patient. If the healthcare can be provided at home within a medically justifiable time limit, then authorization can also be refused. However, Member States will need to explain why such a decision is necessary and will need to base their assessment of what is "medically justifiable" on your individual case.

What if I am refused authorization?

Patients have the right to request a review of any administrative decision on cross-border healthcare for their individual case.

How much will I be reimbursed after receiving a treatment abroad?

Patients will be reimbursed the same amount as they would receive in their own country for the same type of healthcare. Member States where care is free at the point of delivery will need to inform patients about their reimbursement tariffs. If the treatment abroad is cheaper than in the home country, the reimbursement will reflect the real price of the treatment.

Can I seek healthcare abroad if the treatment is not available in my country?

Yes, but you will only be entitled to reimbursement if it falls within the "basket of benefits" you are entitled to according to the legislation or rules of your home country.

Your National Contact Point will be able to advise you how to check whether a given treatment falls within your "basket of benefits".

Do I need to pay for cross-border treatment upfront?

Yes, generally the patient pays upfront and would then be reimbursed by their national authority as quickly as possible. The law also gives Member States the option of confirming the amount of reimbursement in writing in advance.

Member States also have the option of paying for the healthcare directly, rather than reimbursing patients.

Can I transfer my medical data to the Member State where I will be treated?

You have the right to a copy of your medical data from your home country prior to receiving treatment in another Member State, and from the provider in the country where you receive treatment before returning to your home country.

What should I do if something goes wrong whilst receiving treatment abroad?

The National Contact Point of that country will be able to explain your rights and give information on the regime applicable in the country of treatment.

Your home country is obliged to provide you with the same follow-up treatment it would have provided had the treatment taken place on its territory.

How can I be sure that the treatment I received abroad will be followed up properly on my return home?

Your home country has an obligation to ensure that the medical follow-up is of the same quality regardless of where in the EU the treatment took place.

Will my prescription be recognized in another EU Member State?

A prescription issued in another EU country should be recognized in a patient's country of residence and vice versa. This ensures that the healthcare provided in another EU country is properly followed-up on the patient's return home. The patient is entitled to obtain the prescribed medicine provided that the medicine in question is authorized for sale and available in the country where he or she wishes to have the product dispensed.

Although these principles are not new, in practice getting prescriptions recognized can be difficult. Although it will not solve the problem overnight, the provisions of the Directive should greatly increase the ability of pharmacists to understand and dispense prescriptions issues in another Member State.

What are the benefits of the networks on Health Technology Assessment (HTA) or eHealth?

Health Technology Assessments help decision-makers to make the right decisions on health investment and spending. There is clearly great potential benefit in greater collaboration between EU countries in this area, where currently each country makes such assessments on their own.

Similarly, eHealth has the potential to deliver great benefits to health systems. Formal and permanent cooperation between Member States will help decision-making within countries and improve interoperability between them.

These networks benefit national health systems directly, and patients indirectly.

Where can I find more information about my rights to healthcare abroad?

Check with your National Contact Point, or on the Your Europe website:

http://europa.eu/youreurope/citizens/health/index_en.htm

What is cross-border healthcare?

Cross-border healthcare refers to medical services received by a citizen in an EU member state other than the one in which they are insured.

Am I entitled to reimbursement for healthcare services received in another EU member state?

Yes. If you are a beneficiary in Cyprus and receive healthcare in another EU member state, you may request reimbursement for the expenses, subject to certain conditions

Which healthcare services are covered?

Only services that are part of the healthcare benefits package in your country of insurance are covered (e.g. diagnostics, hospital treatment, pharmaceuticals). Services that are not covered in Cyprus are also not eligible for reimbursement.

How is the reimbursement calculated?

The reimbursement is based on the cost that would be incurred by the competent Member State (e.g. the Health Insurance Organisation in Cyprus) if the same healthcare service were provided within Cyprus. If the cost abroad is higher, the patient is responsible for covering the difference.

Is prior authorisation required?

Prior authorisation from the Ministry of Health is required for certain types of services, such as inpatient hospital care involving an overnight stay or specialised diagnostic procedures. For standard outpatient services, prior authorisation is not necessary.

What is the reimbursement procedure?

After your return gather all relevant documentation (invoices, medical reports, receipts), complete the reimbursement application and submit it to the Ministry of Health. The reimbursement is paid directly to the applicant.

How long does it take to receive the reimbursement?

The processing time depends on the completeness of the submitted documents and the workload of the competent authority. In general, it ranges from a few weeks to several months.

Are there any restrictions or exceptions?

Yes. Reimbursement may be denied in the following cases:

1. The service is not covered by the healthcare system of Cyprus.
2. Prior authorisation was not obtained when required.
3. The cost is deemed unreasonably high without sufficient justification.

What is the difference between Directive 2011/24/EU and Regulation (EC) 883/2004?

1. Directive 2011/24/EU: Allows patients to seek healthcare in another Member State on their own initiative
2. Regulation 883/2004: Primarily governs planned healthcare provision through the use of the S2 form and ensures coordination between national social security institutions.

Where can I find more information about my rights to healthcare abroad?

1. The Ministry of Health of Cyprus Contact Information: Phone: +357 22 605622 / +357 22 605723 Fax: +357 22 605499 / +357 22 605492 Email: ncpcrossborderhealthcare@moh.gov.cy
2. European Union You can contact your National Contact Point or visit the Your Europe website: http://europa.eu/youreurope/citizens/health/index_en.htm
   Additional information is available at: https://health.ec.europa.eu/cross-border-healthcare/overview_en Source: https://ec.europa.eu/commission/presscorner/detail/en/MEMO_13_918