The European Health Insurance Card

Transcription

1 The European Health Insurance Card EHIC Questionnaire Jozef Pacolet & Frederic De Wispelaere HIVA-KU Leuven June 2015

2 EUROPEAN COMMISSION Directorate-General for Employment, Social Affairs and Inclusion Unit D/2 European Commission B-1049 Brussels

3 EUROPEAN COMMISSION The European Health Insurance Card EHIC Questionnaire Directorate-General for Employment, Social Affairs and Inclusion Network Statistics FMSSFE (Contract No VC/2013/0301 Network of Experts on intra-eu mobility Lot 2: Statistics and compilation of national data ) 2015

4 Network Statistics FMSSFE This report has been prepared in the framework of Contract No VC/2013/0301 Network of Experts on intra- EU mobility social security coordination and free movement of workers / Lot 2: Statistics and compilation of national data. This contract was awarded to Network Statistics FMSSFE, an independent research network composed of expert teams from HIVA (KU Leuven), Milieu Ltd, IRIS (UGent), Szeged University and Eftheia bvba. Network Statistics FMSSFE is coordinated by HIVA. Authors: Prof Dr Jozef Pacolet, Head of the Welfare State research group, HIVA - Research Institute for Work and Society, University of Leuven (KU Leuven) Frederic De Wispelaere, Senior research associate, HIVA - Research Institute for Work and Society, University of Leuven (KU Leuven) Peer reviewers: Prof Dr József Hajdú, Head of the Department of Labour Law and Social Security, Szeged University Dr Gabriella Berki, Professor Assistant at the Department of Labour Law and Social Security, Szeged University Europe Direct is a service to help you find answers to your questions about the European Union. Freephone number (*): (*) The information given is free, as are most calls (though some operators, phone boxes or hotels may charge you). LEGAL NOTICE This document has been prepared for the European Commission however it reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. More information on the European Union is available on the Internet ( ISBN: doi: / Catalogue number: KE EN-N European Union, 2015 Reproduction is authorised provided the source is acknowledged.

5 Table of Contents List of Tables... 6 List of Figures... 7 Executive Summary Introduction The number of forms issued / in circulation Changes in the issuing procedure The period of validity and the issuing procedure of the EHIC Raising awareness The use of the EHIC Methodological issues Reimbursement claims in numbers and amounts From the perspective of the competent Member State From the perspective of the Member State of stay or the insured person Practical and legal difficulties in using the EHIC Inappropriate (abusive or fraudulent) use of the EHIC Refusal of the EHIC by health care providers Alignment of rights Invoice rejection Conclusion Annex I EHIC Questionnaire

6 LIST OF TABLES Table 1 The number of EHICs issued / in circulation / as a percentage of the insured population and the number of PRCs issued, Table 2 The validity period of the EHIC, Table 3 Reimbursement by the competent Member State, Table 4 Reimbursement to the Member State of stay or the insured person, Table 5 Concentration of reimbursements,

7 LIST OF FIGURES Figure 1 % insured persons with a valid EHIC, Figure 2 Percentage change compared to 2009 (=100%) 12 Figure 3 Maximum deadlines for claims based on actual expenditure (using the E125 form) 15 Figure 4 Breakdown by type of procedure, competent Member State, Figure 5 Figure 6 Figure 7 The number of E125 forms received (in,000) and corresponding amounts (in million ), Expenditure related to necessary healthcare treatment (E125 forms received + E126 forms issued + other) as share of total health expenditure, Correlation between relative necessary cross-border healthcare expenditure (2014) and healthcare expenditure per inhabitant (2011) 20 Figure 8 Breakdown by type of procedure, Member State of stay, Figure 9 The number of E125 forms issued (in,000) and corresponding amounts (in million ),

8 EXECUTIVE SUMMARY In 2014 some 206 million EHICs were in circulation. 1 Between 2009 and 2014, the total number of EHICs in circulation rose by 10% and by 4% compared to This number is steadily increasing in most of the Member States. About 39% of the total number of insured persons living in a reporting competent Member State has a valid EHIC. Some 47 million EHICs were newly issued. Compared to the previous three years, the number of EHICs issued in 2014 shows a relatively strong increase. This can be explained by the applied issuing procedure and period of validity by competent Member States, which have an impact on the annual number of EHICs issued and on the number of valid EHICs in circulation. The EHIC Questionnaire also provides information on the number of reimbursement cases and the flow of funds involved in unplanned healthcare. Some 1.6 million E125 forms were received in 2014 for reimbursement claims. Most of the reimbursement claims (more than nine in ten claims) are settled between Member States via an E125 form and not between the insured person and the competent Member State, indicating a widespread and routinised payment and reimbursement procedure. The share of the payments involved is even higher via this procedure, which indicates that the reimbursement claimed by the insured person directly in the competent Member States is related to smaller amounts. In 2014, a total cost of medical treatment provided by the Member States of temporary stay of more than 800 million was reported. About 0.1% of total health expenditure is related to necessary healthcare treatment during a temporary stay abroad. Despite many efforts, most of the reported refusals of an EHIC by health care providers are still related to their lack of knowledge about the EHIC: Member States have to properly inform insured persons and health care providers in order to raise awareness about the use of the EHIC. Member States reported in detail on practical and legal difficulties they experience. The overall reported problems seem rather marginal compared to the annual number of provided healthcare treatments during a temporary stay abroad. Nevertheless, the problems reported should be solved in order to maintain and improve the EHIC system to guarantee cross-border access to unplanned healthcare. 1 Including the estimate for some Member States based on a previous year. 8

9 1. INTRODUCTION The European Health Insurance Card (EHIC) proves the entitlement to necessary healthcare in kind during a temporary stay in a Member State 2 other than the competent Member State. The reimbursement procedures are described by Regulations (EC) Nos 883/ and 987/ These procedures will be described and assessed based on data from the EHIC Questionnaire. The first part of the EHIC Questionnaire 5 aimed to collect statistics concerning the use of the EHIC from 1 January to 31 December The second part of the questionnaire covers practical and legal difficulties in using the EHIC. Since 2013 an additional element was introduced: Member States are asked, on an optional basis and considering that such data are available to them, to provide information about the amount of reimbursements related to the use of the EHIC. Compared to last year, more Member States have provided such data. This report summarises to a high extent the detailed answers Member States have given in the EHIC Questionnaires. 2. THE NUMBER OF FORMS ISSUED / IN CIRCULATION The number of EHICs issued in 2014 and the number of EHICs in circulation give us a first impression of the applied issuing procedures by Member States and the validity period of the EHICs. Some 47 million EHICs were issued (no data available for DE) in 2014 and some 206 million EHICs (including the estimate for some Member States based on a previous year) were at that moment in circulation (Table 1). When confronting these figures to the total number of insured/entitled persons, we see the following picture: about 39% of the total number of insured persons living in a reporting competent Member State has a valid EHIC. 6 In Italy (app. 100%), the Czech Republic (app. 100%), Liechtenstein (100%), Luxembourg (98%), Switzerland (96%), Malta (95%), the Netherlands (95%) and Austria (95%) all or almost all insured persons received an EHIC (Figure 1). Lower percentages will be influenced by issuing procedures, the validity period, the mobility of insured persons and their awareness of their cross-border healthcare rights. We observe a rather low percentage of EHICs issued to insured persons by Lithuania (12%), Latvia (10%), France (8%), Spain (7%), Croatia (6%), Bulgaria (5%), Poland (5%), Greece (1%) and Romania (1%). Paragraph 5 of the Administrative Commission (AC) Decision No S1 7 of 12 June 2009 concerning the European Health Insurance Card states: When exceptional circumstances 8 prevent the issuing of a European Health Insurance Card, a Provisional Replacement Certificate (PRC) with a limited validity period shall be issued by the competent institution. The PRC can be requested either by the insured person or the institution of the State of stay. Some 4 million PRCs were issued in 2014 (no figures available for CZ, DE and CH). 2 Relevant for the EU/EEA countries and Switzerland. 3 Regulation (EC) No 883/2004 of the European Parliament and of the Council of 29 April 2004 on the coordination of social security systems. 4 Regulation (EC) No 987/2009 of the European Parliament and of the Council of 16 September 2009 laying down the procedure for implementing Regulation (EC) No 883/2004 on the coordination of social security systems. 5 The 2014 EHIC Questionnaire is included in Annex I of this report. 6 Only calculated for Member States which reported the total number of EHICs in circulation and the number of insured persons for Decision S1 of 12 June 2009 concerning the European Health Insurance Card, C 106, 24/04/2010, p Exceptional circumstances may be theft or loss of the European Health Insurance Card or departure at notice too short for a European Health Insurance Card to be issued (Recital 5 of Decision No S1 of 12 June 2009 concerning the European Health Insurance Card). 9

10 Table 1 The number of EHICs issued / in circulation / as a percentage of the insured population and the number of PRCs issued, 2014 MS Number of EHICs issued Number of PRCs issued Total number of EHIC in circulation (A) Number of insured persons (B) % insured persons with an EHIC (A/B) BE 2,623,665 32,644 3,556,792 10,815, % BG 150,282 28, ,546 6,078, % CZ app. 4,100,000 n.a. 1 app. 10,000,000 10,419,458 app. 100% DK 2,275,302 56,171 3,494,522 5,600, % DE n.a. n.a. app. 45,000,000 4 n.a. n.a. EE 77,741 12,231 n.a. 1,232,819 n.a. IE 368, ,102 1,101,373 n.a. app. 30% EL 134,372 34, ,442 app. 9,900, % ES 1,893, ,474 3,417,348 46,420, % FR 4,737,581 2,528,005 4,737,581 58,800, % HR 248,852 4, ,081 4,349, % IT app. 8,900,000 app. 100,000 app. 59,000,000 app. 59,000,000 app. 100% CY 38, app. 44, ,780 n.a. LV 74, ,109 2,268, % LT 178,051 4, ,361 2,976, % LU 763,815 9, , , % HU 441,135 37,247 1,645,941 9,951, % MT 34, , , % NL app. 4,844,000 app. 8,000 app. 16,000,000 16,823, % AT 1,106,232 app. 20,000 8,208,058 8,652, % PL 2,319,798 17,559 1,678,089 35,130, % PT 421,460 19,730 1,469,633 RO 261,501 68, , ,174, % SI 510, , ,376 2,163, % SK 712,072 85,305 2,619,879 5,177, % FI 804,267 11,531 1,462,950 5,474, % SE 1,632,561 8,567 app. 3,000,000 4 n.a. n.a. UK 5,400,701 9,402 26,801,935 n.a. n.a. EU28 45,054,180 4,044, ,259, % 5 IS 51, , , % LI 1, ,393 38, % NO 681,986 8,315 app. 1,500,000 n.a. n.a. CH app. 797,667 n.a. 7,850,000 8,200, % Total 46,586,394 4,053, ,738, % 5 1 n.a.: not available. 2 DK: residents of DK. 3 RO: issued in 2014 and still valid on 31 December Number of EHICs in circulation for DE, CY and SE: figures insured from previous years. DE: no data available since In its reply to the 2009 EHIC Questionnaire, DE estimated the number of EHICs in circulation in 2008 around 45,000,000. CY: no data available since In its reply to the 2009 EHIC Questionnaire, CY calculated the number of EHICs in circulation in 2008 at 44,789. SE: no data available since In its reply to the 2011 Questionnaire, SE replied that 3,000,000 EHICs were in circulation in EU28 and total: average weighted figures. Only Member States which reported the number of EHICs in circulation and the number of insured persons for We have excluded DE, CY and SE as the reported figures on the number of EHICs in circulation are based on previous years. Source Administrative data EHIC Questionnaire

11 IT LI CZ LU CH MT NL AT DK SK Average SI BE IE IS FI HU LT LV FR ES HR PL BG EL RO % insured persons with an EHIC The European Health Insurance Card Figure 1 % insured persons with a valid EHIC, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 00% % insured persons with an EHIC Average reporting MSs * No data available for DE, EE, CY, PT, SE, UK and NO Source Administrative data EHIC Questionnaire 2015 Figure 2 gives an overview of the evolution of the number of EHICs issued/in circulation and the number of PRCs issued between 2009 and A change of the applied procedures or of the period of validity by Member States could have an impact on these numbers. The number of EHICs issued shows again an increase after a negative evolution since Especially the Czech Republic, 9 Denmark, 10 Luxembourg 11 and the Netherlands show a strong increase compared to last year. It is, however, more useful to look at the evolution of the number of EHICs in circulation. We observe a positive evolution of the number of EHICs in circulation (assuming a stable figure for Germany, Cyprus and Sweden, for which no figures were available in 2013), approaching almost 206 million EHICs. Including the estimates for these Member States the total number of EHICs in circulation has risen between 2009 and 2014 by 10%. This number is in most Member States steadily increasing. In particular for the Netherlands, Latvia, Bulgaria, Denmark, Hungary and Finland we observe a strong increase of the number of EHICs in circulation between 2009 and The increase between 2009 and 2014 will mainly be influenced by the EU-13 Member States. 12 The number of PRCs issued increased by 21% between 2010 and Czech Republic: Most of the EHICs were issued in 2004 with a validity period of five years. The majority of the EHICs were renewed in 2009 and in Denmark: The increase is considered to be a consequence of the termination of the coverage by the Danish public tourist health insurance during the first month of vacation in an EU/EEA country or Switzerland and the application of Article 19 of Regulation (EC) No 883/2004 as of 1 August As a result, a large number of persons applied for an EHIC. 11 Luxembourg: All EHICs were renewed in 2014 due to a change of the composition of the national personal identification number. 12 EU-15 Member States refers to Belgium, Greece, Luxembourg, Denmark, Spain, the Netherlands, Germany, France, Portugal, Ireland, Italy, the United Kingdom, Austria, Finland and Sweden. EU-13 Member States refers to Croatia, Romania, Bulgaria, Poland, the Czech Republic, Latvia, Lithuania, Slovenia, Estonia, Slovakia, Hungary, Cyprus and Malta. 11

12 % change The European Health Insurance Card Figure 2 Percentage change compared to 2009 (=100%) 130% 120% 110% 100% 124% 121% 110% 90% 80% Number of EHICs issued Number of PRCs issued Number of EHICs in circulation * For the number of PRCs issued the reference year is Source Administrative data EHIC Questionnaires CHANGES IN THE ISSUING PROCEDURE The EHIC Questionnaire did not explicitly ask the Member States to describe their issuing procedures but rather to report the changes for 2014 compared to previous years. We therefore refer to the EHIC report of 2013 to have a more detailed overview of the issuing procedures applied by the different Member States The period of validity and the issuing procedure of the EHIC France, Croatia, Greece, Hungary and the Netherlands reported a change in the validity period of the EHIC compared to All these Member States have extended the validity period (in general or for certain categories). Romania and Malta intend to modify the validity period in In general, the period of validity varies significantly between Member States, within certain Member States, and between categories/situations (active population, posted workers, family members, children, students, pensioners etc) (Table 2). The general validity period varies from six months in Romania and Poland to a maximum of / on average five years in the Czech Republic, Denmark, Cyprus, Luxembourg, Malta, Austria, the Netherlands, the United Kingdom and Switzerland. Some Member States have also defined a (much) longer validity period of EHICs issued to pensioners (e.g. BG (10 years), PL (5 years), SI (5 years), IS (5 years)). As mentioned before, these differences in the length of the validity period will have an impact on the annual number of EHICs issued by the Member States. Only Spain has reported a change in their national issuing procedure of the EHIC. 14 Denmark explicitly reported a longer delivery time. 15 The EHIC report of 2013 (or Annex 5 of the EHIC report of 2014) provides a more detailed overview of the issuing and withdrawal procedures. 13 Coucheir, M. (2013), EHIC Report 2013, tress Ghent University, 27 p. 14 Online: using the portal named 'Tu espacio de seguridad social' (Your social security space - TUSS). 15 Because of the termination of the coverage by the Danish public tourist health insurance as of 1 August 2014 a large number of persons applied for EHICs within a quite short period. 12

13 Table 2 The validity period of the EHIC, 2014 MS Validity period of the EHIC BE 1 to 2 years (i.e. until 31/12 of the next year) BG 1 year (economically active persons), 5 years (children), 10 years (pensioners) CZ 5 years DK (max) 5 years, shorter periods for specific cases DE several days/weeks to several years EE max 3 years (adults), max 5 years (children) IE 4 years EL 1 year (employed and self-employed), 1 to 3 years (pensioners), app. 6 months (students) ES 2 years, 12 months (one competent institution) FR 2 years HR 3 years (all insured persons), 4 to 5 years (diplomatic personnel) IT 6 years CY max 5 years LV 3 years LT max 2 years (active population), up to 6 years (those insured by State means), max 1 year (students) LU 3-60 months (proportionate to the length of the insurance record), min 1 year for defined groups registered with an S1 HU max 3 years (insured persons), max. 4 years for posted civil servants MT 5 years (subject to the applicant moving to another country throughout the validity period) NL 1-5 years Some competent institutions have changed the validity of the EHIC to 5 year. AT 1 or 5 years, 10 years (pensioners) PL 6 months, 5 years (pensioners), shorter periods in defined cases PT 3 years RO 6 months * SI 1 year, 5 years (pensioners and their family members, children) SK indefinite (possibility of a limited duration for foreign workers on fixed-term contracts) FI 2 years SE 3 years UK 5 years IS 3 years, 5 years (pensioners) LI 5 years NO 3 years CH between 3 and 10 years (5 years on average) * For 2015, RO intends to increase the validity period of the EHIC. ** In italics: Member States which have changed the validity period of the EHIC. Source Update EHIC report 2014 Table 2 (Pacolet and De Wispelaere, 2014) 3.2. Raising awareness The EHIC Questionnaire made a distinction between information provided to the insured persons and to the healthcare providers. Most of the Member States make information available and/or up to date for insured persons, sometimes just before the start of the winter or summer season (e.g. BG, PL, SI and SE), by means of websites (BE, CZ, HR, IT, LT, NL, PL, RO, SI, SE and NO), a mobile application (CZ), brochures/guides/leaflets/flyers (BE, CZ, DE, HR, IT and AT) and telephone assistance (IT, PL and SI). Frequently, information is published in magazines (DE and AT) and newspapers (EE, HR and LV), distributed by press releases (LU, MT, RO, SI and NO) or communicated on TV (HR, LV, PL and SI) and radio (LU, MT, AT and SI). Denmark explicitly reported the launch of an information campaign as a consequence of the termination of the Danish public tourist health insurance as of 1 August Luxembourg launched an information campaign because of a change of the composition of the national personal identification number. Poland reported the launch 13

14 of an information campaign focused on pensioners. Finland has informed pensioners living in a Member State other than Finland for which Finland is the competent Member State of a change in legislation. 16 The United Kingdom has tried to raise awareness of copycat websites charging for the processing of the EHIC. Finally, there were also public campaigns in Croatia and Romania. Healthcare providers are informed by the competent institutions (and liaison bodies) via leaflets/brochures (DE, IT and SK), websites (DE, PL, PT, NO and CH), training courses (IT, CY, MT, AT and PL), personal advise and support (IE, IT and LV), (in)formal instructions (HR, CY and PT) and consultations/visits/meetings (EE, LV, LT and MT). With regard to the transposition of the Directive on Patients' Rights in Crossborder Healthcare 17, Estonia has transmitted a questionnaire to hospitals to be filled in by foreign patients in order to clarify which rules apply. Finland has prepared a document about the use of the EHIC that can be given to the client who experiences difficulties to receive healthcare with the EHIC. The document is translated into several languages and can also be given to the healthcare provider in another Member State. 4. THE USE OF THE EHIC 4.1. Methodological issues A distinction has to be made between the reimbursement of costs on the basis of actual expenditure or on the basis of fixed amounts. 18 With regard to the calculation of reimbursement of costs for healthcare benefits in kind provided by another Member State, according to Article 62 of Implementing Regulation (EC) No 987/2009 the amount refunded has to be calculated on the grounds of the real expenses according to the accounting of the respective institution. Only in special cases may the calculation be done on the basis of a lump-sum payment. 19 The EHIC Questionnaire only refers to reimbursement on the basis of actual expenditure by an E125 form ( Individual record of actual expenditure )/SED S080 ( Claim for reimbursement ) or an E126 form ( Rates for refund of benefits in kind )/SED S067 ( Request for reimbursement rates stay ). The Member State of stay will claim reimbursement from the competent Member State using the E125 form/sed S080 on the basis of the real expenses of the healthcare provided abroad. The competent Member State will use an E126 form/sed S067 to establish the amount to be reimbursed to the insured person who paid the healthcare treatment him/herself. The form will be sent to the Member State of stay in order to obtain more information on the reimbursement costs. The period between treatment and reimbursement will differ if the reimbursement is asked by the Member State of stay (using the E125 form/sed S080) or by the insured person concerned. Article 67 of Regulation (EC) No 987/2009 lists the following deadlines on actual expenditure (using the E125 form/sed S080): 67(1): deadline for the introduction of claims based on actual expenditure; 67(5): deadline for the payment of undisputed claims; 67(6): deadline for the settlement of disputed claims. 16 As of 2014 these pensioners are during a stay in FI entitled to receive all medical care and not only medically necessary care. 17 Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients rights in cross-border healthcare, OJ L 88, , p Articles 62 (reimbursement on the basis of actual expenditure) and 63 (reimbursement on the basis of fixed amounts) of Regulation (EC) No 987/ Article 63 (2) of Regulation (EC) No 987/

15 Figure 3 Maximum deadlines for claims based on actual expenditure (using the E125 form) Source A.C. Note 593/11 The reader should be aware of the fact that between the date when the healthcare was provided and the date when the reimbursement claim was paid by the competent Member State more than 30 months can pass (even more for disputed claims). The current EHIC Questionnaire only asks the number of E125 forms/seds S080 received/issued in All claims related to an E125 form/sed S080 should be introduced within 12 months following the end of the calendar half-year during which those claims were recorded by the Member State of stay. This implies that for 2014 the E125 forms/seds 080 received/issued are (mainly) applicable to healthcare provided in The period of time will differ if reimbursement is asked immediately by the insured persons from the competent Member State. Among others, no deadlines are defined concerning the settlement procedure (request by and reply to the E126/SED S067 form) in the Regulations. Also the date when the insured person asked the competent Member State for reimbursement will differ from the date when this is asked by the Member State of stay (by an E125 form/sed S080). One E125 form/sed S080 or E126 form/sed S067 issued/received is not necessarily equal to one treatment or to one insured person. However, knowing the cost of the received healthcare in kind per person or per treatment is more useful compared to the average amount of an E125 or E126 form. For that reason we did not yet calculate this in this report. The reimbursement to the insured person without determining reimbursement rates by means of an E126 form is provided in some cases on the basis of other internal provisions Reimbursement claims in numbers and amounts Regulation (EC) No 987/2009 describes two different procedures to meet the costs of the healthcare provided in the Member State of stay. The insured person could ask the reimbursement directly from the institution of the Member State of stay (Article 25(4) of Regulation (EC) No 987/2009) (the Member State of stay will later claim the reimbursement from the competent Member State) or personally cover the cost of the healthcare received and asks for reimbursement by the competent Member State after the return (Article 25(5) of Regulation (EC) No 987/2009). 15

16 From the perspective of the competent Member State In 2014, the competent Member States received some 1.6 million E125 forms, issued some 63,000 E126 forms and paid some 65,000 claims without verification via the E126 form (Table 3). On average 87% of the claims were settled by an E125 form (only selecting those Member States which reported both the number of E125 forms received and the number of E126 forms issued) (Figure 4). Most claims of reimbursement of the costs of medical treatments provided by the Member State of temporary stay were received by Germany (461,000 E125 forms received), the United Kingdom (243,166 claims, of which 215,471 E125 forms received) and France (184,032 E125 forms received) (Table 3 and Figure 5). Almost all reporting competent Member States (which reported both the number of E125 forms received and the number of E126 forms issued) received the majority of the claims by an E125 form (Table 3 and Figure 4). Especially Austria, Romania, Norway, Bulgaria, Finland, Cyprus and Malta show a high percentage of claims settled by an E125 form (above 98% of total claims received). For Belgium (13%), Denmark (13%), Croatia (11%), Lithuania (9%), Poland (9%) and Slovakia (8%) we observe a reasonably high percentage of claims issued by insured persons and verified by an E126 form. Belgium (45%) settled most of the claims received via an internal method other than those defined in Articles 25(4) and (5) of Regulation (EC) No 987/2009. However, the total amount which is claimed/paid to/by Belgium via this other procedure is much lower compared to amounts claimed using the E125 or E126 forms. In 2014, a total cost of medical treatment provided by the Member States of temporary stay of more than 800 million was reported (no figures available for CZ, EL, ES, IT and LU) (Table 3). Most of the claims of reimbursement of the costs of medical treatments provided by the Member State of temporary stay were paid by Germany ( million related to the number of E125 forms received), the United Kingdom ( million, of which million related to the number of E125 forms received) and France ( million related to the number of E125 forms received) (Table 3 and Figure 5). On average 94% of the claims paid were settled by an E125 form (only selecting those Member States which reported both the number of E125 forms received and the number of E126 forms issued) (Figure 4). The share of the amount settled by an E125 form in the total expenditure (94%) is higher compared to their share in the total number of forms received (87%). This implies a higher amount per E125 form compared to the amounts per E126 form or per claim not verified by an E126 form. Under the Regulations, the budgetary impact of cross-border expenditure related to unplanned healthcare treatment during a stay abroad on average amounts to 0.1% of total health expenditure. Only BG shows a cross-border expenditure of more than 1% of total health expenditure. The EU-13 Member States show a higher relative crossborder expenditure compared to the EU-15 Member States. 16

17 Table 3 Reimbursement by the competent Member State, 2014 E125 received E126 issued Claims not verified by E126 Total Number of forms Amount MS Number Amount paid Number of Amount Number of Amount Number of Amount paid E125 E126 Other E125 E126 Other of forms (in ) forms paid (in ) claims paid (in ) forms/claims (in ) BE * 48,600 32,154,275 14,979 9,371,685 52,186 3,757, ,765 45,283, % 12.9% 45.1% 71.0% 20.7% 8.3% BG 34,798 20,812, , ,559 35,188 21,192, % 1.0% 0.1% 98.2% 1.0% 0.8% CZ 35,522 n.a. n.a. n.a. n.a. n.a. DK * 9,196 4,100,000 1,364 n.a. 10,560 n.a. 87.1% 12.9% 0.0% DE 461, ,500,000 n.a. n.a. n.a. n.a. EE 6,081 4,824, n.a. 6,522 n.a. 93.2% 6.8% 0.0% IE 28,163 8,748,982 n.a. n.a. n.a. n.a. EL n.a. n.a. 39 8,811 1 n.a. n.a. n.a. ES n.a. n.a. 6, ,471 n.a. n.a. FR 184, ,689,276 n.a. n.a. n.a. n.a. HR 4,695 3,196, n.a. 5,247 n.a. 89.5% 10.5% 0.0% IT n.a. n.a. n.a. n.a. n.a. n.a. CY 3,201 2,075, , n.a. 3,242 2,080, % 0.6% 0.7% 99.8% 0.2% 0.0% LV 4,565 3,539, , ,579 4,712 3,618, % 2.9% 0.2% 97.8% 1.3% 0.9% LT 5,849 4,996, , ,459 5,065, % 9.3% 0.2% 98.6% 1.4% 0.0% LU n.a. n.a. n.a. n.a. n.a. n.a. HU 17,532 10,188, ,144 18,399 10,341, % 4.7% 0.0% 98.5% 1.5% 0.0% MT , , , % 1.9% 0.0% 98.7% 1.3% 0.0% NL 25,756 59,638, n.a. 26,550 n.a. 97.0% 3.0% 0.0% AT 64,882 10,675, ,108 64,900 10,679, % 0.0% 0.0% 100.0% 0.0% 0.0% PL 67,966 36,610,528 6, ,335 74,408 37,537, % 8.7% 0.0% 97.5% 2.5% 0.0% PT 40,865 50,513,088 1, ,000 42,010 50,643, % 2.7% 0.0% 99.7% 0.3% 0.0% RO 24,664 36,728, ,393 24,748 36,766, % 0.3% 0.0% 99.9% 0.1% 0.0% SI 46,644 13,989,336 4, ,229 50,788 14,254, % 8.2% 0.0% 98.1% 1.9% 0.0% SK 73,610 11,453,639 3,217 n.a. 742 n.a. 77,569 n.a. 94.9% 4.1% 1.0% FI 21,318 6,731, ,559 21,579 6,794, % 1.2% 0.0% 99.1% 0.9% 0.0% SE 58,632 24,959,965 3,999 n.a. 62,631 n.a. 93.6% 6.4% 0.0% UK 215, ,185,798 15,344 4,895,379 12,351 3,464, , ,545, % 6.3% 5.1% 94.2% 3.4% 2.4% IS 2, ,113 n.a. n.a. n.a. n.a. LI ,485 n.a. n.a. n.a. n.a. NO 96,864 14,115,804 1,029 n.a. 97,893 n.a. 98.9% 1.1% 0.0% CH 53,200 32,043,992 n.a. n.a. n.a. n.a. Total 1,636, ,952,237 62,818 16,985,698 65,365 7,421, % ** 5.6% ** 6.6% ** 93.9% ** 4.2% ** 1.9% ** * BE and DK: only E125 forms received electronically. ** Only selecting Member States which have reported both the number of E125 forms received and the number of E126 forms issued. Source Administrative data EHIC Questionnaire

18 Figure 4 Breakdown by type of procedure, competent Member State, % 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% AT RO NO BG FI CY MT PT NL LV HU SK SE EE SI PL LT HR UK DK BE 0% AT RO CY PT FI MT LT HU BG SI LV PL UK BE E125 received - Forms E126 issued - Forms E125 received - Amounts E126 issued - Amounts Other - Forms Average E125 received - Forms Other - Amounts Average E125 received - Amounts * No figures available for CZ, DE, IE, EL, FR, IT, LU, IS, LI, CH (forms) and CZ, DK, DE, EE, IE, EL, ES, FR, HR, IT, LU, NL, SK, SE, IS, LI, NO, CH (amounts) Source Administrative data EHIC Questionnaire

19 BG RO EE LV SI PT LT SK CY PL HU CZ BE HR CH NL Average UK SE DE FR NO AT FI IE MT DK IS % of total health expenditure DE UK FR NL PT RO PL BE CH SE BG NO SI SK AT HU IE FI LT EE DK LV HR CY LI MT IS Amounts (in million ) Number of E125 forms received (in,000) The European Health Insurance Card Figure 5 The number of E125 forms received (in,000) and corresponding amounts (in million ), Amount paid (in Million ) Number of E125 forms received (in,000) * No data available for ES, CZ, EL, IT and LU. Source Administrative data EHIC Questionnaire 2015 Figure 6 Expenditure related to necessary healthcare treatment (E125 forms received + E126 forms issued + other) as share of total health expenditure, ,40% 1,20% 1,00% 0,80% 0,60% 0,40% 0,20% 0,00% As share of total health expenditure Average reporting MSs * No data available for ES, EL, IT, LU and LI. Source Administrative data EHIC Questionnaire 2015; EUROSTAT [spr_exp_fsi] The current provisions (i.e. full reimbursement by the competent Member State of the costs of medical treatments provided by the Member State of temporary stay in accordance with the tariffs of the Member State of temporary stay and not of the competent Member State), also result into a higher financial burden of unforeseen cross-border healthcare on total health expenditure in the Member States which show a low healthcare expenditure per inhabitant (Figure 7). 19

20 Figure 7 Correlation between relative necessary cross-border healthcare expenditure (2014) and healthcare expenditure per inhabitant (2011) * No data available for ES, EL, IT, LU and LI. ** Strong negative correlation coefficient of Source Administrative data EHIC Questionnaire 2015; EUROSTAT [spr_exp_fsi], [hlth_sha1h] From the perspective of the Member State of stay or the insured person In 2014, the Member States of temporary stay issued some 1.7 million E125 forms (no data available for IT and LU). Also, some 61,000 E126 forms were received (no data available for FR, IT, LU, FI and SE) (Table 4). On average 96% of the claims were settled by an E125 form (only selecting those Member States which reported both the number of E125 forms received and the number of E126 forms issued) (Figure 8). Most of the claims of reimbursement of the costs of medical treatments provided by the Member State of temporary stay were issued by Germany (405,307 forms, of which 392,000 E125 forms issued) and Spain (342,038 forms, of which 336,347 E125 forms issued) (Table 4 and Figure 9). Only a limited number of Member States of temporary stay received a relatively high number of E126 forms (compared to the total number of forms (E125 forms issued + E126 forms received)) (more than 10% for BG (33%), CH (26%), NO (23%), LV (15%) and BE (14%)) (Table 4 and Figure 8). This confirms our earlier conclusion that most of the claims are settled between Member States and not between insured persons and their competent Member State. 20

21 Table 4 Reimbursement to the Member State of stay or the insured person, 2014 E125 issued E126 received Total Number of forms Amount MS Number of forms Amount received (in ) Number of forms Amount received (in ) Number of forms Amount received (in ) E125 E126 E125 E126 BE 31,528 36,434,131 4,960 1,033,245 36,488 37,467, % 13.6% 97.2% 2.8% BG 2, ,250 1,078 23,390 3, , % 32.6% 92.0% 8.0% CZ 39,713 n.a. 938 n.a. 40,651 n.a. 97.7% 2.3% DK 9,038 2,800, n.a. 9,249 n.a. 97.7% 2.3% DE 392, ,500,000 13,307 n.a. 405,307 n.a. 96.7% 3.3% EE 14,675 1,895, n.a. 14,792 n.a. 99.2% 0.8% IE 25,552 1,353, n.a. 26,202 n.a. 97.5% 2.5% EL 38,802 11,434,336 2,134 32,320 40,936 11,466, % 5.2% 99.7% 0.3% ES 336, ,065,065 5, , , ,842, % 1.7% 99.5% 0.5% FR 47, ,571,375 n.a. n.a. 47,818 n.a % 0.0% HR 109,412 8,423,451 3,396 n.a. 112,808 n.a. 97.0% 3.0% IT n.a. n.a. n.a. n.a. n.a. n.a. CY 13,028 2,078, ,445 13,186 2,081, % 1.2% 99.8% 0.2% LV , , , % 15.0% 81.6% 18.4% LT 1, , ,111 1, , % 6.7% 95.7% 4.3% LU n.a. n.a. n.a. n.a. n.a. n.a. HU 7,692 1,295, ,297 7,826 1,315, % 1.7% 98.5% 1.5% MT 2, , ,462 3, , % 4.2% 97.0% 3.0% NL 42,557 36,460,594 3,615 n.a. 46,172 n.a. 92.2% 7.8% AT 182,752 81,957,616 2,629 13, ,381 81,971, % 1.4% 100.0% 0.0% PL 135,005 17,131, , ,887 17,197, % 0.6% 99.6% 0.4% PT 125,295 26,245,513 3,000 1,400, ,295 27,645, % 2.3% 94.9% 5.1% RO 1, , ,668 2, , % 9.5% 97.7% 2.3% SI 13,589 3,875, n.a. 13,842 n.a. 98.2% 1.8% SK 31,052 6,637,791 1,106 n.a. 32,158 n.a. 96.6% 3.4% FI 4,294 3,127,229 n.a. n.a. 4,294 n.a % 0.0% SE 23,114 19,300,344 n.a. n.a. 23,114 n.a % 0.0% UK 3,439 6,453, n.a. 3,672 n.a. 93.7% 6.3% IS 2, , ,279 2, , % 1.9% 97.7% 2.3% LI , , , % 6.4% 97.4% 2.6% NO 1,484 8,679, n.a. 1,912 n.a. 77.6% 22.4% CH 44,260 70,004,664 15,162 n.a. 59,422 n.a. 74.5% 25.5% Total 1,684, ,891,953 60,754 3,475, % *** 3.6% *** 99.0% *** 1.0% *** * BE: E125 forms: only figures for the first semester E.g. in 2012, BE has issued 59,820 E125 forms equal to an amount of 68.9 million. ** CZ and PT: Only SEDs S080 were issued. *** Only selecting Member States which have reported both the number of E125 forms issued and the number of E126 forms received. Source Administrative data EHIC Questionnaire

22 PL EE CY AT ES HU SI IS DK CZ PT IE HR DE SK MT EL UK LI LT NL RO BE LV NO CH BG The European Health Insurance Card Figure 8 Breakdown by type of procedure, Member State of stay, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% AT CY EL PL ES HU RO IS LI BE MT LT PT BG LV E125 issued - Forms E126 received - Forms E125 issued - Amounts E126 received - Amounts Average E125 issued - Forms Average E125 issued - Amounts * No data available for FR, IT, LU, FI, SE (forms) and for CZ, DK, DE, EE, IE, FR, HR, IT, LU, NL, SI, SK, FI, SE, UK, IS, NO and CH (amounts). Source Administrative data EHIC Questionnaire

23 DE ES FR AT CH NL BE PT SE PL EL NO HR SK UK SI FI DK CY EE IE HU RO IS MT LI BG LT LV Amounts (in Million ) E125 forms issued (in,000) The European Health Insurance Card Figure The number of E125 forms issued (in,000) and corresponding amounts (in million ), Amount received (in Million ) Number of E125 forms issued (in,000) * No data available for CZ, IT and LU. Source Administrative data EHIC Questionnaire 2015 Table 5 below provides more information about the extent to which claims issued or received by Member States are concentred in a specific receiving or issuing Member State. More than 50% of the claims issued by Cyprus (89%), Spain (73%), Croatia (70%), Romania (61%), Greece (59%), France (53%) and Austria (52%) as Member State of stay are concentred in one particular competent Member State. Most of these claims apply to Germany. Also, more than 50% of the claims received by Cyprus (83%), Austria (66%), Latvia (62%), Poland (59%), the United Kingdom (55%), Croatia (52%) and Bulgaria (52%) as competent Member State are concentrated in one particular Member State of temporary stay. Again, most of these claims apply to Germany. 23

24 Table 5 Concentration of reimbursements, 2014 MS A MS A= Member State of stay MS A= Competent Member State Main competent MS % share of expenditure Main MS of stay % share of expenditure BE FR 52.6% FR 35.8% BG DE 19.7% DE 51.6% CZ n.a. n.a. n.a. n.a. DK n.a. n.a. n.a. n.a. DE n.a. n.a. n.a. n.a. EE FI 47.6% DE 34.0% IE n.a. n.a. n.a. n.a. EL DE 58.5% NL 26.0% ES BE 72.8% n.a. n.a. FR UK 21.2% BE 31.5% HR DE 70.9% DE 51.7% IT n.a. n.a. n.a. n.a. CY UK 88.9% DE 83.3% LV NO 24.9% DE 61.8% LT UK 26.5% DE 28.9% LU n.a. n.a. n.a. n.a. HU RO 35.2% DE 44.1% MT n.a. n.a. n.a. n.a. NL n.a. n.a. n.a. n.a. AT DE 51.8% DE 65.7% PL DE 42.5% DE 59.3% PT n.a. n.a. n.a. n.a. RO IT 60.6% IT 25.3% SI n.a. n.a. n.a. n.a. SK CZ 39.1% CZ 32.4% FI EE 34.1% ES 25.8% SE DE 22.8% DE 31.3% UK PL 22.2% ES 55.3% IS DE 33.7% BE 38.0% LI CH 48.5% AT 27.5% NO DE 33.3% DE 26.7% CH n.a. n.a. n.a. n.a. * n.a.: No data available. Source Administrative data EHIC Questionnaire PRACTICAL AND LEGAL DIFFICULTIES IN USING THE EHIC 5.1. Inappropriate (abusive or fraudulent) use of the EHIC Many Member States (BG, CZ, DK, DE, EE, ES, CY, LV, LT, HU, MT, NL, AT, PL, PT, RO, SK, FI, UK, IS, NO and CH) reported cases of inappropriate use of the EHIC by persons who are no longer insured, however, in relation to the total number of EHICs issued this phenomenon is rather marginal. 20 Bulgaria reported the reimbursement of 2.2 million or 11% of the total sum reimbursed to the Member States of stay on the basis of an EHIC, for EHIC holders who were not entitled to healthcare under Bulgarian legislation in the period of receiving benefits in kind. The result of this inappropriate use may be problematic for both the Member State of stay which has to claim a reimbursement and the competent Member State which has to cover it. Actions to avoid such cases misuse are defined by the AC Decision No S1 concerning the EHIC (i.e. cooperation between institutions in order to avoid misuse of the EHIC, the EHIC should contain an expiry date ). 20 Only a limited number of Member States were able to quantify the inappropriate use of the EHIC (e.g. CZ: less than 100 cases, DK: just a view cases, EE: 42 persons, CY: only one case, LT: 112 persons, HU: more than 100 cases, AT: 423 cases, FI: some cases, CH: minor number of cases). 24

25 Isolated individual cases of inappropriate use were reported on counterfeited or modified EHICs by Spain, the Czech Republic, Finland and Sweden. Only Ireland, the United Kingdom and Norway are aware of intermediaries charging for advice on the application of the EHIC. Those Member States have already taken action, especially by stressing on their official website that the application is free of charge Refusal of the EHIC by health care providers The data collected provides for a distinction between refusals of the EHIC by healthcare providers of the reporting Member States and refusals by healthcare providers of other Member States. For both only isolated cases were reported, in particular for healthcare providers of other Member States. Reasons for a refusal of the EHIC by healthcare providers of the reporting Member States are: a lack of knowledge of procedures (CZ, HU, SK and IS); an incomplete EHIC (PL); considered as planned healthcare (LU and PL); the scope of necessary healthcare (CZ, HR, LT, RO and FI); a private healthcare provider (CH); preference of cash payments (AT); identification codes not conform with the AC Decision S2 21 (ES); failure to pay or late payment (SK); administrative burden (BG, CZ and SK). Member States try to solve these cases by explaining the rules (e.g. EE and LV) or by properly investigating the reported cases (e.g. ES, HR, PL and RO). As mentioned before (see p. 7), with regard to the transposition of the Directive on Patients' Rights in Cross-border Healthcare, Estonia has transmitted a questionnaire to hospitals to be filled in by foreign patients in order to clarify which rules apply. Reasons of a refusal of the EHIC by healthcare providers of other Member States known by the reporting Member States are: 22 a lack of knowledge of procedures (IT, LV, PT); the absence of a microchip (or unreadable) (IT, LV, AT and PL); doubts about the validity of the EHIC or the PRC (ES, PL and PT); length/interpretation of temporary stay (in particular for students) (IT and HU); considered as planned healthcare (DK, ES, PL, IT and FI); scope of necessary health care (ES, PL, IT, HU and PT); private healthcare provider (IE, NL and PT); private insurance (travel assistance) (BE, IT, NL and SE); the high cost of the treatment (IT); preference of cash payments (HR,); Hidden refusal 23 (IT, LV, ES, PL, RO, SE, NO and CZ); failure to pay or late payment (IT); administrative burden (SK). 21 Decision S2 of 12 June 2009 concerning the technical specifications of the European Health Insurance Card, C 106, , p Reporting Member State between brackets (and not the Member State of stay). 23 Treatment on the basis of an EHIC, but invoice afterwards sent to the insured person and not via the appropriate reimbursement procedure (E125 form). 25

26 Member States try to solve these cases by contacting the foreign liaison body (CZ), the foreign health care provider (CZ) or the foreign competent institute (RO). As mentioned before, Finland has prepared a document about the use of the EHIC that can be given to the health care provider in another Member State. Only some Member States were not aware of refusals to accept EHICs by health care providers established in another Member State (EL, LU, MT and UK). Some Member States were confronted with only a few cases (e.g. BG, DK, HR, CY, FI, NO and IS) and other Member States received numerous reports of refusals or considered it as a continuous problem. However, it seems that some of the reported problems are more concentrated in certain Member States and tourist areas. Refusals based on an incorrect interpretation of the scope of necessary healthcare, still reported by several Member States, will be discussed below Alignment of rights Despite the Administrative Commission Decisions 24 and the Commission s explanatory notes 25 on the matter, several reporting Member States (BE, CZ, DE, EE, ES, IT, CY, LV, HU, MT, NL, AT, PL, PT, RO, SK, FI, UK, IS and NO) signalled difficulties in connection with the interpretation of necessary healthcare. Healthcare providers of the Member States of stay may refuse to provide healthcare on the basis of an EHIC, or competent Member States may refuse reimbursement of the provided healthcare due to too narrow or too broad an interpretation of necessary healthcare. There appears to be a lack of a consistent interpretation between Member States, and within these Member States, between healthcare providers. First, healthcare providers struggle with making a correct distinction between necessary healthcare and scheduled healthcare. Some Member States of stay may ask to issue a PD S2 even in cases of necessary care. An example was reported by Spain, as they observe a considerable increase in the number of complaints concerning the refusal to accept the EHIC in other Member States to cover surgical operations that are necessary on medical grounds. Even for types of benefits that are defined in the AC Decision S3 and covered by the EHIC, some Member States report difficulties, such as cases of dialysis treatment, childbirth, chemotherapy, chronic diseases and long periods of hospitalisation. Second, some health care providers may narrow necessary healthcare down to emergency care Invoice rejection No distinction will be made between the invoices (E125 forms) received but rejected by the reporting Member State and the invoices (E125 forms) issued by the reporting Member State but rejected by other Member States, given that both groups show similar reasons. 24 Decision S1 indicates that all necessary care is covered by the EHIC, and Decision S3 of 12 June 2009 (C 106, , p. 40) defines specific groups of benefits which have to be considered as necessary care, namely (1) benefits in conjunction with pregnancy and childbirth, (2) benefits in conjunction with preexisting and chronic diseases and (3) necessary care for which a prior agreement with the specialised medical unit is required. 25 Explanatory notes on modernised social security coordination Regulation (EC) Nos 883/2004 and 987/2009 are available at 26

27 Main reasons reported to refuse an invoice were: Invalid EHIC at the moment of treatment (= not insured in the competent Member State) Of which o outdated EHIC; o date of treatment before EHIC was issued. Incomplete E125 form Of which o wrong personal ID number; o missing EHIC ID number; o invalid EHIC ID number; o insufficient information concerning the EHIC. Duplication of claims. Despite the high number of Member States which are aware of rejections of invoices by themselves or by other Member States (and this for numerous reasons), it seems a rather marginal problem looking at the number of rejections reported (see also the 2014 EHIC report) Only a limited number of Member States were able to quantify the number of rejections (e.g. CY: 64 rejections of invoices issued and 23 rejections of invoices received; CZ: cases of rejections of invoices received; SI: 419 rejections of invoices issued and 158 rejections of invoices received; SK: 181 rejections of invoices received; UK: 459 rejections of invoices issued and 40 rejections of invoices received. 27

28 CONCLUSION Some 47 million EHICs were newly issued in Compared to the previous three years, the number of EHICs issued in 2014 shows a relatively strong increase. More important, however, is the positive evolution of the number of EHICs in circulation, approaching for 2014 almost 206 million. 27 The total number of EHICs in circulation has risen between 2009 and 2014 by 10%, by 4% compared to About 39% of the total number of insured persons living in a reporting competent Member State has a valid EHIC. However, the issuing procedure and period of validity applied by competent Member States have an impact on the annual number of EHICs issued and on the number of valid EHICs in circulation. About 0.1% of total health expenditure is related to necessary healthcare treatment during a temporary stay abroad. Most of the reimbursement claims (more than 9 in 10 claims) are settled between Member States via an E125 form, indicating a widespread and routinised payment and reimbursement procedure. The share of the payments involved is even higher via this procedure, which indicates that the reimbursement claimed by the insured person directly in the competent Member States is related to smaller amounts. Despite the exhaustive reporting of Member States about the practical and legal difficulties they experience, the reported problems seem rather marginal compared to the annual number of provided healthcare treatments during a temporary stay abroad. Still, some issues, such as the lack of awareness about the use of the EHIC amongst insured persons and health providers, require continuous attention and action in order to further improve the EHIC system. 27 Including the estimate for some Member States based on a previous year. 28

29 ANNEX I EHIC QUESTIONNAIRE 2014 Part I Statistics concerning the use of the European Health Insurance Card (EHIC) from 1 January to 31 December Number of EHICs issued/in circulation How many EHICs did your institutions issue between 1 January and 31 December 2014? How many EHICs issued by your institutions were in circulation on 31 December 2014? (This means valid EHICs). 2. Number of provisional replacement certificates (PRC) issued How many PRCs were issued between 1 January and 31 December 2014? 3. Number of insured persons Please provide the number of insured persons per 31 December If the number of insured persons is lower than the number of EHICs in circulation please explain why. 4. Period of validity of the EHIC Did you modify the validity period of the EHIC in 2014 or do you have any intention to modify the validity period in 2015? If so, why? What is the validity period of the EHIC issued by your institutions? Please only specify changes compared to your reply concerning Is the validity period of the EHIC identical for all categories of insured persons? If not, for which reason and for which categories of insured persons is the validity period different? Please only specify changes compared to your reply concerning Issuing and withdrawal procedures 5.1. Issuing of the EHIC Did you change the issuing process of the EHIC in 2014? If so, why? How (telephone, fax, internet, or other means) can the EHIC be requested? Please only specify changes compared to your reply concerning Does an insured person have to provide any specific information/documentation in order to obtain an EHIC? If so, what type of information/documentation? Please only specify changes compared to your reply concerning How long did it take, on average, for an EHIC to be issued in 2013? Was there some improvement in relation to 2013? 5.2. Issuing of Provisional Replacement Certificates (PRC) Did you change the issuing process of the PRC in 2014? If so, why? How (telephone, fax, internet, or other means) can the PRC be requested? Please only specify changes compared to your reply concerning

30 How (fax, or other means) is the PRC issued to insured persons currently on a temporary stay abroad? Please only specify changes compared to your reply concerning In which situations is the PRC issued to insured persons before going abroad? Please only specify changes compared to your reply concerning Withdrawal procedure of the EHIC Did you introduce special procedures in 2014 to withdraw the EHIC when the cardholder of the EHIC is no longer insured under your legislation? If so, what are they? 6. Awareness-raising 6.1. Information for the insured persons Were public information campaigns ongoing or newly introduced during 2014? If so, which ones? 6.2. Information for the health care provider Do you have any ongoing or newly introduced initiatives in 2014 to improve health care providers' knowledge of the EHIC? If so, which ones? 7. Use of the EHIC 7.1. Reimbursement of benefits in kind between institutions How many E 125 forms were issued following the use of the EHIC in your country between 1 January and 31 December 2014? Please also indicate, if available, the related amount (in ) claimed by the E 125 forms issued. If you started issuing SED S080 can you estimate the number of individual invoices you issued following the use of the EHIC in your country between 1 January and 31 December 2014? If so, how many individual invoices were issued? Please also indicate, if available, the related amount (in ) claimed by the SED S080 forms issued. How many E 125 forms did you receive following the use of the EHIC by persons insured under your sickness insurance scheme between 1 January and 31 December 2014? Please also indicate, if available, the related amount (in ) claimed by the E 125 forms received. If you started receiving SED S080 can you estimate the number of individual invoices you received following the use of the EHIC by persons insured under your sickness insurance scheme between 1 January and 31 December 2014? If so, how many individual invoices were received? Please also indicate, if available, the related amount (in ) claimed by the SED S080 forms received. What percentage does the use of the EHIC abroad represent in respect of the total health expenditure of your country, comprising of both national and crossborder expenditure? 7.2. Reimbursement of benefits in kind according to Article 25 B) (5) of Regulation (EC) No 987/2009 How many requests (E 126/ SED S067) according to Article 25 B) (5) of Regulation (EC) No 987/2009 did you send during 2014? Please also indicate, if available, the amount (in ) covered by the E 126 forms issued. 30

31 How many requests (E 126/ SED S067) according to Article 25 B) (5) of Regulation (EC) No 987/2009 did you receive during 2014? Please also indicate, if available, the amount (in ) to be reimbursed. How are the reimbursement rates applied by your institutions determined when replying to requests (E 126/ SED S067) according to Article 25 B) (5) of Regulation (EC) No 987/2009? Please only specify changes compared to your reply concerning year Do you have a centralized organization for applying to requests (E 126/ SED S067) according to Article 25 B) (5) of Regulation (EC) No 987/2009? If not, how are your institutions organized for this purpose? Please only specify changes compared to your reply concerning year What type of information (receipts, prescriptions, vignettes etc.) do you need to be able to reply to a request (E 126/ SED S067) according to Article 25 B) (5) of Regulation (EC) No 987/2009? Please only specify changes compared to your reply concerning year Part II Practical and legal difficulties in using the European Health Insurance Card (EHIC) 1. Inappropriate use (abusive or fraudulent) of the EHIC Are you aware of cases of inappropriate use of a valid EHIC by a person who was no longer insured under your scheme? If so, can you quantify such cases? Are you aware of other cases of fraud (for example of the fake cards)? If so, can you describe and quantify these cases? Are you aware of intermediaries (websites or other) charging for advice on application for the EHIC? If so, did you take any action to discourage such activity? 2. Awareness of the health care providers Are you aware of cases of refusals to accept EHICs by health care providers established in your country? If so, what are the reasons given by health care providers to refuse the EHIC? Can you quantify the frequency of such refusals, and did you take any action to remedy the situation? Are you informed about cases of refusals to accept EHICs by health care providers established in another country? If so, do you have information on the reasons for these refusals? Can you quantify the frequency of such refusals, and did you take any action to remedy the situation? 3. Alignment of rights Are you aware of the difficulties relating to the interpretation of the "necessary health care" concept? If so, could you describe the difficulties encountered? 4. Invoice rejection Are you aware of any rejection of invoices (forms E 125/ SED S080) drawn up on the basis of an EHIC issued by your institutions? If so, could you quantify the number and indicate the reasons for rejection? Are you aware of any rejection by your institutions of invoices (forms E 125/ SED S080) drawn up on the basis of an EHIC issued by institutions in other countries? If so, could you quantify the number and indicate the reasons for rejection? 31

32 5. Other possible difficulties in using the EHIC Were you aware of other problems/incidents related to the use of the EHIC in your territory or in the territory of another state? If so, which? 6. Enquiry and complaint management Do you know the number of enquiries/complaints you receive concerning EHIC? If so, how many enquiries/complaints did you receive during 2014? How can citizens submit an enquiry/complaint concerning EHIC and what are your procedures for dealing with it? Please only specify changes compared to your reply concerning How can health care providers submit an enquiry/complaint concerning EHIC and what are your procedures for dealing with it? Please only specify changes compared to your reply concerning

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