engleski

Social Security and Health Care Abroad

The aim of this work has been to determine how far the Member States can go in regulating the coverage of treatments received in other Member States, within the limits set by EU law. The main research question is: given the actual EU legal framework, to what extent can the EU Member States limit social security coverage of medical treatment obtained in Member States in which patients are not socially protected? To answer this question, several intermediary questions were to be addressed. Firstly, what is the national legal framework on social security coverage of health care abroad? Here, there are several limitations in covering foreign treatments, stemming from the Member States’ preservation of equal access to socially covered health care, the financial sustainability of social health care systems and the quality control over the treatments provided. These mechanisms include, for instance, the application of a mandatory prior authorisation procedure for coverage in cases when patients travel abroad for the specific purpose of receiving health care, or the limitation of the coverage of foreign treatments to providers affiliated with the social security health system. The general motivation for these obstacles can be especially derived from the financial pressures Member States are facing due to the economic crisis in Europe, but some other reasons like the inertia in implementing the new EU law developments can be invoked as well as an explanatory factor. Secondly, the question is addressed what the actual legal framework of the European Union is, concerning the patients’' freedom to receive health care outside their Member State of social protection? The EU has developed a framework to which the national rules have to be aligned. The EU framework prescribes that national social security health systems have to provide coverage of health care abroad even though no prior authorisation has been obtained. This is especially true for non- hospital health care treatments. The European rules also prescribe that the national systems have to provide possibilities of refunding treatments obtained from non-affiliated providers, on the basis of the most favourable tariffs (tariffs applied by the state of social protection or by the state of treatment) when patients temporarily stay abroad. After answering the first two questions, the issue is addressed to which extent there is still some space left by EU law to the Member States to organise and limit their coverage of health care abroad ; in addition, an analysis is made of the problems which the countries are facing, or might face, in integrating EU law requirements into their national systems. EU law has left significant space to Member States to organise and limit their coverage of health care abroad. These cases especially include the freedom to define their general national coverage (range of covered treatments) in a non-discriminatory manner, freedom to define the general tariffs, possibilities to choosedifferent payment methods, freedom in setting up procedural frameworks for enforcing rights arising from EU law and several justifications Member States can use to impose limitations to coverage of health care abroad. Another element addressed is the approach of using the space: how can this be done in a manner that it aligns the EU framework of patient mobility in the best possible way, guaranteeing at the same time equal access to health care, financial sustainability and quality? Here, the Member States can employ two types of measures. The first type consists of proactive measures. These are new or expanded legislative and policy developments on the national level limiting coverage of health care abroad, adapted to the challenges provided by EU law. The second type consists of defensive measures exercising the possibilities provided by EU law to maintain the current national rules limiting coverage of treatments abroad. Proactive measures include the possibility of acting preventively and entering into contracts with foreign providers which provide for strict quality control. These contracts could also be used to control costs and to set clear and objective referral criteria for patients based on need, thereby protecting the principle of equal access. Secondly, new or modified methods of defining the range of covered health care, such as the introduction of a Health Technology Assessment Agency with legal powers to determine the national health package, could be introduced. This kind of Agency could save the countries from having to cover an extremely wide range of foreign treatments, while maintaining flexibility in introducing new health care treatments into their own general social packages and protecting equal access to health care. In the range of more defensive measures, Member States have been left with considerable space to still have national rules limiting coverage, such as the apllication in exceptional situations of the prior authorisation mechanism. This mechanism can be kept if the Member States are able to prove that it is necessary to ensure sufficient and permanent access to a balanced range of high- quality hospital treatment on their territory, thereby protecting financial sustainability of their health systems.

EU ; social security ; health care

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