COMMUNICATION FROM THE COMMISSION concerning the introduction of a European health insurance card

Table of contents

Table of contents

Introduction

1. Health insurance cards: an overview

1.1 Highly diverse national situations

1.2 Cross-border projects

1.3 The contribution of Community policies

1.3.1 The eEurope 2005 Action Plan

1.3.2 The Netc@rds project

1.3.3 The 6th research and development Framework Programme

2. Common features

2.1 The model

2.2 The information on the card

2.3 Validity period

2.4 How the card operates

2.4.1 The insured

2.4.2 Care providers

2.4.3 The social security institutions

3. Flexible, phased introduction of the European card

3.1 Visible data: the options

3.1.1 Combining the European card with the national card(s)

3.1.2 Creation of a mobility-dedicated card

3.2 Arrangements for introduction

3.2.1 General distribution

3.2.2 Issue on request

3.3 Timetable

3.3.1 Phase 1 : Preparation

3.3.2 Phase 2 : Distribution

3.3.3 Phase 3 : Electronification

Conclusion

European Union

EFTA and some Candidate Countries

Introduction

When it approved the action plan for removing obstacles to geographical mobility by 2005, the Barcelona European Council decided to create a European health insurance card which would "replace all the current paper forms needed for health treatment in another Member State". It would also "simplify procedures, but would not change existing rights and obligations".

In this context, the European Council asked the Commission to submit a proposal before its next meeting in Brussels on 20 March 2003.

The new European card will, first and foremost, benefit European citizens by eliminating the current procedures for obtaining the various forms, replacing them with a single, personalised card. It will facilitate temporary stays abroad, initially holidays, the E111 form being the first to be replaced; and, later, employees posted to another country (E128), international road transport (E110), study (E128) and job seeking (E119).

In so doing, it will enable the public to take advantage more easily of the essential facility provided by the coordination of statutory health insurance schemes for over thirty years under Regulation 1408/71 [1]. Anyone staying temporarily in another Member State has access to immediately necessary care under the same conditions as nationals of that country. Patients who have to pay on the spot, e.g. for a visit to the doctor, in the country in which they are staying, will be able to be reimbursed more quickly by their own scheme. A European card will simplify access to care in the country visited while providing a guarantee for the bodies financing the health system in that country that the patient is fully insured in his or her country of origin and that they can therefore rely on reimbursement by their counterparts. Account must be taken here of the many national differences in the use of cards in social protection and health systems, and of the fact that responsibility for social security and organisation of health care systems lies with the Member States. While cards have been widely distributed in some countries, the aim of which in some cases goes well beyond simple administration of cost reimbursement, this is far from being the general rule. Furthermore, there is so far no cross-border interoperability between cards, except in the context of a few projects which are still at the pilot stage, because they have been designed for use solely within a national system.

[1] Regulation EC No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons and their families moving within the Community, OJ L 149, 5 July 1971 (consolidated version OJ L 28, 30 January 1997, page 1).

The introduction of the European health insurance card, in connection with the coordination of statutory social security schemes under Regulation 1408/71, must be based on decisions of the Administrative Commission on Social Security for Migrant Workers (CASSTM). The Administrative Commission is made up of representatives of the Member States, and its responsibilities include promoting and developing cooperation between Member States with a view to modernising information exchange between institutions and speeding up the provision and reimbursement of benefits. Once the Accession Treaty has been signed, on 16 April, it is planned that the ten candidate countries due to become members on 1 May 2004 will attend CASSTM's discussions on this subject as observers.

The purpose of this communication is to facilitate the Administrative Commission's future work in this field. It is the fruit of extensive consultation with the Administrative Commission following the Barcelona European Council. The Member States, together with the EEA countries and Switzerland, Slovenia and the Czech Republic, have also contributed considerably by providing detailed information on the situation in their own countries as regards existing cards or projects. On this basis, it has been possible to put together an accurate overview of the current situation, which is summarised in the Annex to this communication.

Thanks to this preliminary work, the Commission is now in a position to put forward a timetable with various options for implementing the Barcelona decision. Initially, the European card will carry in visually readable form the information needed for the granting and reimbursement of health care provided in a Member State other than that in which the recipient is insured. This does not in any way preclude the information also being carried in electronic form with a view to future cross-border interoperability. It will be phased in progressively, in three stages:

- legal and technical preparation;

- launching, as from 2004, in two stages: initially replacing only form E111, and subsequently all the other forms used for temporary stays;

- a third stage leading ultimately to electric versions of the forms and some of the procedures. In some border regions, such an electronic system already exists for planned care (E112), but because of the differences in national situations and the technology used, this phase cannot be embarked upon immediately, although it is the ultimate objective of the European card. For temporary stays, certain current projects, such as Netc@rds, funded by the European Union under the eTEN action programme, are looking into the technical, administrative, legal and financial aspects of a large-scale move to the use of electronic forms. The eEurope 2005 plan, approved by the Seville European Council, envisages using the European card as a basis for promoting a common approach to patient identifiers and developing new functions such as the storgae of medical emergency data.

1. Health insurance cards: an overview

There is great diversity in Europe in this area, stemming from the fact that individual countries have responsibility for the organisation of their own health and social security systems. The European card project will obviously have to work with this diversity and there is no intention to standardise the existing arrangements. Its implementation must therefore be gradual and flexible, and the means must be strictly proportional to the objective of promoting mobility in the form of temporary stays abroad.

1.1 Highly diverse national situations

While all countries have a system for identifying persons covered by social insurance, not all have a card system at the moment for the relationships between the health system, the social security system and the insured (UK, S, IRL, EL, FIN and most of the applicant countries). In some, however, projects are under way (FIN, EL, S and CZ). In others, there is no national card, but there are plans for the regions (E) or the sickness insurance bodies (NL) to distribute them.

Of the Member States with sickness insurance or health cards [2] (or which will soon have them on an operational or experimental basis), their functions vary widely. They may, for example:

[2] Annex 1 gives an overview of the situation in the various countries, based on the information supplied by the Member States, Switzerland, Slovenia and the Czech Republic.

- serve solely to identify the insured (L),

- enable acquired rights to be verified and facilitate payment or reimbursement procedures (F, B, D, DK, NL),

- carry identification data which provide access to online services (A, I, E, SI),

- extend beyond the field of social security: they may, for example, carry medical emergency data (FIN, IT), enable the individual's legal status in respect of labour law to be verified to combat undeclared working (B), provide access to public services such as public libraries (DK) or employment agencies (E). In IRL, the national card is used to issue certain social benefits electronically and to register with the employment office,

- finally, some Member States plan to integrate medical data (diseases, treatment received, medical or surgical history, etc., into a secure health network (F, NL, SI).

The nature and scope of the data stored on the various cards depends on the purpose for which they are intended. Some carry only the information necessary to identify the insured, and possibly to allow online access to resources and services. Others also store information on acquired rights (e.g., the basic scheme of which the holder is a member, any supplementary scheme, the rate of reimbursement for various types of care). So far there is no European standard for the information to be included on such cards.

The technology used obviously depends on the card's functions. Some have a microprocessor chip (F, D, A, E, NL), others a memory chip (B, SI, D) or magnetic strip (DK, FIN, IRL, L). At the moment, therefore, these cards are not compatible, although there are projects working on this (e.g. in EL, in anticipation of the 2004 Olympic Games and the influx of European visitors to the Olympic sites). They also require different kinds of reader depending on the "intelligence" carried on the cards themselves, which sets additional limits on their capacity to dialogue (or their "interoperability").

Like technological developments, changes in health systems entail constant adaptation. The internet, for example, with its data transmission protocol and network security and cryptography systems (Public Key Infrastructure), provides new opportunities for developing online services for all those invovled in care provision [3]. The European landscape is therefore in constant evolution, which makes it difficult to contemplate harmonising the technologies and functions associated with the cards. Efforts should focus rather on card "interoperability". This approach would seem both realistic and appropriate to achieving the coordination of Member States' social security schemes under Regulation 1408/71.

[3] See the report "Smart Cards as Enabling Technology for Future-Proof Healthcare: A Requirements Survey" published in November 2002 by the "Smart Card Charter" as part of the "eEurope Smart Card" initiative.

1.2 Cross-border projects

In the border regions, the aim is often not so much to facilitate access to care (and therefore reimbursement procedures) in the course of a temporary stay as to improve the coordination of supply. This is why certain experimental projects focus on simpler, more open access to scheduled care.

Meuse-Rhine Euregio: at the initiative of two sickness insurance institutions, one in Germany and the other in the Netherlands, persons insured in the Netherlands have, since 2000, been issued with a specific health insurance card, technically similar to the German insurance card, which gives them access to health care in the border zone in Germany. The arrangement is reciprocal, persons insured in this border zone in Germany being able to use their German health insurance card to obtain care in the corresponding region in the Netherlands.

Baden-Württemberg - Vorarlberg: under an agreement between sickness insurance institutions, the German card is recognised by care providers in Austria in place of the E111 form.

Transcards: with a view to opening up French Thiérache and Belgian Hainaut, since May 2000 an agreement between the French and Belgian social security bodies has enabled those living in the border areas (150 000 people) to use their national card to obtain care in a hospital near their home but on the other side of the border. Such access does not require prior authorisation -- upon presentation of proof of identity and the insurance card (the Belgian SIS or the French VITALE), the hospital completes form E112 automatically from the details on the card.

Netlink: since October 2001, hospitals in Baden-Württemberg treating hemodialysis patients from Alsace under an agreement between the German and French social security systems, have been able to read the VITALE card and complete form E112 on the basis of it.

1.3 The contribution of Community policies

1.3.1 The eEurope 2005 Action Plan

Approved by the Seville European Council in June 2002, the eEurope 2005 Action Plan seeks, on the basis of the future European health insurance card created at the Barcelona European Council, to support European cooperation on electronic health cards. In particular, the section on e-Health refers to a common approach to patient identifiers and electronic health record architecture through standardisation (eTen programme).

This builds on work already carried out by the Smart Card Initiative under eEurope 2002, which aimed to encourage the deployment of smart cards throughout Europe, responding to the needs of both citizens and the business community. In the development of health cards, the Smart Card Charter recommends focusing on their role as infrastructure elements within secure networks, for example enabling online access to the patient's administrative and medical files. Their role in storing medical and administrative information should therefore be limited.

In this context, the health insurance card represents an essential stage in the possible development of new services or functions using information technologies, such as storing medical data on a smart card or secure access to the medical file through the insured's indentifier.

1.3.2 The Netc@rds project

As part of trans-European network policy (RTE) [4], eTEN is a Community action programme supporting the deployment of trans-European e-services based on the telecommunications networks and promoting public interest services for greater social and territorial cohesion.

[4] Regulation EC 2236/95, amended by Regulation EC 1655/99.

One recipient of this support is the first stage of the Netc@rds project, launched in 2002 for 12 months by four Member States (Greece, Germany, Austria, France). The object of the project is to replace the paper forms E111 and E128 by electronic transfer of data carried on the existing national cards and/or accessible online. The project is being run within the existing legal and technical framework, i.e. working with the different types of card being used by the participants and with the national projects in progress.

In the first stage of the project, the idea is to draw up an "investment plan" comprising all the technical, administrative, legal and financial aspects needed for the second stage, i.e. the initial distribution of electronic cards carrying the forms. A third stage is envisaged enabling use of the cards to be extended further.

The work carried out during these phases will support the technical and legal preparations for implementing the Barcelona decision.

1.3.3 The 6th research and development Framework Programme

The 6th RDFP seeks to improve understanding of certain aspects of patient mobility within the Union. The research will cover the way in which temporarystays in another Member State are taken into account by health systems, including the reimbursement aspects; possibilities for cross-border sharing of care supply; and prospective cross-border patient flows in an enlarged Union.

2. Common features

The European card must have common features enabling it to be recognised and used in all Member States. This essentially concerns the nature and presentation of the information carried, as the cards must be readable irrespective of the language of the user, and conformity with a European model.

2.1 The model

A common model for the card -- with a distinctive European symbol, perhaps a logo symbolising European mobility -- is needed to ensure immediate recognition of the card by all those involved in the health system, irrespective of where the cardholder is staying.

The European model is subject to three constraints:

- Member States are free to choose between adding a European side to a national card or creating a separate European card, which latter would obviously leave more scope for flexibility for a European model;

- in the case of a combined card, the model must be adaptable to the different technologies used (magnetic strip or chip card);

- where the Member State opts for a specific European card, the model must be designed to allow transfer ultimately to an electronic carrier in the form of a chip.

2.2 The information on the card

To ensure that the card is readable, it should only carry the data which is absolutely necessary for the provision of care and reimbursement of the cost to the institution in the place of stay. The paper E111 form already contains this essential information, but also certain redundant or superfluous data. The Commission therefore suggests that the obligatory information on the European card should be cut down to the following (list to be established by CASSTM):

- surname and first name of the cardholder,

- identification number of the cardholder,

- card validity date,

- ISO code of the Member State of registration,

- identification number, or, if none, name of the competent institution,

- the logical number of the card, which must enable the information it carries to be checked against the information held by the insuring organisation for the same logical number, to reduce the risk of fraud.

For the countries distinguishing between different types of acquired rights, (e.g. hospital treatment only or all health care), this could be indicated.

Similarly, since in the first stage of the card's introduction only form E111 will be replaced, under Regulation 1408/71 in its current form a distinction will have to be made between the information corresponding to the old "E111" and "E111+" forms, so as not to restrict the entitlement of one of the insured categories. At the moment, holders of retirement or invalidity pensions are entitled to all necessary care, and not only that which is "immediately necessary", in the Member State of temporary stay.

Finally, the presentation of this data must be standardised to enable it to be read irrespective of the user's language, by superimposing fields.

2.3 Validity period

There are two aspects to consider when deciding on the validity period for the European card. On the one hand, some Member States may decide to add the model for the European card onto one side of their own national sickness insurance card, which will already have a validity date. On the other, the date must be fixed with two objectives in mind: promoting mobility and simplifying procedures while preventing improper or fraudulent use of the European card.

Moreover, if all the forms used for temporary stays are to be replaced, the validity period will have to be realistic and effective, both from the point of view of the holders' entitlement and in the interests of the social security institutions and health care providers.

In view of this, and on the basis of CASSTM discussions, the Commission therefore considers that the only reasonable approach is to allow the Member States to decide on the validity period of the European cards they issue. This flexibility, however, is absolutely dependent on applying the principle of the responsibility of the issuing country, if legal certainty and the credibility of the card are to be guaranteed.

This has two essential implications:

- in all cases, the institution of the country issuing the card will have to reimburse the competent institution of the country of stay for care dispensed on the basis of a valid card,

- the issuing country will be responsible for taking all necessary measures to combat fraud and abuse, including providing for legal action and adequate penalties against offenders.

On the latter point, the risk of fraud is greater at the moment using the paper forms, which are often completed by hand, than with a standardised card, and would be very limited if electronic cards were distributed in the future.

2.4 How the card operates

The use of a health insurance card involves three main parties: the insured, the service providers (doctors, hospitals, medical auxiliaries, etc.) and the social security institutions - that of the country of registration and that of the place of stay, which will then request reimbursement from the former for the cost of care.

2.4.1 The insured

The insured will be the main beneficiary of the new card. They will no longer have to apply to the relevant institution for a new form before any temporary stay in another Member State, and will enjoy to their best advantage all the current benefits of the coordination of statutory health insurance schemes at European level.

All insured persons must have a separate personalised card, rather than being included on a family card, for use when travelling alone (business or school trips, etc.).

Initially, the card will be used like the current E111 form, i.e. the insured will present it to the care provider or social security institution of the place of stay.

However, if the new card is really to simplify procedures, two measure are needed which will require amendment of Regulation 1408/71 and its implementing Regulation 574/72:

- Alignment of entitlement between all categories of insured. Regulation 1408/71 in its current form provides for various situations in which insured persons may be entitled to health care during a temporary stay in another Member State. The extent of this entitlement varies according to category of insured, some having access only to "immediately necessary" care, others to "necessary" care.

Essentially, all persons insured under the legislation of a Member State, with the exception of third country nationals and the members of their families, are entitled to all "immediately necessary" care. "Necessary" care, on the other hand, is available to those receiving retirement or invalidity pensions (E111 with appropriate endorsement), students (in the country of study, using E128), posted workers, seafarers, etc. (E128), transport workers (E110), unemployed persons moving to another Member State to seek work (E119) and employed or self-employed victims of an industrial accident or occupational disease (E123).

These differences are not in themselves an obstacle to introducing the European card, but they are a complicating factor and could increase the cost, in that the cards would have to carry a means of identifying the "category" of the insured, and the procedures for checking entitlement between social security institutions would be more involved. In its proposal for modernising and simplifying Regulation 1408/71, the Commission has suggested bringing into line the entitlements of all insured persons travelling to another Member State, to enable them to benefit from "medically necessary" care irrespective of the nature of the temporary stay. The Council of Social Affairs Ministers of 3 December 2002, through its agreement on the "Sickness" chapter of Regulation 1408/71, opened the way for a specific proposal on alignment of entitlements.

- Removal of certain formalities currently required in addition to presentation of the form for obtaining care in a Member State other than that of insurance.

For certain Member States, in certain cases, there are specific instructions on the form in addition to the requirement to present it in order to obtain care during a temporary stay in another Member State. For example, the insured may have to go to the social security institution of the place of stay before approaching a care provider. For short stays abroad, this obligation can appear unrealistic and sometimes a real obstacle to obtaining care and to the free movement of persons. Many countries have already decided not to penalise non-compliance with this kind of procedure. Moreover, patients are often unaware of the obligation and genuinely believe that they are guaranteed access to care in the country of stay if needed, simply by having the form.

The Commission will shortly be submitting a proposal for an amendment to Regulation 574/72 along these lines.

2.4.2 Care providers

Care providers will no longer receive forms which are badly completed, illegible or incomprehensible, as they do at present. Standardising the fields of the card - with visible data - will mean that the care provider has immediate access to clearer, more legible data.

The care provider will have to return the card to its owner, making a copy or, in some cases, entering the data identifying the insured and the competent institution on a document provided under the national system. This process will be made easier by the standardised presentation. Use of the new card must not entail any additional charge or administrative formalities for the care provider.

By eliminating these manual steps in the procedure, the move to an electronic system will simplify the care provider's task still further.

2.4.3 The social security institutions

In the initial stage, the card would carry visibly, in standardised form, the data needed for the institution of the place of stay to request reimbursement from the insuring institution. Its introduction should reduce the number of such requests rejected. The data will actually be more legible and more accurate than on the current forms , which are often still hand-written. Here again, transfer to an electronic system would simplify the procedures while greatly reducing the risk of error, rejection of requests for reimbursement, fraud and abuse.

Aligning the entitlement of different categories of insured persons will simplify the administration of reimbursement between institutions still further by eliminating the differences between the categories of insured on the current paper forms.

3. Flexible, phased introduction of the European card

The Barcelona European Council wished to make a strong gesture in favour of mobility and the European citizen, as a result of which the Commission is putting forward a proposal for a health card based on three aspects: free choice of type of card; flexible means of introduction; phasing-in in three stages.

This concept respects fully the Member States' independence in the organisation and running of their health and social security systems, particularly in respect of health insurance cards. The Member States will therefore also have responsibility for arranging appropriate financing as they see fit.

3.1 Visible data: the options

There is a choice of type of card -- either integration into an existing national card, or the issue of a new card. Initially, however, the European card will have to carry visible information, which will obviously make its integration into a national card more difficult.

3.1.1 Combining the European card with the national card(s)

This would mean conforming to the technical specifications and model proposed above, while ensuring compatibility with the technology (magnetic strip, chip, embossed or non-embossed) used for the national cards, some of which already use both sides.

In addition to these constraints, there are specific points to be addressed:

- With electronic cards, the European data will have to be loaded onto the card while incorporating the same information visibly onto a "European" side of the card. This will allow the information to be read by a card reader in the country or region of stay, without preventing it from being read visually in the other cases. CASSTM would also need to define the electronic format for the data stored on the European card.

- Many national cards have relatively long periods of validity, and replacing the national card to add the European information on one side would require time to adapt the existing stock, unless all the cards were replaced, which would incur excessive costs. The changeover could be helped along in various ways, such as affixing a sticker pending renewal of the card, or issuing European cards to the insured "on request". In any event, this question is closely linked to that of the validity period of the European card, as the national and European sides could hardly carry different expiry dates [5].

[5] National cards have a longer validity period than the current E111 form. The new Belgian SIS card to be brought out in 2003, for example, will be valid for ten years and the date will be carried only on the chip (and therefore invisible to the naked eye); while the French SESAM-VITALE and the Danish card are valid for an indefinite period for basic entitlement.

Finally, the cardholders will need full information on how to use the two sides of the card, which serve different purposes. The cover afforded by the national card, which forms the basis of the holder's social security entitlement, and that of the European card are not at all the same. The European card gives access only to health care in another Member State under the conditions defined by the coordinating Regulation 1408/71 during a temporary stay in another country.

3.1.2 Creation of a specific European card

This option has many advantages. A special European health insurance card would appear to respond more obviously and clearly to the European Council's mandate. Its distribution could also be restricted to people actually moving within the Community. Issuing a separate European card would alleviate considerably certain constraints, such as the temporary disparity between the validity periods of the two sides of a combined card. It would also avoid unsatisfactory makeshift solutions such as affixing stickers. Creating a specific European card would not prevent the data on it from also being loaded onto a chip in countries or regions with cards, to make its use easier for stays in countries or regions with compatible equipment.

3.2 Arrangements for introduction

There are two possibilities: the European health insurance card could either be distributed generally, or can be issued only to those who apply for it, as needed. It is worth pointing out again here that the card is intended for temporary stays (holidays, road transport, study, postings abroad) and is therefore not, in the vast majority of cases, for everyday use.

3.2.1 General distribution

If this option is taken, the card should be generally distributed before its entry into force, which would coincide with the discontinuation of the paper forms by the Member State in question. The European card could be distributed wholesale, prior to its entry into force and before the paper forms are withdrawn. This "big bang" option would have the advantage of creating maximum awareness of the benefits of the European card. It would, however, be expensive, unless, for example, the Member State decided to introduce a national card at the same time. The experience of many countries has demonstrated that over a year of detailed preparation is often required for successful general distribution.

The European card could also be integrated into a national card when the latter is renewed, whether because it has expired, been lost or stolen or has become obsolete for a specific reason. In this way, it would be brought gradually into general circulation. While this would reduce the cost, it would also be a long and drawn out process since, in some countries, fewer than 5% of cards are replaced annually.

3.2.2 Issue on request

This more targeted option would be the safest way of ensuring that the deadline of 1 June 2004 proposed in this communication for introduction of the European card and general withdrawal of the paper forms could be met. As from the date of its entry into force and general withdrawal of the forms, the card could be issued as and when the insured requests it from his or her insurance institution.

If a European side has been added to a national card, this would mean either re-issuing cards according to the new format, or affixing a temporary sticker.

3.3 Timetable

When it decided to replace the various forms with the European card, the Barcelona European Council asked the Commission to submit a proposal in 2003. In view of the situation as described above, it would seem best to phase in the card in three stages - preparation/distribution/electronification.

3.3.1 Phase 1 : Preparation

Following the Barcelona European Council's decision to create the card, intensive consultation with those invovled in the statutory social security schemes enabled the priorities for the effective launch of the card to be identified.

1. In view of the deadlines set by the Barcelona European Council, the Commission proposes that CASSTM concentrate on replacing only form E111 with the European card. The relevant decisions should be taken by summer 2003 and specify the administrative and technical requirements for creating the European card, providing for it to be issued in visually readable form with the possibility right from the outset for those countries which so wish to issue an electronic card.

In particular, CASSTM should establish a list of the data to be carried visibly on the card, and incorporated electronically either immediately or at some point in the future. It should also decide on a model for the European card, with a common distinctive symbol.

The Commission would recommend taking 1 June 2004 as the deadline for effective replacement of form E111, in view of the time needed for the technical and administrative preparations for introducing the card. However, it will provide for those Member States which do not at present use a card in their health insurance system to opt for a transitional period, during which they may continue to issue E111 in paper form. The latter will therefore be accepted in the other countries until expiry of the transitional period set by the Member States concerned.

Certain Member States may well find it difficult to introduce a card by 1 June 2004, even if it is issued only on request to insured persons planning a temporary stay abroad. A transitional period will spare them disproportionate constraints and costs. This kind of flexibility will, however, inevitably mean that the country of stay will have to operate a parallel European card/E111 form system, whether or not they are benefiting from the transitional period themselves. Member States which have opted to introduce the card by 1 June 2004 will still have to cater for visitors whose countries of origin are not operating the new system, which will detract considerably from the simplification the European card is intended to produce. For this reason, these transitional periods must be relatively brief, and in no circumstances longer than 18 months.

2. The Commission will propose an amendment to Regulation 1408/71 on aligning entitlement to "medically necessary care" for all categories of insured (old-age pensioners, students, employed and self-employed workers), following the agreement at the Council meeting of 3 December 2002.

3. The Commission will also propose an amendment to Regulation 574/72 eliminating the formalities currently required in addition to presentation of the form by the insured in the country of temporary stay. Temporary visitors must have access to treatment at normal prices to ensure that they do not encounter difficulties in the reimbursement of care received in another Member State.

4. In 2004, CASSTM should press ahead with adopting the decisions needed to replace all the other forms used for temporary stays. The replacement of the paper E111 form should make this stage easier.

5. At the same time, on the basis of the results of the first stage of the Netc@rds project, the technical specifications needed for the changeover to electronic forms should be examined. The means of registering and reading the electronic data must be defined with a view to possible electronic processing of the procedures for access to care and administration of cost acceptance at the place of stay.

3.3.2 Phase 2 : Distribution

Distribution of the card could be in two successive stages:

1. The first stage, starting on 1 June 2004, would see the introduction of the card to replace form E111. The paper forms would cease to be recognised in the other Member States, subject to any transitional periods.

In the event of a transitional period, the other Member States would have to continue to accept the paper E111 forms until the expiry of that period.

2. The second stage, to be completed by 31 December 2005 at the latest, would mark the end of the transitional periods and replacement of all the forms used for a temporary stay.

This would end the parallel circulation of cards and forms. In principle, only the European health insurance card would then give access to health care in another Member State during a temporary stay.

3.3.3 Phase 3 : Electronification

Replacing the forms with the European card, simplifying procedures, aligning the entitlement of different categories of insured persons and running pilot projects on card interoperability form a coherent whole, which will take on its full significance when an electronic system and automated administration of the forms and procedures are in general use. This changeover would represent a third phase, the timing of which depends both on the evaluation of Phase 2, which could be completed by 2008 (two years after the end of the second stage and the transitional periods) and on the results of the first stage of the Netc@rds project.

This final stage could also include evaluating the possibility of integrating into the card functions linked to personal health data, such as access to important medical information in emergencies or records of treatment received.

Conclusion

The European health insurance card is an ambitious project serving the interests of a real citizens' Europe. Drawing on the wealth and diversity of experience of many countries, it will, in the Commission's view, be able to be brought into use as a simple, practical and flexible facility from 2004. The concept for its introduction as presented in this communication, in particular its phasing-in in three stages - preparation/distribution/electronification - and the associated timetable, are a reflection of this analysis and this ambition.

ANNEX

European Union

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EFTA and some Candidate Countries

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