Communication from the Commission concerning the introduction of a European health insurance card
Date: 2003-02-17
Institutions: European Commission
Subjects: European citizenship, administrative formalities, health card, health insurance

COMMISSION OF THE EUROPEAN COMMUNITIES

Brussels, 17.02.2003
COM(2003) 73 final

COMMUNICATION FROM THE COMMISSION

concerning the introduction of a European health insurance card

Table of contents

Table of contents ........................................................................................................................ 2

Introduction ................................................................................................................................ 4

1.

1.1

1.2

1.3

Health insurance cards: an overview............................................................................ 5

Highly diverse national situations................................................................................ 5

Cross-border projects ................................................................................................... 7

The contribution of Community policies ..................................................................... 7

1.3.1

The eEurope 2005 Action Plan .................................................................................... 7

1.3.2

The Netc@rds project .................................................................................................. 8

1.3.3

The 6th research and development Framework Programme........................................ 8

2.

2.1

2.2

2.3

2.4

Common features ......................................................................................................... 8

The model .................................................................................................................... 8

The information on the card......................................................................................... 9

Validity period ............................................................................................................. 9

How the card operates................................................................................................ 10

2.4.1

The insured................................................................................................................. 10

2.4.2

Care providers ............................................................................................................ 11

2.4.3

The social security institutions................................................................................... 12

3.

3.1

Flexible, phased introduction of the European card................................................... 12

Visible data: the options............................................................................................. 12

3.1.1

Combining the European card with the national card(s)............................................ 12

3.1.2

Creation of a mobility-dedicated card........................................................................ 13

3.2

Arrangements for introduction................................................................................... 13

3.2.1

General distribution.................................................................................................... 13

3.2.2

Issue on request .......................................................................................................... 14

3.3

Timetable ................................................................................................................... 14

3.3.1

Phase 1 : Preparation.................................................................................................. 14

3.3.2

Phase 2 : Distribution................................................................................................. 15

3.3.3

Phase 3 : Electronification ......................................................................................... 15

2

Conclusion................................................................................................................................ 16

European Union........................................................................................................................ 17

EFTA and some Candidate Countries ...................................................................................... 29

3

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  1408/711.  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.

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.

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).

4

                                                
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.

5

Of the Member States with sickness insurance or health cards2 (or which will soon have them
on an operational or experimental basis), their functions vary widely. They may, for example:

– 

– 

– 

– 

– 

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 provision3. 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.

2

3

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.
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.

6

                                                
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.

7

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.

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;

4

Regulation EC 2236/95, amended by Regulation EC 1655/99.

8

                                                
– 

– 

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.

9

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
(E111  with  appropriate
those 

invalidity  pensions 

retirement  or 

receiving 

10

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

11

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

12

validity period of the European card, as the national and European sides could hardly
carry different expiry dates5.

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.

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.

13

                                                
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, 
three  stages  –
preparation/distribution/electronification.

it  would  seem  best 

to  phase 

the  card 

in 

in 

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,

14

2.

3.

4.

5.

these  transitional  periods  must  be  relatively  brief,  and  in  no  circumstances  longer
than 18 months.

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.

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.

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.

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.

2.

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.

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.

15

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.

16

EUROPEAN UNION

ANNEX

Belgium

Denmark

Germany

Greece

Spain

Name of card / project

Carte SIS / SIS Kaart:
Sociaal Identiteit Carte /
Carte d'Identité Sociale
(Social Identity Card)

Sygesikringsbeviset
(Social Security Card)

Versicherten-karte
(Insurance-Card)

AMKA-EMAES
(Creation of National General
Register of Social Security)

Card purpose

Certificate of entitlement to
health care benefits in kind. It
has also a function as tourist
health insurance certificate.
Furthermore it may be used
as a library card and as an
identity card in relation to
private and public
enterprises.

This card is multi-functional;
the visible data and the PDBF
can be used by social security
organisations, health care
practitioners, employers and
the tax authority; the data
located in the SFDF can only
be accessed by a health
professional card with a SAM
(i.e. the health insurance
organisation, the health care
practitioners and the social
inspection authority).

Entitling a person with
statutory sickness insurance
to medical and dental
treatment.

Every person entered in the
National General Register of
Social Security is to be
provided with a social
security card.

TSI
Tarjeta Sanitaria Individual
(Health Insurance Card)

To provide access to health
care through the national
health system by identifying
the person and providing
information on entitlement to
pharmaceutical benefits.

TASS
Tarjeta de Affiliacion de la
Seguridad Social
(Social Security Affiliation
Card)

To be used as an individual
identification document
within the social security and
health areas
Its use will facilitate common
transactions, in particular
with the Ministry of Work
and Social Affairs, and the
immediate delivery of general
and personal information
through terminals (kiosks)
disseminated in the whole
Community.

Card introduction
date

1998

1993

1994

1993

In 1995, a project was initiated, combining both cards to
form one single card. It has been introduced as a pilot
project in the Autonomous Community of Andalusia

Amount of cards in
circulation

More than 10 million

A social security card
containing identification data
is issued to all residents in
Denmark.

All those in Germany with
statutory sickness insurance,
i.e. about 80 million cards.

By December 2002, 2.5
million people have already
received cards

5.5 million

All citizens, irrespective of
how they qualify for access to
public health care.
TSI are issued by each of the
17 Autonomous Community
+ the Ministry of Health and
Consumer affairs which is
responsible for the
autonomous cities of Ceuta
and Melilla

17

Belgium

Denmark

Germany

Greece

Spain

Evolution

This card has still some
memory space available for
sectorial applications to be
activated by a different type
of SAM card. It could also be
used in the Belgian e-
Government projects.
A new version of the card
will be distributed to all card
holder over 2003/2004
A smart card for public
identity with electronic
authentication and signature
is intended to be distributed
to all Belgian residents; the
pilot project has been started
in 2002. This card could be
used for securely accessing
on-line health insurance data.

There has been a discussion
of whether the Health
Insurance Certificate should
be a smart card with a digital
signature based on PKI. Right
now we are awaiting the
implementation of a
software-based digital
signature based on PKI. If or
when the demand of security
in Denmark will require a
hardware-based digital
signature, we will reconsider
if the Health Insurance
Certificate should be a smart
card with a digital signature.

It is planned to distribute it to
all insured persons (titular
and beneficiaries)

It is planned over the next
four years to introduce a new
generation of
microprocessor-based health
card. In addition to the
administrative data, this card
would include health data as
well as the information
required for using the card as
an E111. There are plans to
add the electronic
prescription on the card.

After project completion
(2003), the social security
card will be replaced by the
corresponding memory/smart
card in accordance with
decisions taken by the
competent Greek Ministries
and the Technical
Commission of the
Administrative Commission
of Social Security for
Migrant Workers

Comments

The SIS card interacts with
the Health Professional Card
which includes a
microprocessor card with a
SAM (Secure Access
Module)
Due to its multi-function
characteristics, it is excluded
that the card includes more
visible data than pure
identification.

The name and address of the
insured person as well as the
CPR-number and the health
benefit group are in
embossed print. The back of
the card contains information
in English about the Tourist
Health Insurance, the secure
signature strip and the
magnetic stripe

a) The data on the card is not
encrypted.
b) The card has no special
protection against access.
c) Insured persons are
provided with new cards in
case of exceeding the period
of validity or change the
insurance fund.
d) The investment was about
250 million Euro for the first
equipment.

Technical specifications of
the future memory/smart card
still to be defined

TSI is also used as an
element of an information
system for planning and
resource management tool for
health resources
TSI is not used as an identity
document nor as evidence of
worker's situation with
regards to social security.

18

Belgium

Denmark

Germany

Greece

Spain

Identification
(*) = Visible data

Social security identification
number (NISS) (*)
surname, first given name,
initial for the second given
name (*)
sex (graphical icon) (*)
date of birth (*)

CPR Nr. (Central Personal
Register Number of the card
holder)(*),
name and address (*)

Number + name of the
issuing sickness insurance
fund (*)
Surname and first name of
the insured person (*)
Date of birth (*)
Address of the insured person
Health insurance number (*)
Status of the insured person
(*)

All visible data(*):
First 3 letters of the given
name,
first letter of the patronymic
and the family name of the
cardholder (in Greek and
Latin characters)
initials of the family name,
given name and patronymic
SSRN in barcode / SSRN in
OCR form
the SSRN in indent form.

Surname and first name of
the card holder (*)
Affiliation number (*)

Personal identifier of the card
holder (*)
Social security number (*)
National identity document
number (*)
Given name and surnames (*)

Other data in the card
(*) = Visible data

Validity date (start and end)
(*),
card number (*)

APC-File
Starting date of insurance
coverage
Where the card is valid for a
limited period of time, period
of validity of the card (*)

Identification of the
Secretariat General for Social
Security (postal address, tel.
number..)
Note: date of birth and sex
are included on SSRN

Distribution date
Date of birth
…

All visible data(*): Name and
telephone number of General
Practitioner (GP)
Name and Logo of home
county.
Name and telephone number
of local municipality.
Health benefit group. Name,
address and telephone
number of the Tourist Health
Insurance.
Starting validity date

On the front side:
- Name of the Autonomous
community issuing the card
(*)
- Identification code of the
issuing territory: Spain +
Autonomous Community(*)
- Type of entitlement (e.g.
worker, pensioner, details of
pharmaceutical benefits) (*)
- Expiry date (*)
On the back side:
- Name of the primary health
care practitioner (*)
- Address and telephone
number of the primary care
centre (*)
In terms of design, there are 7
communities where it differs
and 10, including Ceuta and
Melilla where it does not. .

Authentication

None

Secure signature strip

In the back of the card:
secure signature stripe

Authentication of the card
holder: in the back of the
card: secure signature stripe

The identification system
implies the use of biometric
(i.e. fingerprint)

None

19

Belgium

Denmark

Germany

Greece

Spain

Category of other data
stored on the card

The visible data plus a few
other such as nationality, the
card-issuer, the type of the
card, registration number of
GP, and code number of
county and municipality are
stored in the magnetic strip.
There is a bar code with
cardholders CPR. Nr.

Card directory (CDIR) => for
localising the data files
Issuer data file (ISDF) =>
including for instance the
card validity date
Public data file (PDBF) =>
including all visible data
related to the card holder
Sickness fund data file
(SFDF)=> including the
identifier of the health
insurance organisation, its
access codes and some data
related to the covered health
insurance rights
+ ATR; AID=A0 00 00 33

None

Control information (protocol
and memory layout)
Information for card
diagnosis and card
identification (card
manufacturer data)
Directory information
(identification of the
personaliser and type of
application)
Application file (see above
list of data)
Filler data object for
controlled occupation of the
memory not needed for the
application file

Personal identifier of the card
holder
Given name and surnames
Identification code of the
issuing territory: Spain +
Autonomous Community
Type of entitlement
Expiry date

Type of card

Memory chip card

A magnetic stripe card

Memory chip card

Credit card format without
magnetic stripe on the rear

Memory chip card with a
magnetic stripe on the back
side for interoperability with
TSI

A magnetic stripe card, with
the exception of the Card
from the Autonomous
Community of Andalusia
which combines TSI with
TASS

Processor type used on
chip card

1024-bytes EEPROM

None

256-bytes EEPROM

None

 16 Kb ROM
240 bytes RAM
3,024 bytes EEPROM

None

Operating system used
on the card

Starcos s2.1c

None

./.

None

TIBC, compatible with VISA None

International
standards used

 ISO 7816 (size of the card,
positioning and
characteristics of the memory
chip, interfaces and
communication protocols)

Magnetic stripe: DS/ISO
7811-2, Barcode: EAN/UPC-
128

Conform to relevant ISO
standards, in particular in
respect of ISA-compliant
location of the contacts (ISO
7816-2)

ISO 843 for conversion of
Greek characters into Latin
characters

ISO standards applicable to
the cards

20

France

Ireland

Italy

Luxembourg

Netherlands

Name of card / project

Carte Vitale
(Vitale Card)

Social Service Card

Carta Nazionale dei
Servizi
CNS
(National Service Card)

CIE
(Electronic Identity
Card)

Carte d'identification à
la sécurité sociale
(Identification card for
social security)

Verzekeringpas
(Insurance pass)

Zorgpas
(Care pass)

Identity Card and
network service card

The card is only used for
identification purposes
(registration number)
and does not entitle the
holder to benefits.

Insured person
identification and proof
of entitlement

- Permanent record of
the holder's PPSN
- The card is also
currently used for the
electronic withdrawal of
certain social welfare
payments and by the
unemployed for the
purpose of 'signing on'.

This card is issued by
local authorities
(municipalities and
regions) in accordance
to national standards in
order to provide various
type of services (e-
Government, transport,
health ...) to citizens. It
is equivalent to the CIE,
but without the laser
stripe.

Card purpose

Health care
reimbursement (e.g.
visit to health care
practitioners,
pharmaceutical
products)
The Vitale card is
closely linked with the
CPS card of the health
professionals and the
FSE (electronic health
care sheet). More than
130 000 health
professionals are
monthly producing 60
million electronic health
care sheets (50% of the
total amount) using the
Vitale card for obtaining
the necessary insured
data.

Card introduction date

1998 / 2001

1992

1998
(pilot project in 4 local
health units as part of
the NETLINK project)

2001

 In the eighties

1998

1999
(Regional chip card
experiment)

21

France

Ireland

Italy

Luxembourg

Netherlands

100.000 up to the end of
2001 with the aim to
distribute it to the whole
population in the
coming years

The card is issued to
every person covered by
health insurance

Each health insurance
organisation is free to
use cards as proof of
entitlement. However, if
a magnetic card is used
they are to comply with
national specifications

In the next four years
the card will became the
national electronic
identity card

None

The functions can in the
future be extended to
other applications, such
as health data.

There are alternatives
available for enabling
care providers to check
the insurance
entitlement of their
patients electronically
without use of a card.
For this reason, the use
of the card as proof of
entitlement was
cancelled on 1st
September 2002.

Number of cards in
circulation

40 million
53,5 million

1.75 million people have
received cards

Evolution

The Social Services
Card will be superseded
by a Public Service
Card, incorporating new
technology which will
facilitate access to these
services

The Vitale 1ter project
(2003-2004) is opening
more the Vitale card to
the complementary
schemes in order to
produce a "request for
electronic
reimbursement"
Since the card is used
more and more over the
Internet, the whole data
flow will have to be
encrypted.
The Vitale 2 project is
aimed at providing a
card to all beneficiaries
(60 millions) and would
include health
emergency data, the last
3 or 4 signed
prescriptions, some
pointers (e.g. address of
the health care provider,
location of the medical
files), some indications
on the last financial
transactions and a set of
information on the
complementary health
insurance regime

The first example for
this service card is the
Lombardy Regional
Service Card (CRS-
SISS), a health card
issued to 300 000
persons in Lecco
Another example is the
military health card.
Other municipalities
have also distributed one
similar or close to CNS
(Bologna, Siena,
Brescia).

The INPS (National
Social Welfare
Institution) is also
involved in the project
NETLINK as an
associated partner,
studying the possibility
of extending its use to
the pensions and social
benefits sector.

22

France

Ireland

Italy

Luxembourg

Netherlands

Comments

See information on
Transcards, Netlink and
Netc@rds

a) Under recent
legislation the use of the
PPSN will be widened
and it will eventually
become the unique 'key'
for citizens to access a
wide range of services
across the public sector.

Qualified operators will
be provided with a
special card named
CNS/O "Carta
Nazionale dei
Servizi/Operatore"
which will allow to
access confidential data
under the control of the
citizen.

This card is open to host
several functions and it
is possible that in the
near future will become
theonly one used in
Italy. In any case, this
card is the standard
supported in the Public
Administration domain
by Italian Authority for
Information
Technology.

Each person linked to a
Social Security
organisation receives a
card. Information is not
updated automatically,
but users can request a
new card if any
information changes.

The magnetic stripe is
not always used, this
situation is partly cause
by the medical
suppliers, especially the
general practitioners,
who don't have the
equipment to read the
card.

Identification
(*) = Visible data

National identification
number (NIR) (*)
surname, given name of
the card holder (*)
 maiden name for
women (*)

PPSN (Personal Public
Service Number) (*)
holder's name (*)
date of birth (*)

Personal dataNational
Registration Number
(Tax number) of the
ownerIdentification data
of the municipality

Personal dataNational
Registration Number
(Tax number) of the
ownerIdentification data
of the municipality

Registration number (in
numeric and bar code
format), surname at
birth, given name and,
for married women,
husband's surname

Surname and given
name (*)
Registration number (*)
Date of birth (*)
Sex (*)

Other data in the card
(*) = Visible data

Compulsory health
insurance regime
Contact office
Card holder address

Card issue date
Card expiry date
sex

Emergency data
E111 Netlink data set

Emergency data
E111 Netlink data set

Card number

Name of insurance
organisation (*)
Name of primary health
care practitioner and
pharmacist (*)
Insurance details (*)
Validity date (start and
end) (*)

Authentication

Mutual recognition of
the Vitale card and the
CPS one
(microprocessor card for
health care
professionals)

In the back of the card:
secure signature stripe

Yes, based on a strong
digital signature and on
a challenge response
mechanism.

Yes, based on a strong
digital signature and on
a challenge response
mechanism.

23

France

Ireland

Italy

Luxembourg

Netherlands

Category of other data
stored on the card

Card validity
entitlement details
including its validity
entitlement to
complementary health
insurance

E-111 in accordance to
the Netlink
specifications

In addition to the data
mentioned, the magnetic
strip also contains
details of the holder's
address

E-111 in accordance to
the Netlink
specifications
no applications on the
card. Only a couple of
keys for asymmetric
crypto based
identification &
authentication and
services data for the use
as service card

Type of card

Microprocessor card

Plastic card with
magnetic stripe

Smart card
(microprocessor)

Microprocessor +
optical memory card

Credit card format with
magnetic strip on the
back side

Plastic card with
magnetic stripe (used by
most of sickness funds)

Microprocessor card

Processor type used on
chip card

Operating system used on
the card

COS

None

None

16 K EEPROM

None

None

None

None

24

 
 
 
France

Ireland

Italy

Luxembourg

Netherlands

International
standards used

 ISO 7816

Conform to relevant ISO
standards

see NETLINK
recommendations

ISO 7816 pile and
PKCS- RSA pile.

ISO/IEC 7810:
Identification cards -
Physical characteristics
NEN-EN-ISO/IEC
7811: Identification
cards - Recording
techniques
ISO/IEC 7813:
Identification cards -
Financial transaction
cards
NEN 1888: Overall
definition of personal
data
NEN 5825: Addresses -
Definition, character
sets, exchange format
and physical
presentation
EN 1387: Health care
application cards -
General characteristics
ENV 12018:
Identification,
administrative and
common clinical data
structure

25

Austria

e-Card

Name of card /
project

Card purpose The first stage is to use

the card to replace the old
system of health
insurance certificates for
all insured persons in
Austria.

Portugal

Sweden

Finland

United Kingdom

Cartão do Utente
Ministério da Saúde
(Identification Card for
persons registered with the
National Health Service)

For use in any SNS (Serviço
Nacional de Saúde) health
service or institution, and in
pharmacies and institutions
which have agreements with
the Ministry of Health

CARDLINK
(Emergency card for
diabetics)

N/A
(see COMMENTS)

(Standard health insurance
card (without/with picture))

N/A
(see COMMENTS)

The main environment in
which the cards are used is
pharmacies, where insured
persons must present their
personal card in order to
receive refunds for
prescription drugs.
The card with the photo is
used to prove identity, even it
is not an official proof of
identity

The main objective is to
exploit the card's potential
as a portable search key for
network-based information
retrieval.
- Electronic identity
- Health insurance.
- Social welfare and Health
care

Card
introduction
date

Number of
cards in
circulation

Evolution

2001

1990

1999

All insured persons in
Austria

Approximately 9 million

1100 diabetics’ cards and
250 health professionals’
cards

Regional pilot

The standard card has been
issued to all permanent
residents of Finland, of
whom about 600,000 have
exchanged it for a photo card
(available for a fee).

A Social Security
identification card (under
examination)

In the second phase, the
card will become a key
card for other
applications in the social
insurance and healthcare
fields and - especially in
connection with electrical
signature - a citizen's card
for e-government
applications available
through the Internet.

26

Austria

Portugal

Sweden

Finland

United Kingdom

Comments

a) The card is designed to
act as a key to the
Austrian healthcare
system, it does not in
itself carry specific data,
but rather facilitates
access to services and
data.
b) The access to data in
the card and/or the
activation of applications
is possible only with a
right card put at the same
time
c) The card is prepared
for electrical signature.

Identification
(*) = visible
data

Nationwide social
insurance number (*)
first name, surname name
and title (*)
date of birth
sex
carte number (*)

SNS registration number (*)
card holder’s full name (*)
date of birth (*)
place of birth,
sex,
nationality,

Other data in
the card
(*) = visible
data

Certificates for
authentication and
electronic signature with
related private keys.

Date of issue (*),
Region/sub-region/health
centre,

The card may be used
wherever the SNS
registration card is used

.

There are no electronic
identification/information
cards for people residing in
Sweden in use within the
Swedish social insurance
administration and there are
no current plans for
introducing such cards.
There is however a pilot
project for electronic
identity cards, providing
authentication and electronic
signature services to be used
in the context of e-services.

The main objective is to
give the customer an
electronic identification,
encrypt discrete information
to be sent and verify the sent
message with electronic
signature

A public consultation
started in July 2002 and
will run until January 2003
(www.homeoffice.gov.uk/d
ob/ecu.htm)

SNS registration number (*)
card holder’s full name (*)
date of birth (*)

- cardholder's population
register number
- family and given names
- date of birth
- place of residence

For social security, the card
includes the same data as the
health insurance one.

Its electronic data content
will include - besides
identification, signature and
encryption elements (PKI) -
e.g. vaccination, chronic
illnesses, and direction for
organ donation, closest
relatives.

The photo card includes
additional information
relating mainly to pension
recipients.

+ Name of the social
insurance institution

Date of issuing

Other data related to social
security

27

Austria

Authentication The "key" is unique

None

within the entire system.

Portugal

None

Sweden

Finland

United Kingdom

The photo card bears the
cardholder's signature.

Certificates for
authentication and electronic
signature

Depending on the
sensitivity of the various
applications different
safety stages are possible:
a second authorized card,
an encrypting procedure,
a PIN, an electronic
signature.

Category of
other data
stored on the
card

Work on a possible
loading of E-111 is
currently under way as
part of the Netc@rds
project

Identification of cost-sharing
system for prescription
charges, of exemption from
flat-rate charges, and the
existence of sub-systems or
insurance companies with
relevant details of validity

key information (encrypted)
from the delivery of social
and health services

Type of card Processor chip card with

Magnetic strip

crypto processor

Smart card with magnetic
strip

Plastic "SII card"

Microprocessor card with
crypto processor

32 K EEPROM

None

Processor type
used on chip
card

Operating
system used on
the card

MICARDO 2.1 (multi
application operating
system with post-issuance
loading facilities)

None

International
standards used

Applicable technical and
international standards

None

None

Appropriate ISO standards

Appropriate ISO standards +
EU/G7 and CEN
TC/251standards

28

EFTA AND SOME CANDIDATE COUNTRIES

Iceland

Lichtenstein

Norway

Switzerland

Czech Republic

Slovenia

Name of card / project

N/A

N/A

N/A

Card purpose

Card introduction date

Number of cards in
circulation

Covercard®System

Swiss health insurance card
project

Certification of insurance
entitlements.
Allows providers of care
(hospitals, pharmacies, doctors
etc.) to check "on line", and at
any time, the validity of the
card presented by the holder
when benefits are provided.

Certification of insurance
entitlements.
Facilitates administrative
exchanges of data (for
reimbursement purposes).

MACHA
(Health and Health Insurance
Card)

Kartica zdravstvenega
zavarovanja
HIC
(Health Insurance Card)

Electronic Health and Health
Insurance card.
Identification patients/insured
Confirmation of provided
health care for Health
Insurance office.
The cards include
identification and medical
data, PIN, electronic signature,
social security identification

HIC is the only document
applicable for the purposes of
identification and
implementation of the health
insurance rights deriving from
compulsory and voluntary
health insurance. It is also a
key to the services provided
through the self-service
terminal network.

Introduced in Switzerland on 1
June 1996.

The project still has to be
approved by the Swiss
Parliament.

1997-9

35 insurance organisation (out
of 93) have issued
approximately 4 million of
cards to their insured persons.

None

Pilot project: 30.000 cards of
insurees, 100 health
professionals cards

Pilot introduction in one
region in 1998,
National introduction
completed in October 2000

HIC was issued to all persons
covered by the compulsory
health insurance in Slovenia,
i.e. to the entire population
(i.e. close to 2 million);
some 18 000 Health
Professional Cards are in use.

29

Evolution

Iceland

Lichtenstein

Norway

Switzerland

Czech Republic

Slovenia

It is intended that the health
insurance card eventually
become a genuine health card
giving insured persons and
providers of care secure access
to data concerning the insured
person.

Project was steered by
Ministry of Healthcare and
supported by General Health
Insurance Office.
The pilot is still in operation.
In 2002, it has served as basis
for preparing a nation-wide
roll out for an "Electronic
Identificator of Health
Insurees" whose 1st stage
(analyses and project design)
will start in 2003

2000: The first phase, the HIC
system covered identification
of the insured person and
proof of entitlement of his/her
insurance rights and
registering of the selected
personal physicians.
2001: New service - ordering
convention certificates (similar
to the EU E111 form) through
self-service terminals, with the
HIC serving as access key.
2003: New data - recording of
data on medical technical aids
issued, recording of data on
allergies and vaccination,
recording of the card holder's
voluntary commitment to
organ donations.
2004: Technology upgrade -
PKI and electronic signature to
be implemented (in the first
phase on the HPC, in the
second phase on the HIC). The
system is open to upgrades
with / downloading of new
applications and datasets on
the cards in circulation;
standard SM procedure is
applied for this purpose.

30

 
Iceland

Lichtenstein

Norway

Switzerland

Czech Republic

Slovenia

Comments

An entitlement card is
envisioned.

If the European Union's
insurance card project takes
shape before the Swiss project,
the latter will be adapted
accordingly.

Project was supported by EU
programme PHARE. Pilot site:
city Litomerice (main regional
town). Scope of participants: 1
municipal hospital, 14
physicians, 1 Health Insurance
Company. Pilot project has
created and stabilized a
steering team which is
permanent involved in health
card issues.

With regards to the data
currently foreseen in the E111
1. Data relating to the insured
person, except details
concerning their status as an
employed person, self-
employed person or pensioner,
etc.
2. Cards are issued for
individuals; no details of
family members are shown.
3. In some cases, the card's
period of validity isn't there.
4. The name of the competent
institution, but not its
particulars.

The HIC system includes the
Health Professional Cards
(HPC), card readers, a network
of self-service terminals,
unified standard APIs in all
health care providers
workstations.
Health professionals can
access HIC data only using
their personal HPC and a
dedicated card reader. HPC
holders are classified into
several groups; groups have
different keys on their HPC
and consequently different
access rights to data on the
HIC.
The self-service terminal
network is used for on-line
updating of the HIC data,
services (such as ordering of
convention certificates, with
the HIC serving as access
key), adding new applications
and functions on the HIC (new
files, changing access rights)
and providing information.

Identification
(*) = visible data

Name of insurer (*)Name, first
name, date of birth and sex of
insured person (*)Insurance
number (*)Emergency
telephone number (*)Bar code
(*)

At least the same as currently
shown on cards issued in
Switzerland. There are plans
to assign new insurance
numbers which will remain
valid for the entire duration of
a person's cover under the
Swiss system.

Name and surname (*), Date
of birth (*), Address,Health
insurance number (*), Health
insurance company (*)

- Health insurance number (*),
- Card instance number (*),
- Name and surname (*),
- Ddate of birth (*)

31

Iceland

Lichtenstein

Norway

Switzerland

Czech Republic

Slovenia

Other data in the card
(*) = visible data

Insurance coverage: common
sickness and maternity
insurance institution (LAMal),
additional private insurance.

It is intended that insured
persons be allowed to provide
sensitive data about
themselves for emergencies
(blood group, allergies to
certain medicines, etc.).

ID data for social security,
ID data of patient (contact
address, address of health care
provider, address of patient
health record),
Selected medical data,
Date of issue (*)

Authentication

PIN

- Card holder data (address,
sex),
- Insurance contribution
details (registration number,
firm name, address),
- Compulsory health insurance
details (date of confirmation,
insurance validity),
- Private (voluntary) health
insurance details (insurance
company, type of insurance
policy, insurance validity),
- Selected primary level
doctors' details (general
physician/ paediatrician,
dentist, gynaecologist)

Mutual recognition of Health
Insurance Card and Health
Professional Card (using
challenge/response
mechanism),
HPC serves as an access key
to data on the HIC (using
symmetrical 3DES
cryptography and PIN codes).

Category of other data
stored on the card

Type of card

Processor type used on
chip card

Operating system used
on the card

Security data, PIN

None

Magnetic-stripe card

Microprocessor card is
planned

Microprocessor card

Microprocessor card

MOTOROLA SC21, 3KB
EEPROM, 6KB ROM

16 kB EEPROM, 32 kB ROM,
1280 B RAM, 16-bit CPU

ORGA ICCRe/V.24

GEMXCOS

None

None

32

 
 
 
 
 
 
Iceland

Lichtenstein

Norway

Switzerland

Czech Republic

Slovenia

International
standards used

ISO 2.

Possibly the international
NETLINK standards.

ISO standards: 7816- 1, 2, 3,
7810

- ISO/IEC 7816 (Physical
characteristics, dimensions
and locations of contacts,
electronic signals and
transmission protocols,
interindristry commands for
interchange, numbering
system and registration
procedure for application
identifiers, interindustry data
elements, security related
interindustry commands),
- ISO/IEC 10373 (Test
methods),
- ISO/IEC 11770
(Mechanisms using
asymmetric techniques),
- ISO/IEC 7810 (Physical
characteristics),
- ISO/IEC 7812 (numbering
system),
- ISO/IEC 8824, 8825
(Abstract Syntax Notation
One,
- CEN ENV 1375 (ID-000
card size and physical
characteristics),
- prEN (General
characteristics),
- EN 1867 (Numbering
system),
- EN 726 (Application
independent card
requirements),
- and following available
relevant EU recommendations.

33