REPORT FROM THE COMMISSION TO THE COUNCIL AND THE EUROPEAN PARLIAMENT compliant with the obligations foreseen under Article 20(3) of Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients' rights in cross-border healthcare
Date: 2014-02-03
Institutions: European Commission
Subjects: cross-border cooperation, free movement of persons, health care, organisation of health care, patient's rights, provision of services, residential mobility, social security













EUR-Lex - 52014DC0044 - EN











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52014DC0044

REPORT FROM THE COMMISSION TO THE COUNCIL AND THE EUROPEAN PARLIAMENT compliant with the obligations foreseen under Article 20(3) of Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients' rights in cross-border healthcare /* COM/2014/044 final */









TABLE OF CONTENTS
REPORT FROM THE COMMISSION TO THE COUNCIL AND
THE EUROPEAN PARLIAMENT compliant with the obligations foreseen under Article
20(3) of Directive 2011/24/EU of the European Parliament and of the Council of
9 March 2011 on the application of patients' rights in cross-border healthcare
1........... Introduction.................................................................................................................. 3
2........... Background.................................................................................................................. 4
2.1........ Directive 2011/24/EU of the
European Parliament and the Council of 9 March 2011 on the application of
patients' rights in cross-border healthcare..................................................................... 4
2.2........ Regulations (EC) No’s 883/2004
and 987/2009 of the European Parliament and of the Council on the coordination
of social security systems........................................................................ 5
2.3........ On the relationship between
Directive and Regulations.............................................. 6
3........... Main findings................................................................................................................ 6
3.1........ The use of prior authorisation
systems.......................................................................... 7
3.2........ Financial consequences for “lump
sum” payment arrangements under 
............. the Regulations............................................................................................................. 8
4........... Measuring impacts in future
reports........................................................................... 10
4.1........ Zero-measurement...................................................................................................... 10
4.2........ Measurement after transposition
of the Directive...................................................... 10
4.3........ Impact Measurement.................................................................................................. 11
5........... Conclusions................................................................................................................. 11
REPORT FROM THE COMMISSION TO THE
COUNCIL AND THE EUROPEAN PARLIAMENT
compliant with the obligations foreseen under
Article 20(3) of Directive 2011/24/EU of the European Parliament and of the
Council of 9 March 2011 on the application of patients' rights in cross-border
healthcare
(Text with EEA relevance)
1.           Introduction
This report considers the effects resulting
from Directive 2011/24/EU[1]
of the European Parliament and of `the Council of 9 March 2011 on the
application of patients' rights in cross-border healthcare, for insured
patients wishing to be reimbursed for healthcare received outside their country
of residence and in another EU Member State. Specifically it considers the
potential effects of prior authorisation systems introduced under Directive 2011/24
/EU and of the definition of the Member State responsible for reimbursing
patients the costs of cross-border healthcare. The latter point particularly
concerns the specific case of pensioners having transferred their residence and,
for that reason, their access to healthcare to their new Member State of residence, which is different from the Member State that has recognised the
pensioner's rights to social security benefits. This latter Member State remains responsible for the coverage of the costs of healthcare for these groups
of pensioners. Through this report the Commission complies with the requirement
in paragraph 3 of Article 20 of Directive 2011/24/EU. 
As from 25 October 2013, two legal
instruments apply to the situation of patients seeking healthcare outside their
country of residence: Directive 2011/24/EU, hereinafter “the Directive”, and
Regulations (EC) No 883/2004 and (EC) No 987/2009 of the European Parliament
and the Council on the coordination of social security systems, hereinafter
“the Regulations”. As the Directive was due to be transposed by Member States
into national legislation by 25 October 2013, there is obviously no data
available at this point in time on the impact of the Directive, either alone or
in interaction with the Regulations. Consequently, this first report considers
the possible effects resulting from the joint application of the two
instruments to the situation of patients seeking healthcare in another Member State. It is intended to serve as a reference point for future reports produced
according to Article 20(3) of the Directive.
This report outlines the two instruments and
then goes on to assess possible impacts of their interaction in two areas:
possible substitution effects between the prior authorisation systems used under
the two instruments; and the adequacy of the financial compensation for costs
of healthcare paid between Member States under the Regulations. On the latter part
it will specifically consider those cases where Member States receive fixed
amounts intended to cover the costs of healthcare benefits in kind for
pensioners. It will then explain that, due to the lack of available information
noted above, no clear conclusions can currently be drawn on either of these two
issues but some important messages for the future administration of the two
instruments can nevertheless already be discerned.
This report has been produced with the
collaboration and assistance of the Member States as represented by their
delegates in the Administrative Commission for the Coordination of Social
Security Systems (henceforth " Administrative Commission") and in the
Implementing Committee of the Directive.
2.                     Background
2.1.        Directive
2011/24/EU of the European Parliament and the Council of 9 March 2011 on the
application of patients' rights in cross-border healthcare
The general objective of the Directive is
to facilitate the access to safe and high-quality cross-border healthcare in
another Member State and to be reimbursed for it in accordance with the
principles established by the Court of Justice as well as to promote
cooperation on healthcare between Member States. 
The Directive requires the Member State of affiliation[2]
to reimburse an insured person who receives cross-border healthcare if the
healthcare in question is among the benefits to which the insured person is
entitled in this Member State. The Member State of affiliation may provide for
a system of prior authorisation for reimbursement of costs of cross-border
healthcare limited to specific types of planned healthcare as defined in Article
8 (including care requiring an overnight stay in hospital or the use of highly specialised
and cost-intensive medical infrastructure or medical equipment), if such system
is justified and proportionate.  This prior authorisation may not be refused when
the patient is entitled to the healthcare in question and this healthcare
cannot be provided on its territory within a time limit which is medically
justifiable (also called " undue delay"). 
This decision on whether the waiting time
for treatment is medically justifiable must be based on an objective medical
assessment of the patient’s medical condition, the history and probable course
of the patient’s illness, the degree of the patient’s pain and/or the nature of
the patient’s disability at the time when the request for authorisation was
made or renewed[3].
The overall use of prior authorisation is
subject to the requirement that the system of prior authorisation shall be
restricted to what is necessary and proportionate to the objective to be
achieved.
The patient may be required to pay for care
first and then claim reimbursement. Reimbursements for cross-border healthcare
will be up to the level of costs that would have been assumed by the Member State of affiliation, had the healthcare been provided within its territory (without
exceeding the actual costs of healthcare received).
The application of the Directive does not
depend on whether the healthcare provider is affiliated to a public health
system: it covers all providers.
2.2.        Regulations (EC) No’s
883/2004 and 987/2009 of the European Parliament and of the Council on the
coordination of social security systems
As regards healthcare, the Regulations
focus on publically insured persons and the members of their family living or
staying in a Member State different from the competent Member State[4]. Healthcare which
becomes necessary on medical grounds during a stay ("unplanned
healthcare") will be provided without prior authorisation and the costs
covered by the competent Member State (e.g. through use of the European Health
Insurance Card). 
The Regulations also allow an insured
person to seek authorisation from the competent institution when travelling to
another Member State with the purpose of receiving healthcare. This
authorisation should be accorded "where the treatment in question is among
the benefits provided for by the legislation in the Member State where the
person concerned resides and where he/she cannot be given such treatment within
a time limit which is medically justifiable"[5], thus in the same
circumstances as under the Directive. Prior authorisation is granted to the patient
through the issuance of a so-called S2 Form (formerly E112) by the competent
institution.
For this "planned" healthcare,
the competent Member State is responsible for the assumption of the cost of
treatments that shall be provided on the basis of the rules of the Member State
of treatment and cost compensation will be managed at the level of Social
Security Administrations with no upfront payment from the patient other than
co-payments established in the Member State of treatment. 
The Regulations do not cover all providers:
some providers not affiliated to a public health system are not encompassed
within the scheme.
The Regulations also provide for situations
in which certain insured persons move their residence to a Member State, but continue to be covered by the social security system of another Member State. In these cases, the person concerned is given an S1 form, with which he/she can
register for healthcare coverage in their Member State of residence. The Member State of residence reclaims the cost of healthcare from the competent Member State. The Member State of residence may choose between two types of compensation
arrangements: 
·                        
reimbursement on the basis of real costs, which
requires production of proof of actual expenditure; or
·                        
(for certain categories of persons) on the basis
of fixed amounts (lump-sums) for Member States "where the use of
reimbursement on the basis of actual expenditure is not appropriate"[6],[7] 
The latter compensation arrangements may
only be applied to pensioners and their family members, or family members of an
insured person who reside in a different Member State from the insured person where
this Member State has opted for the system of reimbursement based on fixed
amounts. 
The Audit Board, which is the body created
under Article 74 of Regulation (EC) No 883/2004, is responsible for
establishing the methods for determining the elements in order to calculate the
fixed amounts. These elements are listed in Regulation (EC) No 987/2009 and the
Administrative Commission, which is a body under Regulation (EC) No 883/2004,
"consisting of a government representative from each Member State, charged
in particular with dealing with all administrative questions or questions of
interpretation arising from the provisions of this Regulation, and with
promoting further cooperation between the Member States", shall present in
2015 a specific report on its application and in particular on the reductions
applicable to ensure that the calculation of fixed amounts comes as close as
possible to the actual expenditure incurred and the reductions do not result in
unbalanced payments or double payments for the Member States. 
Member States claiming the reimbursement on
the basis of fixed amounts are Norway, Ireland, Spain, Cyprus, The Netherlands, Portugal, Finland, Sweden and United Kingdom[8].
2.3.         On the relationship
between Directive and Regulations 
The following points highlight the main
similarities and differences between the instruments: 
Regarding the personal scope, the
Directive applies to persons covered by Regulation (EC) No 883/2004 as well as
to the third country nationals and their family members who are legally
resident in the territory of a Member State[9].

As a general principle, when the terms of
the Regulations are met, treatment should be delivered under the Regulations,
unless a patient, fully informed about his/her rights, requests otherwise. Where
the patient requests a prior authorisation for cross-border healthcare and the
application of the Regulations is more advantageous to the patient, the prior authorisation
should be granted under the conditions of the Regulations, unless the patient,
fully informed about his/her rights, requests otherwise.  
The procedures and level of
reimbursement under the Regulations and the Directive are different, as
noted above. Regarding procedural guarantees, the requirements on provision of
information are broadly similar and Member States are advised to apply under
the Regulations the general procedure and administrative guarantees made
explicit in Article 9 of the Directive to the benefit of the patient. 
In the case of insured persons residing
outside the competent Member State: the Directive does not apply with regards
to access to healthcare benefits in the Member State of residence.
3.                     Main findings
This report considers the two specific
points as requested by the legislators. It looks at:
·                         
The use of prior authorisation by Member States
under the Directive, in particular the implications of the requirement to
justify any authorisation system as proportionate, along with any substitution
effects between the two legal instruments caused by the existence of two
systems of prior authorisation
·                         
Financial consequences, in Member States which
have opted for reimbursement on the basis of fixed amounts under the Regulations,
of the definition used in the Directive of the term "Member State of affiliation" (the Member State responsible for reimbursing the cost of
cross-border healthcare)[10].
3.1.        The
use of prior authorisation systems
As set out above there are two legal
instruments which deal with cross-border healthcare which both feature systems
of prior authorisation.  Depending on the choices made by Member States, this
may result in two systems of prior authorisation co-existing side by side.  
There are similarities between the two
systems (for example in both cases a request for authorisation may be turned
down where treatment may be provided without “undue delay”).  However, there
are also significant differences between them which should be noted.
The use of prior authorisation is the rule
under the Regulations, whereas it is an option that Member States may – but are
not obliged to – use under the Directive.  There will therefore be a large
number of treatments subject to authorisation under the Regulations but not
under the Directive.  As set out in section 2 above, prior authorisation may be
required for all treatments under the Regulations, whereas it may only be used
for some treatments under the Directive.  The authorisation scheme under the Directive
covers all providers, whereas the Regulations scheme does not cover some
providers which are not affiliated to a public health system.  And, as noted
above, it is important to remember that the level of coverage of costs may vary
considerably between the two instruments.
It is important to note that this will mean
that the scope of the prior authorisation system under the Directive will vary
from Member State to Member State (indeed, it may not be an option that every Member State uses).
The Directive also sets out certain
procedural guarantees that should apply to authorisation schemes: for example
the right to appeal and the requirement for Member States to set time limits
for dealing with requests for authorisation.  The Directive also requires that
decisions on authorisation be “properly reasoned” – which means that, where
authorisation is refused on grounds of no “undue delay”, the patient is
informed what would have constituted “undue delay” in their particular case. 
These differences, in reality, make explicit principles of good governance that
should be applied equally to authorisations under the Regulations – and
therefore these differences in the texts should not be apparent in practice.
Given the overlap between the two systems
there is the clear potential for substitution effects to occur.  By way of
examples to illustrate this:
·                        
there could be a reduction in the use of the
Regulations for healthcare not subject to prior authorisation under the
Directive by patients who do not wish to go through the authorisation procedure
and who therefore choose to use the Directive;
·                        
there could be a reduction in the use of the
Regulations by patients who wish to be treated by a private provider which is
not covered by the Regulations scheme;
·                        
conversely there could be an increase in the use
of the Regulations by patients who apply for authorisation under the Directive
and who are judged to face “undue delay” – and who then request an
authorisation under the Regulations (which must be granted according to the
“undue delay criterion”) since the coverage under the Regulations can be
financially more beneficial.
Monitoring and assessing these effects
would require a level of detail that does not currently exist.  The only
available data at present is that used under the Regulations (see Annex 1). 
This suggests (with some exceptions) relatively low numbers of prior
authorisation requests and high rates of granting of requests.  It also
suggests that Member States, in general, do not currently track the type of treatments
for which authorisation is sought.
It is also important to note that any
authorisation scheme under the Directive is subject to the requirement that it
is necessary and proportionate to the objective to be achieved, and may not
constitute an unjustified obstacle to the free movement of patients.  This
implies that Member States will need to provide data to justify their use of prior
authorisation.  The current data suggests that extensive systems of prior
authorisation under the Directive will be difficult to justify in the absence
of robust evidence demonstrating why the situation under the Directive is so
different from that under the Regulations.
3.2.        Financial consequences for
“lump sum” payment arrangements under the Regulations 
Section 2 above has described the situation where some groups of
people reside in a Member State different from the one which has recognised
their rights to social security benefits (the ‘competent Member State’) and the   Member State of residence opts for reimbursement on the basis of fixed
amounts, or “lump sums”.  The calculation method used for these lump sums is
defined in Article 64 of Regulation (EC) No 987/2009 and shall be as close as
possible to actual expenditure.  The amounts involved are therefore adjusted
regularly to take into account possible disproportionalities or cases of double
payment.  
Of these groups of people this report considers lump sum payments
for pensioners and does not consider lump sum payments for other groups (such
as Erasmus bursary students).  This is for reasons of scale: both in terms of
the numbers involved and the amount of healthcare used, pensioners will be by
some way the most significant group.  
The Directive may have an impact on the calculations used to set
these amounts, for two reasons.  
Firstly, due to different rules on the treatment of pensioners and
their family members in their competent Member State, under the Regulations,
all Member States paying lump sums receive a 15 per cent reduction on the
amount to compensate for the cost of unplanned healthcare received by
pensioners and their family members in a Member State other than the Member
State of residence.  This is because, under the Regulations, it is the
competent Member State who will eventually bear this cost (for example via the
European Health Insurance Card system).  With regard to healthcare in the
competent Member State, pensioners and their families usually have only limited
rights of access – essentially to care which becomes medically necessary during
their stay in that Member State.
Certain Member States choose to give pensioners and their families
additional rights of access to healthcare.  These Member States are entitled to
a 20 per cent reduction in the lump sums by way of compensation for this, and
are listed in Annex IV to Regulation 883/2004.
The rules under the Directive are different.  Pensioners and their
families resident in a lump-sum Member State which is not their competent Member State may seek healthcare in their competent Member State under the terms of the
Directive.  If the competent Member State is listed in Annex IV then the same
terms and conditions apply as for the Regulations.  If the competent Member State is not listed in Annex IV then the rules vary depending on whether the treatment
in question is subject to prior authorisation in the Member State of residence.  If so, then the usual reimbursement rule in the Directive applies: it is
the Member State of residence which, as the Member State of affiliation, is
responsible for reimbursement.  If the treatment is not subject to prior
authorisation in the Member State of residence then it is the competent Member State which is responsible for bearing the costs.     
This can be summarised thus: under the Directive Member States not
listed in Annex IV are nevertheless required to provide healthcare which they
are not required to provide under the Regulations.  They may therefore consider
that they are responsible for a greater proportion of total healthcare costs
for the insured persons concerned than they previously were, and that this
should be taken into account when adjusting the lump sum amounts.
The second way in which the Directive may have an impact on lump-sum
amounts is with regard to unplanned healthcare in a third Member State received
by pensioners and their family members resident in a lump-sum Member State
which is not their competent Member State.  Under the Regulations it is the
competent Member State which is responsible for the costs of this healthcare,
as noted above, and for which they receive a 15% reduction on the amount of the
lump sum.  Under the Directive the patient may choose to claim reimbursement
directly from the Member State of residence, as this is his or her Member State of affiliation.  Therefore the Member State of residence might consider that
it is now bearing costs for which it is not being reimbursed via the lump sum,
and that this should be taken into account when adjusting the lump sum amounts.
Whether or not these impacts come to pass depends on the decisions
made by Member States and individual patients on the use of prior
authorisation, the choice of country for planned healthcare, the preferred
system of reimbursement and so on.  Robust data will therefore be needed to
monitor any effects and to assess what this might entail for the lump sum
amounts.
Currently, there is no information available to assess the financial
consequences of the application of this Directive on ‘lump sum’ Member States.
According to a preliminary appraisal from Member States that answered a March
2013 survey on ‘Reporting obligations under Article 20(3) of Directive
2011/24/EU’ regarding the potential impact of the Directive on the adequacy of
the lump sums, Member State expectations vary.  Some thought that the lump sum
amounts would increase; others thought that Annex IV would no longer be
relevant; others thought that there would be no significant impact; others
thought that there would be an impact only for care not subject to prior
authorisation but that this was unquantifiable at present.
Given the lack of data, no assessment of disproportionalities is
currently feasible. Any disagreement between Member States on
disproportionalities in the payment and receipt of lump sums related to the
actual cost of healthcare received will need to be addressed at a later date.
Article 64(5) of Regulation (EC) No 987/2009 requires the
Administrative Commission to presents a report no later than 1 May 2015 on the
application of Article 64 of Regulation (EC) No 987/2009, in particular on the
reductions under Article 64(3). The aim of the analysis is to ensure that the
calculation of fixed amounts comes as close as possible to the actual
expenditure incurred and that the reductions referred to in Article 64(3) do
not result in any disproportionality or double payments for Member States. The
report may contain a proposal for any amendments which may prove necessary in
the light of experience of the application of the above provision. In short,
each Member State is asked to provide a note with an analysis of whether or not
the basic reduction applied to average costs is realistic. To the extent
possible, the analysis should be supported by quantitative evidence and data.
Member States are to present the data and accompanying notes to the Audit Board
no later than 30 June 2014.
4.           Data
for future reports
To be able to assess the impact of the
Directive on the number of patients using the Regulations, a
"baseline" zero-measurement needs to be established to capture
patient mobility under the Regulations prior to the implementation of the
Directive. Next, this zero-measurement needs to be compared with another
measurement that will be made after transposition of Directive 2011/24/EU.
It will therefore be necessary to improve
the current situation, where there is a dearth of statistical data on
cross-border healthcare. 
Considerably improved data will, in the
majority of cases, also be needed in order for those Member States introducing
a prior authorisation system under the Directive to demonstrate that such
systems meet the overall requirements of proportionality.
4.1.        Zero-measurement
For future analysis within the scope of
this report, a zero-measurement baseline is needed against which future impacts
could be measured. The Commission has seen that this cannot be established
through means of historically collected data. In Annex 1 available statistical
data on patient mobility under the Regulations for planned healthcare are
presented and discussed. It is found that available data are incomplete across
Member States and do not distinguish whether related healthcare is among the
basket of publicly covered benefits in the competent Member State. Further, no data on the type of healthcare are available.
For future reports on patient mobility
under the system of prior authorisation as required under the Directive,
further data collection is needed, for 2012 and 2013, with a greater level of
detail. For that purpose, a new round of data collection has been launched
within the Administrative Commission. However, certain Member States have
communicated that they will not provide data for 2012 or 2013. Moreover, for
Member States willing to provide data for 2012 and or 2013, there is no
guarantee that they will do so with the level of detail requested, such as the
distinction of whether episodes of treatment fell inside or outside of the
basket of benefits. 
Consequently, to constitute the most likely
zero-measurement baseline for all Member States the extrapolation and
interpolation of the limited available data will probably be required. 
4.2.        Measurement
after transposition of the Directive 
Data for 2014 will be collected for the
assessment of the general operation of this Directive within the Implementing
Committee of the Directive.
For the purpose of the analyses, data on
prior authorisation should: 
·                        
be collected by year of request,
·                        
be collected by the Member State of affiliation to
which the request was addressed,
·                        
concern requests for healthcare that is covered
by the basket of publicly covered goods/services of the Member State of affiliation,
·                        
indicate the number or percentage of requests
that have been granted,
·                        
ideally, indicate the number or percentage of
granted requests where undue delay was found to apply,
·                        
indicate the percentage of refused requests and
the main reasons for refusal,
·                        
ideally, distinguish by type of patient
indication (e.g. rare disease patients).
4.3.        Impact
Measurement
Only if and when the zero-measurement and
post-transposition of the Directive measurement have been established, will it
be possible for the Commission to analyse:
·                        
Substitution effects (directly compared to
zero-measurement): e.g. a drop in authorisations under the Regulations that can
be explained by an increase in authorisation under the Directive: Is this a
conscious choice of patients (e.g. use of the Directive for free choice of
provider)? 
·                        
Dynamic impacts: e.g. analysing whether more
patients will receive prior authorisation under the Regulations as a result of
additional information on undue delay becoming available to patients under the
Directive, or as a result of increased awareness about patients' rights.  
5.           Conclusions
At this point in time – close after the end
of transposition deadline of the Directive - it is clearly not possible for the
Commission to consider the use that Member States have made of the possibility
to introduce prior authorisation systems under the Directive, and the possible
substitution effects with the Regulations. 
For similar reasons, it is not possible for
the Commission to conclude that there are or are not any disproportionality
resulting from the implementation of the Directive. 
It is, however, possible at this point to draw
some conclusions with a view to addressing both of these points fully in the
report on the general operation of the Directive, which the Commission is
required to present by 25 October 2015. This will be the first in a series of
triennial reports.
With regard to prior authorisation systems the
concept of a medically-justifiable time limit should be the same under both
instruments. Similarly, the procedural guarantees established under the
Directive should be applied to any authorisation system under the Regulations.
Member States wishing to introduce a prior
authorisation system under the Directive would need to review their current
systems of data collection as the current data would, in most cases, not seen sufficient
to justify an extensive system of prior authorisation. 
In order to be able to properly examine the
effects of the Directive on the use of the Regulations and on the adequacy of
the lump sums, it would be useful to develop the way in which data is collected
as set out in 4.2, above.
The development by Member States of a
monitoring system under the Directive will pose a challenge of coordination
with that established under the Regulations. Methodological issues need to be
discussed to adjust these systems to the statistical international standards.
Member States should unify – as far as possible - the collection of
information, for the sake of efficiency. 
Annex 1: Historical data on patient
flows
A 2008 note of Directorate General
Employment, Social Affairs and Inclusion reporting on a questionnaire related
to the E112 form sent to delegates in the Administrative Commission pointed to
some interesting observations: Small numbers of prior authorisation requests and
high rates of authorisations granted upon requests are reported for most Member
States[11].
With some notable exceptions, according to the information provided by Member
States, requests for prior authorisation were refused mainly for absence of
undue delay, with a very low rate of contested refusals[12]; the mobility of
patients mainly concerns neighbouring Member States or those using the same
language; and the parallel existence of other procedures (such as specific
bilateral agreements between Member States) covering cross-border healthcare
was noted by six Member States (DK, EE, CY, LT, MT and NL).
Furthermore, the note raises two relevant
data issues:
·                        
Data on clinical indication (diagnosis and/or
specific procedure) would not fall within the traditional competence of the
Administrative Commission.
·                        
Distinguishing the number of applications from
the actual number of patients who have applied for authorisation is not
straightforward, as often more than one authorisation refers to the same
patient case. 
An overview of available data of E112 forms
requested by Member State for the year 2006, 2007 and 2008 is presented below.
Data are only available for 24 Member States. There is a great variability between
countries in the number and evolution of prior authorisations issued. The
highest rates (per head of population) are observed in LU, AT, SI, CY (above
average in 2008) as shown in Annex 1. The average rate without LU (that
presents 36,046 issued authorisations per million inhabitants) is 55
authorisations per million inhabitants. Member States above this average are
AT, SI, CY, SK, BE, IE, EL and LV. 
It is important to underline, therefore,
that historical data collection exercises within the Administrative Commission
do not distinguish whether the healthcare for which prior authorisation was
requested was within the basket of entitlements in the Member State of residence and offer no insight into the mix of clinical indications involved.
In addition, they do not provide a complete
picture as these figures do not include mobility of patients under parallel
schemes (e.g. bilateral agreement between Member States or regions planning and
organising transfers of patients).
 Number of E112 requests forms by year of receipt of request  
 Member State || 2006 || 2007 || 2008 
 Requested || Issued || % Issued / Requested || Requested || Issued || % Issued / Requested || Issued 
 AT || 3,643 || 3,566 || 98 || 2,946 || 2,835 || 96 || 2,935 
 BE || 1,222 || 1,066 || 87 || 1,322 || 1,094 || 83 || 1,165 
 BG || NA || NA ||   || 81 || 4 || 5 || 10 
 CY || NA || NA ||   || 156 || 156 || 100 || 146 
 CZ || NA || NA ||   || 425 || 411 || 97 || 328 
 DK || 396 || 65 || 16 || 733 || 64 || 9 || 84 
 EE || 8 || 8 || 100 || 1 || 1 || 100 || 5 
 IE || 656 || 630 || 96 || 690 || 648 || 94 || 372 
 EL || 813 || 768 || 94 || 795 || 770 || 97 || 816 
 ES || NA || 722 ||   || NA || 722 ||   || 800 
 FR || 1,169 || 695 || 59 || NA || NA || NA || NA 
 HU || 209 || 193 || 92 || 185 || 215 || 116 || 232 
 LT || 7 || 6 || 86 || 19 || 14 || 74 || 12 
 LU || 17,825 || 17,290 || 97 || 17,280 || 16,800 || 97 || 17,439 
 LV || 46 || 29 || 63 || 132 || 110 || 83 || 127 
 MT || NA || NA || NA || 0 || 0 ||   || 0 
 NL || 3,482 || 2,912 || 84 || NA || NA || NA || NA 
 PL || 12 || 10 || 83 || 25 || 13 || 52 || NA 
 PT || 218 || 200 || 92 || 207 || 178 || 86 || 166 
 RO || NA || NA ||   || 213 || 124 || 58 || 562 
 SE || 163 || 81 || 50 || 330 || 115 || 35 || NA 
 SI || 493 || 340 || 69 || 504 || 262 || 52 || 442 
 SK || 679 || 640 || 94 || 792 || 743 || 94 || 685 
 UK || 560 || 366 || 65 || 634 || 552 || 87 || NA 
 Source: ADMINISTRATIVE COMMISSION FOR THE COORDINATION OF SOCIAL SECURITY SYSTEMS ||   ||   
 Number of E112 issued forms per million inhabitants by year of receipt of request 
 Member State || 2006 || 2007 || 2008 
 AVERAGE || 110 || 112 || 163 
 AT || 432 || 342 || 353 
 BE || 101 || 103 || 109 
 BG ||   || 1 || 1 
 CY ||   || 200 || 185 
 CZ ||   || 40 || 32 
 DK || 12 || 12 || 15 
 EE || 6 || 1 || 4 
 IE || 150 || 150 || 85 
 EL || 69 || 69 || 73 
 ES || 16 || 16 || 18 
 FR || 11 ||   ||   
 HU || 19 || 21 || 23 
 LT || 2 || 4 || 4 
 LU || 36,859 || 35,280 || 36,046 
 LV || 13 || 48 || 56 
 MT ||   || 0 || 0 
 NL || 178 ||   ||   
 PL || 0 || 0 ||   
 PT || 19 || 17 || 16 
 RO ||   || 6 || 26 
 SE || 9 || 13 ||   
 SI || 170 || 130 || 220 
 SK || 119 || 138 || 127 
 UK || 6 || 9 ||   
 Source: own calculations on the basis of ADMINISTRATIVE COMMISSION FOR THE COORDINATION OF SOCIAL SECURITY SYSTEMS 
[1]               See http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:088:0045:0065:EN:PDF
[2]               Generally, the Member State that is competent to
grant to the insured person a prior authorisation to receive appropriate treatment
in another Member State according to Regulation (EC) 883/2004 and (EC) No
987/2009. For a third country national in a cross-border situation within the
EU it is according to Regulation No 859/2003 or Regulation (EU) No 1231/2010. As
regards the latter, in special cases, where no Member State is competent
according to those Regulations, the Member State of affiliation shall be the Member State where the person is insured or has the rights to sickness benefits according to
the legislation of that Member State. It is important to notice that the
concept of Member State of affiliation in the Directive was based on the
concept of competent Member State, which is a concept defined by the
Regulations on social security coordination. 
[3]               See Article 8(5) of Directive 2011/24/EU
[4]               The Member State where the competent institution is situated. In turn, the competent
institution means:
.               "(i) the institution with which the person concerned is insured at
the time of the application for benefit;
or
(ii) the
institution from which the person concerned is or would be entitled to benefits
if he/she or a member or members of his/her family resided in the Member State
in which the institution is situated;
or
(iii) the
institution designated by the competent authority of the Member State concerned;
or
(iv) in the
case of a scheme relating to an employer's obligations in respect of the
benefits set out in Article 3(1) of Regulation (EC) No 883/2004, either the
employer or the insurer involved or, in default thereof, the body or authority
designated by the competent authority of the Member State concerned".
[5]               Article 20(2) of Regulation (EC) No 883/2004.
[6]               This will be the case if the actual amount of the
expenses for the benefits received is not shown in the accounts of the institution
that provided them
[7]               See Article 63, paragraph 1 of REGULATION (EC) No
987/2009 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 16 September 2009
laying down the procedure for implementing Regulation (EC) No 883/2004 on the
coordination of social security systems
[8]               Article 63(1) of the Regulation (EC) No 987/2009 of the
European Parliament and of the Council of 16 September 2009 laying down the
procedure for implementing Regulation (EC) No 883/2004 on the coordination of social
security systems, and listed in its Annex 3.
[9]               Or, in the case of Denmark, who satisfy the
conditions of the legislation of the Member State of affiliation for
entitlement to benefits and are in a situation which is not confined in all
respects within a single Member State.
[10]             According
to Article 20(3) of the Directive, these financial consequences should be
addressed in cases covered by Articles 20(4) and 27(5) of the Regulation. For
the sake of clarity, and considering the methodological nature of the report,
the report will be focused on pensioners as presented to Member States in the
Administrative Commission on 17 April 2013 and in the Cross-border Healthcare
Committee on 3 June 2013.
[11]             Only one Member State (LU) reported over 17,000 and two
Member States (BE and AT) over thousands; the majority of them reported few
hundred (CZ, DK, IE, EL, CY, HU, PT, RO, SI, SK, SE, UK, ); and the rest (BG,
EE, LT and PL) reported fewer than 100.
[12]             At less than 1% for most Member States.