Planned cross-border healthcare : PD S2 questionnaire.
Date: 2015-02-10
Institutions: Directorate-General for Employment, Social Affairs and Inclusion
Subjects: EU Member State, cross-border dimension, data collection, health care, health insurance, public health, social security

Planned cross-border 
healthcare 

PD S2 Questionnaire 

Jozef Pacolet & Frederic De Wispelaere - HIVA-KU Leuven 

October 2015 

 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 

Directorate-General for Employment, Social Affairs and Inclusion 
Unit D/2  

European Commission 
B-1049 Brussels 

 
 
 
 
 
 
 
EUROPEAN COMMISSION 

Planned cross-border 
healthcare 

PD S2 Questionnaire 

Directorate-General for Employment, Social Affairs and Inclusion 
Network Statistics FMSSFE (Contract No VC/2013/0301 ‘Network of Experts on intra-EU mobility –  
Lot 2: Statistics and compilation of national data’) 
2015 

Network Statistics FMSSFE 

This report has been prepared in the framework of Contract No VC/2013/0301 ‘Network of Experts on intra-
EU mobility – social security coordination and free movement of workers / Lot 2: Statistics and compilation 
of national data’. This contract was awarded to Network Statistics FMSSFE, an independent research 
network composed of expert teams from HIVA (KU Leuven), Milieu Ltd, IRIS (UGent), Szeged University and 
Eftheia bvba. Network Statistics FMSSFE is coordinated by HIVA.  

Authors: 

Prof Dr Jozef Pacolet, Head of the ‘Welfare State’ research group, HIVA Research Institute for Work and 
Society, University of Leuven (KU Leuven). 

Frederic De Wispelaere, Senior research associate, HIVA Research Institute for Work and Society, University 
of Leuven (KU Leuven). 

Peer reviewers: 

Prof Dr József Hajdú, Head of the Department of Labour Law and Social Security, Szeged University. 

Dr Gabriella Berki, Professor Assistant at the Department of Labour Law and Social Security, Szeged 
University. 

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ISBN: 978-92-79-69749-4 
doi: 10.2767/992052 
Catalogue number: KE-01-17-640-EN-N 

© European Union, 2015 
Reproduction is authorised provided the source is acknowledged. 

 
 
 
 
 
 
 
 
 
Planned cross-border healthcare 

Table of Contents 

1. 

2. 

3. 

4. 

List of Tables .......................................................................................... 6 

List of Figures ......................................................................................... 7 

Executive Summary ................................................................................. 8 

Introduction ........................................................................................... 9 

5. 

The number of PDs S2 issued and received ................................................. 9 
5.1.  The current flow of PDs S2 between Member States .................................. 9 
5.2.  As share of insured population ............................................................. 14 
5.3.  2014 and previous years: a comparison ................................................. 15 

6. 

7. 

8. 

9. 

Treatment of the request and reasons for refusal ....................................... 16 

Parallel schemes ................................................................................... 19 

Conclusion ........................................................................................... 20 

Annex 1 The existence of parallel schemes ................................................ 22 

10. 

Annex 2 PD S2 Questionnaire .................................................................. 25 

5 

 
 
 
Planned cross-border healthcare 

1.  LIST OF TABLES 

Table 1 

The number of PDs S2 issued, breakdown by Member State of 
treatment, 2014 

Table 2 

The number of PDs S2 received, breakdown by competent Member 
State, 2014 

Table 3 

The percentage of insured persons entitled to receive planned cross-
border healthcare on the basis of a prior authorisation, 2014 

Table 4 

The number of PDs S2 issued and received, 2012-2014 

Table 5 

The number of PDs S2 requests refused and accepted, 2014 

Table 6 

Reasons for refusal to issue a PD S2, 2014 (as a percentage of the 
total number of refused requests) 

Table 7 

The percentage of contested decisions to refuse to issue a PD S2, 
2014 

Table 8 

Care (not) included in the services provided for by the national 
legislation, 2014 

11 

12 

15 

16 

17 

18 

19 

20 

6 

 
 
 
Planned cross-border healthcare 

2.  LIST OF FIGURES 

Figure 1 

The number of PD S2 issued, percentage breakdown by receiving 
Member State, 2014 

Figure 2 

The number of PDs S2 issued, percentage breakdown by 
neighbouring Member State or not, 2014 

13 

14 

7 

 
Planned cross-border healthcare 

3.  EXECUTIVE SUMMARY 

  This  report  on  the  collection  of  data  on  planned  cross-border  healthcare  (on  the 
basis  of  Portable  Document  S2)  relates  to  reference  year 2014.  For  the first  time 
data  has  been  provided  by  Member  States  on  a  mandatory  basis.  This  should 
guarantee  a  more  complete  view  on  the  number  of  insured  persons  travelling 
abroad  with  the  purpose  of  receiving  healthcare.  Please  note,  however,  that 
Germany,  Iceland  and  Switzerland  were  unable  to  provide  data  for  the  current 
reporting year.  

  This data collection for 2014 could be compared with the baseline measurement of 
2013 in order to assess the possible impact of the Patient Mobility Directive1 on the 
number  of  PDs  S2  issued,  given  that  the  Directive  was  due  to  be  transposed  by 
Member States by the end of 2013. However, based on the data available for the 
year after the transposition deadline of the Directive, no decisive conclusion could 
yet be made. 

 

In 2014, the 29 reporting Member States issued a total number of 39,650 PDs S2, 
of which 40% were issued by Luxembourg (15,991 PDs S2 issued). 

  Planned cross-border healthcare seems to be rather limited observing that in 2014 
only about 12 out of 100,000 insured persons received a PD S2. Only Luxembourg 
shows a rather high patient mobility (roughly 2 in 100 insured persons).  

  Alongside the procedures determined by Regulation (EC) No 883/2004 and (EC) No 
987/2009,  several  Member  States  reported  the  existence  of  parallel  procedures. 
However,  there  is  no  indication  that  patient  flows  abroad  are  larger  under  the 
Patient Mobility Directive or under other parallel schemes. Bilateral agreements in 
border  areas  seem  to  considerably  influence  the  number  of  persons  entitled  to 
receive planned cross-border healthcare. 

  Approximately  87%  of  the  total  number  of  prior  authorisations  are  issued  to 
receive a scheduled treatment in an EU-15 Member State2. Moreover, 7 in 10 prior 
authorisations  issued  by  the  EU-13  Member  States3  related  to  a  scheduled 
treatment  in  an  EU-15  Member  State  compared  to  almost  9  in  10  prior 
authorisations issued by the EU-15 Member States.  

  The assessment of the potential push and pull factors falls outside the scope of this 
report. Nonetheless, proximity seems to be an important factor as roughly 80% of 
the PDs S2 are issued to receive a scheduled treatment in a neighbouring Member 
State. 

  Some  8%  of  the  requests  for  a  PD  S2  were  refused  by  the  reporting  Member 
States. The fact that care can be delivered within a medically acceptable period in 
the competent Member State is the most frequent reason to refuse a request for a 
PD S2. 

1 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. 
2  EU-15  Member  States:  Belgium,  Greece,  Luxembourg,  Denmark,  Spain,  Netherlands,  Germany,  France, 
Portugal, Ireland, Italy, United Kingdom, Austria, Finland and Sweden.  
3  EU-13  Member  States:  Croatia,  Romania,  Bulgaria,  Poland,  Czech  Republic,  Latvia,  Lithuania,  Slovenia, 
Estonia, Slovakia, Hungary, Cyprus and Malta. 

8 

 
 
 
 
 
 
 
 
 
 
 
                                          
Planned cross-border healthcare 

4.  INTRODUCTION 

The Portable Document S2 (PD S2) ‘Entitlement to scheduled treatment’ (the old E112 
form)  certifies  the  entitlement  to  planned  health  treatment  in  a  Member  State  (MS) 
other than the competent MS of the insured person.4 A questionnaire on the ‘old’ E112 
form  was  introduced  between  2006  and  2008  and  re-launched  in  2013  for  the 
collection  of  data  on  PD S2  for  reference  year  2012.  This  report  on  the  collection  of 
data  on  PD  S2  relates  to  reference  year  2014.  For  the  first  time  data  has  been 
provided  by  MSs  on  a mandatory  basis.  Nonetheless,  data  for  Germany,  Iceland  and 
Switzerland are still missing.  

The  data  collection  should  provide  important  information  on  the  application  of 
Regulation  (EC)  No  883/2004,5  but  also  on  the  impact  of  Directive  2011/24/EU  (the 
so-called  ‘Patient  Mobility  Directive’).  Differences  in  material  scope  and  procedures 
with regard to prior authorisation and the reimbursement of costs between both may 
have an impact on the evolution of the number of PDs S2 used. The data collection for 
2014  could  be  compared  with  the  baseline  measurement  of  2013  in  order  to  assess 
the  possible  impact  of  the  Patient  Mobility  Directive  on  the  number of  PDs  S2 issued 
given  that  the  Directive  should  have  been  transposed  by  MSs  by  the  end  of  2013. 
Moreover, the evolution of the number of PDs S2 issued in 2014 compared to previous 
years  could  be  considered  as  a  first  indicator  to  measure  the  impact  of  the  Patient 
Mobility  Directive  given  that  differences  in  claims  and  amounts  of  reimbursement 
related to planned healthcare will  become visible only after a longer period. A recent 
report  published  by  the  Commission  already  showed  the  low  patient  flows  for 
healthcare  abroad  under  the  Patient  Mobility  Directive.6  For  instance,  17  MSs  who 
introduced a system of prior authorisation granted 360 authorisations in 2014.7  

5.  THE NUMBER OF PDS S2 ISSUED AND RECEIVED 

5.1.  The current flow of PDs S2 between Member States 

Table 1 gives a detailed overview of the PDs S2 issued by 29 reporting MSs (excluding 
DE,  CH  and  IS).  In  2014,  these  reporting  MSs  issued  a  total  number  of 
39,650 PDs S2.  Patient  mobility,  in  this  report  limited  to  planned  cross-border 
healthcare  related  to  a  PD  S2,  seems  to  be  rather  low  observing  this  total  figure.8 
40%  of  the  reported  PDs  S2  were  issued  by  Luxembourg  (15,991  PDs  S2  issued). 
Austria, Italy, the Netherlands and the United Kingdom issued more than 1,000 prior 
authorisations  in  2014.  Romania,  Slovakia,  France,  Ireland,  Belgium,  Greece  and 
Sweden issued less than 1,000 but more than 500 prior authorisations. Croatia, Spain, 
Slovenia,  Bulgaria,  Cyprus,  Latvia,  Liechtenstein,  Denmark  and  Hungary  issued  less 
than 500 but more than 100 prior authorisations. Finally, the Czech Republic, Norway, 
Lithuania,  Poland,  Finland,  Estonia,  Portugal  and  Malta  issued  less  than  100  prior 
authorisations. Belgium, the Netherlands, Germany, Luxembourg and France are also 
involved  in  a  large  number  of  cooperation  agreements  in  border  areas  (IZOM9, 
ZOAST10  etc)  where,  depending  on  the  cooperation  agreement,  prior  authorisation 
often becomes a simple administrative authorisation that is granted automatically. For 

4 Relevant for the EU/EEA countries and Switzerland. 
5  Regulation  (EC)  No  883/2004  of  the  European  Parliament  and  of  the  Council  of  29  April  2004  on  the 
coordination of social security systems. See also 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. 
6 See http://ec.europa.eu/health/cross_border_care/docs/2015_operation_report_dir201124eu_en.pdf. 
7  In  addition,  France  granted  roughly  57,000  authorisations  covering  both  the  Social  Security  Regulations 
and the Directive. 
8  However,  limited  to  the  application  of  Regulation  (EC)  No  883/2004.  Also  Directive  2011/24/EU  or  other 
parallel procedures defined by MSs will influence planned cross-border healthcare.  
9  The  agreement  facilitates  patient  mobility  in  the  country  triangle  of  Germany,  The  Netherlands  and 
Belgium (Meuse-Rhine Euregion). 
10 The agreement facilitates patient mobility between Belgium, France and Luxembourg. 

9 

 
                                          
 
Planned cross-border healthcare 

instance,  Belgium  reports  that  17,227  authorisations  are  provided  under  IZOM  and 
111 authorisations under the ZOAST arrangements (see Annex I – Table A1.1).     

A breakdown by receiving MS makes it possible to determine the main flows between 
the  competent  MS  and  MS  of  treatment.  Most  of  the  prior  authorisations  certify  the 
entitlement  to  a  scheduled  treatment  in  Germany,  Belgium,  France  and  Switzerland. 
Table  1  illustrates  four  main  flows,  namely  from  Luxembourg  to  Germany,  from 
Austria to Germany, from Luxembourg to Belgium and finally from the Netherlands to 
Belgium. While data on the total number of PDs S2 issued by German authorities was 
not available for the reporting year 2014, significant outflows of insured persons from 
Germany  are  observed  based  on  the  number  of  PD  S2  issued  by  Germany  based  on 
which  treatment  was  received  in  other  Member  States  (e.g.  on  the  basis  of  the 
number of PDs S2 received, reported in Table 2, Austria shows a high number of PDs 
S2 received from Germany). 

Table  1  and  Figure  1  show  that  approximately  87%  of  the  total  number  of  prior 
authorisations  have  been  issued  to  receive  a  scheduled  treatment  in  an  EU-15  MS. 
This  percentage  varies  markedly  across  the  EU-13  and  EU-15  issuing  MSs,  but  also 
across MSs individually. For instance, 7 in 10 prior authorisations issued by the EU-13 
Member States applied to a scheduled treatment in an EU-15 MS compared to almost 
9 in 10 prior authorisations issued by the EU-15 MSs. Latvia and Slovakia issued most 
of  their  prior  authorisations  to  receive  a  scheduled  treatment  in  an  EU-13  MS.  In 
contrast to most of the EU-15 MSs, the United Kingdom (mainly to Poland) and Italy 
(mainly  to  Switzerland)  show  a  relatively  low  percentage  of  prior  authorisations 
certifying an entitlement to a scheduled treatment in another EU-15 MS.         

In  total  23  MSs  provided  figures  on  the  number  of  PDs  S2  received  (Table  2).  They 
reported a total number of 21,825 PDs S2 received. Belgium received 11,932 PDs S2 
(including  the  PDs  S2  received  under  ZOAST  arrangements  provided  by  France  and 
Luxembourg)  in  2014,  mainly  issued  by  neighbouring  MSs  France,  Luxembourg  and 
the Netherlands (Table 2). Austria reported a high number of PDs S2 received (5,548 
PDs  S2)  mainly  issued  by  Germany.  Luxembourg  and  the  United  Kingdom  also 
received  more  than  1,000  prior  authorisations.  Bulgaria,  Ireland,  Norway,  Cyprus, 
Latvia  and  Malta  received  less  than  ten  PDs  S2.  Some  important  receiving  MSs, 
observed  on  the  basis  of  the  reporting  on  the  number of  PDs  S2  issued  by  receiving 
MS (see Table 1), such as Germany and France, did not provide data on the number of 
PDs  S2  received.  This  explains  to  a  large  extent  the  difference  in  the  number  of 
reported  prior  authorisations  in  Table  1.  Also,  different  reasons  may  explain  the 
discrepancy between the reported flows of issuing and receiving PDs S2 (see Tables 1 
and 2). Firstly, the period of time  between the date  of the decision to issue a PD S2 
and  the  date  the  PD S2  was  received  by  the  appropriate  healthcare  institution  will 
have  an  important  impact  on  the  discrepancy  between  the  number  of  PDs  S2  issued 
and  received.  Secondly,  not  every  insured  person  who  received  a  prior  authorisation 
will eventually use this. 

10 

 
Planned cross-border healthcare 

Table 1 

The number of PDs S2 issued, breakdown by Member State of treatment, 2014 

CZ  DK  DE 
12 
1 
0 
0 
0 

EE 
0 
0 
0 
0 
17 

IE 
0 
0 
0 
0 
10 
0 

EL 
22 
0 
0 
0 
146 
0 
0 

AT 

PL 
4 
0 
1 
0 

Competent Member State 
HU  MT  NL 
LT  LU 
3,334  7 
0 
2  4,209  0 
0 
0 
0 
0 
0  0 
1 
2 
0 
0 
0  5 
1 
1 
0  0 
0 
0 
686  5,201  54 
27  9,027  41  3 
0 
0 
0 
7  0 
4 
0 
0 
0  0 
0 
0 
0 
0  1 
4 
0 
0  8 
0 
28 
0 
1  2,146  5 
0 
0 
0  0 
0 
15  0 
0 
0  61 
0 
0 
0 
0  0 
3 
0 
0 
0  1 
3 
0 
0 
0 
2 
0 
0 
0 
0 
0 

0 
0 
0 
7 
8 
1 
6 
0 
0 
0 
0 
5 
1 
29 

ES  FR  HR 

144  6 
0 
0 
9 
0 
0 
0 
341  173  764 
0 
0 
0 
3 

0 
0 
0 
0 
11 

LV 
11 
0 
0 
0 

IT 
207 
0 
2 
0 

CY 
0 
0 
0 
0 
232  80 
39 
0 
0 
0 
0 
1 
0 
0 
0 
0 
23 
0 
1 
1,158  1 
0 
0 
0 
0 
14 
0 

0 
0 
0 
0 
1 
0 
19 

10  27 
0 
0 
0 
0 
0 
0 
84  0 
2 
0 
0 
0 
2 
7 
199  190 
2 
0 
2 
0 
4 
0 
0 
21 
0 
0 
0 
0 
0 
0 
2 
0 
9 
0 
0 
0 
0 
0 
0 
75  0 

0 
0 
0 
1 
0 
0 
15 
7 
0 
0 
0 
2 
0 
1 
0 
1 
0 
4 
0 
19 
1 
90 
18 
0 
0 
0 
0 
0 
0 
2,427  0 

80 
0 
0 
0 
4 
3 
2 
0 
0 
0 
0 
3 
7 
5 
0 
0 
0 
2 

0 
0  1 
0  0 
22  48 
3  22 
8  4 
0  21 
0  0 
0  0 
0  0 
0  5 
1  17 
3  19 
0  9 
0  0 
0  0 
7  387 

0 
0 
0 
0 
0 
1 
1 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
4 
0 
4 
0 
0 
0 
0 

0 
1 
0 
81 
1 
0 
0 
101 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
8 
2 
124 
1 
0 
3 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
29 
20 
556  79 
0 
0 
0 
20 

0 
0 
0 
2 

0 
0 
0 
51  0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
1 
0 
0 
0 
0 
0 
2 
0 
0 
0 
0 
0 
0 
51  3 

3 
0 
0 
0 
0 
0 
0 
6 
0 
0 
0 
50 
0 

1 
0 
0 
2 
1 
0 
0 
9 
0 
0 
0 
111 

t
n
e
m
t
a
e
r
t

f
o
e
t
a
t
S
r
e
b
m
e
M

BE 

BG 
83 

0 

0 
0 
1 
0 
0 
212  162  37 
0 
0 
0 
0 
1 
0 
8 
0 
156  23 
0 
0 
2 
0 
1 
1 
0 
0 
0 
0 
0 
3 
1 
0 
0 
0 
197  1 
1 
0 
0 
0 
0 
0 
0 
1 
8 
0 
0 
1 
12 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 
UK 
IS 
LI 
NO 
CH 
Unkn. 
Total 
161 
Row %  1.5  0.8  0.2  0.4 
135 
EU-15 
0 
EU-13 
26 
EFTA 

24 
0 
0 
0 
0 
9 
0 
0 
0 
0 
0 
0 
0 
0 
4 
1 
0 
0 
0 
0 
0 
0 
53 
32 
0 
0 
26 
0 

0 
0 
0 
1 
7 
0 
0 
0 
0 
0 
0 
1 
0 
6 
3 
0 
0 
0 
2 
23 
0 
0 
7 
0 
0 
0 
4 
6 

586  299  62 
26 
4 
2 
4 
0 
13 

20 
2 
0 
0 
0 
0 
0 
6 
1 
0 
0 
0 
0 

601  303  98 

PT 
1 
0 
0 
0 
1 
0 
0 
0 
2 
19 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

0 
0 
0 
0 
0 
3 
0 
0 
0 
0 

7 

FI 
SK 
SI 
RO 
1 
1 
2 
14 
0 
1 
0 
0 
601  0 
7 
2 
2 
0 
0 
0 
31 
336  169  50 
18 
0 
0 
0 
0 
6 
0 
0 
1 
1 
4 
0 
1 
104  36 
0 
0 
0 
150  23 
0 
0 
0 
0 
0 
0 
0 
0 
1 
44 
0 
0 
3 
0 
204  141  120  0 
1 
0 
0 
0 
0 
0 
0 

0 
0 
0 
0 
10 
0 
2 
0 
0 
0 
0 
7 
0 
3 

0 
0 
0 
0 
0 
0 
1 

2 
0 
0 
0 

0 
0 
0 

0 
0 
1 
2 
9 
0 
0 
0 
10 

0 
0 
0 
8 
0 
0 
0 
25 

0 
0 
2 
0 
0 
0 
5 

0 
0 
0 
0 
4 
0 
1 
0 
0 
0 
0 
0 
0 
3 
1 
0 
0 
0 
0 
0 
0 
1 
8 
0 
0 
0 
2 

3 
35 
13 

SE  UK 
47 
4 
13 
3 
66 
3 
61  0 
91  109 
7 
0 
2 
124  201 
29  151 
6 
4 
1 
6 
4 
0 
22  49 
1 
4 
6 
37  387 
0 
4 
0 
0 
68  6 

2 
57 
2 
1 
32 
4 

3 
2 
4 
81 

0 
28 
18 

IS 

LI 
0 
0 
0 
0 
1 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
8 
0 
0 
0 
0 
0 
0 
0 
0 
0 

NO  CH  Tot. 
0 
0 
3 
12 
11 
1 
0 
0 
2 
7 
0 
1 
0 
0 
3 
0 
1 
0 
2 
1 
17 
0 
0 
0 
4 
2 
19 
2 
3 
0 

8,112 
17 
703 
77 
18,036 
75 
46 
18 
389 
3,997 
16 
475 
6 
11 
122 
93 
136 
2 
393 
1,137 
473 
28 
8 
30 
111 
93 
212 
902 
19 
0 
95 
3,384 
6 
39,650 
100.0 
34,008 
1,710 
3,498 

0 
211  1 

220  92 
0.6  0.2 
59 
9 
29 
0 
211  4 

12 
3 
0 
0 
1 
4 

16 

24  1 
1 
6 
0 
0 
14  3 
10  15 

622  584  428  683  450  4,916  282  237  81  15,991  151  21  4,126  5,391  79 

12.5 

0.7  0.6  0.2  40.3 

0.4  0.1  10.4  13.6 

27 
0.1  1.6  1.5  1.1  1.7  1.1 
26 
1 
0 

32 

1 
14 
2,427  0 

606  418  2,475  281  114  59  15,584  99  18  4,068  5,268  76 
2 
75  0 

599  582  0 
0 
0 
3 
20 
0 
2 
* Blank: no data available 
** BE: + 18,635 PDs S2 issued for more flexible procedures, of which IZOM agreement: 17,227; ZOAST arrangements: 111; main residence in a 
border region: 783; functional rehabilitation in DE for insured persons living in the German-speaking community: 342; and maternity (Decision at the 
254th meeting of the AC): 172. 
** FR: the reported number of 683 PDs S2 issued should be considered as a (huge) underestimation given that only the forms issued at a national level 
are reported and not the forms issued locally (see also Annex I - Table A1.1). France also reported in the questionnaire on the operation of the 
Directive that they granted 57,000 authorisations covering both the social security Regulations and the Directive. 
Source PD S2 Questionnaire 2015 

121  15  11 
2 

0 
1 
51  3 

12 
111 

7  396 

8 
50 

1 
2 

5 

26 

890  419  803  77 
0.2  0.1  2.2  1.1  2.0  0.2  1.4  3.4 
417  689 
834  380  188  51 
94  642 
610  21 
46 
30  19 
5 
10 

26 
0 
0 

14 
25 

541  1,350 

11 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Planned cross-border healthcare 

Table 2 

The number of PDs S2 received, breakdown by competent Member State, 2014 

Member State of treatment 

BE 

BG  CZ  DK  DE 
1  1 
0 

e
t
a
t
S
r
e
b
m
e
M

t
n
e
t
e
p
m
o
C

2 
0 
0 

85 
0 
2 
0  0 
5 
0  41 
84 
3 
0  0 
0 
0 
0  0 
7 
0 
0  0 
23 
0 
16 
0  1 
2 
7,552  2  4 
0 
0  23 
8 
0 
0  3 
193 
1 
0  2 
2 
0 
0  0 
11 
1 
2 
0  0 
0 
2,673  0  3 
0 
0  0 
0 
0 
0 
0  0 
0 
1,197  0  0 
1 
0  1 
7 
0 
0  1 
3 
1 
0  0 
1 
0 
0  3 
12 
0 
0 
0  4 
0 
0  475  0 
1 
1 
0  1 
1 
5 
0  0 
4 
1 
6  82 
39 
0 
0  0 
0 
0 
0  0 
0 
1 
0  0 
1 
0 
0  0 
3 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 
UK 
IS 
LI 
NO 
CH 
Unkn. 
Total 
Row %  54.7 
EU-15 
EU-13 
EFTA 

0  508  2 
1 
0  0 

EE 
0 
0 
0 
0 
0 

0 
0 
0 
0 
0 
1 
0 
28 
4 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
8 
1 
0 
0 
0 
0 
0 

IE 
0 
0 
0 
0 
0 
0 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
7 
0 
0 
0 
0 

EL 
0 
0 
0 
0 
52 
0 
0 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
1 
0 
0 
0 
1 
0 
0 
0 
0 
3 
1 
0 
0 
0 

ES 

FR 

IT 

HR 
0 
0 
0 
0 
96 
0 
0 
0 
0 
0 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
4 
0 
0 
0 
3 
0 
0 
0 
0 

CY 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

LV  LT 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 

LU 
728 
0 
0 
0 
123 
0 
0 
0 
3 
335 
0 
2 
0 
103  0 
0 

0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  0 
0  27 
0  0 
0  0 
0  0 
0  0 

0 
0 
0 
0 
0 
1 
0 
0 
0 
2 
0 
4 
0 
0 
0 
0 

HU  MT  NL  AT 
0 
4 
0 
0 
12 
0 
2 
0 
0 
0 
5 
2 
0 
0 
0 
2 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
6 
0 
1 
0 
0 
166  0 
0 
0 
0 
20 
0 
1 
0 
0 
0 
10 
0 
0 
0 
0 
0 
1 
0 
1 

PL 
0 
1 
0 
0 

3 
30 
2 
1 
4,688  123 
0 
1 
116 
5 
4 
115 
152 
20 
2 
3 
7 
60 
0 
15 

0 
3 
0 
0 
2 
0 
3 
0 
2 
7 
11 
0 
0 
5 
7 

6 
0 
162 
89 
40 
2 
2 
11 
0 
2 
0 
10 

0 
0 
0 
0 
4 
0 
235 
3 
0 
5 
2 

11,932  9  645  19 
0  3.0  0.1 
11,802  9  137  16 
126 
4 

42 
7 
0.2  0 
7 
10 
0 
32 
0 
0 
* Blank: no data available 
** BE: including the PDs S2 received under ZOAST arrangements (applicable for FR and LU). 
Source PD S2 Questionnaire 2015 

0  130  1,198  233  0 
1.1  0 
0  0.6 
0 
0  27 
196  0 
0  103  0 
0 
2 
0 
0  0 

5,548  413 
25.4 
1.9 
5,007  393 
529 
12 

103 
0.5 
99 
4 
0 

5.5 
1,198  35 

58 
0.3 
56 
1 
1 

0 
0 
0 
0 
0 

10 
10 

PT 

RO 

IS 

SI 
0 
0 
0 
0 
15 
0 
0 
0 
0 
0 
16 
1 
0 
0 
0 
0 
0 
0 
0 
2 
0 
0 
0 

0 
0 
0 
2 
0 
0 
0 
0 

SK 
0 
0 
1 
0 
6 
0 
0 
0 
0 
1 
0 
3 
0 
0 
0 
0 
3 
0 
0 
0 
0 
0 
0 
0 

0 
0 
46 
0 
0 
3 
1 

FI 
0 
0 
0 
0 
3 
4 
0 
0 
0 
0 
0 
1 
0 
0 
0 
2 
0 
0 
0 
0 
0 
0 
0 
0 
0 

4 
2 
0 
0 
0 
0 

0 
7 
4 

SE  UK 
7 
7 
0 
44  14 
21  8 
3 
1 
36  880 
17  59 
14 
3 
4 
5 
0 
0 
34  49 
25 
1 
2 
3 
2 
0 
4 
9 
1 
0 
0 
0 
6 
0 
0 
0 
4 
5 
1 
0 
0 
1 
0 
1 
0 
0 
1 
4 
6 

8 
0 
0 
9 
0 

0 
0 
0 
0 

64 

218  1,092 

36 
16 
0.2  0.3  0.1  1.0  5.0 
12 
20 
4 
16 
0 
0 

188  1,046 
21  46 
9 

56 
4 
4 

0 

LI 
0 
0 
0 
0 
1 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

0 
55 

NO  CH  Tot. 
742 
0 
134 
0 
9 
0 
66 
2 
5,278 
2 
8 
0 
929 
0 
215 
0 
45 
1 
7,909 
0 
167 
0 
445 
0 
50 
0 
152 
0 
18 
0 
2,711 
0 
64 
0 
0 
0 
1,225 
0 
23 
0 
21 
0 
3 
0 
345 
0 
98 
0 
536 
0 
25 
0 
22 
0 
487 
1 
4 
0 
2 
0 
20 
72 

0 

56 
6 
0.3  0 
6 
1 
0 
0 
0 
55 

21,825 
100.0 
20,125 
1,602 
98 

12 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Planned cross-border healthcare 

Figure 1 

The number of PD S2 issued, percentage breakdown by receiving Member State, 
2014 

*  ES: No breakdown available 
Source PD S2 Questionnaire 2015 

It  could  be  interesting  to  determine  the  main  reasons  for  asking/receiving  planned 
cross-border healthcare (from/to a MS). Different push and pull factors may have an 
impact  on  this  decision.  Push  factors,  among  others  when  the  treatment  cannot  be 
given within a medically acceptable period or a lack of treatment facilities or expertise 
in  the  competent  MS,  may  influence  the  decision  to  grant  a  PD  S2.  In  addition, 
multiple  pull  factors  are  thinkable  to  receive  a  scheduled  treatment  in  one  particular 
MS  (e.g.  proximity,  familiarity,  language,  availability,  medical  expertise/quality, 
affordability (e.g. reimbursement rates, out-of-pocket expenses) etc).  

The assessment of potential push and pull factors falls outside the scope of this report. 
Nonetheless,  we  have  verified  the  importance  of  proximity  to  receive/issue  a  PD  S2 
based on the current quantitative input. Figure 2 illustrates the percentage of PDs S2 
issued by / received from a neighbouring MS. Roughly 80% of the PDs S2 are issued 
to receive a scheduled treatment in a neighbouring MS. However, only 33% and 23% 
of  the  PDs  S2  issued  by  the  EU-13  and  EFTA  MSs  apply  to  a  neighbouring  MS 
compared to 87% of the PD S2 issued by the EU-15 Member States. The Netherlands, 
Austria,  France,  Luxembourg,  Belgium,  Slovakia  and  Liechtenstein  have  issued  more 
than 90% of the PDs S2 to receive a scheduled treatment in a neighbouring Member 
State.  

13 

 
Planned cross-border healthcare 

Figure 2 

The number of PDs S2 issued, percentage breakdown by neighbouring Member State 
or not, 2014 

*  ES: No breakdown available 
Source PD S2 Questionnaire 2015 

5.2.  As share of insured population 

The absolute figures could be confronted with the total number of insured persons in 
order to calculate the relative usage of cross-border planned healthcare (Table 3). In 
2014  approximately  12  in  100,000  insured  persons  received  a  PD  S2.  We  observe  a 
rather  high  patient  mobility  for  persons  insured  in  Luxembourg  (2  in  100  insured 
persons)  and  Liechtenstein  (6  in  1,000  insured  persons).  If  we  apply  a  broader 
definition  and  include  also  the  18,635  PDs  S2  issued  by  Belgium  for  more  flexible 
procedures, Belgium also shows a relatively high and concentrated (within the border 
areas) patient mobility ratio (2 in 1,000 insured persons). 

14 

 
Planned cross-border healthcare 

Table 3 

The percentage of insured persons entitled to receive planned cross-border 
healthcare on the basis of a prior authorisation, 2014 

MS 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 
UK 
IS 
LI 
NO 
CH 
Total* 

Number of insured 
persons (A) 
10,815,037 
6,078,287 
10,419,458 
5,600,000 
n.a. 
1,232,819 
n.a. 
9,900,000 
46,420,010 
58,800,000 
4,349,958 
59,000,000 
548,780 
2,268,599 
2,976,287 
781,826 
9,951,038 
205,459 
16,823,215 
8,652,656 
35,130,363 
n.a. 
17,174,986 
2,163,317 
5,177,717 
5,474,155 
n.a. 
n.a. 
324,007 
38,393 
n.a. 
8,200,000 

Number of PD S2 
issued (B) 
601 
303 
98 
161 
n.a. 
27 
622 
584 
428 
683 
450 
4,916 
282 
237 
81 
15,991 
151 
21 
4,126 
5,391 
79 
26 
890 
419 
803 
77 
541 
1,350 
n.a. 
220 
92 
n.a. 
39,650 

Share of insured 
population (B/A) 

0.005% 
0.005% 
0.001% 
0.003% 
n.a. 
0.002% 
n.a. 
0.006% 
0.001% 
0.001% 
0.010% 
0.008% 
0.051% 
0.010% 
0.003% 
2.045% 
0.002% 
0.010% 
0.025% 
0.062% 
0.000% 
n.a. 
0.005% 
0.019% 
0.016% 
0.001% 
n.a. 
n.a. 
n.a. 
0.573% 
n.a. 
n.a. 
0.012% 

in 100,000 insured 
persons 
5 
5 
1 
3 
n.a. 
2 
n.a. 
6 
1 
1 
10 
8 
51 
10 
3 
2,045 
2 
10 
25 
62 
0 
n.a. 
5 
19 
16 
1 
n.a. 
n.a. 
n.a. 
573 
n.a. 
n.a. 
12 

* Selection of the Member States of which the number of insured persons is available. 
Source EHIC and PD S2 Questionnaire 2015 

5.3.  2014 and previous years: a comparison 

The current data collection (reference year: 2014) could be compared to the previous 
ones  (reference  years:  2013  and  2012)  to  look  into  trends  in  terms  of  number  of 
persons  accessing  planned  healthcare  abroad.  The  evolution  of  these  numbers  could 
be  considered  as  a  first  indicator  to  measure  the  impact  of  the  Patient  Mobility 
Directive on the number of PDs S2 issued. 

The  number  of  PDs  S2  issued  decreased  by  12.3%  in  2014  compared  to  2013  (by 
selecting only those MSs which reported figures for 2013 and 2014). 

Compared  to  2013  Latvia  (+36%),  Finland  (+31%),  Bulgaria  (+29%),  Greece 
(+20%), the United Kingdom (+11%), Lithuania (+10%) and Slovakia (+4%) issued 
more PDs S2 in 2014. This in contrast to Hungary (-55%), Belgium (-49%), Estonia (-
48%),  Malta  (-36%),  the  Netherlands  (-28.2%),  Liechtenstein  (-16%),  Romania  (-
15%), Poland (-10%), Ireland (-9%), Luxembourg (-9%), Portugal (-7%), the Czech 
Republic  (-2%)  and  Italy  (-0.3%),  which  have  issued  less  forms.  This  clearly  shows 
that  the  evolution  and  its  direction  strongly  differ  between  Member  States.  The 
question  whether  the  adoption  of  the  Patient  Mobility  Directive  is  a  possible 
explanation  for  the  change  in  the  number  of  PDs  S2  issued  was  not  in  scope  of  this 

15 

 
Planned cross-border healthcare 

report,  however  it  is  certainly  essential  to  monitor  the  evolution  of  the  reported 
figures. 

Table 4 

The number of PDs S2 issued and received, 2012-2014 

2014 

2013 

2012 

Issued 

% change 
2014 -2013 

2014 

2013 

2012 

Received 

% change 
2014-2013 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 
UK 
Sel.* 
IS 
LI 
NO 
CH 
Total 

602 
303 
98 
161 
n.a. 
27 
622 
584 
428 
683 
450 
4,916 
282 
237 
81 
15,991 
151 
21 
4,126 
5,391 
79 
26 
890 
419 
803 
77 
541 
1,350 
30,984 
n.a. 
220 
92 
n.a. 
39,650 

1,190 
235 
100 
n.a. 
n.a. 
52 
683 
486 
n.a. 
n.a. 
n.a. 
4,933 
n.a. 
174 
74 
17,538 
334 
33 
5,745 
n.a. 
88 
28 
1,049 
n.a. 
769 
59 
n.a. 
1,216 
34,786 
n.a. 
261 
n.a. 
n.a. 
35,047 

1,280 
129 
281 
n.a. 
n.a. 
n.a. 
847 
318 
n.a. 
n.a. 
n.a. 
4,661 
n.a. 
156 
n.a. 
17,765 
300 
n.a. 
5,050 
n.a. 
118 
29 
1,131 
n.a. 
730 
45 
81 
1,126 

n.a. 
n.a. 
n.a. 
n.a. 

-49.4% 
28.9% 
-2.0% 
n.a. 
n.a. 
-48.1% 
-8.9% 
20.2% 
n.a. 
n.a. 
n.a. 
-0.3% 
n.a. 
36.2% 
9.5% 
-8.8% 
-54.8% 
-36.4% 
-28.2% 
n.a. 
-10.2% 
-7.1% 
-15.2% 
n.a. 
4.4% 
30.5% 
n.a. 
11.0% 
-12.3% 
n.a. 
-15.7% 
n.a. 
n.a. 

11,932 
9 
645 
19 
n.a. 
42 
7 
58 
n.a. 
0 
103 
n.a. 
0 
0 
130 
1,198 
233 
0 
n.a. 
5,548 
413 
n.a. 
n.a. 
36 
64 
16 
218 
1,092 

n.a. 
56 
6 
n.a. 
21,825 

3,318* 
5 
934 
n.a. 
n.a. 
n.a. 
4 
n.a. 
n.a. 
n.a. 
n.a. 
n.a. 
n.a. 
0 
50 
1,095 
48 
n.a. 
n.a. 
n.a. 
408 
n.a. 
2 
n.a. 
292 
n.a. 
n.a. 
1,080 

n.a. 
n.a. 
n.a. 
n.a. 
7,265 

* Sel.: selection of MSs which reported figures for 2013 and 2014 
* BE: figures first semester 2013. 
Source Administrative data PD S2 Questionnaire 2015, 2014 and 2013 

4,019 
2 
973 
n.a. 
n.a. 
n.a. 
8 
n.a. 
n.a. 
n.a. 
n.a. 
n.a. 
n.a. 
1 
n.a. 
1,120 
16 
n.a. 
4,782 
n.a. 
241 
n.a. 
2 
n.a. 
353 
n.a. 
216 
1,491 

n.a. 
n.a. 
n.a. 
n.a. 

n.a. 
80.0% 
-30.9% 
n.a. 
n.a. 
n.a. 
75.0% 
n.a. 
n.a. 
n.a. 
n.a. 
n.a. 
n.a. 

160.0% 
9.4% 
385.4% 
n.a. 
n.a. 
n.a. 
1.2% 
n.a. 
-100.0% 
n.a. 
-78.1% 
n.a. 
n.a. 
1.1% 

n.a. 
n.a. 
n.a. 
n.a. 

6.  TREATMENT OF THE REQUEST AND REASONS FOR REFUSAL 

About  3,112  requests  for  a  PD  S2  were  refused  by  the  26  reporting  MSs11  in  2014 
(Table  5).  Luxembourg  (818  refusals),  France  (548  refusals)  and  Belgium  (434 
refusals)  refused  the  highest  number  of  requests  (in  absolute  values).  This  is  in 
contrast  to  Denmark,  Lithuania,  Malta  and  Liechtenstein,  which  refused  none  of  the 
requests.  

In  order  to  calculate  the  authorisation/refusal  rate  these  absolute  values  should  be 
confronted with  the  number  of  PDs  S2  issued  (Table  5).  In  2014,  roughly  8%  of  the 
requests for a PD S2 were refused, which still implies a very high authorisation rate of 
92% (mainly influenced by the low refusal rate of 5% of Luxembourg). Finland (58%), 
Norway (54%), France (45%), Belgium (42%), Sweden (36%) and the Czech Republic 

11 Reporting MSs: BE, BG, CZ, DK, EE, IE, EL, FR, HR, IT, CY, LV, LT, LU, MT, AT, PL, PT, RO, SI, SK, FI, SE, 
UK, LI and NO. 

16 

 
 
 
 
 
 
 
 
 
 
 
 
                                          
Planned cross-border healthcare 

(34%)  refused  more  than  a  third  of  the  requests  for  a prior  authorisation.  Especially 
Belgium (+18.5 p.p.)12 and the Czech Republic (+13.5 p.p.) show a higher refusal rate 
compared to last year. 

Table 5 

The number of PDs S2 requests refused and accepted, 2014 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 
UK 
IS 
LI 
NO 
CH 
Total* 

Issued 

Refused 

Total  % accepted 

601 
303 
98 
161 

27 
622 
584 

683 
450 
4,916 
282 
237 
81 
15,991 

435 
36 
50 
0 

3 
41 
11 

548 
99 
107 
20 
10 
0 
818 

1,036 
339 
148 
161 

30 
663 
595 

1,231 
549 
5,023 
302 
247 
81 
16,809 

58.0% 
89.4% 
66.2% 
100.0% 

90.0% 
93.8% 
98.2% 

55.5% 
82.0% 
97.9% 
93.4% 
96.0% 
100.0% 
95.1% 

% 
refused 
42.0% 
10.6% 
33.8% 
0.0% 

refused 
2013 
23.5% 
7.5% 
20.0% 
n.a. 

10.0% 
6.2% 
1.8% 

44.5% 
18.0% 
2.1% 
6.6% 
4.0% 
0.0% 
4.9% 

10.3% 
3.7% 
6.5% 

n.a. 
n.a. 
2.1% 
n.a. 
7.0% 
0.0% 
3.4% 

21 

0 

21 

100.0% 

0.0% 

0.0% 

5,391 
79 
26 
890 
419 
803 
77 
541 
1,350 

220 
92 

210 
19 
10 
42 
38 
50 
104 
298 
55 

0 
108 

5,601 
98 
36 
932 
457 
853 
181 
839 
1,405 

220 
200 

96.3% 
80.6% 
72.2% 
95.5% 
91.7% 
94.1% 
42.5% 
64.5% 
96.1% 

3.7% 
19.4% 
27.8% 
4.5% 
8.3% 
5.9% 
57.5% 
35.5% 
3.9% 

n.a. 
21.4% 
28.2% 
3.1% 

7.0% 
57.9% 
n.a. 
0.5% 

100.0% 
46.0% 

0.0% 
54.0% 

0.0% 
n.a. 

Change in p.p. 
compared to 2013 

18.5 p.p. 
3.1 p.p. 
13.8 p.p. 
n.a. 

-0.3 p.p. 
2.5 p.p. 
-4.7 p.p. 

n.a. 
n.a. 
0.0 p.p. 
n.a. 
-3.0 p.p. 
0.0 p.p. 
1.5 p.p. 

n.a. 
-2.0 p.p. 
-0.4 p.p. 
1.4 p.p. 

-1.1 p.p. 
-0.4 p.p. 
n.a. 
3.4 p.p. 

n.a. 

34,945 

3,112 

38,057 

91.8% 

8.2% 

* The number of PDs S2 issued by NL, ES and HU are not included as they could not provide 

figures on the number of refused requests.  

Source Administrative data PD S2 Questionnaire 2015 and 2014 

The  fact  that  care  may  be  delivered  within  a  medically  acceptable  period  in  the 
competent MS is on average the most frequent reason to refuse a request for a PD S2 
by the reporting competent MSs (46% of refusals) (Table 6). It was the main reason 
for  Bulgaria,  the  Czech  Republic,  Greece,  France,  Estonia,  Croatia,  Italy,  Cyprus, 
Poland, Austria, Portugal, Slovakia and Finland. On average 10% of the requests were 
refused  by  the  reporting  competent  MSs  because  the  care  in  question  was  not 
included in the services provided for by the legislation of the competent MS. Only for 
Slovenia  and  Latvia  was  this  the  main  reason  to  refuse  requests.  Finally,  for  45%  of 
refusals  other  circumstances  were  the  main  reason  to  refuse  a  request.13  Belgium, 
Ireland,  Lithuania,  Luxembourg,  Romania,  Sweden,  the  United  Kingdom  and  Norway 
indicated ‘other reasons’ to refuse most of the applications. 

12 p.p.: percentage points. 
13 Also reasons within the MSs of stay could have an impact on the refusal of an application (e.g. treatment 
is  not  provided  for  by  the  legislation  of  the  MS  of  stay  or  not  given  within  a  time  limit  which  is  medically 
justifiable or has a (very) high expected cost …).  

17 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                          
Planned cross-border healthcare 

Table 6 

Reasons for refusal to issue a PD S2, 2014 (as a percentage of the total number of 
refused requests) 

Number of 
refusals* 

The care in question is 
not included in the 
services provided for by 
the legislation of your 
MS 

The care in question 
may be delivered within 
a medically acceptable 
period in the competent 
MS 

447 
36 
50 

3 
41 
11 

548 
99 
107 
20 
10 
1 
818 

210 
19 
10 
43 
38 
50 
103 
326 
55 

108 

12.8% 
0.0% 
40.0% 

0.0% 
0.0% 
0.0% 

6.8% 
0.0% 
8.4% 
0.0% 
40.0% 
0.0% 
App. 5% 

9.5% 
21.1% 
10.0% 
18.6% 
71.1% 
6.0% 
8.7% 
9.8% 
14.5% 

25.0% 

34.5% 
100.0% 
40.0% 

100.0% 
46.3% 
100.0% 

60.0% 
50.5% 
81.3% 
100.0% 
30.0% 
0.0% 
App. 45% 

81.4% 
42.1% 
90.0% 
18.6% 
10.5% 
60.0% 
75.7% 
5.8% 
3.6% 

13.9% 

Other circumstances 
(e.g. incomplete file, 
non-compliance with 
procedures, institution 
requesting a second 
opinion etc) 
52.8% 
0.0% 
20.0% 

0.0% 
53.7% 
0.0% 

33.2% 
49.5% 
10.3% 
0.0% 
30.0% 
100.0% 
App. 50% 

9.0% 
36.8% 
0.0% 
62.8% 
18.4% 
34.0% 
15.5% 
84.4% 
81.8% 

61.1% 

3,153 
* Total figure differs from the one reported in Table 5 due to a higher figure reported by BE 

45.8% 

44.5% 

9.7% 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 
UK 
IS 
LI 
NO 
CH 
Total 

and SE (i.e. more than one reason for the same refusal).  

Source Administrative data PD S2 Questionnaire 2015 

The  22  MSs14  which  have  been  able  to  provide  figures  on  the  number  of  contested 
decisions,  received 235  contested  decisions  to  refuse  authorisation  to  issue  a PD  S2. 
On  average  11%  of  the  decisions  to  refuse  a  request  were  contested  (Table 7). 
Especially  Greece  (46%),  Bulgaria  (33%),  Slovenia  (29%),  Norway  (28%),  Ireland 
(29%)  and  Poland  (26%)  show  a  high  percentage  of  contested  decisions  to  refuse 
authorisation. In absolute values, especially Luxembourg has reported a large number 
of contested figures (app. 100). This in contrast to Denmark, Malta, Portugal and the 
United Kingdom which did not receive a contested decision. 

14 Reporting MSs: BE, BG, CZ, DK, EE, IE, EL, CY, LV, LT, LU, HU, MT, PL, PT, RO, SI, SK, FI, SE, UK and 
NO. 

18 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                          
Planned cross-border healthcare 

Table 7 

The percentage of contested decisions to refuse to issue a PD S2, 2014 

MS 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 
UK 
IS 
LI 
NO 
CH 
Total 

Number of 
contested 
decisions (A) 

Number of 
refusals (B) 

8 
12 
10 
0 

3 
12 
5 

3 
1 
1 
app. 100 
8 
0 

5 
0 
1 
11 
1 
18 
9 
0 

30 

235 

435 
36 
50 
0 

0 
41 
11 

20 
10 
0 
818 
47 
0 

19 
10 
42 
38 
50 
104 
298 
55 

108 

2,195 

% contested in 
2013 

Change in p.p. 
compared to 
2013 

n.a. 
15.80% 
24.00% 
n.a. 

15.40% 
25.00% 

n.a. 
15.40% 
n.a. 
9.10% 
42.3% 
n.a. 

n.a. 
0.00% 
0.00% 

20.70% 
15.80% 

0.00% 

n.a; 
17.5% 
-4.0% 
n.a. 

13.9% 
20.5% 

n.a. 
-5.4% 
n.a. 
2.9% 
-30.3% 
n.a. 

n.a. 
0.0% 
2.4% 

-18.7% 
1.5% 

0.0% 

% of contested 
decisions to 
refuse to issue a 
PD S2 (A/B) 
1.8% 
33.3% 
20.0% 
0.0% 

0.0% 
29.3% 
45.5% 

15.0% 
10.0% 
0.0% 
app. 12% 
17.0%* 
0.0% 

26.3% 
0.0% 
2.4% 
28.9% 
2.0% 
17.3% 
3.0% 
0.0% 

27.8% 

10.7% 

* HU: percentage applies to the contested decisions to refuse planned treatment abroad and 

not only to the refusals to issue a PD S2. 

Source Administrative data PD S2 Questionnaire 2014 

7.  PARALLEL SCHEMES 

Most  of  the  reporting  MSs  issued  PDs  S2  exclusively  for  care  that  is  included  in  the 
services provided for by the legislation of the MS (BG, DK, IE, FR, IT, LV, LT, MT, RO, 
LI and NO) (Table 8). Only in Croatia and Portugal were PDs S2 issued exclusively for 
care that is not included in the services provided for by the legislation of these MSs.  

Alongside  the  procedures  determined  by  Regulation  (EC)  No  883/2004  and  (EC)  No 
987/2009,  but  also  by  the  Patient  Mobility  Directive,15  several  MSs  reported  the 
existence of parallel procedures (BE, BG, CZ, EE, IE, EL, HR, CY, HU, MT, NL, PT, RO, 
FI, LI and NO) (Table A1.1 – Annex 1). These parallel procedures are mostly the result 
of provisions in national legislation (e.g. reported by CZ, EE, EL, HR, NL, PT, RO, FI, LI 
and NO) or in bilateral agreements (for instance reported by BE, IE and MT). Also, EE, 
CY and HU issue in specific cases a ‘letter of guarantee’.  

15  The  patient  flows  for  healthcare  abroad  under  the  Directive  were  recently  reported  by  the  Commission. 
See http://ec.europa.eu/health/cross_border_care/docs/2015_operation_report_dir201124eu_en.pdf.  

19 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                          
Planned cross-border healthcare 

The  size  of  these  parallel  schemes  (in  terms  of  number  of  treatments  provided 
abroad)  is,  however,  only  available  for  a  number  of  countries.  Belgium  is  involved, 
amongst  others,  in  a  large  number  of  cooperation  agreements  in  border  areas  (i.e. 
IZOM,  ZOAST  etc)  where,  depending  on  the  cooperation  agreement,  prior 
authorisation  (using  a  PD  S2)  often  becomes  a  simple  administrative  authorisation 
that  is  granted  automatically.  The  number  of  prior  authorisations  issued  by  Belgium 
for existing parallel schemes (18,635 in 2014) exceeds to a large extent the number 
of PDs S2 issued (601 in 2014) (see also Table 1). Portugal reported that 482 patients 
were authorised to receive treatment abroad under its national legislation (compared 
to only 26 PDs S2 issued in 2014). Estonia made 248 decisions to send a person for a 
specific treatment abroad. In most cases they issued a letter of guarantee. Finally, for 
530 patients Cyprus sent a letter of guarantee (compared to 282 PDs S2 issued). 

Table 8 

Care (not) included in the services provided for by the national legislation, 2014 

For care that is included in the services provided for 
by the legislation of your MS 

For care that is not included in the services provided 
for by the legislation of your MS 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 
UK 
IS 
LI 
NO 
CH 

100% 
app. 60% 
100% 

14.8% 
100% 
97% 

100% 
0% 
100% 

100% 
100% 

100% 

87% 

0% 
100% 
1.9% 

75% 

20% 

100% 
100% 

0% 
app. 40% 
0% 

85.2% 
0% 
3% 

0% 
100% 
0% 

0% 
0% 

0% 

13% 

100% 
0% 
98.1% 

25% 

80% 

0% 
0% 

Source Administrative data PD S2 Questionnaire 2015 

8.  CONCLUSION  

This report on the collection of data on PDs S2 applies to reference year 2014. For the 
first time data has been provided by Member States on a mandatory basis. This should 
guarantee a more complete view on the size of planned cross-border healthcare. 

Planned  cross-border  healthcare  seems  to  be  rather  limited  observing  that  in  2014 
only about 12 out of 100,000 insured persons received a PD S2. Moreover, there is no 
indication  that  patient  flows  abroad  are  larger  under  the  Patient  Mobility  Directive  or 
under  other  parallel  schemes.  Only  bilateral  agreements  in  border  areas  seem  to 

20 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Planned cross-border healthcare 

considerably influence the number of persons entitled to receive planned cross-border 
healthcare. 

Approximately 87% of the total number of prior authorisations are issued to receive a 
scheduled treatment in an EU-15 Member State. Moreover, 7 in 10 prior authorisations 
issued  by  the  EU-13  Member  States  applied  to  a  scheduled  treatment  in  an  EU-15 
Member  State  compared  to  almost  9  in  10  prior  authorisations  issued  by  the  EU-15 
Member States.  

The  assessment  of  the  potential  push  and  pull  factors  falls  outside  the  scope  of  the 
report. Nonetheless, proximity seems to be an important factor, as roughly 80% of the 
PDs S2 are issued to receive a scheduled treatment in a neighbouring Member State.  

Some 8% of the requests for a PD S2 were refused by the reporting Member States. 
The  fact  that  care  can  be  delivered  within  a  medically  acceptable  period  in  the 
competent Member State is the most frequent reason to refuse a request for a PD S2. 

21 

 
 
Planned cross-border healthcare 

9.  ANNEX 1 THE EXISTENCE OF PARALLEL SCHEMES 

Table A1.1  The existence of parallel schemes, 2014 

MS 
BE 

Detail 
Belgian  legislation  on  the  subject  of  compulsory  healthcare  insurance  already  includes 
the  possibility  for  persons  whose  principal  residence  is  in  a  border  region  to  be 
reimbursed  for  the  costs  of  healthcare  received  in  a  neighbouring  country  (number  of 
authorisations: 783).  

A  total  of  342  authorisations  were  also  issued  for  functional  rehabilitation  services  in 
Germany for insured persons who live in the German-speaking community.  

Belgium is also party to a large number of cooperation agreements which make it easier 
to  obtain  prior  authorisation  in  border  areas.  In  such  cases  authorisation  is  granted  on 
the basis of a  more flexible  procedure.  Depending on  the cooperation agreement, prior 
authorisation (the S2 form) often becomes a simple administrative  authorisation that is 
granted automatically: 

- 
- 

IZOM: 17,227 authorisations, 
ZOAST arrangements: 111 authorisations. 

Belgium  also  proceeds  on  the  basis  of  the  consensus  reached  at  the  254th  meeting  of 
the Administrative Commission regarding a broad interpretation of Article 22(1)(c)(i) of 
Regulation  (EEC)  No  1408/71  (now  Article  20  of  Regulation  (EC)  No  883/2004)  for  the 
benefit  of  pregnant  women  who,  for  personal  reasons,  wish  to  give  birth  in  another 
Member State (172 'pregnant women' S2 forms issued).  

In 2014 the total number of S2 forms for all more flexible procedures was 18,635. 
The PD S2 for treatment not covered by  the NHIF’s budget is  issued by the Ministry of 
Health. Another option is to use health care services abroad in accordance with Directive 
2011/24/EC.  
The  Czech  health  insurance  fund  may  consider  granting  approval  to  the  applicant  in 
accordance with § 16 of Act No 48/1997 Coll. on public health insurance in cases where 
the application relates to health care that is not included in the services provided for by 
the  Czech  legislation,  which  is  not  covered  according  to  the  legislation  of  the  other 
Member  State  concerned  that  is  subject  of  the  application,  or  when  the  application 
relates to health care which is covered according to the legislation of the other Member 
State  concerned,  but  which  is  to  be  provided  in  a  non-contractual  health  care  facility, 
and when at the same time providing such care is the only option in terms of the health 
condition  of  the  patient  in  question.  If  such  approval  is  granted,  there  is  a  direct 
payment  made  by  the  Czech  health  insurance  fund  to  the  health  care  facility  providing 
the  treatment.  Changes  in  the  Czech  legislation  were  caused  by  the  transposition  of 
Directive 24/2011/EC. Pre-authorisation was not introduced. 
A  PD  S2  can  be  issued  when  Danish  patients  are  referred  for  treatment  at  (public) 
hospitals in other EU/EEA countries.  

EE grants authorisation on the basis of their national legislation. The criteria for granting 
the authorisation are the following: 1) healthcare service (or alternative) is not provided 
in  EE;  2)  the  provision  of  the  healthcare  service  applied  for  by  the  insured  person  is 
therapeutically justified; 3) the medical efficacy of the healthcare service applied for has 
been  proved;  4)  the  average  probability  of  the  aim  of  the  health  service  applied  for 
being achieved is at least 50 per cent. If a board of doctors finds that these criteria are 
fulfilled  EE  grants  the  authorisation  and  issues  a  letter  of  guarantee  to  the  healthcare 
facility or concludes a contract with the insured person on partial advance payment. EE 
only  issues  a  PD  S2  if  the  foreign  healthcare  facility  does  not  accept  the  letter  of 
guarantee and specifically requests the form. None of PDs S2 were issued on the basis 
of  Article  20  of  Regulation  (EC)  No  883/2004.  Altogether,  in  2014,  EE  made  248 
decisions  to  send  a  person  for  a  specific  treatment  abroad  (EU,  EFTA,  CH).  In  most 
cases EE issued the letter of guarantee. 
The  HSE  has  established  certain  cooperations  with  services  in  Belfast  and  Northern 
Ireland (the UK).  We do not have records of these arrangements that can be reported 
at this time. 

BG 

CZ 

DK 

DE 
EE 

IE 

22 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MS 
EL 

ES 
FR 

HR 

IT 

CY 

LV 

LT 
LU 
HU 

MT 
NL 

AT 
PL 

Planned cross-border healthcare 

Detail 
According  to  national  legislation,  the  EOPYY  may  bear  the  costs  for  urgent  treatments 
(exempt  from  waiting  lists)  not  available  in  Greece,  and  offered  by  European  private 
clinics  or  public/university  hospital  private  wings.  The  same  authorisation  procedure  is 
followed  as  with  the  S2  scheme,  and  a  Health  Board  referral  is  taken  into  account. 
Patients privately admitted for treatment are accountable for a 10% (5% for children up 
to 16 years of age) charge on the total treatment costs. The same principle as above is 
valid  for  approved  treatments  outside  Europe  (a  patient  charge  is  not  applicable).  The 
EOPYY  may  also  cover  the  full  costs  for  insured  persons  who  receive  urgent  vitally 
necessary treatment in European non-Member States of the EU, and outside Europe.  

The number of S2 forms issued is not representative:  

-  An  S2  form  is  required  in  France  for  a  limited  number  of  scheduled  treatments.  For 
other  scheduled  treatments  the  patient  is  supported  by  the  French  health  insurance 
without PD S2. 
- The data in this report is only partial as the PDs S2 issued correspond to applications 
processed at a national level (the French National Health Insurance Fund). Requests for 
a PD S2 handled locally (by primary health insurance funds), which are the vast majority 
of PDs S2 issued, are not yet recorded. 
It  is  possible  that  the  number  of  S2  forms  is  not  representative  for  the  number  of 
patients covered for health care abroad for Croatia. A parallel authorisation procedure is 
indeed  in  place.  According  to  the  Act  on  Compulsory  Health  Insurance  (Article  26.3), 
every insured person is entitled to treatment abroad (both in EU and non-EU countries) 
for  cases  where  such  treatment  cannot  be  provided  for  by  the  contracted  health  care 
provider  in  Croatia,  but  can  successfully  be  performed  abroad.  The  procedure  of 
authorisation  is  elaborated  in  detail  in  Article  25-33  of  the  Ordinance  on  entitlements, 
conditions and usage of cross-border healthcare. It is not stipulated that the treatment 
abroad has to be provided for within contracted health care facilities, or that it has to be 
within the healthcare system of the State of treatment. Therefore, there are cases where 
the  S2  form  cannot  be  used,  i.e.  if  the  treatment  is  to  be  provided  by  a  private 
healthcare facility, or if the treatment in question is outside the scope of the healthcare 
system of the Member State of treatment. If the authorisation for such a procedure has 
been  granted,  the  Croatian  health  insurance  fund  pays  the  healthcare  facility  which 
provides the treatment directly, and issues a letter of affidavit. 
There  are  no  parallel  procedures  allowing  patients  to  seek  healthcare  abroad  on  the 
basis  of  an  S2  form.  If  it  is  not  possible  to  use  application  form  S2  because  the 
healthcare  abroad  is  provided  in  a  private  structure,  the  patient  who  got  the 
authorization can get reimbursement by their competent institution afterwards.  
530  patients  were  sent  to  other  Member  States  by  the  use  of  a  letter  of  guarantee 
issued  by  the  Cypriot  government.  In  many  of  these  cases  state  hospitals  refused  to 
accept the S2 form. 109 patients were sent to third countries like Israel, Lebanon etc.  
The number of S2 forms represents the number of patients covered for health care 
abroad. No parallel procedure exists. 
No parallel schemes. 
Directive 2011/24/EU. 
The  number  of  S2  forms  is  definitely  not  representative  of  the  number  of  planned 
treatment  abroad.  There  are  treatments  in  the  EU  where  the  health  care  provider  is  a 
private provider; therefore they do not accept the S2 form. Or, there is no S2 form used 
for  genetic  testing  (for  example:  CENTOGENE).  If  treatment  cannot  be  delivered  in 
Hungary  and  there  is  a  real  chance  for  improving  the  quality  of  life  of  the  patient,  the 
NHIF  gives  authorisation  for  planned  treatments  in  third  countries.  For  genetic  and 
biochemical  analysis  or  bone  marrow  donor  search,  the  NHIF  does  not  issue  S2  forms 
because  these  centres  request  direct  payment.  In  these  cases  the  NHIF  issues  a 
guarantee letter for payment. 
Maltese patients have access to treatment abroad based on bilateral agreements. 
The Health Insurance Act contains the principle of world coverage. Persons may apply 
for reimbursement of costs under the Health Insurance Act, as long as the treatment is 
within the basket of care. 

23 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MS 
PT 

RO 

SI 
SK 
FI 

SE 

UK 

IS 
LI 
NO 

CH 

Planned cross-border healthcare 

Detail 
1.  The  Portuguese  national  health  system  has  legislation  in  force  that  recognises  the 
right  of  patients  to  have  access  to  specialised  healthcare  abroad  which,  for  lack  of 
technical or human means, cannot be provided within the Portuguese Health System. 2. 
The  process  of  medical  assistance  abroad  is  organised  by  the  public  hospital  of  the 
National  Health  Service  where  the  patient  is  being  treated  and  is  subject  to  prior 
authorisation  by  the  Director-General  of  Health.  3.  In  the  process,  the  hospital  must 
specify the following: - the reasons  that underlie the impossibility, material and human, 
of the medical assistance to be provided in a national health institution; - the clinical aim 
of  displacement;  -  the  foreign  healthcare  institutions  (inside  or  outside  the  EU  or  EEA) 
where  the patient can receive medical care and  its fundamentals; - a  maximum period 
for  the  medical  assistance;  otherwise,  it  will  not  produce  its  normal,  useful  effect;  - 
whether  the  patient  needs  to  be  accompanied  by  a  person,  with  or  without  adequate 
technical  training;  -  report  with  resource  to  consultants  and  experts  of  recognised 
competence in the clinical issues under appreciation. 4. If the Director-General of Health 
authorises the patient to travel abroad, the National Health Service will assume the full 
payment of all medical expenses, accommodation, travel, meals and medication. 5. The 
requests  for  medical  assistance  must  be  concluded  within  15  days  and,  in  cases  of 
exceptional  urgency,  within  five  days.  6.  In  2014,  482  patients  were  authorised  for 
treatment  abroad  under  this  legislation.  7.  The  Director-General  of  Health  did  not 
authorise only two cases, as the treatment was available in Portugal within a reasonable 
time. 
A  parallel  procedure  is  used  when  the  insured  person  receives  planned  treatment 
without prior approval from the competent institution. The health insurance fund where 
the person is registered as an insured person will pay the value of the medical services 
provided.  According  to  Article  8  of  CNAS  Order  No  729  of  17  July  2009  approving  the 
methodological  norms  regarding  reimbursement  and  recovery  of  the  cost  of  healthcare 
provided under the provisions of international documents in the field of health to which 
Romania is a party, as amended and supplemented, the reimbursement is made at the 
written  request  of  the  insured,  a  family  member  (parent,  husband/wife,  son/daughter) 
or persons authorised by him or her, accompanied by supporting documents. The health 
insurance  fund  reimburses  the  value  of  the  medical  services  provided  and  paid  for,  at 
the price rates in Romania provided for by regulations in force at the date of payment, 
for  the  insured  person.  The  provisions  of  Article  8  of  CNAS  Order  No  729  of  17  July 
2009,  with  subsequent  amendments  and  additions,  were  repealed  on  30  April  2014  – 
the date of entry into force of HG No 304/2014 approving detailed rules on cross-border 
healthcare.  However,  policy  holders  of  the  social  security  system  of  health  in  Romania 
who  have  received  medical  treatment  in  a  Member  State  of  the  European  Union  and 
have not submitted an application for refund of medical services prior to the date of 30 
April  2014,  have  been  entitled  to  submit  applications  for  reimbursement  to  the  health 
insurance house no later than 31 December 2014. 

If a patient wants to  receive health care abroad,  the public health care  in Finland can also  if 
necessary purchase this health care from abroad. In these cases the public healthcare unit in 
Finland also pays directly to the healthcare provider abroad and the patient receives the health 
care as in Finland (same client fee etc). 
A  patient  can  apply  for  a  prior  authorisation  according  to  the  law  for  reimbursement  of 
healthcare costs within EEA (lag (2013:513) om ersättning för kostnader till följd av vård i ett 
annat  land  inom  Europeiska  ekonomiska  samarbetsområdet)  which  is  the  result  of  the 
implementation  of  Directive  2011/24/EU.  It  is  not  compulsory  for  the  patient  to  apply  for  a 
prior authorisation. The advantage with this procedure is the economic certainty, which means 
that the patient will be reimbursed with the amount stated on the decision provided that the 
treatment given is the same as the prior authorisation was granted for. The decision is binding 
for the Swedish Social Insurance Agency. A patient can also apply for reimbursement after he 
or she has received a treatment in another EEA country. By doing so the patient takes a risk 
not to receive any reimbursement at all. This procedure is suitable for those who do not want 
to wait for a decision. Equal for both procedures is the possibility to receive reimbursement by 
handing in a receipt or an invoice. This means that it is not necessary that the patient has paid 
for the treatment. It should be noted that it is not possible to receive reimbursement for other 
costs, such as travel or accommodation.  
Directive 2011/24/EU provides for another route for patients to seek planned healthcare 
abroad. 

Because of legal requirements in Liechtenstein, it is possible to receive benefits abroad. 
There are also arrangements for situations where hospitals in Norway lack the necessary skills 
and/or  equipment,  in  which  case  the  patients  can  be  sent  abroad.  These  arrangements  are 
based on national legislation and fall outside the scope of the Regulations. 

Source Administrative data PD S2 Questionnaire 2015 

24 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Planned cross-border healthcare 

10. 

ANNEX 2 PD S2 QUESTIONNAIRE 

1/  Countries  in  which  patients  have  been  authorised  to  receive  care  by  the 
reporting Member State (= number of issued S2 forms) 
Each Member State shall indicate "not applicable" in its own row. 
N.B. This is determined by the dates of the decisions to issue authorisation for issuing 
an S2 form, even if the request for authorisation was received in year N-1. 

Number of S2 forms issued in year N for each State  

Member State  
BE 
CZ 
DK 
DE 
EE 
EL 
ES 
FR 
IE 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
SK 
SI 
FI 
SE 
UK 
BG 
RO 
IS 
LI 
NO 
CH 
Total  number  of  S2 
forms  issued  by  the 
reporting  country  for 
care  in  other  Member 
State 

25 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Planned cross-border healthcare 

2/ Countries from which patients have been authorised to receive care in the 
reporting Member State (= number of received S2 forms) 
Each Member State shall indicate "not applicable" in its own row. 
N.B.  This  is  determined  by  the  dates  the  S2  form  was  received  by  the  appropriate 
healthcare institution in the reporting country under in year N. 

Number of S2 forms received in year N from each State 

Member State  
BE 
CZ 
DK 
DE 
EE 
EL 
ES 
FR 
IE 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
SK 
SI 
FI 
SE 
UK 
BG 
RO 
IS 
LI 
NO 
CH 
Total  number  of  S2 
forms received by the 
reporting 
Member 
State 

26 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Planned cross-border healthcare 

3/  Countries  in  which  patients  have  been  refused  by  the  reporting  Member 
State authorisations to receive care (= number of refused S2 forms) 
Each Member State shall indicate "not applicable" in its own row. 
N.B.  This  is  determined  by  the  dates  of  the  decisions  to  refuse  authorisation  for 
issuing an S2 form, even if the request for authorisation was received in year N-1. 

Number of S2 forms refused in year N for each State  

Member State  
BE 
CZ 
DK 
DE 
EE 
EL 
ES 
FR 
IE 
IT 
CY 
LV 
LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
SK 
SI 
FI 
SE 
UK 
BG 
RO 
IS 
LI 
NO 
CH 
Total  number  of  S2 
forms  refused  by  the 
reporting  country  for 
care  in  other  Member 
State 

27 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Planned cross-border healthcare 

4/ Reasons for refusals to issue an S2 form  

(Reason  1):  the  care  in  question  is  not  included  in  the  services  provided  for  by  the 
legislation of your Member State  
(Reason  2):  the  care  in  question  may  be  delivered  within  a  medically  acceptable 
period in the competent State   
(Reason  3):  other  circumstances  (for  example:  incomplete  file,  non-compliance  with 
procedures, institution requesting a second opinion).  

N.B. This is determined by the dates of decisions to refuse authorisation for issuing an 
S2 form, even if the request for authorisation was received in year N-1. 

Year 

N 

Number of refusals 
for Reason 1 

Number  of  refusals  for 
Reason 2 

Number  of  refusals  for 
Reason 3 

5/ Number of contested decisions to refuse authorisation to issue an S2 form 
in year N 

Year 
N 

Number of contested decisions to refuse to issue an S2 form 

6/ Number of S2 forms issued 
-For  care  that  is  included  in  the  services  provided  for  by  the  legislation  of  your 
Member State  
-For  care  that  is  not  included  in  the  services  provided  for  by  the  legislation  of  your 
Member State  

7/  It  is  possible  that  the  number  of  S2  forms  is  not  representative  of  the 
number of patients covered for health care abroad for certain Member States, 
on  account  of  the  existence  of  parallel  procedures  allowing  patients  to  seek 
healthcare abroad. 

Please describe, if applicable, the existence of parallel schemes to the S2 system, the 
procedures  how  these  schemes  work  and  their  consequences  for  the  people 
concerned. 

8/ Your explanatory comments on the data forwarded 
If necessary, please make any comments that may make it easier to understand the 
data transmitted in accordance with your national legislation or practice. 

28 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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