What legislation applies when healthcare is received in another European state?

In the area of cross-border healthcare, Regulations No 883/2004 and No 987/2009 on the coordination of social security systems have been applied, we have established a system aimed at ensuring healthcare in several situations, such as temporary stays abroad and residence outside the competent Member State. The Regulations also include provisions on planned healthcare.

Furthermore, Directive 2011/24/EU on the application of patients' rights in cross-border healthcare entered into force on 24 April 2011 in order to facilitate access to safe and high-quality healthcare. The Directive codifies the Court of Justice's abundant case-law on the application of healthcare and complements the rights citizens already have across the EU thanks to the Regulations. Royal Decree 81/2014 of 7 February establishing rules to ensure cross-border healthcare transposes the provisions set forth in the Directive into the Spanish legal system.

Both legal instruments, the Directive and the Regulations, apply in the Member States of the European Union and the European Economic Area.

Will this new regulation affect existing legislation on these matters (Regulations No 883/2004 and No 987/2009 on the coordination of social security systems)?

Both the Directive and the Regulations cover the healthcare received in other Member States. The Directive will be applied without detriment to the existing social security coordination framework established in the Regulations and will not affect the benefits the current Regulations on social security already offer to citizens.

Any person needing healthcare when temporarily abroad (for holidays, work, studies, etc.) will continue to benefit from the existing Regulations and receive the healthcare they need upon showing their European Health Card. In the case of planned treatments, it will not affect citizens' right to obtain authorisation to receive healthcare in another State when the conditions laid down in these Regulations are met; in other words when they cannot receive the treatment in Spain within a reasonable period of time from a medical standpoint.

Thus, in general terms, when the terms of the Regulations are met, treatment may be provided according to the Regulations, unless a patient who is fully aware of his/her rights requests the new legislation to be applied.

What novelties does this new legislation bring?

The Directive and Royal Decree 81/2014, which transposes the former into Spanish legislation, clarify what rights citizens have to receive healthcare in another Member State and complement the rights they already benefitted from according to prior legislation.

One of the main novelties is that patients will be able to choose healthcare service providers in another country. In addition, patients will be able to receive healthcare and request reimbursement of its costs upon their return. This right not only covers public healthcare service providers but also private providers.

With regard to both hospital healthcare and non-hospital healthcare, patients will receive information on the quality and safety of the healthcare they receive.

Patients will have to pay for the costs, which will subsequently be reimbursed to them under the conditions established for such purpose.

What specific differences arise from the application of one or other legal framework in Spain?

There are specific differences concerning costs (procedures and amount of reimbursement) and the authorisation to receive care.

Regarding costs, the costs of healthcare benefits received in another State will be reimbursed based on the reimbursement conditions and rates of the State of treatment according to the Regulations. The reimbursement procedure will be carried out between the institutions of the States involved.

If the citizen chooses the provisions set forth in Royal Decree 81/2014, the patient will directly pay the healthcare provider in keeping with the costs and rates of the country of treatment. However, reimbursement will be effectuated upon his return in accordance with the conditions and rates that would have applied to that healthcare provision in Spain, which is the State of affiliation, excluding any associated costs (accommodation, board and travel expenses).

Regarding authorisation to receive healthcare, prior authorisation is a necessary requirement in order to receive planned treatment in another State according to the Regulations.

If the patient opts for the provisions set forth in Royal Decree 81/2014, a prior authorisation system has been established which only affects some cases, which are listed in Annex II of said Royal Decree.


Which persons can benefit most from cross-border healthcare?

Opting for this new legislation can benefit patients requiring specialised treatment or who seek to obtain a diagnosis or treatment for a rare disease. This also applies to people living in border areas and people who work or live in Spain, but who wish to be treated near their family members in another Member State.

What rights do citizens from other States have if they receive healthcare in Spain?

Before seeking healthcare, they will be entitled to receive information on quality and safety standards and on the healthcare providers in Spain and whether these have been duly authorised to provide healthcare according to Spanish regulations. Providers have to inform them about the different treatment options available, provide them with clear information about prices and give them a copy of the report on the treatment they have received.

European citizens may not be discriminated against with regard to Spanish citizens. They will have the same rights and the legislation and regulations which apply in Spain will be applied to them regarding both their treatment and the conditions of access to such treatment. These patients may not be deprived of the most beneficial rights ensuring from the Regulations on the coordination of social security systems (for example, using the European Health Card) if they have not explicitly opted for the framework laid down by the Directive.

If they opt for this new legislation, European citizens will have to pay for the costs of the healthcare they have received, which will subsequently be reimbursed in their own country. In order to so, they will receive a clear invoice in the country of treatment, which includes patient data, centre or service, the treatment in detail and the amount actually paid.

What should Spanish citizens know who wish to seek healthcare in another State?

If the citizen is entitled to receive publicly funded healthcare benefits through the National Health Service, or if he is a civil servant through his mutual society, he will also be entitled to reimbursement for the costs of healthcare received in another country. However, the citizen should obtain information on the treatments that will be reimbursed and on their conditions before seeking healthcare.

The citizen is entitled to choose a public or private healthcare provider in another Member State, but should first obtain information on the quality and safety standard required, whether the providers are duly authorised in that country and the cost of the treatments. The citizen can also obtain information on the mechanisms to file complaints and obtain redress for damages that may have been laid down in that State. In Spain, the citizen is entitled to receive the clinical documentation.

Once the healthcare has been delivered, the citizen is entitled to receive a report on the treatment before returning to Spain and to follow-up treatment in Spain.

Which citizens can receive cross-border healthcare and be entitled to reimbursement in Spain?

People whose State of affiliation is Spain will be entitled to reimbursement in Spain for the healthcare received abroad.

These people are entitled to receive publicly funded healthcare from the National Health Service, as are their beneficiaries who meet the requirements laid down in Spanish legislation and European Regulations on the coordination of social security systems. This includes pensioners insured in other States and their family members who are resident in Spain, to whom the Community regulations apply.

Nevertheless, if a pensioner from another State residing in Spain decides to receive a treatment which does not require prior authorisation in his own State of origin, that State will cover the costs and refund the amount paid in advance. If the pensioner decides to receive treatment in a State other than his State of origin, Spain, as his country of residence, will be responsible for reimbursing him.

Where can citizens obtain information about of their rights to healthcare abroad?

A National Contact Point located at the Ministry of Health, Social Services and Equality has been set up, from which the citizens can obtain practical information on reimbursement conditions and percentages, the procedures laid down, in particular to apply for reimbursement, the prior authorisation scheme and the circumstances and treatments requiring prior authorisation. It will be complemented by the information provided by the responsible units of the regional authorities.

It will also interchange information with other States on possible treatments, healthcare providers, complaints procedures, etc. Citizens will therefore have a clearer idea about the safety of the healthcare offered in other countries, which will enable them to take more fully informed decisions.

What if damages are caused to patients during treatment in another country?

The new legislation sets forth the liabilities of the country of treatment with regard to complaints, redress and compensation. The national contact points of each country will offer patients the information they need in this regard.


What kind benefits are Spanish citizens entitled to when they go to another State?

The people entitled to public healthcare in Spain may seek healthcare in another State if they so choose. However, the cost of the treatment received will only be reimbursed to them if that treatment is included in the National Health System's portfolio of services and if the conditions required for its delivery are met.

Is it necessary to request prior authorisation from the authorities before receiving treatment abroad?

A citizen who wishes to receive treatment in another country will have to request prior authorisation from his regional authority for the subsequent reimbursement of costs in the following cases:

  1. where hospital accommodation for at least one night is required;
  2. where the healthcare requires the use of highly specialised or cost-intensive medical infrastructure or equipment.

Can such authorisation be refused?

The competent health authorities may refuse to grant authorisation if the treatment sought is not included in the portfolio of services, if it can pose a risk to the patient or to public health or if the healthcare provider does not meet safety and quality standards and can pose a risk. Authorisation may also be refused if appropriate healthcare can be provided in Spain within a reasonable time limit that can be justified on medical grounds.

The time limit to issue an authorisation resolution is forty-five days and the application will be construed to have been accepted if notice is not given before the time limit has elapsed.

Can an appeal be lodged if authorisation is refused?

Patients are entitled to seek a review of any administrative decision on cross-border healthcare affecting them. They can therefore seek a review of the refusal, as appropriate, to grant authorisation. The claims and appeals which may be lodged in accordance with Spanish legislation will appear on the resolution refusing authorisation served to the citizen.

What percentage of the treatment costs abroad will be reimbursed?

A citizen who seeks healthcare in another European country will be entitled to reimbursement for the treatment by his regional authority, provided that the treatment is included in the National Health System's common portfolio of services or, as appropriate, in the complementary portfolio of each regional authority.

The patient will be reimbursed for the same amount as if he/she had received the healthcare in Spain under the same terms and conditions. The rates approved and published by the competent Spanish health authority will apply, without exceeding the actual cost of the healthcare delivered. Accommodation and travel expenses will not be reimbursed.

How will treatment costs be reimbursed?

Once the citizen has returned to Spain, he has to file an application for reimbursement of the healthcare costs before the units or agencies designated for such purpose in his regional authority. The application has to be filed within three months of having effectuated payment and the invoices, clinical report and authorisation, as appropriate, should be attached to it.

Will continuity of treatment be ensured once the patient returns after receiving treatment in another country?

High-quality medical follow-up will be ensured in Spain, regardless of where in the EU the treatment was delivered.

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