DECISION No S1

of 12 June 2009

concerning the European Health Insurance Card

(Text of relevance to the EEA and to the EC/Switzerland Agreement)

2010/C 106/08

THE ADMINISTRATIVE COMMISSION FOR THE COORDINATION OF SOCIAL SECURITY SYSTEMS,

Having regard to Article 72(a) of Regulation (EC) No 883/2004 of the European Parliament and of the Council of 29 April 2004 on the coordination of social security systems(1), under which the Administrative Commission is responsible for dealing with all administrative questions or questions of interpretation arising from the provisions of Regulation (EC) No 883/2004 and 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(2),

Having regard to Article 19 of Regulation (EC) No 883/2004 concerning the entitlement of an insured person and the members of his/her family, staying in a Member State other than the competent Member State to benefits in kind which become necessary on medical grounds taking into account the nature of the benefits and the expected length of the stay,

Having regard to Article 27(1) of Regulation (EC) No 883/2004,

Having regard to Article 25(A) and (C) of Regulation (EC) No 987/2009,

Whereas:

(1) The Barcelona European Council, held on 15 and 16 March 2002, decided: ‘that a European Health Insurance Card will replace the current paper forms needed for health treatment in another Member State. The Commission will present a proposal to that effect before the Spring European Council in 2003. Such a card will simplify procedures, but will not change existing rights and obligations.’ (point 34).

(2) Given that the use of health and social security cards differs widely from one Member State to another, the European Health Insurance Card is initially introduced in a format in which the data necessary for the provision of health care and the reimbursement of the costs can be read with the naked eye. This information may additionally be incorporated in an electronic medium. The use of an electronic medium will furthermore become generalised at a later stage.

(3) The European Health Insurance Card must conform to a single model defined by the Administrative Commission, which should both help facilitate access to health care and help to prevent irregular, abusive or fraudulent use of the card.

(4) Institutions of the Member State determine the period of validity of the European Health Insurance Cards they issue. The period of validity of the European Health Insurance card should take into account the presumed duration of the insured person’s entitlement.

(5) In the event of exceptional circumstances, a provisional replacement certificate of limited duration should be issued. ‘Exceptional circumstances’ may be theft or loss of the European Health Insurance Card or departure at notice too short for a European Health Insurance Card to be issued. The provisional replacement certificate can be requested by the insured person or the institution of the State of stay.

(6) The European Health Insurance Card should be used in all situations of temporary stay during which an insured person requires health care irrespective of the purpose of the stay, be it for reasons of tourism, professional activity or study. However the European Health Insurance Card cannot be used when the purpose of the stay abroad is solely to obtain healthcare.

(7) In accordance with Article 76 of Regulation (EC) No 883/2004, Members States should cooperate to put in place procedures to avoid that, in the event that a person ceases to be entitled to sickness benefits in kind on behalf of a Member State and becomes entitled to benefits in kind on behalf of another Member State, he/she continues to use the European Health Insurance Card issued by the institution of the first Member State beyond the date from which he is no longer entitled to benefits in kind on its behalf.

(8) The European Health Insurance Card issued before the entry into application of Regulations (EC) No 883/2004 and (EC) No 987/2009 will remain valid till the expiry date mentioned on the card.

Acting in accordance with the conditions laid down in Article 71(2) of Regulation (EC) No 883/2004,

HAS DECIDED AS FOLLOWS:

General principles

The European Health Insurance Card certifies the entitlement of an insured person and a pensioner as well as the members of their family, staying in a Member State other than the competent Member State to benefits in kind which become necessary on medical grounds taking into account the nature of the benefits and the expected length of the stay.

The European Health Insurance Card cannot be used in the situation where the aim of the temporary stay is to receive medical treatment.

The European Health Insurance Card shall be an individual card made out in the name of the card holder.

The period of validity of the European Health Insurance Card shall be determined by the issuing institution.

Benefits in kind provided by the institution of the Member State of stay on the basis of a valid European Health Insurance Card shall be reimbursed by the competent institution in accordance with the provisions in force. A valid European Health Insurance Card is a card where the validity period indicated on the card has not expired.

The competent institution may not reject the refund of the cost of benefits on the grounds that the person has ceased to be insured with the institution which has issued the European Health Insurance Card, provided that the benefits were given to the holder of the card or the Provisional Replacement Certificate within the validity period of the card or the certificate.

When exceptional circumstances prevent the issuing of a European Health Insurance Card, a provisional replacement certificate with a limited validity period shall be issued by the competent institution. The provisional Replacement Certificate can be requested either by the insured person or the institution of the State of stay.

The European Health Insurance Card and the provisional replacement certificate shall conform to a single model meeting the characteristics and technical specifications laid down by decision of the Administrative Commission.

Data contained on the European Health Insurance Card

The European Health Insurance Card shall contain the following data:

— surname and forename of the card holder,

— personal identification number of the card holder or, when no such number exists, the number of the insured person from whom the rights of the card holder derive,

— date of birth of the card holder,

— expiry date of the card,

— ISO code of the Member State issuing the card,

— identification number and acronym of the competent institution,

— logical number of the card.

Use of the European Health Insurance Card

The European Health Insurance Card can be used in all situations of temporary stay during which an insured person requires benefits in kind irrespective the purpose of the stay, be it for reasons of tourism, professional activity or study.

The European Health Insurance Card proves the entitlement of the card holder in the Member State of stay to sickness benefits in kind which become medically necessary and which are granted during a temporary stay in another Member State with a view to preventing the card holder from being forced to return before the end of the planned duration of stay to the competent State or the State of residence to obtain the treatment he/she requires.

The purpose of benefits of this type is to enable the insured person to continue his/her stay under safe medical conditions.

10.

The European Health Insurance Card does not cover sickness benefits in kind in situations where the aim of the stay is to receive medical treatment.

11.

The European Health Insurance Card guarantees that the card holder receives in the Member State of stay the same treatment (procedures and tariffs) as person covered by the sickness insurance scheme of this State.

Cooperation between institutions in order to avoid misuse of the European Health Insurance Card

12.

In the event that a person ceases to be entitled to sickness benefits in kind on behalf of a Member State’s legislation and becomes entitled to benefits in kind on behalf of the legislation of another Member State, the institutions of the Member States concerned should cooperate in order to avoid the insured person continuing to use the European Health Insurance Card issued by the institution of the first Member State beyond the date from which he is no longer entitled to benefits in kind on its behalf. Where appropriate, the institution of the latter State shall provide a new European Health Insurance Card.

13.

This Decision shall be published in the

Official Journal of the European Union

. It shall apply from the date of entry into force of Regulation (EC) No 987/2009.

The Chair of the Administrative Commission

Gabriela PIKOROVÁ

(1)

OJ L 166, 30.4.2004, p. 1

(2)

OJ L 284, 30.10.2009, p. 1