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The benefits which you can receive within the framework of the EC Directives depends on the statutory range of benefits of the state of treatment. If German law provides for the service of which you wish to avail yourself, such as a specific form of treatment, but the law in the state of treatment does not, you cannot receive that specific treatment in the state of treatment. The quickest way to find out what benefits the state of treatment offers for persons with statutory health insurance is by consulting the statutory health insurance locally. Proceeding within the EC Directives can therefore mean either a restriction in individual cases, or you may actually have a wider range of benefits at your disposal. If for instance the law of the state of treatment has a benefit for persons with statutory health insurance for which German law does not provide, your German health insurance fund may nonetheless authorise the treatment in the Member State in question. It is however not obliged to do so (see "Authorisation").
In order to be able to take up benefits within the EC Directives which are available to persons with statutory health insurance in the state of treatment, you always need the authorisation of your health insurance fund in Germany. You must submit the authorisation in the Member State before starting treatment. This also applies to treatment which your health insurance fund would not need to authorise in Germany, such as out-patient computer tomography.
Whether your health insurance fund authorises you to undergo specific treatment in a Member State is generally discretionary. It is not obliged to grant authorisation if
The health insurance fund can however also issue an authorisation in such cases.
The health insurance fund must authorise the desired treatment if it is provided for in accordance with the German regulations and cannot be provided in Germany within a medically-justified period. Your state of health and the course which your illness is likely to take are the decisive criteria for assessing the justifiable period.
If your health insurance fund grants prior authorisation for the treatment in a Member State or in one of the states mentioned above, it issues you with a form known as an E 112 or S2 as proof of the authorisation. The health insurance fund can issue this authorisation either for the requested treatment, or for a specific healthcare provider and for a specific place and a defined period.
You would like to have a computer tomography carried out. You would not need to obtain authorisation for this examination from your health insurance fund if you went to a doctor in Germany. However, you have chosen a doctor in Austria whose surgery you can reach more easily than the nearest German doctor, and the doctor whom you have chosen is registered as a Kassenarzt (registered contract doctor) in Austria.
You can apply to your health insurance fund in Germany to be treated as a patient of the statutory health insurance in Austria. If your health insurance fund authorises the treatment, it will issue a form E 112 or S2. It may restrict the authorisation to this treatment, to this doctor and to a specific period, but is not obliged to make any such restrictions.
The healthcare provider you have selected, such as a doctor, may establish that the treatment which has been authorised is not sufficient. If your health insurance fund has restricted the authorisation on the first form to a specific treatment, you need to apply for a renewed authorisation, that is for another form E 112 or S2.
If you have received an authorisation within the framework of the EC Directives to receive medical treatment in another Member State, in Switzerland or in an EEA state, you must first take this authorisation to the statutory healthcare insurer in the state of treatment. If there are several, you may choose one. You will find an overview of the healthcare insurers at the end of the leaflets entitled “On holiday in …?” on the pages of the German Liaison Agency Health Insurance – International. You can also approach these healthcare insurers if you fall ill when on holiday and have any questions concerning the range of statutory benefits available.
If you have opted to undergo treatment within the framework of the EC Directives, we recommend clarifying with the healthcare insurer in the state of treatment before starting treatment what costs are paid or reimbursed in accordance with its regulations. If you have to meet some of the costs yourself, you can apply for a partial or complete reimbursement (depending on the law applying in the state of treatment) once the treatment has been carried out. You can make the application either
Most Member States provide for co-payments to be made by patients for benefits provided within statutory social insurance. You will initially have to pay these yourself.
Particularly in cases in which you have to pay the entire cost of the treatment upfront on the basis of the regulations applicable in the state of treatment, and you have received a reimbursement in the state of treatment within the statutory range of benefits, it makes sense to apply to your health insurance fund for a reimbursement of the co-payment that you had to pay. This is particularly worthwhile if the co-payments in the state of treatment are very high.
You have received an authorisation from your health insurance fund (form E 112 or S2) for out-patient treatment in France. You have submitted the authorisation to the French healthcare insurer, which then certified that you can receive out-patient treatment.
The French system is a cost reimbursement system. You therefore had to pay the costs to the doctor yourself in the first instance.
After the treatment, you then submitted the invoice to the French healthcare insurer for a reimbursement, which however only reimbursed you the statutory share of 70%. Patients in France have to pay 30% of the cost themselves as a co-payment.
If you now submit the remaining co-payments to your German health insurance fund, it will examine whether it is possible to make an additional reimbursement. This applies if the German health insurance fund would have paid a larger amount for this benefit in Germany.
Alternatively, you can also submit the invoices which you paid in France directly to your health insurance fund for a reimbursement. Your health insurance fund then automatically calculates the reimbursement amount which is more favourable for you overall.
Whether overnight costs and travel expenses or additional costs are reimbursed in the context of cross-border healthcare depends on a large number of factors, and therefore cannot be stated in general terms. Please contact your health insurance fund directly should you have any questions on this matter.
The authorisation procedure that was described above enables you to be certain that the costs of the treatment will be assumed to a considerable extent.
You must however always obtain authorisation from your health insurance fund before undergoing treatment in another Member State or in one of the states mentioned above. What is more, you may only receive treatment from healthcare providers there who have a contract with the statutory health insurance funds there.
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