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Within the framework of the European Patient Mobility Directive, you can only take up treatment in another EU country where your German health insurance fund would also assume the costs for persons in Germany who have statutory health insurance. According to this procedure, authorisation is also necessary if this would be the case under German law, for instance in the case of hospital treatment.
If you undergo hospital treatment, your health insurance fund is only obliged to grant approval of treatment in a hospital in another EU country if the treatment method is recognised in Germany and cannot be provided in Germany promptly, or is not available at all. In all other cases, it will take a discretionary decision orientated towards the individual case. It can therefore grant approval, but does not have to do so.
Some services may only be provided in Germany subject to specific conditions or in a certain form (such as dental prostheses or rehabilitation services). You will need to make sure that these conditions are also met if you undergo treatment in another EU country. Should you have any doubts, we recommend that you contact your health insurance fund or ourselves before undergoing treatment.
Services absolutely requiring prior authorisation by your health insurance fund include:
Out-patient treatments that do not require prior authorisation, such as x-ray diagnostics, computed tomography (CT), magnetic resonance tomography (MRT), etc. will be reimbursed according to the rates applied by German health insurance funds – less a fixed amount for administrative expenses of the health insurance fund – if you submit the invoices.
Before beginning treatment please contact your health insurance fund or the National Contact Point in order to verify whether a prior authorisation is required for the treatment you wish to undergo or not.
You have statutory health insurance in Germany and need a dental prosthesis. You would like to have this dental prosthesis fabricated and inserted in Poland. According to German law, the costs are met only if a treatment and cost plan was drawn up prior to undergoing the treatment on the form which is intended for this and the health insurance fund has approved the treatment and cost plan. These prerequisites also have to be met if you obtain false teeth in Poland.
Before undergoing treatment in another EU country, you must therefore always enquire of your health insurance fund to find out whether certain preconditions must be met. Otherwise, it may happen that costs which you have incurred in relation to a healthcare service are not reimbursed later.
You will find more information on this topic in the link box below when selecting the link “Treatment subject to advance approval”.
If you opt for treatment within the Patient Mobility Directive, you can turn to any registered doctor or dentist in the state of treatment. You are therefore not restricted to doctors and dentists who may only treat persons with statutory insurance.
If you have found a suitable healthcare provider, you conclude a treatment contract with him/her. This should contain information on the benefits to be provided and the costs involved.
Carefully keep all invoices issued by the healthcare providers during treatment. They absolutely must be submitted for a cost reimbursement. Make sure that the invoice clearly states exactly what was done and what it cost.
After the treatment, submit the itemised invoices issued in the respective Member State to your German health insurance fund for a reimbursement.
Before undergoing treatment in a Member State within the framework of the European Patient Mobility Directive, you should contact your health insurance fund and ask what reimbursements can be provided.
As a matter of principle, your health insurance fund will reimburse up to a maximum of the amount which it would have to pay for the same treatment in Germany. It may also deduct specific amounts, for instance for administrative costs or because no value-for-money audit was carried out, as well as the co-payments provided for under German legal provisions. The reimbursement will never be more than the cost which you actually incurred. It is best for you to enquire of your health insurance fund as to what reimbursement amount you can expect before the treatment you are planning is carried out in another EU country. If you are unsure, you can also use the query form for the Standard Schedule of Fees provided by the National Association of Statutory Health Insurance Physicians to obtain information regarding any reimbursement amounts for out-patient treatment.
You have statutory health insurance in Germany and have received authorisation to undergo private treatment in France. You have therefore not received an E 112 or S2 form. Your health insurance fund would have had to pay Euro 5,000 for this operation in Germany. Costs totalling Euro 8,000 were incurred in France.
Your health insurance fund will reimburse you a maximum of Euro 5,000 minus the deductions and co-payments detailed above.
Your health insurance fund will be glad to answer any questions on reimbursing overnight stays, travel or additional costs involved with cross-border healthcare.
You can lodge an objection if your health insurance fund refuses to approve treatment that is planned in another EU country. The same applies if you consider the refund amount paid by your health insurance fund to be too low.
It is best for your objection to be made by letter or fax. It is important for your letter to reveal that you are not satisfied with the decision that has been taken. You can also visit your health insurance fund in person, where an official will take receipt of your objection. Please note that an objection sent by e-mail is not valid.
The objection should generally be filed with your health insurance fund within one month of your receiving the negative decision. This period is extended to three months if the decision was sent to you abroad. Please check to see if the negative decision that you have received from your health insurance fund indicates the possibility of lodging an objection. If this is not the case, you have one year in which to lodge a written objection.
It is recommended in your objection to inform the health insurance fund of the reasons why you are you are not satisfied with their decision. This is however not obligatory.
Once it has received your objection, the health insurance fund will examine the decision that it has taken. If it remains convinced that the decision that it took was correct, your objection will be forwarded to the “Objection Committee”. This committee is composed of representatives of insured parties and employers. The Objection Committee will then let you have a final written statement regarding whether or not it considers the decision taken by the health insurance fund to have been correct. You will also be informed at the end of the decision on the objection that you have the possibility to lodge an action with the Social Court that has jurisdiction within one month. The Social Court with jurisdiction is specified at the end of the Objection Committee’s ruling.
The period within which an action is to be lodged is once more extended to three months if the decision was sent to you abroad. The action can be sent to the court in writing. Since the action needs to meet certain requirements in terms of its content, it is recommended to lodge the action with the social court in person if you do not have legal counsel. In this case, the certifying official of the court registry records your action in writing and ensures that all the requirements in terms of its content are satisfied.
You do not have to have legal counsel in these “first instance” proceedings before the Social Court. This therefore means that you can engage in the proceedings without commissioning an attorney. The litigation before the social court also does not cost you anything.
If the court confirms the view taken by your health insurance fund, you will only have to meet your own expenses yourself. If however the Social Court upholds your view, your health insurance fund will have to pay the costs incurred by both you and by the court.
Treatment within the European Patient Mobility Directive generally offers greater scope with regard to the range of benefits available. However, it may be more expensive than treatment under the conditions for persons with statutory health insurance in the state of treatment. What is more, you will certainly have to pay the costs incurred yourself upfront. You should therefore seek detailed advice from your health insurance fund in Germany before undergoing treatment in the other state.
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