FAQ : Directive on cross-border healthcare

Directive No. 2011/24/EU of March 9, 2011 on patients' rights in cross-border healthcare aims to guarantee patient mobility and the free provision of healthcare services.

It aims to facilitate access to safe, high-quality cross-border healthcare and to promote healthcare-related cooperation between EU and EEA (Iceland, Liechtenstein, and Norway) member States.

To whom does the directive apply?

  • All European Union and European Economic Area citizens and their families.
  • Nationals of other countries residing legally in the 28 EU member States, but not those residing in European Economic Area countries (Iceland, Liechtenstein, and Norway).

What types of care are covered by the directive?

  • all healthcare provided or prescribed in a European member State
  • the prescription and dispensation of medications
  • the prescription of medical devices provided as part of a healthcare service.

However, the following are not covered:

  • long-term care (home care services)
  • organ donations
  • public vaccination campaigns

In which countries does the directive allow me to seek care?

  • The 28 European Union Member States and the European Economic Area countries (Iceland, Lichtenstein, and Norway).

What role does the directive assign to the national contact point?

It provides patients with information on:

  • healthcare quality and safety-related standards and guidelines, including provisions for the oversight of healthcare providers.
  • the healthcare providers who are subject to these provisions
  • healthcare providers' authorization to provide care and any restrictions on their professional practice
  • healthcare facility accessibility for people with disabilities
  • patients' rights with regard to cross-border healthcare, procedures and conditions for exercising these rights, and how healthcare costs are reimbursed.
  • the legal and administrative processes for appeal and redress following the provision of cross-border healthcare
  • the information that must appear on prescriptions for medication or medical devices that are written in another member State
  • the contact information for the member States' national contact points

What healthcare providers can I go to in an EU member State other than France?

All public or private healthcare providers, whether or not they are "conventionné" (adhere to a national agreement between practitioners and the social security system), practicing legally in a European Union or European Economic Area (Iceland, Liechtenstein, and Norway) country.

How do I choose a healthcare provider in another country if I plan to seek care there (scheduled care)?

1) If you are covered by the French healthcare system:

  • your regular doctor can also tell you about available care.
  • you can get this information from the national contact point of the country in which you plan to seek care (see online list)
  • you will need to check whether the healthcare provider you have chosen, especially if you have chosen a specialist physician, can be accessed directly or upon referral from a GP.

2) If you are covered by another country's healthcare system:

  • you can get this information from your home country's national contact point or from your local health insurance fund (see online list)
  • your regular doctor can also tell you about available care.
  • The website Annuaire santé is a service provided by the French Health Insurance system. You can use this site to do a multi-criteria search (name, specialty, location, type of care) for a healthcare professional (doctor, nurse, pharmacist, etc.) or a healthcare facility (hospital, clinic) authorized to provide care in France. It also lists fees and reimbursement rates for care and services.
  • You are not required to follow France’s coordinated care pathway (selecting a primary care physician and seeing them before consulting a specialist). You will need to show the GP or specialist your S2 form as proof that the coordinated care pathway does not apply to you and to ensure that you are not charged an extra fee.

Whom do I contact for information on health care costs abroad?

The healthcare provider you see is required to provide you with clear information on his/her rates.

The national contact point of the country you plan to visit may also be able to provide you with information on applicable healthcare rates https://ec.europa.eu/health/cross_border_care/overview_fr

What to do before leaving, during, and after treatment abroad ?

Before you decide to receive healthcare abroad:

  • you will need to find out about your entitlement to coverage of cross-border health care
  • you will need to be aware of the financial implications and the requirements for coverage of your expenses.
  • you will need to check how much of your health care expenses will be out-of-pocket (all of your expenses or the flat-rate charge known as the « ticket modérateur », travel expenses, and the costs of translating your medical files).
  • you will need to know whether a prior authorization for care is required
  • you will need to learn from your doctor about the treatment you wish to receive and identify the health care professional or facility you will be contacting.
  • you will need to assess your need for private travel insurance or supplementary health insurance (coverage for expenses in private facilities, medical transport or repatriation, etc.)

Before you travel abroad for treatment:

  • you will need to learn about your rights to informed consent
  • you will need to have your medical file transferred to your chosen health care provider in France and have it translated if necessary
  • you will need to consider the possible need for an interpreter when you meet with your health care provider
  • you will need to set up follow-up treatment in your home country to ensure continuity of care.

During your treatment abroad:

  • you will need to have your health care provider add your diagnosis, test results, treatment results, list of pharmaceuticals administered, post-op results, etc. to your medical file, either in writing or electronically.
  • you will need to gather and secure all of the documents you will need to submit to the health fund to which you belong to apply for reimbursement.

Following treatment abroad:

  • you are entitled to pay the same fees for health care as those insured in the country in which you receive care.
  • you will need to make sure to get prescriptions that are in line with the applicable regulations so that they can be used in your State of residence when you go home.
  • you will need to have your medical records transferred once they have been added to by your healthcare provider in France.

Before you leave France, it is important that you contact the other country's national contact points and before you come to France, France’s national contact point (soinstransfrontaliers@cleiss.fr) to get all the information you need to ensure that your cross-border care goes forward smoothly.

Do I have the right to access my medical file?

Directive 2011/24/EU guarantees each patient the right to obtain a copy of his/her medical file, containing iinformation such as diagnosis, test results, assessments of treatment by the patient’s various health care providers, and information on any treatment or surgery provided.

How do I request a copy of my medical file before I come to France?

Your country’s designated national contact point can provide all the information you need on how to get a copy of your medical file.

If you receive care in France, make sure that the health care provider you see adds to your medical file (diagnosis, test results, treatment results, list of pharmaceuticals administered, post-op results, etc.)

How do I access my medical file in France and request a copy before I leave the country?

You can request access to your medical file, either personally or through your physician, by sending a registered letter to a health care professional or facility.

You are entitled to access your file within a maximum of eight days following your request, and at the earliest following a forty-eight hour waiting period. The maximum turnaround time is two months for medical information that is more than five years old.

You can access your file free of charge if you go in person. If you want photocopies of your information, you cannot be charged more than the cost of photocopying or any postal fees.

Whom do I contact if I am denied access to my medical file in France?

a) denial by a private-practice professional

  • Appeal to the medical or dental association (« Conseil départemental de l’ordre professionnel ») that covers the doctor’s or dentist’s place of residence
    Or
  • Apply for interim relief before the judge known as the « juge des référés » of the district court « Tribunal de grande instance » with jurisdiction over the practitioner’s office location;

b) denial by a public or private health care facility:

  • within a 2-month deadline following a denial or failure to reply, you can apply to the « Commission d’accès aux documents administratifs/ Cada ») (Committee for access to administrative documents), attaching a copy of your request to access your file, the facility’s denial, and the information needed to identify your file, to your submission. By phone: +33 (0)1 42 75 79 99 – By mail: 35 rue Saint-Dominique, 75700 Paris 07 SP – By email: cada@cada.fr

Cada then has a one-month deadline to notify you of its opinion. If the facility fails to comply with this opinion (continued denial of access), Cada can bring action before the administrative court (« tribunal administratif ») for ultra vires.

What information is included in my French medical file?

  • test results,
  • appointment, operation, exploration, or hospitalization reports,
  • treatment protocols and prescriptions used,
  • follow-up sheets and correspondence between health care professionals.

If you receive care in another country, make sure that the health care provider you see adds to your medical file (diagnosis, test results, treatment results, list of pharmaceuticals administered, post-op results, etc.)

Where can I check the applicable quality and safety standards?

1) if you are considering coming to France to seek care:

  • you can check the website scopesante.fr (in French only), which provides quality indicators for each healthcare facility.

2) if you are planning to seek care in another European Union member State:

  • you can get this information from your home country's national contact point or from your local health insurance fund.

Where can I find information on my rights as a patient in another country?

Since cross-border healthcare is provided pursuant to local law in the country of treatment, patients’ rights under that country’s domestic law apply. You have the same rights and privileges in terms of access to health care and treatment as domestic patients: rights to choose your health care provider, to informed consent, to equal treatment, to privacy, to access your medical records, to appeal and receive compensation, and to information on the cost of care.

For France, please refer to the page: Patients’ rights in France.

For other countries: the national contact point of the foreign country in which you receive treatment (list) or the health care provider you have chosen can supply more information on these rights.

Will a prescription for medications or medical devices written in another member State be recognized in France?

  • Pursuant to Directive 2011/24 EU, each member State must determine the rules for writing a cross-border prescription in order to ensure that medications and medical devices are dispensed securely and that the prescription is clearly understood by the health professional in the other country. Furthermore, the enforcement directive 2012/52 EU establishes a minimum set of information that must appear on all cross-border prescriptions.
  • Your prescription must contain at least the following information:

    Identification of the patient: Last name(s), First name(s), Date of birth

    Authentication of the prescription: Date issued

    Identification of the healthcare professional issuing the prescription

    Last name(s), First name(s), Professional qualifications, Direct contact information (email address and telephone or fax number preceded by international country code)

    Professional address (including the name of the Member state), Signature (either handwritten or digital, depending on the chosen prescription format)

    Identification of the prescribed pharmaceutical, where applicable: common name, brand name indication, pharmaceutical form (tablet, solution, etc.), quantity, dosage, and directions for use.

  • if the prescription is written outside of France, you can check with the other country's national contact point for information on the provisions applicable in that member.
  • the health professional writing the prescription must be licensed to prescribe in his/her home member State.

Will a prescription for medications or medical devices written in France be recognized in another member State?

A prescription written in France must include the following information:

  • The patient's identity: Last name, first name, sex and birthdate, weight and height if necessary.
  • The prescribing doctor's identity: Last name, first name, capacity, title or specialty where necessary, professional address specifying "France," phone number preceded by country code "33" and email address, prescriber's (hand-written or digital) signature, and date of the prescription.
  • Medications: Common denomination of the product, i.e. molecule name. The medication must also be identified by its pharmaceutical form, quantity, dosage and usage instructions. If the prescription is for a biological medicinal product, it must also include the brand name of the prescribed drug in addition to the common denomination. If the doctor does not want the medication to be substituted with a generic, the brand may be written on the prescription along with the annotation "no substitutions" and the reason for this request.

The health professional writing the prescription must be licensed to prescribe in his/her home member State.

Make sure to request a prescription in line with these requirements.

Under what circumstances can a prescription for medication or medical devices be declined?

  • the medications or medical devices prescribed do not have market authorization in the State where treatment is being received.
  • the prescribed medications or medical devices do not have market authorization in the other member State
  • the professionals licensed to dispense medical devices or medications consider that filling the prescription is not in your best interests as a patient, or if they have legitimate, justified doubts as to the authenticity or the content of the prescription, or as regards the capacity of the healthcare professional who wrote the prescription.

How do I appeal a denial of prior authorization (S2 form)?

To appeal an administrative decision, you will need to start by filing a submission with your local health insurance fund (CPAM)’s arbitration board (« Commission de recours amiable »/ CRA). (list of France’s local health insurance funds).

If your appeal is denied, you can then bring proceedings before the court of social security affairs (« Tribunal des affaires de sécurité sociale »/ Tass).

As a last resort, you can appeal to the court of appeals (« Cour d’appel ») and/or to the court of cassation (« Cour de Cassation »).

To appeal a medical decision, you will need to start by asking your local health insurance fund (« Caisse d’Assurance Maladie ») to conduct an expert medical assessment.

On France’s Ministry of Justice website, you can search for contact information for each of the courts to which you can appeal by entering the name of the town in which the health insurance fund that denied the S2 form is located.

Are there restrictions on the coverage of healthcare provided within the European Union?

Important: A member State of insurance may require prior authorization for the coverage of certain types of care requiring a hospital stay of at least one night or the use of major medical equipment.

In addition, they may require those insured under other States' healthcare systems to go through the same administrative and regulatory formalities for reimbursement (healthcare pathway, consulting a primary care physician first, getting a medical prescription, etc.)

1) If you are insured in a State other than France:

You will need to get this information from one of the national contact points of the country in which you are insured or from your local health insurance.

2) If you are covered by the French healthcare system:

You will need to apply for prior authorization (S2 form) from your local health insurance fund (CPAM, MSA, etc..) for any of the following types of care:

  • Care requiring a hospital stay of at least one night
  • Care requiring the use of major medical equipment : scintillation camera with or without a positron coincidence detection system, positron emission tomography, positron camera, clinical nuclear magnetic resonance imaging or spectroscopy, CT scanner, hyperbaric chamber, medical cyclotron;
  • Cardiological procedures using medical imaging, via the endovascular route ;
  • Neuroradiology procedures via the endovascular route ;
  • Procedures on the crystalline lens, with or without a vitrectomy ; or any other surgical ophthalmological procedure ;
  • Ambulatory carpal tunnel and other superficial nerve release procedures, as well as other surgical hand procedures;
  • Treatment of chronic renal insufficiency through extrarenal purification ;
  • Cancer treatment ;
  • The examination of a person's genetic characteristics or identification of a person through genetic fingerprints for medical purposes ;
  • Clinical and biological assisted reproductive technology procedures and biological prenatal diagnostics activities. .

However, for all other types of care that do not require prior authorization (S2 form) you will need to follow France's prior authorization procedure for the following care/services:

  • Dentofacial orthopedic treatments,,
  • Massage-physical therapy procedures requiring prior authorization beyond a predetermined number of sessions,
  • Certain laboratory tests and analyses,
  • Certain cholesterol-lowering drugs, certain medical prostheses,
  • Certain medical prostheses,
  • Long-distance transportation (over 150 km), frequent transportation, commercial airline or boat transportation, transportation connected to the care or treatment of children and adolescents enrolled in early-intervention medical-social centers (centres d'action médico-sociale précoce/CAMSP) and medical-psycho-pedagogical centers (centres médico-psycho-pédagogiques/ CMPP).

Under what circumstances can my request for prior authorization be denied?

  • if the care you intend to receive is not reimbursed by the health care system of the country in which you are insured and is not part of that country's prioritized list of health services.
  • if the care is not appropriate to my state of health
  • if the care can be provided in my country of residence within a reasonable timeframe

How and where do I apply for prior authorization?

1) If you are insured in a country other than France:

You can get this information from your local health insurance fund in your home country.

2) If you are insured in France:

You will need to apply for this document (S2 form) from your local health insurance fund in France, specifying:

  • the type of care you intend to receive as documented by a detailed medical certificate
  • the medical reasons for which you intend to seek care elsewhere in Europe
  • the facility in which you will receive care
  • the expected beginning and end dates of your course of treatment.

You must apply for your authorization far enough in advance so that your local health insurance fund can process it before you leave.

You will receive notice of prior authorization or refusal of coverage from your health insurance fund within 14 days of receipt of your application. If you receive no response within this timeframe, your application has been approved.

To appeal a denial, you may contest the decision before your health insurance fund's arbitration board (commission de recours amiable).

How and where do I apply for prior authorization (under French law) ?

Before you leave, you need to inquire whether the care or treatments you plan to receive will require prior authorization from the Health Insurance Fund in order to be covered. If so, prior authorization will be also required for coverage of scheduled care in another State.

Your designated primary care provider must fill out the request for prior authorisation of coverage and give it to you. You must then complete it and send it to the medical Service of your local Health Insurance Fund in France. You must also send the prescription (original or copy) for care or procedures performed by allied health professionals (physical therapists, speech therapists, orthoptists), for travel expenses for medical purposes, for lab exams or for medical equipment along with your application.

You will receive notice of prior authorization or refusal of coverage from your Health Insurance Fund within a period of 15 to 21 days of receipt of your application, depending on the nature of the care. If you receive no response within this timeframe, your application has been approved.

If your request for prior authorization has been denied, the decision must be reasoned and include instructions on the appeals procedure.

Will I need to pay upfront for the care I receive abroad and then apply for reimbursement?

Under the Directive No. 2011/24 EU, the patient is generally required to pay for healthcare upfront and then apply directly to his/her local health insurance fund in the home member State for reimbursement.

1) If you are covered by a foreign social security system:

your home State's national contact points or your local health insurance fund in your home state can inform you about the applicable reimbursement process.

2) If you are covered by the French social security system:

There are various possible situations:

a) If you have received prior authorization (S2 form) for care subject to prior agreement:

  • you must show this authorization to the facility where you plan to receive care.
  • If a direct settlement system ("tiers payant") is available, the local social security fund will cover your expenses and you will only have to pay any applicable copayment ("ticket modérateur") or out-of-pocket flat fee ("franchise");
  • If you have paid upfront, you will need to submit your paid bill along with your prior authorization to the local health insurance fund in the country where you received care. That fund will reimburse your expenses pursuant to local legislation;
    Important: if you go to a private health care provider or facility that has not signed an agreement with the local social security system, your S2 form will not be recognized. You will need to pay upfront and then submit your paid bills directly to your local health insurance fund in France.
  • if you do not apply for reimbursement in the country where you receive care, or if you receive care from a professional or facility in the private sector, you will need to pay all of your expenses upfront and apply to your local health insurance fund in France when you return home. Your local fund will reimburse you either according to the rates applicable in the country where you received care, or according to French rates.
    Important: if you apply for reimbursement when you return home, you will have to choose between the reimbursement rates applicable in the country in which you received care or those applicable in France. Depending on how much you spent, it is very important to check the rates applicable in each country and to contact the local health insurance funds or national contact points before you make this decision.

b) If you receive ambulatory care not subject to prior authorization:

You will need to pay your expenses upfront and then apply to your local health insurance fund for reimbursement when you return home. Your local sickness fund will reimburse you only according to French rates.

Important: coverage for non-emergency ambulance care is not provided for in the agreements with Switzerland.

What steps can I take if I am denied care in France?

You can bring proceedings before either:

  • the «Défenseur des droits » (Defender of Rights), by submitting your complaint directly via the online form ;
  • the director of the local health insurance fund (« Caisse Primaire d’Assurance Maladie »/ CPAM - list of CPAMs) and/or the health insurance mediator (« conciliateur de l’assurance maladie »), by letter;
  • the head of the local chapter of the appropriate professional association : medical association, nurses’ association, dental surgeons’ association (see online list)

How do I get reimbursement for care I received outside of France?

You will need to fill out and submit form S3125C to your local health insurance fund along with your paid medical bills and proof of payment to apply for reimbursement of your health care expenses in another country.

You have a two-year deadline in which to apply to your local health insurance fund for reimbursement of your care.

How do I appeal the amount I have been reimbursed by my local fund?

If the amount of your reimbursement is not what you expected, you will you will need to start by filing a submission with your local health insurance fund (CPAM)’s arbitration board (« Commission de recours amiable »/ CRA)  (list of Frace's local insurance funds)

If your appeal is denied, you can then bring proceedings before the court of social security affairs (« Tribunal des affaires de sécurité sociale »/ Tass).

As a last resort, you can appeal to the court of appeals (« Cour d’appel ») and/or to the court of cassation (« Cour de Cassation »).

On France’s Ministry of Justice website, you can search for contact information for each of the courts to which you can appeal by entering the name of the town in which the health insurance fund to which you belong is located.

What procedures do I follow if I suffer harm from cross-border healthcare?

Important: the applicable law is that of the country in which the care was provided:

1) If the care was provided in France:

Three procedures can be conducted at the same time  :

  • Arbitration proceedings: you may request arbitration with the facility, either by applying directly to the hospital's director, or by going through the medical or non-medical ombudsman, or the user relations and quality of care board (Commission des relations avec les usagers et de la qualité de la prise en charge (CRUQPC), by letter specifying your complaints regarding your care. You may be offered a direct transaction with the healthcare facility's insurance company. Under certain conditions, you may also apply to the medical accident arbitration and compensation board (commission de conciliation et d'indemnisation des accidents médicaux (CCI - http://www.oniam.fr/trouver-ma-commission et http://www.oniam.fr/indemnisation-accidents-medicaux/partenaires). If the seriousness criteria are met, this board conducts an examination at no cost to the applicant, considering evidence from both parties, to determine the cause-and-effect relationship between the care provided and the harm reported by the patient.
  • Litigation proceedings: proceedings for damages may be brought against the practitioner, either before a civil court if the case involves a physician or other healthcare professional with his/her own practice or a private healthcare facility, or before an administrative court if the case involves a public health facility where the doctor practices, with the patient being considered a public service user. On France’s Ministry of Justice website, you can search for contact information for each of the administrative (public health care providers) or civil courts (private health care providers) to which you can apply by entering the name of the town in which the health care provider in question is located.
  • Disciplinary proceedings: You may submit your complaint to the professional association to which the health professional (practicing either in a public facility or in a private practice) belongs in order to bring ethics-related disciplinary proceedings. (see online list of associations)

2) If the care was provided in another member State:

  • You will need to get this information from the national contact point of the country in which you received care.

How will I be treated if I need emergency care in another country?

  • Always make sure you have a European health insurance card (EHIC) before you go abroad.
  • This card covers all unscheduled (medically necessary) care you may receive during a trip abroad. If you don't have this card and contact the local health insurance fund in the country you are visiting, the foreign health insurance fund may request this document from your local health insurance fund in your home country.
  • If you do not apply for reimbursement of your healthcare expenses in the country you are visiting, you will need to pay upfront and then apply to your local health insurance fund in your home country for reimbursement. Your local health insurance fund in France will reimburse your expenses, using either the reimbursement rates of the country in which you received care or the French reimbursement rates.

Important: if you apply for reimbursement when you return home, you will have to choose between the reimbursement rates applicable in the country in which you received care or those applicable in your home State. Depending on how much you spent, it is very important to check the rates applicable in each country and to contact the local health insurance funds or national contact points before you make this decision.

  • the EHIC also covers care for chronic or preexisting conditions as well as pregnancy and delivery if the purpose of your trip abroad was not to receive care.

Why did the European Commission create the European Reference Networks (ERN)?

The ERNs are being set up under the 2011 Directive on patients' rights in cross-border healthcare and their work stated on 1st march 2017. This Directive also makes it easier for patients to access information on healthcare and thus to increase their treatment options.

Cooperation at EU level makes a real difference to rare diseases patients and their families, as well as the health professionals helping them. No country alone has the knowledge and capacity to treat all types of rare, complex and low-prevalence conditions and diseases, but by cooperating and exchanging life-saving knowledge at European level through ERNs, patients across the EU will have access to the best expertise available.

What are European Reference Networks?

European Reference Networks (ERNs) are networks involving healthcare providers across Europe. They aim to tackle complex or rare diseases and conditions that require highly specialised treatment and a concentration of knowledge and resources. Currently, 24 thematic ERNs are active, involving over 900 medical teams in more than 300 hospitals from 25 EU countries, plus Norway.

The Commission has created the framework for the ERNs and provides grants and technical networking facilities to support network coordinators. However, the driving forces behind the ERNs are healthcare providers and national health authorities.

What medical areas are covered?

The 24 ERNs will work on a wide range of rare diseases. The full list of rare and complex pathologies can be found here: https://ec.europa.eu/health/ern/networks_en

How can the ERNs improve the lives of patients?

Between 6 000 and 8 000 rare diseases affect an estimated 30 million people in the EU. An unfortunate feature of rare diseases and complex conditions is the scarcity and fragmentation of specialist knowledge, which is often not available in the patient's region or country. Many patients therefore do not find a satisfactory explanation for their symptoms or the necessary knowledge on treatment options. By consolidating knowledge and expertise scattered across countries, the ERNs will give healthcare providers access to a much larger pool of expertise. This will result in better chances for patients to receive an accurate diagnosis and advice on the best treatment for their specific condition.

How will the ERNs work in practice?

ERNs are not directly accessible to individual patients. However, with the patients' consent, and in accordance with the rules of their national health system, a patient's case can be referred to the relevant ERN member in their country by their healthcare provider.

To review a patient's diagnosis and treatment, healthcare providers/members of an ERN will consult, exchange information and share knowledge with other members of the network. Coordinators of a specific ERN can convene inter-ERN 'virtual' advisory boards composed of medical specialists across different disciplines. A dedicated IT platform and telemedicine tools can be used for this purpose.

Will the ERNs tackle other diseases or work on other areas of cooperation?

The 24 ERNs currently cover the main clusters of rare, complex and low-prevalence pathologies. In the future, the ERN could possibly be extended to other diseases.

Aside from the diagnosis and treatment of patients, the ERNs will also facilitate research cooperation, joint trainings, knowledge generation, the development of medical guidelines, the facilitation of large clinical studies to improve understanding of diseases, the development of new drugs and medical devices by gathering a large pool of patient data and the development of new care models, eHealth solutions and tools.

OTHER FAQs