Directive No. 2011/24/EU on patients' rights in cross-border healthcare, which incorporates European Union Court of Justice legal precedent with regard to the free movement of services (particularly the Kohll and Decker rulings), does not apply to this country. This legal precedent allows an insured individual to be reimbursed for ambulatory care by his/her member State of affiliation without prior authorization from his/her health insurance fund.
If you are insured* (or the beneficiary of an insured individual) under the French Social Security system, you may be covered for your healthcare expenses if you travel to Switzerland in order to receive medical care.
* Worker, unemployed, pensioner, daily benefits recipient.
The European Social Security coordination rules (Regulations No. 883/2004 and 987/2009) apply to the EEA member States and Switzerland.
In order to be covered for scheduled treatment (hospital-based care) provided in Switzerland, you must apply for prior authorization from your French health insurance fund.
Standard (non emergency) ambulatory care will not be covered. However, you can be covered for emergency or unscheduled treatment using your European health insurance card (EHIC).
If you are a Swiss cross-border worker who has opted for French health insurance membership, special provisions have been adopted to ensure that you benefit from continuity of care while in Switzerland.
Before you leave, you must apply for prior authorization of coverage for care requiring at least a one-night hospital stay or the use of highly specialized and costly medical equipment or facilities.
Treatments subject to prior authorization are as follows:
The portable S2 certificate, "Entitlement to scheduled treatment," authorizes you to travel to Switzerland to receive medical care. It means that your care will be covered as provided by local law and according to local rates. Indeed, you will receive the same care as members of the local social security system.
You will need to apply for this document (S2 form) from your local health insurance fund in France. Your application must be sent along with a detailed medical certificate issued by your designated primary care physician specifying:
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.
You must apply for your authorization far enough in advance so that your local health insurance fund can process it before you leave.
Your authorization will not be granted automatically. Indeed, the following conditions apply:
If your application is approved, you will be issued with an S2 certificate you will need to show in the Member State you are visiting either to one of the local health insurance fund or directly to your health care provider so that your care is covered locally pursuant to local law.
If your request for prior authorization has been denied, the decision must be reasoned and include instructions on the appeals procedure.
If you are not a resident of the competent State, you will need to apply for authorization of scheduled care through the institution of your place of residence, which will immediately forward your application over to your fund of membership (competent institution). In this case, authorization can be granted:
If you need critical emergency care and prior authorization cannot be denied (the care is covered domestically by the member State of residence and cannot be provided within a reasonable timeframe from a medical standpoint), you will be granted authorization by the health insurance fund of your place of residence on behalf of your fund of membership.
If you or your family members are residing in a State that has opted for the reimbursement of care on a lump-sum, the competent institution to issue the prior authorization will be the health insurance fund of your place of residence as that is the fund that will cover the cost of your scheduled care.
Coverage of transportation expenses:
When the medical service processes an application for prior authorization of scheduled care, it must also process any request for coverage of related transportation expenses at the same time, using the criteria set forth by French regulations (submission of an application for prior authorization valid as a medical prescription).
Transportation expenses must have been medically prescribed to the patient and are reimbursed on the basis of the least expensive itinerary and means of transportation that are compatible with the patient's state of health.
If you paid your medical expenses upfront, you can submit your paid invoices and proof of payment, along with a completed S3125c form, to your health insurance fund to request reimbursement. Your health insurance fund may require additional documents, such as medical reports or scan results.
You have a two-year deadline to apply to your health insurance fund for reimbursement of your medical expenses.
If your reimbursements are related to an illness, your two-year deadline begins on the date of care and expires at the end of the same calendar quarter, two years later.
If your reimbursements are maternity-related, your two-year deadline begins on the date your pregnancy was medically confirmed.
The fund will examine your request for reimbursement. In particular, it will check whether prior authorization had been granted and whether the conditions for reimbursement provided by French law, such as the requirement for a prior agreement or a medical prescription, were met.
Where applicable, your health insurance fund will reimburse you for your care based on Social Security rates in the country where the care was provided or, if you so request, based on French Social Security rates up to a maximum of actual expenses. A supplement can be considered if the foreign rates are lower than the French rates for the same treatment: the French health insurance fund will issue a supplementary reimbursement, up to a maximum of your upfront expenses. For example, for a procedure billed 150 euros, if you were issued a 100-euro reimbursement in the foreign country and the French social security rate is 150 euros, you may receive a 50-euro supplement from your French fund.