Access to healthcare : a view from the European Court of Justice Piet Van Nuffel EPPOSI workshop Berlin November 2004

Legal framework for regulating access to health care  Limited powers for the EC  Organisation of healthcare/ maintaining the financial balance = falls mainly to the Member States  Member States must respect EC Legislation Free movement principles

Right to medical care abroad under EC Regulation  If insured person abroad needs immediate treatment (E111)  If insured person is authorised to go to other State to receive there treatment (E112) Entitlement to benefits under terms of the host State Authorisation not to be refused by home State if: benefits covered in home State treatment not available there within time normally necessary What about Ms Keller?

Right to medical care abroad outside EC Regulation (1)  Kohll and Decker  requirement of authorisation under scrutiny: Barrier to free movement of goods or services Can it be justified? Financial balance of social security system Objective of maintaining a medical and hospital service open to all

Right to medical care abroad outside EC Regulation (2)  Requirement of authorisation justified for hospital care (Smits/Peerbooms and Van Riet) necessity of planning of number of hospitals, geographical distribution, mode of organisation, equipment and nature of the medical services aim of controlling costs and preventing wastage of financial, technical and human resources ensuring sufficient and permanent access to high-quality hospital treatment

Patient mobility dependent on type of social security system?  Patient mobility rights: No prior authorisation for ambulatory treatment abroad Prior authorisation for hospital treatment abroad  Apply to home State with reimbursement system (Kohll and Decker)  Apply to home State with system of benefits in kind + agreements with « contracted providers» (Smits/Peerbooms and Müller-Faure/Van Riet) No discrimination between non-contracted providers in home State and abroad

Conditions for grant of authorisation  Benefits to be covered (Smits/Peerbooms)  Requirement of « necessity » for treatment abroad (Smits/Peerbooms) No necessity if same or equally effective treatment available without undue delay  Are waiting lists relevant?

When is an insured person covered for treatment abroad?  Urgent treatment abroad no authorisation needed (E111) covered under host State terms  Ambulatory care abroad if authorised with E112: covered under host State terms without prior authorisation: reimbursed under home State terms  Hospital care abroad: prior authorisation needed if authorised with E112: covered under host State terms reimbursed under home State terms if authorised otherwise

Patients’ mobility rights: challenge for healthcare?  Limitations require justification on grounds of public health/ financial stability  Administrative complication  Change for the better….or not?