A-Z on social security coordination (FAQs) - Material scope, Maternity benefits, Medical care & Member of the family

The material scope of the coordination regulation extends to all legislation (see the relevant keyword) concerning the following branches of social security: sickness; maternity and equivalent paternity benefits; invalidity pensions; old-age pensions; survivors’ benefits; benefits in respect of accidents at work and occupational diseases; death grants; unemployment benefits; pre-retirement benefits; and family benefits. This list is exhaustive. Consequently, a branch of social security which is not mentioned is in principle outside the scope of the regulation. This is the case, for instance, for housing allowances (see also the keyword social security risks and benefit).

Over and above these social security benefits, the coordination regulation also applies to special non-contributory cash benefits listed in an annex (Annex X to Regulation 883/2004) (see the keyword special non-contributory cash benefit).

Benefits other than those referred to in the answer to question 40.1 do not come within the material scope of the coordination regulation.

A number of benefits are expressly excluded from the regulation’s scope. First of all, it does not extend to social assistance (see the relevant keyword). Furthermore, the regulation does not cover benefits in relation to which a Member State assumes the liability for damages to persons and provides for compensation, such as benefits for victims of war or its consequences (see the keyword benefits for victims of war) but also benefit schemes for victims of crime, assassination or terrorist acts, for victims of damage occasioned by State agents in the course of their duties and for victims of political or religious repression. Moreover, it does not apply to advances to maintenance payments and to special childbirth and adoption allowance (see the keywords childbirth allowances and adoption allowances), as mentioned in Annex I to Regulation 883/2004.

No, not necessarily. Even if social security rights for migrant persons are covered by the coordination regulation, other legal provisions, in particular Article 7(2) of Regulation 492/2011, could also help when claiming social benefits. This provision, which implements the principle of non-discrimination in the context of the freedom of movement of workers, gives migrant workers in the State of employment the right to enjoy the same social advantages as national workers. It is not necessary to reside in that State to be a migrant worker for the purposes of Regulation 492/2011. The notion of “social advantages” is very broad and encompasses, inter alia, benefits excluded from the scope of the coordination regulation, such as advances to maintenance payments, special childbirth and adoption allowances. Residence conditions for entitlement to social advantages are indirectly discriminatory, as they can be more easily met by national workers than by those from other Member States. As a migrant worker or a member of his/her family, you could rely on Article 7(2) of Regulation 492/2011 to challenge such a residence requirement in the legislation of the State where you work. If the authorities of that State cannot demonstrate that the requirement is objectively justified and proportionate to the aim pursued, you could have the benefit exported to the Member State where you reside.

See also the keyword free movement of workers.

It is not always easy to distinguish between maternity benefits and family benefits. The correct classification is crucial, however, as the coordination of maternity benefits, on the one hand, and family benefits, on the other, is governed by different rules.

The coordination of maternity benefits follows the same rules as those which apply to sickness benefits (see the relevant keyword). maternity benefits are usually cash benefits, in which case they are provided in accordance with the legislation of the competent Member State and at its expense. A typical example would be maternity allowance paid during maternity leave in the period immediately preceding and following childbirth. Maternity benefits can also be in kind, such as the provision of medical care in conjunction with pregnancy and childbirth. These benefits are provided in the competent State (subject to certain conditions for family members of frontier workers), in the State of residence and in the State of stay, in accordance with the legislation of these States, and at the expense of the competent State. For more details, please refer to the keywords sickness benefits in cash and medical care.

As indicated, the coordination of family benefits is governed by different provisions. Specific rules of priority apply in cases of overlapping entitlements (see the keyword family benefits). Family benefits within the meaning of the regulation are all benefits in kind or in cash intended to meet family expenses, typically over a longer period of time. It is a broad concept, covering not only general child benefits (family allowances) and special supplements, but also child-raising allowances or parental benefits and child care allowances.

Nevertheless, there might be a grey area, notably when benefits are paid immediately after childbirth and continue to be paid for some years to the person caring for the child. In such cases, it is not clear how long these benefits can continue to be regarded as maternity benefits and when they become family benefits.

When you are entitled to medical care under the legislation of the competent State and stay outside that State, e.g. for holiday purposes, to study, to look for a job or for work as a posted worker, you and the members of your family are entitled to medically necessary treatment. The care is provided in accordance with the legislation of the State of stay, at the expense of the competent State. This implies that the benefits package, the conditions under which care is provided (e.g. referral by a general practitioner), the tariffs, payment method and user charges are those laid down in the legislation applied by the institution of the place of stay. You are treated as if you were insured in the State of stay. For instance, if the legislation of that State provides for care free at the point of delivery, you will receive the treatment free of charge. If, on the other hand, user charges are levied in the State of stay, you will have to pay these as well.

In order to receive the care, you must present your European Health Insurance Card (EHIC) to the health care provider in the place of stay. The EHIC is issued upon your request by the competent institution (sickness fund, national health service) with which you are insured. It is a portable document which certifies your entitlement to care during a stay abroad. The period of validity of the EHIC is determined by the issuing institution. The EHIC does not contain medical data. As it is an individual card, each family member should have their own card.

It is important to note that not all medical care provided by the legislation of the State of stay is available to you. You are only entitled to occasional care, i.e. treatment which, owing to sickness or an accident, becomes necessary on medical grounds during your stay outside the competent State, having regard to the nature of the care and the expected length of your stay. The purpose of the benefits is to enable you to continue your stay under safe medical conditions, considering the planned length of the stay. In other words, you are entitled to treatment that is necessary to ensure that you are not obliged to return to the competent State, before the planned end of your stay, in order to receive the treatment required by your medical condition. In order to determine whether a given treatment meets these requirements, only medical factors are to be considered. The relevant assessment is carried out by the health care provider in the place of stay. It follows that the range of benefits that can be obtained with the EHIC is determined by the temporary nature of the stay abroad. Some forms of treatment, such as elective surgery, typically can wait until your return to the competent State. However, the scope of treatment broadens as the stay in the host State is longer. For instance, treatment to which a tourist on a two-week holiday might not be entitled, may well be available to a posted worker or a student staying in the territory of the host State for a period of over a year.

The EHIC also covers medically necessary treatment for chronic or existing illnesses as well as necessary care in conjunction with pregnancy and childbirth, on the condition that the sole purpose of stay abroad was not to give birth there. For practical reasons, it is necessary that for some types of treatment, notably vital medical treatment which is only accessible in a specialised medical unit, by specialised staff or equipment, prior arrangements are made. This is the case in particular for kidney dialysis, oxygen therapy, special asthma treatment, echocardiography in case of chronic autoimmune diseases and chemotherapy.

In any case, the EHIC cannot be used if the purpose of your stay abroad is to receive care. If you go abroad with the intention to obtain treatment, you must, in principle, apply for prior authorisation (see question 41.4-41.5).

You can only visit health care providers (doctors, hospitals etc.) which participate in the statutory sickness insurance scheme of the State of stay. This generally implies that they have to be public providers (working for the national health service) or providers which are contracted by the sickness insurance institution. In many Member States, private providers cannot provide services which give rise to reimbursement under the statutory sickness insurance scheme. Those providers cannot be visited with a European Health Insurance Card.

The fact that you are not in the possession of a European Health Insurance Card does not mean that you are not entitled to medically necessary care during a stay abroad. As other portable documents, the EHIC is not constitutive of rights. However, there is no guarantee that your costs will be reimbursed under the same conditions as if you had been able to present the EHIC. The doctor or hospital might well ask you to pay the full cost or to pay in advance a proportion of the costs which an insured person in that same Member State would not be asked to pay.

In an emergency situation, if you have to be hospitalised, or if you stay for a longer period outside the competent State, your sickness insurance institution might be able to help by faxing or e-mailing you, upon your request, a Provisional Replacement Certificate (PRC), which gives you the same protection as the European Health Insurance Card. The issue of the PRC may also be requested by the institution of the place of stay. Its period of validity can be limited to the duration of your stay.

There is also another option; if you have borne all or part of the cost of the medical treatment yourself, you may send an application for reimbursement to the institution of the place of stay. If the legislation applied by that institution enables reimbursement of those costs to insured persons, it will reimburse you directly the amount of costs corresponding to the care you received, in accordance with the reimbursement rates laid down in its legislation. If you do not apply for such reimbursement, the competent institution will reimburse you in accordance with the reimbursement rates administered by the institution of the place of stay (or alternatively the amount it would have reimbursed to the latter institution, based on actual expenditure). In case you agree to it, the competent institution may also reimburse the costs in accordance with the reimbursement rates of its legislation. The competent institution may do so without your agreement if the legislation of the State of stay does not provide for reimbursement of medical costs to insured persons. In any case, the reimbursement you receive cannot exceed the amount of costs actually incurred by you. If the expenditure is substantial, the competent institution may pay you an appropriate advance as of the moment you submit the application for reimbursement to it.

As explained in question 41.1, you cannot use your European Health Insurance Card if you go to another Member State with the purpose to receive medical care. The regulation provides that in that case, you must apply for authorisation to the sickness insurance institution with which you are insured. This authorisation is not automatically given. The institution is only obliged to grant you the authorisation if it relates to a treatment which is included in the benefits package of the State where you reside and such treatment cannot be given to you in that State within a time limit which is medically justifiable, taking into account your current state of health and the probable course of your illness. This means that the institution can refuse the authorisation if the treatment in question is not covered by sickness insurance in the State where you reside, and also when, even if the treatment is covered, it can be provided to you in the territory of that State without undue delay. In order to determine whether there is undue delay, the assessment of your medical condition is decisive. The existence of waiting lists is not in itself valid ground for refusing authorisation, nor does it necessarily entail that there is undue delay.

Please note that slightly different rules apply if you do not reside in the State where you are insured. In that case, you must seek authorisation from the institution of the State of residence, which shall forward your request to the competent institution. The former institution will certify in a statement whether or not the abovementioned conditions (treatment in benefits package and undue delay) are satisfied in the State of residence. The competent institution may deny the authorisation only if these conditions are not met in the State of residence or if the same treatment can be provided without undue delay in the competent State. If the competent institution does not reply on the request for authorisation within the deadlines set by the legislation it applies, the authorisation is deemed to have been granted. A special procedure is provided for in case you would be in need of urgent vitally necessary treatment; in that case, the institution of the State of residence can grant the authorisation, on behalf of the competent institution. Please note, however, that if you are a pensioner, or a member of a worker's family residing in a different country than the worker, and you reside in Ireland, Spain, Italy, Malta, the Netherlands, Portugal, Finland or Sweden, it will be the institution of the Member State of residence that will be responsible for a decision on granting the prior authorisation.

When the authorisation is granted, you will be issued with a portable document S2 which you need to present to the sickness insurance institution in the State of stay. You will be treated as if you were an affiliate of that institution. This implies, in particular, that the same reimbursement conditions apply to you as to insured persons covered by the legislation of that State. You will incur no additional expenditure (over the amount which a person insured in the State of treatment would have to pay). This is even so where the foreign medical bill exceeds the amount that would have been covered if you were treated in your State of affiliation. Later on, the institution with which you are insured will refund the institution of the place of stay.

If for some reason you have borne all or part (e.g. user charge) of the cost of the medical treatment yourself, you may send an application for reimbursement to the institution of the place of stay. If the legislation applied by that institution enables reimbursement of those costs to insured persons, it will reimburse you directly the amount of costs corresponding to the care you received, in accordance with the reimbursement rates laid down in its legislation. If you do not apply for such reimbursement, the competent institution will reimburse you in accordance with the reimbursement rates administered by the institution of the place of stay (or alternatively the amount it would have reimbursed to the latter institution, based on actual expenditure).
In cases where the reimbursement of costs incurred on the medical care provided in the State of stay, calculated under the rules in force in that State, is less than the amount which application of the legislation in force in the State of affiliation would afford you, the competent institution, upon your request, will reimburse you the difference, within the limits of the costs actually incurred by you. An example may clarify matters:

A patient insured in Member State A goes to Member State B to obtain medical care. The treatment costs EUR 5,100, including a user charge of EUR 1,100. The amount corresponding to the level of cover provided by the sickness insurance system of State B is EUR 4,000. This amount is paid by the institution of State B and is to be refunded by the institution of State A. Let us assume that the level of cover under the system of State A is more advantageous; for the same treatment, provided to an insured person on its territory, institution A would pay EUR 6,000.00. It follows that the patient is entitled to an additional reimbursement of EUR 1,100.00 (EUR 6,000.00 – EUR 4,000.00 = EUR 2,000.00, limited to the actually incurred cost).

Where the legislation of the State where you are insured provides for the reimbursement of travel and accommodation costs connected with medical treatment, the competent institution, when it has granted authorisation for treatment abroad, will assume these costs for you and, if the legislation provides for it, for an accompanying person.

See also question 41.5.

The fact that you have not obtained authorisation to go abroad or you have not applied for it, does not mean that you cannot be reimbursed for the costs of planned non-hospital medical care provided in another State than the State where you are insured. On the basis of the fundamental principle of free movement of services (Directive 2011/24/EU)  - and not on the basis of the regulation - you are entitled to be reimbursed for the cost of medical care obtained abroad by an amount which your sickness insurance institution would have assumed if the same treatment was given in State where you are insured, by a health care provider participating in the public sickness insurance system of that State. Treatment in these circumstances normally means that you have to approach the foreign provider yourself, pay for the treatment up front and file a claim for reimbursement upon your return. The foreign provider need not be part of the social security system of the State of treatment. Unlike under the authorisation procedure of the regulation (see question 41.4), this health care provider is not required to treat you as if you were insured under his/her system. S/he may treat you as a private patient.

Where treatment abroad costs less than it does in your system, you will not be reimbursed more than you have paid. Where it costs more, you will only be reimbursed up to the level of care provided in the State where you are insured. You may also not expect to receive reimbursement of the costs of treatment that is not among the benefits provided for by the legislation of the State of affiliation.

If you do not have authorization, treatment costs are not covered for EEA nationals in Switzerland or vice versa.

In common with other workers who reside outside the competent State (the State where you are insured), you and your family members are entitled to medical care in the Member State in which you reside, at the expense of the competent institution. In order to receive medical care in the State of residence, you must register yourself and your family members with the institution of the place of residence. Upon your request or upon request of the institution of the place of residence, you will receive from the competent institution a document (portable document S1) certifying your entitlement to medical care in the State of residence. Note that, when your family members are entitled to medical care under the legislation of the Member State of residence and your spouse exercises a gainful activity there, the cost of the benefits provided to them is borne by the institution of that State.

Like other workers who reside outside the competent State, you may also obtain benefits while staying in the territory of the competent Member State, provided in accordance with the legislation of that State and at its expense.

The coordination rules thus guarantee you a right to choose in which of the two States – the State in which you reside or the State in which you work – you wish to obtain medical care. There is a difference, however, for the members of your family. Whereas family members of migrant workers other than frontier workers can receive medical care during a stay in the competent State on the same basis as the workers themselves, for frontier workers’ family members, this applies only in 16 out of 27 Member States. In the territory of 11 Member States (i.e. those Member States which are listed in Annex III to Regulation 883/2004) the members of the family of frontier workers are only entitled to occasional medical care, i.e. care which becomes medically necessary during the stay in the competent State, taking into account the nature of the benefits and the expected length of the stay. This implies, in principle, that they cannot travel to the competent State with the purpose to be treated there, unless they apply for prior authorisation (see also question 41.1 and 41.4-41.5). The Member States on the territory of which this restriction applies are Denmark, Estonia, Ireland, Spain, Italy, Lithuania, Hungary, the Netherlands, Finland and Sweden.

As a pensioner, you and your family members are entitled to medical care in the Member State in which you reside, provided in accordance with the legislation of that State. The cost of the medical care is always borne by a Member State which pays a pension. A distinction has to be made between three situations.

When you receive a pension from the State in which you reside and you are entitled to sickness benefits under that State’s legislation, the cost of the care is borne by the institution of that State, even though you additionally draw a pension under the legislation of one or more other States.

Example 1: During his career, Mr. X has worked in Spain and in France. He is now retired and receives pensions from both these States. Mr. X lives in France. Mr. X may receive medical care in France, at the expense of the French institution. The same goes for his family members. 

If you receive a pension under the legislation of one or more Member States, and you are not entitled to medical care under the legislation of the State in which you reside, you and your family members may nevertheless obtain medical care in the State of residence, provided you would be entitled to medical care if you were resident in (one of) the State(s) which is paying you a pension. In those cases, the cost of the care is borne by the institution of the latter State (or, in case you receive pensions from two or more Member States, by the institution of the State where you have been insured for the longest time, or, in case of insurance of exactly the same length, by the institution where you have been insured lastly.

Example 2: During her career, Ms. Y has worked for 21 years in Member State B and then for 9 years in Member State C. Ms. Y is now retired and resides in Member State A. She draws pensions from States B and C. Ms. Y does not satisfy the conditions for entitlement to medical care in State A. If she were to reside there, Ms. Y would satisfy the conditions for entitlement to medical care in State C but not in State B. Ms. Y may obtain medical care in State A, at the expense of State C. Suppose, alternatively, that Ms. Y, if she were to reside there, would be entitled to medical care both in State B and State C. In that case, she could still obtain medical care in State A, but at the expense of State B, as she was insured there for the longest period of time. 

Finally, if you receive a pension under the legislation of one or more Member States, but not under the legislation of the State in which you reside, yet you are entitled to medical care in the latter State on account of the fact that its legislation makes this entitlement subject only to residence on its territory, the same rules apply as in the second situation.

Example 3: During his career, Mr. Z has worked for 11 years in Member State E and then for 11 years in Member State F. Mr. Z is now retired and resides in Member State D. He draws pensions from State E and F. Despite the fact that he does not draw a pension from State D, he is entitled to medical care there, as State D operates a residence-based medical care system. Suppose that Mr. Z, if he were to reside there, would satisfy the conditions for entitlement to medical care in both State E and State F. Mr. Z may obtain medical care in State D, at the expense of State F, as he was last insured there. 

If you are in the second or in the third situation, you and your family members must register with the institution of the State of residence in order to be able to receive care there. Your right to medical care in the State of residence shall be certified by a portable document S1, which is issued, at your request or at the request of the institution of the place of residence, by the institution responsible for bearing the costs of the care. The cost of the medical care provided to you and your family members is refunded by this institution to the institution of your place of residence on the basis of real costs, on production of proof of actual expenditure. However, in respect of several Member States listed in an annex to the regulation (Annex 3 to Regulation 987/2009), the reimbursement is made on the basis of fixed amounts (lump-sums), which are calculated by reference to average annual health care costs broken down by age group. The States claiming reimbursement on the basis of fixed amounts are Ireland, Spain, Italy, Malta, the Netherlands, Portugal, Finland and Sweden.

Outside the State of residence, you can receive treatment which becomes medically necessary during a stay, using your European Health Insurance Card (EHIC), or you can apply for prior authorisation to go abroad for treatment (see questions 41.1 and 41.5). The State which is responsible for the cost of the medical care provided to you and your family members in the State of residence also has to bear the cost of the care you receive during a stay outside that State. It is that State which is responsible for issuing the EHIC and granting the prior authorisation. However, there is an exception for planned (authorised) treatment as regards the nine States mentioned above. Indeed, if you reside in one of the States who have opted for reimbursement on the basis of fixed amounts, it is that State which will be responsible for granting the authorisation and bearing the cost of the planned treatment received outside the State of residence.

Unfortunately the situation of pensioners with regard to health care entitlements is quite complicated under the new regulation. As a special right in relation to only some Member States (Member States listed in Annex IV of Regulation 883/2004 – i.e. Belgium, Bulgaria, Czech Republic, Germany, Greece, Spain, France, Cyprus, Luxembourg, Hungary, the Netherlands, Austria, Poland, Slovenia and Sweden) pensioners and their family members resident outside the State which has to bear the costs of the treatment can return for any treatment to that State (even in cases where they reside in a Member State which has opted for reimbursement on the base of lump-sums). That means that in these cases no prior authorisation is needed.

Example 4: Ms. T receives a pension from Austria (Member State which has to bear the costs) and resides in Spain (to which the costs have to be refunded by Austria on the basis of lump-sums). Ms. T can of course receive all benefits provided by the Spanish health care system. But she is also entitled to come back to Austria for any treatment she needs or wants to receive. If she wants to go to Portugal for a special treatment she needs the authorisation of the Spanish institution. In case Ms. T received not an Austrian pension but a pension from Finland she would need such an authorisation also in case she would like to come back to Finland for a specific treatment.

When you were still economically active, the coordination rules guaranteed you a right to choose in which of the two States – State of residence or State of (self-)employment – you wished to obtain medical care (see question 41.6). Now that you are a pensioner, you are entitled to medical care in the first of those States, i.e. the State of residence. Outside this State, you can receive treatment which becomes medically necessary, using your European Health Insurance Card (EHIC), or you can apply for prior authorisation to go abroad for treatment (see question 41.7).

In principle, this also applies as regards medical care in your former State of (self-)employment, unless that State is the State which has to bear the costs of your treatment abroad and is among the States listed in Annex IV to Regulation 883/2004 (i.e. Belgium, Bulgaria, Czech Republic, Germany, Greece, Spain, France, Cyprus, Luxembourg, Hungary, the Netherlands, Austria, Poland, Slovenia and Sweden). If that is the case, you can receive medical care in the former State of (self-)employment on the same terms as when you were still working there.

Moreover, the regulation contains a number of provisions extending the right for retired frontier workers to receive medical care in the territory of the former State of (self-)employment beyond medically necessary (occasional) care and authorised (planned) care.

First, if you began medical care in this State while you still worked there, you can continue to receive this treatment for its entire duration. Continuation of treatment is a fairly broad concept and covers not only ongoing treatment but also the continued investigation and diagnosis of your illness. This also applies to the members of your family, except when your former State of (self-)employment is among the 11 States listed in Annex III to Regulation 883/2004 (i.e. Denmark, Estonia, Ireland, Spain, Italy, Lithuania, Hungary, the Netherlands, Finland, Sweden and the United Kingdom, see question 41.6).

Secondly, if both the which is competent to bear the costs of treatment and the State where you used to work are listed in an annex to the regulation (Annex V to Regulation 883/2004), you can receive medical care on the territory of the latter State on the same terms as while you still worked there, provided that you worked in that State for at least two years in the five years prior to your retirement. This extension is applicable to your family members unless the former State of (self-)employment is among the 11 States mentioned above. As both States concerned need to be listed in Annex V and only seven Member States are so (Belgium, Germany, Spain, France, Luxembourg, Austria and Portugal), this second extension of the right to medical care in the former State of (self-)employment is only applicable in a limited number of cases.

Example: Mr. X worked in Austria and Germany; he receives pensions from these 2 States. He lives in Austria but carried out his last activity for 3 years as a frontier worker in Germany. As both States are listed in Annex V, Mr. X continues to have a choice either to get treatment in Austria (this State has to bear the costs of any treatment) or in Germany. If Mr. X were a frontier worker from Austria to Italy and he also received pensions from these 2 States he could not rely on this special provision (as Italy is not listed in Annex V) but he could nevertheless continue a treatment in Italy which has already begun during his career as an active frontier worker in Italy.

If you or your family members go to the territory of the former State of (self-)employment to receive treatment in accordance with these extensions, you must submit to the institution of that State a portable document S3 issued by the competent institution of the country of residence.