DG Employment, Social Affairs and Equal Opportunities Modernised Social Security Coordination Zagreb, June 2010 Coordination in the field of sickness, accidents at work and occupational diseases. Maja GRZYMKOWSKA European Commission DG EMPL

2 DG Employment, Social Affairs and Equal Opportunities2 Overview Coordination rules with regards to the Sickness benefits What is sickness benefit in kind/cash? Coordination rules for sickness benefits in kind: Temporary stay EHIC Scheduled treatment abroad Change of residence Coordination rules for sickness benefits in cash Coordination rules with regard to the occupational diseases and accidents at work Recent developments in the EU law

3 Coordination rules for sickness, maternity and paternity Title III, chapter 1 of Regulation 883/2004; Title III, chapter I of Regulation 987/2009. Decisions of the Administrative Commission

4 S1Concerning European Health Insurance Card S2 Concerning the technical specifications of the European Health Insurance Card S3 Concerning the benefits covered by Articles 19(1) and 27(1) of Regulation 883/2004 and Article 25(A)(3) of Regulation 987/2009 S4 Concerning refund procedures for th eimplementation of Articles 35 and 41 of Regulation 883/2004 S5On interpretation of the concept of ‘benefit in kind’ Under deliberations Decision on the substantial benefits in kind

5 Two categories: benefits in CASH & in KIND CASH benefits – intended to replace income, paid by the State where the person is insured (amount and duration depends on the national legislation); benefits in KIND – healthcare, medical treatment, medicines, hospitalisation & direct payments to reimburse the costs, in principle provided by the State where the person resides or stays long term care

6 Sickness benefits in kind Basic scenarios: Temporary stay outside the State of insurance: I. Necessary care (EHIC) II. Scheduled treatment III. Residence outside the State of insurance

7 I. Necessary care during temporary stay (EHIC) Article 19 of Reg. 883/2004 and Article 25 of Reg. 987/2009 “…during temporary stay” right to “…benefits in kind which become necessary on medical grounds during their stay taking into account the nature of the benefits and the length of the stay”

8 EHIC Certifies entitlement of the person to receive the necessary health care in another Member State Is issued always by the competent MS Reimbursements between the institutions for the costs generated by the use of EHIC on the basis of actual costs –See: article 35 of Regulation 883/2004, Decision S4 para. 2-4

9 EHIC layout Decisions S1 and S2 of the Administrative Commission (in principle – eye readable format)

10 DG Employment, Social Affairs and Equal Opportunities10

11 Future – eEHIC Agreement of the MS in Administrative Commission on the concept Different business scenarios explored On hold

12 II. Scheduled treatment abroad Article 20 of Regulation 883/2004 Prior authorisation is always required: Portable Document S2 Prior authorisation can not be refused if: –“…treatment in question is among benefits provided for by the legislation of the MS where the person concerned resides” –“…can not be given within a time limit which is medically justifiable, taking into account the current state of health and the probable course of the illness”

13 Who delivers the prior authorisation? Article 20, 27 of Reg. 883 and 26 of Reg.987 If a person resides outside the competent MS – asks for prior authorisation via the institution of the MS of residence but final decision taken by competent MS (special rules for urgent vitally necessary treatment). Exception: pensioners and the members of the family of worker while residing in a MS receiving lump-sums (listed in annex 3 to Regulation 987/2009) the MS of residence decides on prior authorisation

14 What the person authorised is entitled to? In principle to the treatment on the conditions set by the legislation of the MS where the health care will be delivered. Right to the complement if reimbursement tariff in the MS of residence is higher (C-369/98, Vanbreakel – Article 26(7) of Reg. 987) Reimbursement of travel and accommodation costs if the legislation of the competent MS provides for such a reimbursement (C-466/04,Acereda Herrera – Article 26(8) of Reg. 987)

15 III. Residence outside the competent Member State –Possibility of transfer of the residence – obligation of registration (Article 24 of Reg. 987/2009) Portable Document S1 –Equal rights in the MS of residence as the person insured there –Different scope of rights in the competent MS: Insured persons (article 17 of Reg. 883/2004) Member of the family of the frontier worker (Article 18(2) of Reg. 883/2004, Annex III to Regulation 883/2004) Pensioners (Annex IV to Regulation 883/2004)

16 Sickness benefits in Cash Principle of exportability (article 21 of Regulation 883/2004) Rules preventing overlapping of long term care benefits (article 34 of Regulation 883/2004)

17 Accidents at work and occupational diseases Title III, Chapter II of Regulation 883/2004, Title III, Chapter II of Regulation 987/2009 In principle – the same rules applies as for the sickness benefits in kind and cash Special rules: –Determination of the MS providing benefits for occupational disease if person has been exposed for the same risk in several MS (article 38 of Regulation 883/2004, article 36 of Regulation 987/2009) –Rules in a case of aggravation of occupational disease (article 39 of Regulation 883/2004,) –Procedures for notifications (article 34 of Regulation 987/2009)

18 Recent developments in the EU law: Directive on patients mobility and our Regulation ECJ jurisprudence on the basis of the Treaty: Extension of the right to receive reimbursement for the planned treatment abroad Conditions of reimbursement less advantageous than in Regulations (national tariff) But, in principle, no prior authorisation required In 2007 the Commission presented the proposal of the Directive On 8 th of June 2010 EU Council adopted common position - soon, proposal in the second reading in the European Parliament

19 THANK YOU