ALL WALES PROCEDURE
            ‘ARTICLE 56’ REQUESTS FOR TREATMENT IN
        COUNTRIES OF THE EUROPEAN ECONOMIC AREA 
         Version Number     14 September 2011
         Produced By        All Wales Working Group:
                            Claire Donovan, Cardiff and Vale University Health Board
                            Rob Mahoney, Cardiff and Vale University Health Board
                            Frances Millar, Betsi Cadwaladr Health Board
                            Julie Keegan, Cwm Taf Health Board
                            Maxine Evans, Abertawe Bro Morgannwg University Health Board
                            Yvonne Jones, Powys Health Board
                            Mary Owens, Hywel Dda Health Board
                            Anne-Marie Matthews, Aneurin Bevan Health Board
                            Judith White, Welsh Health Specialised Services Committee
                            Chris Riley, Welsh Assembly Government
                            Legal scrutiny by Welsh Health Legal Services
        Linked Documents     Guidance for the NHS on Cross Border (EEA) Healthcare and 
                              Patient Mobility
                             Policy on Interventions not Normally Undertaken
                             Patient Leaflet
          CONTENTS
          Section 1:    Introduction
          Section 2:    Patient Entitlements to Healthcare Treatment in an EEA Country
                        and Reimbursement of Costs
          Section 3:    Before Obtaining Healthcare Treatment in an EEA Country
          Section 4:    Applying for Treatment in the EEA
          Section 5:    Reimbursement of Treatment Costs
          Section 6:    Process for Applications
          Section 7:    How to Request a Review of the Decision
          Section 8:    Travel Expenses
          Section 9:    Travel Insurance
          Section 10:   Making a Complaint
          Appendix 1: List of EEA Countries 
          Procedure for EEA Requests                                                           Page 2 of 36
        SECTION 1: INTRODUCTION
        Purpose of this Procedure
        1.1  A comprehensive range of NHS healthcare services are routinely made available 
             locally by Health Boards in Wales. In addition, the Welsh Health Specialised Services 
             Committee (WHSSC), working on behalf of all the health boards in Wales, 
             commissions a number of more specialised services at a national level (the use of the 
             term ‘health board’ in this procedure includes WHSSC unless specified otherwise).
             Under certain circumstances, Welsh residents are entitled to secure funding for 
             healthcare treatment in other European Economic Area (EEA) countries. A full list of 
             EEA Member States (countries) is at Appendix 1.
        1.2  Under the “freedom to provide services provisions” of Article 56 of the Treaty on the 
             Functioning of the European Union (TFEU), patients are legally entitled to make 
             request treatment in another EEA country if they would be entitled to that same 
             treatment from the NHS in Wales. In certain, limited, specific circumstances, patients 
             are able either to seek prior authorisation for such treatment before it is carried out and
             then reimbursement of its costs or to make a retrospective claim for reimbursement.
             The National Health Service (Reimbursement of the Cost of EEA Treatment) 
             Regulations 2010 set out the obligations of health boards in Wales in relation to these 
             entitlements. 
        1.3  This All Wales Procedure ensures that health boards in Wales have a clear and open 
             mechanism for making decisions on requests under Article 56 that is fair, lawful, open 
             and transparent. It enables those responsible for decision-making to demonstrate that 
             they have followed due process, given full consideration to the entitlements of patients 
             as set out in the Regulations and been both rigorous and fair in arriving at their 
             decisions. It also provides a clear process for challenge and appeal.
        1.4  Making a request for treatment in another EEA country and the reimbursement of its 
             costs can be a complex task. A patient leaflet is available which summarises the 
             entitlements of patients and explains how to make a request and the people available 
             to help with this. It can be downloaded from our website at 
             www.powysthb.wales.nhs.uk
        Further Information 
        1.5  Further information on obtaining healthcare treatment abroad and on this procedure 
             can be downloaded from our website at www.powysthb.wales.nhs.uk or by contacting:
             The IPFR Co-ordinator
             Powys Health Board
             Monnow Ward
             Bronllys Hospital
             Bronllys
             Powys
             LD3 0LU
              
        Procedure for EEA Requests                                       Page 3 of 36
           Telephone: 01874 712747
      SECTION 2: PATIENT ENTITLEMENTS TO HEALTHCARE TREATMENT IN
                  AN EEA COUNTRY AND REIMBURSEMENT OF COSTS
      Explaining the Routes for Treatment in another EEA Country
      2.1  There are currently two routes for patients to receive planned care in another EEA
           country at the expense of the NHS:
      2.2  Route 1 (“the S2 [previously E112] route”) 
           The S2 (previously E112) route relates only to state-provided treatment and costs are
           dealt   with   directly   between   Member   States.   Member   States   have   discretion   to
           authorise planned treatment in another Member State. However, where treatment
           cannot be provided by the NHS within a time that is medically acceptable, based upon
           clinical assessment, authorisation must be given. 
           A health board will decide whether to authorise treatment, based upon:
              a clinical assessment of the patient’s specific needs;
              agreement that the Teaching Health Board will fund the cost of treatment;
              confirmation that the treatment is not experimental or a drug trial; 
              the treatment being available under the other country’s state health scheme;
               and
              the patient being entitled to treatment under the NHS.
           The S2 (previously E112) route does not cover private sector treatment. 
           Under the S2 (previously E112) route, all care must be authorised in advance. 
           Based on the health board’s decision, the Department of Health would normally
           approve the issuing of an S2 (previously E112) form and separate existing processes
           are in place for this. 
      2.3  Route 2 (“the Article 56 Route”) 
           Subject to the provisions set out below, under the Article 56 route patients can seek
           any health care service (including private care) in another Member State that is the
           same as or equivalent to a service that would have been provided to the patient under
           the patient’s home healthcare system. 
           The patient can choose to receive treatment in the state-provided sector or they can
           access services in the private sector. Except where the legislation requires prior
           authorisation for a special service, a patient may obtain care in another EEA State via
           the Article 56 route without authorisation of the Secretary of State or their Health
           Board. The patient then has a right to claim reimbursement up to the amount that the
           same or equivalent treatment would cost had the patient obtained that treatment from
           their home healthcare system - or the actual amount where this is lower. 
           The principle of reimbursement assumes that patients will pay the overseas provider
           up front for their treatment and then claim reimbursement. It is possible to limit the
           amount that may be reimbursed to the cost of the same or equivalent NHS treatment.
           The patient will also bear the financial risk of any additional costs arising. 
      Procedure for EEA Requests                            Page 4 of 36