Healthcare (European Economic Area and Switzerland Arrangements) Act 2019

Policy background

What is reciprocal healthcare?

3. Reciprocal healthcare is a small and important element of general healthcare policy in the UK. Reciprocal healthcare agreements support people from the UK to obtain healthcare when they live in, work in or visit other countries (and vice versa for people from other countries who are in the UK).
4. These normally involve the UK and the other country agreeing to waive healthcare charges for migrants, workers or visitors. Some agreements involve the UK and other countries reimbursing one another for the cost of healthcare-this approach underpins the EU reciprocal healthcare arrangements. Reciprocal healthcare agreements can facilitate co-operation on planned treatment or other areas of healthcare policy.

EU Reciprocal Healthcare

5. The EU reciprocal healthcare system enables UK citizens to access healthcare when they live, study, work, or travel abroad in the EU, EEA or Switzerland, and likewise for EU/EEA/Swiss citizens when they are in the UK. This includes:
   1. State Pensioners (using "S1" forms): healthcare for 180,000 UK state pensioners living abroad, principally in Ireland, Spain, France and Cyprus and for their dependent relatives. There are smaller numbers of EU state pensioners residing in the UK.
   2. Visitors and students (using European Health Insurance Cards (EHIC)): emergency and needs-arising healthcare when UK residents visit the EU, EEA or Switzerland e.g. on holiday, to study, etc. People who are ordinarily resident in the UK qualify for an UK-issued EHIC and 250,000 medical claims are resolved each year. EU nationals visiting the UK can use EHICs to receive emergency and needs-arising NHS healthcare for free with the cost recouped from their home Member State.
   3. Workers (using "S1" forms or an EHIC): healthcare for employees of UK firms/bodies working in the EU, EEA or Switzerland (posted workers) and for frontier workers living in the EU, EEA or Switzerland and working in the UK and vice versa.
   4. Planned treatment (using "S2" forms): funding for UK residents to travel overseas to receive planned treatment in other countries (e.g. for procedures unavailable in the UK within a medically-justifiable timescale or returning home to give birth). EU citizens may also be able to access planned healthcare in the UK via this system.
6. EU reciprocal healthcare arrangements have to date in the UK been enabled by EU regulations (Regulations (EC) 883/2004 and 987/2009 and their predecessors – "the EU Social Security Coordination Regulations") which set out detailed rules for who is eligible and reimbursements, and provide the legal authority for the Secretary of State to make overseas payments.
7. The UK is responsible for reimbursing other Member States for the cost of healthcare received in other states by people for whom the UK is responsible under the EU Social Security Coordination Regulations. For example, UK nationals using their EHIC to access healthcare as tourists or students in another Member State, or UK pensioners or certain workers residing in another Member State, who are "S1" holders. These all operate on a reciprocal basis, meaning that the other Member States reimburse the UK for the cost of the healthcare provided to their own nationals living in, working in, or visiting the UK if provided for by the EU Social Security Coordination Regulations.
8. These rules mean that UK nationals residing in another Member State may obtain treatment as a resident of the country in question. The range of medical services in Member States may be more (or less) restricted than under the NHS, and in some cases patients may need to make a contribution towards the costs of their care (co-payments), but access to healthcare will be at a reduced cost (and in some cases for free).
9. The table presents a break down by Member State of where UK nationals receive healthcare under the routes described in paragraph 5. More than 90% of UK state pensioners and their dependents reside in Ireland, Spain, France and Cyprus. The use of EHIC by UK residents is highest in Spain, Poland and Germany representing approximately 70% of claims to the UK for healthcare use by UK nationals in the Member States.

Summary of UK-issued S1 and S2 forms and EHIC use, by Member State 1

Member State of residence	Sum of UK Insured S1 Registered Pensioners and Dependents in the EEA and Switzerland (2017 2 )	UK-issued S2 forms (2017) 3	Use of EHIC in EU by UK residents (2016)	Number of UK residents’ visits to the EU/EEA (2017) 4
Belgium	450	25	2,700	1,616,711
Bulgaria	900	<10	690	527,635
Czech Republic	200	60	3,800	576,602
Denmark	30	0	0	468,016
Germany	2,800	90	22,000	2,909,349
Estonia	25	<10	0	N/A
Greece	2,600	10	2,300	2,382,736
Spain	67, 000	150	91,000	15,871,874
France	41,000	100	18,000	8,861,670
Croatia	80	<10	2,200	N/A
Ireland 5	45,000	40	N/A	N/A
Italy	2,400	50	5,200	4,159,927
Cyprus	11,600	0	2,800	901,370
Latvia	35	<10	100	N/A
Lithuania	35	25	900	389,234
Luxembourg	50	<10	100	80,200
Hungary	400	60	<10	669,419
Malta	2,600	<10	0	518,645
Netherlands	250	15	3,800	2,659,846
Austria	600	10	9,200	589,809
Poland	450	550	55,000	2,672,386
Portugal	3,800	<10	0	2,875,595
Romania	35	<10	35	1,008,754
Slovenia	70	0	750	N/A
Slovakia	35	90	5,400	185,988
Finland	45	<10	0	158,613
Sweden	150	10	3,200	376,223
Iceland	<10	<10	700	N/A
Liechtenstein	N/A	0	<10	N/A
Norway	40	<10	0	304,855
Switzerland	300	15	3,300	955,303
Total	180,000	1,350	233,000

10. In addition to reciprocal healthcare under the EU Social Security Co-ordination Regulations, the EU put in place additional arrangements to promote patient mobility and choice within the EEA. These are set out in a Cross-Border Healthcare Directive 2011/24/EU (‘The Directive’). The main measures include: allowing patients to obtain reimbursement for certain healthcare they purchase in the EEA; allowing patients to have prescriptions fulfilled when they visit another Member State; and arrangements for provision of information on services. The UK legislation transposing the Directive includes the National Health Service (Cross-Border Healthcare) Regulations 2013 (SI 2013/2269) for England and Wales, the National Health Service (Cross-Border Health Care) (Scotland) Regulations 2013 (SI 2013/292) for Scotland, and the Health Services (Cross-Border Health Care) Regulations (Northern Ireland) 2013 (SR 2013/299) for Northern Ireland.
11. As set out in the White Paper on the Future Relationship with the EU6, published 12 July 2018, the Government’s ambition is to ensure broad continuation of the current EU reciprocal healthcare arrangements after the UK exits the EU. The UK intends to do this by way of a future agreement with the EU, EEA states and Switzerland. However, it remains open to the UK to enter into bilateral arrangements with individual countries if necessary.
12. Prior to this Act, the Secretary of State only had very limited domestic powers to pay for treatment received in other Member States and to recover costs from Member States in certain scenarios. Domestic legislative implementation options related only to fee waiver and making use of, in England, the Secretary of State’s overseas visitors charging power and underlying regulations (the devolved administrations have similar legislative mechanisms). The Secretary of State did not have specific powers to give effect to comprehensive healthcare arrangements for overseas healthcare, or implement reciprocal healthcare agreements with other countries other than the ability to exempt individuals from charges for relevant NHS services. As the UK leaves the EU, it is necessary for domestic legislation to provide the Secretary of State with such powers.
13. In a deal scenario, primary legislation required for implementation (such as an EU (Withdrawal Agreement) Act) would not support long-term arrangements covering the general UK population after any agreed implementation period. The Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 will work alongside any such primary legislation.
14. In the event the UK does not reach agreement with the EU, powers in the Act can be used to make provision to arrange for healthcare within an EEA state or Switzerland for UK citizens, either on a unilateral basis or by means of bilateral agreements with individual countries, as required.
15. The powers enable the Secretary of State to address the essential matters relating to healthcare within the EEA or Switzerland (including the EU as a whole), such as defining individual arrangements to access healthcare for UK nationals, and operational and administrative matters, including data sharing where necessary to facilitate treatment. This includes being able to reimburse other countries for healthcare costs, and to recover healthcare costs from them.
16. The powers in the Act provide the Secretary of State with the legislative means to address a number of different EU exit outcomes and an ability to implement new comprehensive reciprocal healthcare agreements in the future.
17. The Act:

• Enables the UK to implement any future relationship with the EU on reciprocal healthcare as necessary; and
• Ensures the UK is prepared for any outcome if there is no deal on the UK’s withdrawal from the EU. This could include implementing any negotiated reciprocal healthcare arrangement, or making unilateral arrangements for UK nationals to assist with accessing healthcare abroad in exceptional circumstances.

18. This Act will work alongside other EU exit legislation, such as an EU (Withdrawal Agreement) Act if brought into force in a deal scenario or relevant reciprocal healthcare regulations made under section 8 of the EU (Withdrawal) Act 2018 to take effect in a no deal scenario.