How to access treatment abroad when it is not avialable in your country? Planned treatment abroad with the S2 procedure

Regulations (EC) 883/2004 and 987/2009 onSocial Security Coordination – S2

The so-called Twin Regulations on Social Security Coordination state that all permanent residents of the EU contributing to the healthcare system of a member state are entitled to planned medical treatment in all other EEA states and in Switzerland. The costs will be covered if the patient has received authorization by their national healthcare authority prior to the start of the treatment. 

The process for acquiring such authorisation is regulated with administrative Form S2, a document standardized for all EU member states, which is issued by the health insurance authority responsible for the patients. It is then presented to the medical facility abroad. All payments are handled directly by the healthcare authorities of the two member states involved and no upfront payments by the patient are required, beside any that would have also incurred for a local patient in the country of treatment.

Granting authorization is mandatory if the treatment is included in the care package of both countries and cannot be provided in the patient’s home country within a reasonable, justifiable timeframe (also known as the principle of avoiding “undue delay”). Any further authorization is subject to individual assessment, which often leads to conflicts between patients and healthcare authorities on the definition of necessity of treatment or other formalities. 

Further requirements for authorization usually apply and vary between member states. Patients are advised to contact the National Contact Point(s) in their country to receive information about the specific requirements. Generally, they include documentation proving that all of the basic requirements are met, along with a treatment plan from the target healthcare provider and a written confirmation that a S2 Form will be accepted. 

Healthcare authorities are not obligated to cover travel, accommodation or translation costs, but may do so at their discretion. They are also not obligated to authorise applications that do not meet the formal requirements but are allowed to do so should they deem an exception necessary. The same applies for authorising reimbursement after the commencement of a treatment if the patient has failed to apply for prior authorization in a timely manner. 

You can find more information on this subject and also on routine or emergency healthcare at

What’s behind the S2 procedure?

The first step towards the coordination of social security schemes dates back all the way to 1971, with Regulation 1408/1971, concerning the rights of European citizens relocating between countries in the Union and their families. The signing of the Single European Act in 1985 came and went without introducing any major additions or changes to the existing Regulation, which still only concerned itself with scenarios of unplanned (emergency) healthcare across European borders or with the still rare cases of planned treatments the cost. In the years to follow, this lack of change and adaptation to the developing single market started drawing the attention of both policy-makers and experts [1].

Thus, in 2004, a revised version of the Regulation on the coordination of social security systems was drawn: Regulation 883/2004. This coincided with the first drafting of the now-infamous “Bolkestein Directive” concerning the service sector. While a separate entity, namely a High Level Group (HLG) on Health Services and Medical Care was developing Regulation 883/2004, the European Commission also included said services in the proposal for the Directive , but after being met with widespread resistance abandoned the idea. Thus, 883/2004 remained the sole regulator of necessary medical care as part of the provision of social services and for the first time clearly differentiated them from all other services that could possibly be provided to a consumer. Five years later, Regulation 987/2009 was adopted as well in its function of implementation guideline for 883/2004 [2].

[1] Leidl, R., Rhodes, G., (1997). “Cross-border healthcare in the European Union” European Journal of Public Health Vol. 7(3), 1-3

[2] Baeten R. (2012) “Europeanization of national health systems, National impact and EU codification of the patient mobility case law.” EPSU and OSE.