A survey of medical payments in Europe from the perspective of a British Retired Person


1.   EEA MEDICAL COSTS Paid by the UK to France, Germany, Italy and Spain for each E121 holder to support their health care in those countries..


Published Average Costs as at 16 March 2010



Average cost per person.





Article 95 (annual)




Article 95 (annual)




Article 95 (annual)




Article 95 (annual)





The amount demanded from EEA countries for any foreign pensioner (E121 holder) resident in the UK was in 2007,  £3368.98 and they received 100% free health care.
Figures o
riginate from The Freedom of Information Team,  Department of Health,  Room 317, Richmond House,  79 WhitehallLondonSW1A 2NS


2Care provided...
Spain 100%,  Italy 100%  France +/- 70%  [It is expected that every family in France carries a supplementary mutuelle insurance.]    Germany [100% is believed, but this needs confirmation - ]

Are we to understand that 70% of the cost to the patient in France is 5202 euros -- but in Spain 100%  of the cost is only 3242 euros and only 2704 euros in Italy (Italy for 2006 – but is 2006 so different from 2007 – both are before the collapse of the £ and the recession)!  Is there not something amiss?

It is abundantly clear that although UK payments to France are 60% higher than to Spain and 92% higher than to Italy the apparent benefit to the elderly expatriate in France is far far less.

One might say that the UK is perhaps being taken ‘for a ride’ by France!

One will also notice that the amount asked in reverse by the United Kingdom is lower than that asked by France or Germany from the UK.
It would seem from a paper previously forwarded to me that the Dutch emigrant is facing some similar kind of confusion.

The sum to be paid is calculated by the country of residence.  Though the procedure is described in Article 95 of  EU Regulation 574/1972
* see link at bottom  ,  the calculation is far from transparently accountable. [The Article 95 is quoted by the Dept of Health in the table above.] This EU Regulation is 38 years old and dates from the time before the regular use of computers in every office.  The UK joined the EEC (as it was called then) in 1973, a year later.

The charging system at the local level in France is that there is, to the patient, a gross charge and a net charge.  The Social Security system (CPAM) is informed of the gross charge and it absorbs about 70% (variable according to type of drug, illness, or treatment) and ask the patient’s 'mutuelle' insurance or the patient himself for the remainder, the net charge.   It could well be the case that the UK is told of the gross charge (assuming bureaucratic honesty) and not that sum less the net charge.   This would result in the UK [in effect the NHS] paying out 100% of the costs, whilst the patient has to find on top another +/- 30%.   The total cost becomes about 130% of the presumed true cost!

This is a point which needs urgent clarification!



Article 24 of  EU  Regulation 883/2004….

1. A person who receives a pension or pensions under the legislation of one or more Member States and who is not entitled to benefits in kind under the legislation of the Member State of residence shall nevertheless receive such benefits for himself and the members of his family, insofar as he would be entitled thereto under the legislation of the Member State or of at least one of the Member States competent in respect of his pensions, if he resided in that Member State.


The benefits in kind shall be provided at the expense of the institution referred to in paragraph 2 by the institution of the place of residence, as though the person concerned were entitled to a pension and benefits in kind under the legislation of that Member State.”


2. In the cases covered by paragraph 1, the cost of benefits in kind shall be borne by the institution as determined in accordance with the following rules:

(a) where the pensioner is entitled to benefits in kind under the legislation of a single Member State, the cost shall be borne by the competent institution of that Member State;


Explanation in plain English…. France v. the UK re the UK Pensioner in France.    competent State = UK  ‘State of residence = France’.  ‘Institution of  competent State  =  NHS or Ministry of Health’. ‘benefits= health-care’.

One may rewrite  paragraph 1.:-

1.     1st phrase

A person who receives a pension from the UK and is not entitled to health-care in France shall receive health-care as he would in the UK under the legislation of the UK if he lived there.


That surely means that he should receive total health-care totally freely.   THAT is the legislation of the UK with regard to pensioners.


     2nd phrase

The health-care shall be provided at the expense of the UK (Ministry of Health/NHS)  by the health care system of France, as though the person was entitled to a pension and health-care under the legislation of France.


     France asks the UK for the money.      -----    The treatment is as would be given to a French pensioner.


The French Pensioner pays according to his means, and the nature of the illness.  The only reference in this regulation relating to costs is that the UK should pay. It does not say that the costs are those which apply to a Frenchman.  It quite clearly states that the healthcare should be as under the legislation of the UK and that France asks the UK to pay. ******************************



 4.  Equitable treatment of the Elderly

From the perspective of the British pensioner it is blindingly obvious that his/her care support in cash terms is inequitable across the EEA.   Whereas his/her individual costs are zero in the UK, they are somewhat variable elsewhere.

But then one may argue that the treatment available is variable.  But then again, for those people resident within the UK the treatment varies according to the qualities of the individual NHS hospital from very good in Cheltenham (I understand) to rather bad in Staffordshire, or from doctor to doctor.

Should it not be desirable that the British elderly expatriate is treated equitably across the EEA, within the limits of the local medical service available?

The same costing system should apply everywhere for British retired people who receive a British Old Age Pension.

In extension, is it not desirable that any elderly expatriate of any EEA nation is treated equitably across the EEA compared to their home nation?


5. The unequal costings at present – The situation in reverse.

Whereas the British OAP in France is provisioned from the UK grant at a high charge of  5202.72 euros for 70%-80% care,  a French retired person in the UK is provisioned at 100% care for £3368.98 charge (=4593.8 euros at 2007 exchange).   This seems extraordinary!


6. How to achieve an equitable condition of costing.

The costs to the patient and to the competent State should surely be related to the Social Security contract which exists between the patient and the competent State.

In France for instance it is an approximate 70%-30%  (variable) ratio cover for the State on the one hand and the French national patient on the other who pays Social Security contributions during his/her working life.

In the UK it is respectively 100%-0% .  The payment of an Old Age Pension recognises this contract within the EU.  [The UK has a generous health support system. One remembers however that younger persons pay sometimes quite heavily for medicaments. In this article one is concerned solely with elderly people.]

Logically the ‘competent’ State, responsible for the health costs of the Old Age Pensioner  as is clearly stated in EU law (viz. Article 24 of EU regulation 883/2004)* see link at bottom  should pay the costs as is normal for that pensioner at home.


One could suggest that for a retired French person in the UK, the French Government should pay +/- 70% and the ‘mutuelle’ of the patient (or the patient himself) should pay the rest.

For a British elderly person in France (or in any other EEA country) the UK Government should pay 100% of the local costs. This seems to be what the EU law states!


For France it would be far more simple if the full costs for treatment were transferred between France and  the UK. by electronic transfer.  I have no doubt whatsoever that in the current age of electronic references this is a workable system.  For France, in effect, the NHS would be a chargeable insurance authority and all charges would be passed to it from the CPAM (the French Social Security System) to cover the Old Age Pensioner.

The Carte Vitale which all expatriate pensioners in France possess and is an electronic record card, would carry a 100% cover message for all E121 holders.  It would be an extremely simple system to manage.

A similar system would work in reverse for French OAPs and the CPAM would do as it does now either raise the supplement of  +/-30% from a mutuelle or charge the patient.  The CPAM would have details of the French pensioner.


Similar exchanges could occur between other countries.  The State of residence could charge the competent State the costs, and the competent State could sort out the costs to the individual or the insurance company. 

In effect the charge arises exactly as it would as though the patient was living in their home nation which is the ‘competent’ State for these charges.

This establishes the link most strongly between the ‘competent’ State and the individual for whom it is responsible.  Moreover the payments would be transparently clear and fair.

It would also dovetail in neatly with the provisions of the EHIC

The EU agreement is thereby simplified and Article 95 of EU Regulation 574/1972 would become largely redundant.


THE NEXT STEPS.  The British Government must intervene with the French Government to ensure that the British Citizen is costed for health care as the Regulations demand.

Regulation 574/72  Article 95 paragraph 6 empowers them to do so.   If the Government refuses to do so then a petition to the EU Commission will be necessary.


To go (or return)  to the introduction to this subject on the main blog site click here




CPAMCaisse Primaire Assurance Maladie

NHS  - National Health Service

EHIC  - European Health Insurance Card.

EEA European Economic Area (the EU plus Norway, Iceland and Lichtenstein). Switzerland is affiliated.


LINKS TO original documents – click on item

                        EU Regulations on Health costs --  883/2004 Article 24;  and 1408/1971 Article 28  (As printed above without annotations)


                        EU Regulation 572/1972 Article 95