Determining the applicable social security legislation is only one aspect of planning work abroad. Equally important is ensuring that employees and their family members have access to public healthcare in the country where they work or reside.
Employee Mobility Is About More Than Just A1
In practice, the attention of both employees and employers is often focused on tax and social security matters. Considerable effort is usually devoted to obtaining an A1 certificate confirming the applicable social security legislation. However, employee mobility is about more than just A1. Issues related to access to healthcare services within the EU and EFTA are governed primarily by Regulation (EC) No 883/2004 of the European Parliament and of the Council and Regulation (EC) No 987/2009 laying down the procedure for implementing Regulation (EC) No 883/2004 on the coordination of social security systems. These regulations form the basis for documents such as the European Health Insurance Card (EHIC) and the S1 form, which enable individuals to access healthcare services outside the country responsible for their health insurance.
It should be noted that the principles described below apply primarily to EU and EFTA countries and, to a certain extent, also to the United Kingdom. In the case of third countries, access to public healthcare may result from local legislation or bilateral international agreements.
A1 Does Not Replace Healthcare Documents
One of the most common misconceptions is treating the A1 certificate as a document that grants access to healthcare services abroad. In reality, these documents serve different purposes. An A1 certificate:
- confirms the applicable social security legislation,
- helps avoid double social security contributions,
- does not in itself grant access to the full range of public healthcare services in the country where work is performed.
In practice, obtaining an A1 certificate does not automatically mean that an employee will be entitled to use the public healthcare system abroad on the same basis as persons insured locally.
EHIC vs S1 – Key Differences
Although both documents facilitate access to healthcare services outside the country of insurance, their purpose and scope are significantly different.
| EHIC | S1 | |
|---|---|---|
| Scope of healthcare coverage | Medically necessary healthcare during a temporary stay | Full access to public healthcare in accordance with the rules of the country of residence |
| Planned treatment | Generally not covered | Covered in accordance with the rules applicable in the country of residence |
| Typical situation | Business trip, temporary assignment, temporary stay | Residence or long-term work in another EU/EFTA country |
| Registration in the country of residence | Not required | Required |
The European Health Insurance Card (EHIC) confirms entitlement to medically necessary healthcare during a temporary stay abroad. The scope of such treatment depends on the circumstances of the individual case, including the person's health condition and the expected duration of the stay. The S1 form, on the other hand, allows the holder to register in the country of residence and access healthcare services under the same conditions as individuals insured in that country.
How Can an S1 Form Be Obtained?
As a general rule, the S1 form may be used by individuals who remain insured for healthcare purposes in one country while residing or pursuing professional activities in another country covered by the social security coordination rules. Under EU coordination rules, individuals entitled to use an S1 form are required to register it with the competent healthcare institution in their country of residence. In practice, using an S1 form generally requires:
- having the appropriate insurance status,
- obtaining the S1 form from the competent institution,
- registering the S1 form with the healthcare institution in the country of residence or stay.
Only after registration can the individual fully benefit from the rights associated with the S1 form. In practice, this step is often overlooked despite being essential for obtaining full access to the local public healthcare system.
The Choice of Health Insurance System May Matter
In international mobility projects, situations increasingly arise where an employee working abroad must choose between the public and private healthcare systems available in the host country. For example, in certain countries, such as Germany, employees may be covered by either:
- the public healthcare system,
- the private healthcare system.
The choice is often made primarily on the basis of contribution levels or the scope of medical coverage. However, it is also worth considering the potential impact that a particular healthcare model may have on the ability to benefit from mechanisms available under EU social security coordination rules, including those related to the S1 form. In certain situations, choosing private health insurance may influence the ability to access public healthcare services outside the country that remains responsible for health insurance purposes. For this reason, healthcare considerations should be assessed at the planning stage of an international mobility assignment rather than only when healthcare services are needed.
What Should Employers Verify Before an International Assignment?
Before work abroad begins, it is worth considering:
- whether the employee holds a valid A1 certificate,
- whether EHIC will be sufficient in the specific circumstances,
- whether obtaining an S1 form is advisable,
- whether the S1 form will need to be registered in the country of residence,
- what healthcare rights will be available to accompanying family members,
- whether the selected healthcare insurance model could affect the employee’s future healthcare entitlements.
PwC Commentary
Discussions relating to international assignments typically focus on taxation and social security contributions. However, ensuring access to healthcare services in the country of work or residence is an equally important aspect of international mobility planning.
Properly understanding the respective roles of A1, EHIC and S1 documents, as well as analysing the healthcare insurance model at an early stage, can help avoid many practical difficulties that arise once the assignment has already started.
As a result, healthcare considerations are increasingly becoming an integral part of a broader Global Mobility assessment alongside tax, social security, immigration and employment law matters.
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