The S2 form works only inside the EU/EEA and Switzerland: Regulation (EC) No 883/2004, Article 20, covers planned treatment in another Member State, and Directive 2011/24/EU reimburses care there up to the home tariff. Neither reaches Türkiye, India, Mexico or the UAE. For those destinations the patient’s own scheme decides case by case (Germany: § 18 SGB V says the insurer “can” pay, and only if the treatment is possible solely outside the EU/EEA), NHS.uk offers no route outside Europe, and Medicare generally pays nothing outside the U.S. The realistic payers are a private insurer that gives written pre-authorisation or a guarantee of payment, a Gulf state sponsor with a written approval, or the patient. This guide describes 13 routes, with sources, so that an agency or a provider can ask for the right paperwork before the patient travels. It is planning information, not insurance or legal advice.
Updated: 2026-10-17 · Reading time: 45 min · Guide
Most payer problems in medical travel start with one sentence that nobody checked: “your insurance will pay”. The rules behind it are different in every home country, and the two European mechanisms that people quote most, the S2 form and the cross-border Directive, stop at the border of the EU/EEA and Switzerland. This guide separates the routes that exist from the ones that do not, and says for each who decides, what paperwork is needed, how long it takes, what is usually excluded and what the patient should do before travel.
It is written for health tourism agencies in Europe, the Gulf, the UK and the USA and for the clinics, hospitals and hotels that receive their patients. The payer router at the top of the page asks up to six questions and ends at one of 13 route cards; the sections below hold the same cards in full, a comparison table, the hub destinations, the home-country rules and a list of what an agency must never promise.
The router follows the questions a payer asks. The questions are: (1) where the patient lives: the EU, EEA or Switzerland, the United Kingdom, the United States, a Gulf state, or somewhere else; (2) for patients in the EU, EEA, Switzerland or the UK, where treatment would take place: inside or outside the EU/EEA and Switzerland; (3) whether the treatment is planned or urgent care during a trip; (4) who would pay at home: a public scheme or government sponsor, a private insurer or employer plan, or nobody; (5) whether the treatment is medically necessary or elective and cosmetic; and (6) for EU patients, whether the provider is part of the public system or any provider including private, and for privately insured patients whether the insurer will pay the provider directly. The answers end at one of the 13 routes. Nothing the visitor picks is sent anywhere; the path is kept in the web address so that it can be shared.
The table lists who decides, the main paperwork, the usual time and the main exclusion for each route. Times are the ones the sources publish; where a source gives none, the table says so rather than guessing.
Each route card has the same parts: who pays, who decides, the paperwork, the time it takes, what is typically excluded, what to ask the patient to do before travel, what never to promise and the sources. “Typically excluded” means what the cited rule or payer says is left out, not a prediction for a particular patient.
Who pays: The patient’s own statutory health insurer, at the tariffs and co-payments of the country of treatment. With an S2 the patient is treated as if insured there: where the country of treatment pays providers directly, the bill is settled between the two institutions and the patient pays only the local co-payment (Regulation (EC) No 883/2004, Article 20(2); Manual for patients, section 6.1).
Who decides: The home insurer (the “competent institution”) grants or refuses prior authorisation. It may not refuse when the treatment is among the benefits at home and cannot be given there within a time limit that is medically justifiable, given the patient’s state of health and the probable course of the illness (Article 20(2)).
Paperwork:
Time it takes: No EU-wide deadline: each country sets and publishes “reasonable periods” in advance (Directive 2011/24/EU, Article 9(3)). For comparison, a German statutory insurer must decide a benefit application within 3 weeks, or 5 weeks if its Medical Service is consulted (§ 13(3a) SGB V), and Spain sets a maximum of 45 days for a prior-authorisation decision (Royal Decree 81/2014, Article 16(4)). Ask the insurer for its deadline in writing.
Typically excluded:
Before travel, ask the patient to:
Never promise: That an S2 “will be issued” or that it works at a private clinic: the home insurer decides, and the S2 works only with providers in the public scheme.
Sources: Regulation (EC) No 883/2004, Articles 19 and 20; European Commission, Manual for patients, sections 3.1, 5.1 and 6.1; Directive 2011/24/EU, Article 9.
Who pays: The patient pays the provider; the home insurer reimburses afterwards, up to the cost the same care would have caused under the home scheme and never more than the actual cost (Directive 2011/24/EU, Article 7(4)). Public and private providers are both allowed.
Who decides: The home insurer decides whether the treatment is a benefit at home and whether it needs prior authorisation. A state may require authorisation only for care that involves at least one night in hospital, highly specialised and cost-intensive care, care with a particular risk, or a provider that raises serious quality concerns (Article 8(2)). Where the S2 conditions are met the insurer issues authorisation under the Regulation unless the patient asks otherwise (Article 8(3)).
Time it takes: Requests must be dealt with within reasonable, published periods (Article 9(3)); a state that does not use financial compensation between institutions must reimburse patients “without undue delay” (Article 9(5)). The Directive sets no fixed number of days.
Never promise: A refund amount, or that the whole bill comes back: the cap is the home tariff and the insurer sets it.
Sources: Directive 2011/24/EU, Articles 3, 7, 8 and 9; European Commission, Manual for patients, sections 3.2 and 6.2; Spain, Royal Decree 81/2014, Articles 10 and 16 and Annex II.
Who pays: In practice the patient, unless national law allows a contribution. Neither the S2 nor the Directive reaches a non-EU country: both are written for treatment in another Member State (Regulation 883/2004, Article 20; Directive 2011/24/EU, Article 3(d) and (e)). Example: the German–Turkish social-security agreement gives a statutory-insured holidaymaker in Türkiye only treatment that is needed within 24 hours; all other treatment, private providers and repatriation are paid by the patient (DVKA leaflet “Urlaub in der Türkei”, status 1 April 2026).
Who decides: The patient’s statutory insurer, under its national law and at its discretion. Germany: the insurer “can” pay all or part of the cost, but only if treatment to the accepted medical standard is possible solely outside the EU/EEA, and can add costs for a companion (§ 18(1)–(2) SGB V). France: an exceptional flat-rate reimbursement after a favourable medical opinion, if the patient shows the care cannot be received in France (Code de la sécurité sociale, Article R. 332-2). Netherlands: no special rules for care abroad; the same care must be insured in the Netherlands and costs are reimbursed up to the Dutch tariff, subject to the insurer’s policy terms (Zorginstituut Nederland).
Time it takes: Set nationally and not published for the exceptional route. Germany: a statutory insurer must decide a benefit application within 3 weeks, or 5 weeks if its Medical Service is consulted (§ 13(3a) SGB V). Elsewhere, ask the insurer for its deadline in writing.
Never promise: That an S2, an EHIC or a “European” card works in Türkiye, India, Mexico or the UAE, or that an exceptional contribution is an entitlement.
Sources: SGB V, §§ 13, 18 and 52, gesetze-im-internet.de; DVKA, Urlaub in der Türkei (1 April 2026); Zorginstituut Nederland, Buitenland en zorg; ameli.fr, Soins programmés à l’étranger.
Who pays: The NHS, which pays the state healthcare provider in the country of treatment directly. Some countries still charge the patient a co-payment. The route covers public providers only, never private treatment.
Who decides: In England, NHS England’s European Cross Border Healthcare team; Scotland, Wales and Northern Ireland have their own approving bodies (in Wales the Local Health Board). The treatment must be routinely available on the NHS, and the NHS must confirm that it cannot provide it in a medically acceptable time (“undue delay”).
Time it takes: NHS England says a complete application can take up to 20 working days to process and decide, and longer if information is missing.
Never promise: NHS funding for treatment in the EU: approval depends on undue delay and on the treatment being routinely available on the NHS, and it does not exist for private clinics.
Sources: NHS, Planned treatment (S2 funding route); NHS, Going abroad for medical treatment; NHS Wales 111, S2 funding route.
Who pays: The patient, or the patient’s private insurer. There is no NHS route: the S2 route covers only the EU, Norway, Iceland, Liechtenstein and Switzerland, and NHS.uk says that neither route applies to treatment outside Europe. UKHSA TravelHealthPro calls NHS payment for treatment abroad “very unusual” and adds that it would not usually cover dental care or plastic surgery.
Who decides: No standing scheme exists. For an exceptional request NHS.uk points patients to their local integrated care board (England); a private policy is decided by the insurer under its wording.
Time it takes: There is no application route to time. A private insurer sets its own pre-authorisation time (see the private insurance route).
Never promise: That the NHS will pay for treatment in Türkiye, India, Mexico or the UAE, or pick up the aftercare: UKHSA says follow-up care may not be covered.
Sources: NHS, Going abroad for medical treatment; UKHSA TravelHealthPro, Travelling for treatment (medical tourism), updated 17 June 2024.
Who pays: Nobody under Original Medicare. In most situations Medicare will not pay for health care or supplies outside the U.S. (CMS fact sheet “Medicare Coverage Outside the United States”, April 2026). The three narrow exceptions concern an emergency in the U.S. where a foreign hospital is closer, travel through Canada between Alaska and another state, and a patient living in the U.S. whose home is closer to a foreign hospital; none is a trip made for planned treatment. Medicare Advantage plans may cover extra services abroad: check the plan.
Who decides: Medicare, by rule; a Medicare Advantage plan, by its own terms; a Medigap insurer, for its foreign-travel emergency benefit.
Time it takes: Not applicable to planned treatment abroad, which Medicare does not cover. In the narrow exceptions the patient files the claim after the stay.
Never promise: That Medicare or a Medigap policy will pay for planned treatment abroad.
Sources: CMS, Medicare Coverage Outside the United States (CMS Product No. 11037, April 2026).
Who pays: The plan or insurer, only to the extent the plan documents say so. Federal law requires the summary plan description of an employer plan to state the benefits, the exclusions and the circumstances that can lead to denial (ERISA, 29 U.S.C. § 1022), so the plan documents, not the clinic, decide what is covered abroad. A plan can add a medical-travel benefit or contracted international providers; if it does, the plan documents describe it.
Who decides: The plan administrator or insurer. For employer group health plans covered by ERISA, 29 CFR 2560.503-1 sets the decision times: 72 hours for urgent care, 15 days for a pre-service claim and 30 days for a post-service claim, with one extension of up to 15 days for the last two.
Time it takes: For ERISA group health plans: a decision within 72 hours for an urgent claim, within 15 days for a pre-service claim and within 30 days for a post-service claim, each extendable once by up to 15 days (the urgent claim is not). Other plans and insurers set their own times.
Never promise: That “your employer plan will cover this” before the plan has confirmed it in writing.
Sources: 29 CFR 2560.503-1, claims procedure; 29 U.S.C. § 1022, summary plan description; CMS, Medicare Coverage Outside the United States for Medicare Advantage.
Who pays: The sending state, for patients whose referral abroad its medical committee approves; the patient or family pays for anything the approval does not cover. Published examples. Saudi Arabia: the Ministry of Health announcement of 25 September 2020 says state-funded treatment abroad requires a royal decree or a decision of the Supreme Medical Authority for treatment abroad, while a patient travelling at his or her own expense needs acceptance by a hospital abroad, a certified report that no treatment is available in the Kingdom and a condition the Supreme Medical Council recommends for treatment abroad; approved patients may be accompanied by up to two persons, or as the Authority decides. UAE: the Ministry of Health and Prevention’s “Treatment abroad” service is open to UAE nationals when appropriate treatment is not available in the Ministry’s authorised facilities, and a medical committee decides. Dubai: the Dubai Health Authority’s guideline “Overseas Treatment Policies and Procedures” (2022) is for UAE citizens with a Dubai-issued passport, requires a medical report from an accredited hospital dated within 30 days that recommends overseas treatment, and has a medical committee consider applications at periodic meetings. Oman: the Ministry of Health’s “Treatment Abroad” e-service transfers cases from government hospitals when appropriate treatment is not available in the Sultanate or for approved special reasons.
Who decides: A medical committee of the sending state’s health authority. Saudi Arabia: the Supreme Medical Authority (state-funded) and the Ministry of Health (own-expense travel). UAE: the Medical Committee behind the MOHAP service. Türkiye, as a sending state: the Social Security Institution pays for treatment abroad only in the cases Article 66 of Law No. 5510 lists, notably where the Ministry of Health’s opinion finds that the person cannot be treated in Türkiye. Dubai: the Dubai Health Authority’s medical committee. Oman: the Ministry of Health through its Treatment Abroad service.
Time it takes: Published only for the UAE: the MOHAP service page lists a fee of zero and 5 working days (confirm on the current page). For Saudi Arabia and other states we found no published time, so allow for committee scheduling and ask the patient for the date of the approval.
Never promise: “The ministry will pay” without a written approval that names the facility and the scope.
Sources: Saudi Ministry of Health, Treatment Abroad Scheme Policy Approved (25 September 2020); UAE Ministry of Health and Prevention, Treatment abroad (service page read through search excerpts); Law No. 5510, Article 66, mevzuat.gov.tr. See also Dubai Health Authority, Overseas Treatment Policies and Procedures (2022) and Oman Ministry of Health, Treatment Abroad Request.
Who pays: The insurer, within the policy wording. The territory is a policy term. German private insurers’ model conditions (MB/KK 2009, status June 2024) cover treatment in Europe, extendable to non-European countries by agreement, plus the first month of a temporary stay outside Europe, and the insured event is medically necessary treatment (§ 1(2) and (4)). Other insurers use their own wording.
Who decides: The insurer, through its medical adviser, under the policy wording and the schedule of benefits.
Time it takes: Insurer-specific. Example: Bupa Global says approval can be instant for some treatments and otherwise comes within 48 hours, and that a pre-authorisation is valid for 31 days from the treatment start date.
Never promise: That a policy “covers treatment abroad” without the insurer’s written confirmation for this treatment.
Sources: PKV-Verband, MB/KK 2009 (status June 2024), § 1; BGH, 14 June 2017, IV ZR 141/16; Bupa Global, pre-authorisation guide.
Who pays: The insurer pays the provider directly for the covered part, and the patient pays the rest (deductible, co-insurance and non-covered items), usually only with a network provider and after pre-authorisation. Aetna International’s provider guidance says a guarantee of payment shows which part of the invoice to collect from the patient before discharge and which part the insurer pays; Bupa Global says pre-authorisation lets it settle directly with network providers. See direct billing.
Who decides: The insurer issues or refuses the guarantee after checking cover; the provider should confirm that it accepts that insurer’s guarantee before the patient travels. Aetna International asks providers to request the guarantee before services are rendered.
Time it takes: Insurer-specific. Bupa Global publishes “instant or within 48 hours” for pre-authorisation and 31 days of validity; Aetna International asks the provider to request the guarantee before services, with urgent cases handled by phone around the clock.
Never promise: That a guarantee is unlimited or that the insurer “will pay everything”: it covers only the scope, amount and dates it states.
Sources: Bupa Global, pre-authorisation guide; Aetna International, direct pay process for providers.
Who pays: The patient or the family. This covers treatment where no scheme applies, where cover was refused, and where the chosen provider is one the scheme does not recognise. The contract with the provider sets the price, what it includes and the payment schedule.
Who decides: The treatment contract and the quote. No third party decides, so what the quote includes and excludes is the whole protection (see inclusions and exclusions and the clinic contract checklist).
Time it takes: There is no approval step. The timeline is what the contract says: a deposit at booking and the balance at the stages the contract names.
Never promise: An “all-inclusive” price unless the contract lists what is included and what happens if a complication appears.
Sources: UKHSA TravelHealthPro, Travelling for treatment; Consumer Credit Act 1974, section 75; DVKA, Urlaub in der Türkei.
Who pays: The patient. Public schemes reimburse only what they cover at home: the Directive reimburses care “among the benefits to which the insured person is entitled” in the home state (Article 7(1)); a German statutory insurer must make the patient share the cost of treating complications of an aesthetic operation without medical indication and must withhold or reclaim sick pay in whole or in part for that treatment (§ 52(2) SGB V); and UKHSA says NHS payment for treatment abroad would not usually cover dental care or plastic surgery.
Who decides: Nobody decides a refund, because no scheme covers it. Private insurers follow the wording of the policy, which in the German model conditions is medically necessary treatment (MB/KK 2009, § 1(2)).
Time it takes: Not applicable: there is no approval step.
Never promise: That complications “are covered by insurance at home”: some statutory insurers make the patient share the cost and the NHS may not cover follow-up.
Sources: Directive 2011/24/EU, Article 7(1); SGB V, § 52; UKHSA TravelHealthPro, Travelling for treatment.
Who pays: For a patient who is already abroad and needs care that cannot wait: inside the EU/EEA and Switzerland the EHIC (UK: GHIC) gives access to medically necessary state care on the same terms as local insured people (Regulation 883/2004, Article 19(1); nhs.uk); elsewhere it is travel insurance or the patient. The cards never cover a trip made for treatment: nhs.uk says they do not cover going abroad for planned medical treatments, and the European Commission treats care sought during a holiday that is not medically necessary and could be postponed as planned.
Who decides: The health institution of the place of stay, for the EHIC; the travel insurer’s assistance service, for travel insurance; Medicare only in its three narrow exceptions.
Time it takes: Immediate: the card or the insurer’s emergency line is used at the point of care.
Never promise: That the EHIC or GHIC pays for a trip made for treatment: the cards cover care that becomes necessary during a stay and do not cover planned treatment.
Sources: Regulation (EC) No 883/2004, Article 19; NHS, Going abroad for medical treatment; European Commission, Manual for patients, section 3.
Spain and Germany are EU member states, so an insured patient from another EU/EEA country can use the S2 or the Directive route there, and an NHS patient the S2 route. Türkiye, India, Mexico and the UAE are outside the EU/EEA and Switzerland, so neither the S2 nor the Directive applies, and the NHS S2 route and Medicare do not reach them either. What remains is the patient’s own scheme case by case, a private insurer with a written pre-authorisation or guarantee of payment, a Gulf sponsor with a written approval, or self-pay.
For the destination side of the same decision, see the health tourism hubs guide and, for Türkiye, the authorization certificate guide. Terms such as S2 form, Directive 2011/24/EU, reimbursement and sponsored patient are defined in the health tourism glossary.
The same patient gets a different answer depending on the home country. The table gives the short version for nine home systems with the primary source for each; the route cards above hold the detail.
Every item below is a sentence that sounds helpful and is either false or unprovable at the time it is said. Each is tied to the rule that makes it unsafe.
A provider that wants insurers and agencies to say yes should have ready: an itemised, dated estimate; the treatment plan; a licence and accreditation summary; invoice templates in the insurer’s format; a named contact for payer questions; and a complication clause. The clinic due diligence scorecard and the package price calculator cover the first two.
Health onMESSE is the online trade fair for health tourism. Agencies join free of charge, with no stand fee and no subscription, and meet exhibiting clinics, hospitals and hotels in scheduled video meetings; clinics, hospitals and hotels exhibit to show agencies how they work with insurers, sponsors and self-paying patients.
Agencies join Health onMESSE free of charge and can register as an agency to meet exhibiting clinics, hospitals and hotels in scheduled video meetings and ask them about guarantees of payment, quotes and complication terms before the first case.
Clinics, hospitals and hotels can exhibit at Health onMESSE to show agencies how they handle itemised estimates, guarantees of payment and sponsor invoices, and see the exhibitor packages.
Statutes and regulations were read in their official or consolidated text on 17 October 2026; payer pages are quoted as published on that date. Pages that could not be opened from our server are marked and hedged in the text.
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