FINANCIAL DIMENSIONS OF HEALTHCARE PROVISION UNDER SOCIAL SECURITY COORDINATION

EMPIRICAL EVIDENCE FROM BULGARIA (2018–2024)

Abstract

This study examines the provision of healthcare under the rules on the coordination of social security systems, focusing on their application in Bulgaria on the basis of empirical data from the National Health Insurance Fund (NHIF) for the period 2018–2024. The analysis concentrates on the financial and institutional dimensions of coordination in the context of the free movement of insured persons within the European Union. Planned treatment and the application of Directive 2011/24/EU are explicitly excluded from the scope of the study. The central argument is that the financial flows generated within the coordination mechanism— particularly inter-institutional payments and reimbursements—constitute a key empirical indicator of the functioning of the national health insurance system in a cross-border context. These flows reflect not only the intensity of healthcare utilisation across borders, but also reveal structural characteristics and asymmetries within the system. The findings demonstrate that healthcare provision under the coordination rules forms a distinct and financially significant segment of NHIF activity, characterised by internal differentiation, temporal discrepancies between the incurrence and settlement of expenditures, and a high degree of concentration with respect to a limited number of countries. The study is structured into four main parts. The first part outlines the normative and institutional framework of coordination, with particular emphasis on Regulation (EC) No 883/2004 and Regulation (EC) No 987/2009, as well as the role of the NHIF as the competent institution. The second part presents the methodology and data sources. The third part provides an empirical analysis of the main financial flows, including healthcare provided in Bulgaria to persons insured in other Member States, incoming and outgoing inter-institutional reimbursement flows, and reimbursements of costs to insured persons. The fourth part discusses the results and identifies the main trends. Methodologically, the study employs a combination of complementary approaches, including document analysis, descriptive statistics, and comparative analysis over time, enabling the identification of both short-term fluctuations and more persistent structural patterns. The conclusion argues that the coordination mechanism should not be viewed solely as a technical system for the financial settlement of expenditures between institutions, but as an essential guarantee for the effective exercise of the right to free movement. By shifting the organisational and financial burden onto national institutions, access to healthcare is ensured without direct financial impact on insured persons, thereby underscoring the role of coordination as a key instrument for the effective protection of social rights in a cross-border context.