Prior authorization for planned medical treatment abroad

Prior authorization for planned medical treatment abroad is a decision taken by the Board of the Health Insurance Fund to assume the obligation to reimburse the applicant for their necessary health care services abroad. To apply for prior authorization, you need to submit a respective application to the Health Insurance Fund (for more details, see “Planned medical treatment abroad”).

Before applying for a prior authorization for planned medical treatment abroad, find out with your treating doctor in Estonia which health care service is required. In order to apply for a prior authorization, the patient or his/her legal representative must fill in an application form (for more details see “Applying for a prior authorization for planned treatment abroad”) and the Estonian treating doctor must fill in the council report. For faster processing, please submit your application together with the council report. In the absence of the latter, EHIF will send a request to your doctor.

The council is a team of doctors that have medical specialists’ competence, and the council works as an advisory body, making decisions to achieve the best possible treatment outcome for the patient.

A person insured by the Health Insurance Fund is entitled to receive health care services (planned treatment) abroad on the basis of certain criteria. Availability of specific health care services abroad depends on the legal basis they are applied for, such as:

1. European Parliament and of the Council Regulation (EC) No 883/2004 Article 20 or
2. Article 27¹(1) of the Health Insurance Act

(For more information see “Planned medical treatment abroad”).

The Health Insurance Fund makes a decision on referring a person for treatment abroad based on the assessment of the Estonian Council of Medical Specialists and by checking the compliance of the application with the criteria provided by law. If the application is accompanied by an appropriately completed council report, it will take up to 30 days to process the application. If the application has reached the Health Insurance Fund without the council’s report, the fund will ask the patient's doctor to convene the council. The council helps find out whether the need for health care services abroad is justified and whether the requested health care services or alternative health care services can be provided in Estonia. If the application is submitted without the council’s report or the information in the report is incomplete, the processing can take 2-3 months (see Question 6 for more details).

If a person’s state of health requires an emergency intervention, the person’s treating physician shall send a respective confirmation to the Health Insurance Fund and the application will be processed as a matter of urgency (see Question 13 for details).

The following circumstances may prolong the processing of your application:

• incomplete application;
• incomplete council report;
• the patient refuses from additional evaluation of their state of health;
• the required documents are not received by the deadline;
• when the patient disagrees with their treating physician regarding the necessity and expediency of the health care services;
• misunderstanding of the principles of prior authorization procedure for planned medical treatment abroad.

Pursuant to Article 27¹(3) of the Health Insurance Act, at the request of the Health Insurance Fund, the insured person must undergo an additional evaluation of their state of health, which will be carried out by a doctor appointed by the Health Insurance Fund for the purpose of identifying the conformity of the state of health of the person to the criteria of planned medical treatment abroad. The Health Insurance Fund applies the requirement to undergo an additional evaluation of health, if it is not possible to provide an assessment of the compliance or non-compliance with the criteria of planned medical treatment abroad or if the assessment is in conflict with the criteria.

If the person fails to undergo additional evaluation of health, the Health Insurance Fund will make a decision on the application on the basis of the information available to us.

In processing the application, the Health Insurance Fund proceeds from the application, the evaluation given by the council and the following criteria provided for in Subsection 27 ¹(1) of the Health Insurance Act:

• the health service applied for or an alternative health service cannot be rendered to the insured person in Estonia;
   
• provision of the health service applied for is therapeutically justified with regard to the insured person;
   
• the medical efficacy of the health service applied for has been proved;
   
• the average probability of the aim of the health service applied for being achieved is at least 50 per cent.

Before making a refusal decision, the Health Insurance Fund explains in writing to the applicant why we cannot finance the health care service through the measure of planned medical treatment abroad. The Health Insurance Fund also gives the applicant the opportunity to submit his/her opinion and objections in writing. In case of a negative decision, a written notice is sent to the applicant along with the statement of grounds of denial of referral to treatment.

Treatment for which medically proved efficacy can be assessed on the basis of published clinical trials and the scientific literature.

A written hearing is communicated to the applicant before a negative decision is taken. In a written hearing the Health Insurance Fund explains in writing to the applicant why we cannot finance the health care service through the measure of planned medical treatment abroad.

A written hearing allows the applicant who has submitted an application for prior authorization of planned medical treatment abroad to submit his/her opinion and objections in writing.

Yes. The application for prior authorization for planned medical treatment abroad must be submitted before going abroad for the treatment. You can start treatment once the Health Insurance Fund has issued a prior authorization.

It takes up to 30 days to process an application submitted together with the council’s report. It takes 2 to 3 months, in some cases even longer, to process an application submitted without the council's report (see Question 6 for more details).

If a person’s state of health requires an emergency intervention, the person’s treating physician shall send a respective confirmation to the Health Insurance Fund and the application will be processed as a matter of urgency (see Question 13 for details).

Time resource for emergency cases is limited and will be allocated to the treatment cases of utmost emergency. An application is processed as a matter of urgency if treatment needs to be rendered within the hours or days. A treating doctor will send a respective confirmation to the Health Insurance Fund. The precondition for the urgent application procedure is that both, the application for prior authorization for planned medical treatment abroad and the council report have been completed and submitted correctly.

On weekends or public holidays, application are not processed.

Prior authorization for medical treatment abroad is not processed or issued as a matter of urgency in the following circumstances:

• the consultation or operation time has already been booked in the hospital and the application has not been submitted with a sufficient time reserve;
• travel tickets have been booked, the application has not been submitted with sufficient time reserve;
• the state of health does not require emergency intervention.

The Health Insurance Fund does not help find a hospital, doctor or health care service necessary for medical treatment abroad. Determining the need for planned medical treatment abroad and finding a suitable medical institution abroad is the responsibility of the applicant in co-operation with his/her treatment treating doctor in Estonia.

The Health Insurance Fund does not book appointments, consultations or operation times abroad. Necessary agreements are made either by the Estonian doctor, the patient or his/her legal representative (for example, a parent).

In general, the Health Insurance Fund does not reimburse transport costs incurred with regard to planned medical treatment abroad.

In exceptional cases, the Health Insurance Fund pays for medical air transport if other means of transport are excluded due to the patient's state of health. The need for medical air transport is agreed between the foreign and Estonian medical institutions. The Estonian medical institution settles invoices directly with the Health Insurance Fund.

From 1 January 2021, the Health Insurance Fund will also pay for medical land transport by ambulance and ferry.

Patient receiving inpatient hospital treatment will have no accommodation costs. In the case of outpatient treatment, the Health Insurance Fund reimburses the patient for accommodation costs in the area adjacent to the hospital (the so-called patient hotel) only during the period of treatment.

The Health Insurance Fund does not cover the out-of-hospital accommodation costs of the family members accompanying the patient.

Based on the S2 form or letter of guarantee issued by the Health Insurance Fund, the foreign medical institution sends the invoice(s) for medical services directly to the Health Insurance Fund and the patient does not have to worry about the payment. The patient or his/her legal representative shall pay the foreign medical institution for possible non-medical costs (transport, translation, administrative or office costs, out-of-hospital accommodation, etc.).

According to the Health Insurance Act, the visit fee limit for outpatient specialized medical care is 5 euros and the daily bed fee limit is 2.50 euros. As a result, the Health Insurance Fund assumes the obligation to pay for the part of the visit fee that exceeds 5 euros. The Health Insurance Fund assumes the obligation to pay for the entire visit fee if medical care is provided to a pregnant woman or a child under 2 years of age. The Health Insurance Fund assumes the obligation to pay the bed-day fee in standard accommodation conditions in the extent that exceeds 25 euros (i.e. 2.5 euros per day for a maximum of 10 days). The Health Insurance Fund assumes the obligation to pay the entire bed-day fee during the provision of intensive care, the provision of inpatient specialized medical care related to pregnancy and childbirth or the provision of inpatient specialized medical care to a person under 18 years of age (see Question 19 for more details).

The Health Insurance Fund does not cover the out-of-hospital accommodation costs of the family members accompanying the patient.

According to the Health Insurance Act, the visit fee limit for outpatient specialized medical care is 5 euros and the daily bed fee limit is 2.50 euros. As a result, the Health Insurance Fund assumes the obligation to pay for the part of the visit fee that exceeds 5 euros. The Health Insurance Fund assumes the obligation to pay for the entire visit fee if medical care is provided to a pregnant woman or a child under 2 years of age. The Health Insurance Fund assumes the obligation to pay the bed-day fee in standard accommodation conditions in the extent that exceeds 25 euros (i.e. 2.5 euros per day for a maximum of 10 days). The Health Insurance Fund assumes the obligation to pay the entire bed-day fee during the provision of intensive care, the provision of inpatient specialized medical care related to pregnancy and childbirth or the provision of inpatient specialized medical care to a person under 18 years of age.

The Health Insurance Fund does not cover the out-of-hospital accommodation costs of the family members accompanying the patient.

To apply for a refund, please submit the following documents:

• invoice for the visit or bed-day fee (PDF file or original invoice on paper);
• proof of payment of the invoice.

Please send the application together with required documents to the e-mail address of the specialist on medical treatment abroad who processed your case or mail it to the address Eesti Haigekassa, Lastekodu 48, Tallinn 10113 with the keyword "Medical treatment abroad".

It is possible to apply for reimbursement from the Health Insurance Fund for unauthorized and already provided health care services on two different grounds:

1. Reimbursement based on the rates valid in Estonia, as set out in Article 662 of the Health Insurance Act (Patient’s Rights Directive 2011/24/EU)

Entitlement to reimbursement for planned medical care in the Member States of the European Union and the EEA, in both public and private medical institutions (see Questions 24 and 26 for details). Only those services that are also available and reimbursable by the Health Insurance Fund in Estonia are reimbursed on the same grounds as they would be in Estonia (for more details see “Planned medical treatment abroad”).

Please note that Switzerland is not covered by Directive 2011/24/EU that entitles a person to seek planned treatment in another EU Member State and to claim reimbursement later when they return home.

2. Reimbursement based on the rates of the country where treatment was provided in case of medical necessity (Regulation (EC) No 883/2004)

This right can be exercised only in case of necessary medical care during a temporary stay in another member state (in the Member Sates of the European Union and EFTA), i.e. in a situation where the necessity arose while the person was already in another member state. The medical institution must be included in a national system (see Questions 24 and 25 for details).

The Health Insurance Fund does not reimburse:

• experimental treatment;
• participation in clinical trials;
• services that is available in Estonia but is not included in the list of health care services (paid service);
• non-medical expenses (deductibles, translation service, accommodation, travel expenses). Special conditions apply to accommodation, deductibles and travel expenses (see Questions 16, 17, 18 and 19 for details).

S2 form is a document that is valid in the Member States of the European Union and the European Free Trade Association (EFTA ) (see Questions 24 and 25 for details) and is issued by the Health Insurance Fund, provided that the applicant is insured in Estonia. When submitting the S2 form, the insured person is treated as an insured person in the respective Member State (country providing the health care service). This means that in some cases the patient has to pay certain costs related to the health care services provided in another country (e.g. country-specific deductibles, transport costs, translation costs, administrative or office costs, out-of-hospital accommodation, etc.).

A S2 form is issued only if the patient has been granted a prior authorization for planned medical treatment abroad.

See more https://europa.eu/youreurope/citizens/work/social-security-forms/index_en.htm

A letter of guarantee is a document confirming that the Health Insurance Fund will cover the patient's health care costs abroad. The letter of guarantee does not cover possible non-medical costs (transport, translation, administrative or office costs, out-of-hospital accommodation, etc.) which will be paid to the foreign medical institution by the patient of his/her legal representative 

The letter of guarantee is issued by the Health Insurance Fund to the foreign medical institution providing the requested health care service. The precondition for issuing a letter of guarantee is that the patient has been granted a prior authorization of planned medical treatment abroad.

Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Ireland, Liechtenstein, Lithuania, Liechtenstein, Luxembourg, Latvia, Malta, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland, the United Kingdom*.

There are four EFTA members: Norway, Switzerland, Iceland and Liechtenstein.

The European Union's relations with the EFTA countries can be divided into two. Relations with three EFTA countries - Norway, Liechtenstein and Iceland - are regulated within the European Economic Area (EEA). However, as Switzerland is not a member of the EEA, the European Union's relations with Switzerland are governed by separate bilateral agreements between the European Union and Switzerland.

There are four EFTA member states: Norway, Liechtenstein, Iceland.

If the S2 form or the letter of guarantee is about to expire but the treatment is still ongoing, you have to apply for extension. For that, please send a respective request at least two weeks before the expiry date to the e-mail address of the specialist of treatment abroad who processed your case.