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Applying for prior authorization for planned treatment abroad

To finance planned treatment abroad, you can apply for a prior authorization from the Health Insurance Fund based on two different principles:

 1. Under Article 271(1) of the Health Insurance Act

2. Under article 20 of Regulation (EC) No 883/2004 of the European Parliament and of the Council

  1. Provision of the health service applied for is therapeutically justified with regard to the insured person;
  2. The health care service applied for or an alternative health care service cannot be rendered to the insured person in Estonia;
  3. The medical efficacy of the health care service applied for has been proved;
  4. The average probability of achieving the aim of requested health care service is at least 50 per cent.
  1. Provision of the health care service applied for is therapeutically justified with regard to the insured person;
  2. The health care service applied for is provided in Estonia  and it is a service compensated for by the Health Insurance Fund (list of health care services).
  3. The health care service applied for cannot be provided to the patient during a medically justified period of time, considering the patient’s state of health and the probable course of his/her illness;
  4. It must be a healthcare institution in an EU Member State that belongs to the national system.

Important to know

  • In either case, you must submit an application for prior authorization (with all the data fields filled) to the Health Insurance Fund before travelling abroad for treatment or tests. An incomplete application can be processed only after you have provided all the missing information.
  • The application procedure is conducted in Estonian and if an application and other documents affecting the procedure have been submitted in a foreign language, the Health Insurance Fund has the right to require the translation of the documents into Estonian (See § 20 (1) of the Administrative Procedure Act and § 12 (1) of the Language Act).
  • If possible, please add the decision of a council of Estonian doctors to your application (the council report form is available on the website), as the Health Insurance Fund makes its decision on a prior authorization for planned treatment abroad on the basis of the decision by the council of Estonian medical specialists. To get the council report, you should contact your treating physician (medical specialist, not your family physician), who will prepare the council report.
  • If the Health Insurance Fund receives your application without a council report, the Health Insurance Fund will contact the treating physician of the patient with a request to gather a council to determine the need for the health care service and the possibility of rendering it in Estonia.
  • Please submit your application as early as possible. The Health Insurance Fund can make the decision on the reimbursement for planned treatment abroad only before the requested health care service is provided.
  • Please add to the application and/or the council report the cost of requested healthcare service, i.e. the price offer from a foreign medical institution.
  • Pursuant §271 (1) of the Health Insurance Act, there are no restrictions on the choice of country, but the Health Insurance Fund may consider giving preference to a Member State of the European Union.

You can submit your application:

  • by e-mail.
  • by regular mail to the address of the Estonian Health Insurance Fund, Lastekodu 48, Tallinn 10113. 

As the application includes health data, we ask you to agree on the delivery of the application via e-mail and the data necessary for encryption in advance by e-mail at valisravi [at] haigekassa.ee

 

Before submitting your application, please:

  • tell your treating physician in Estonia about your wish to go to a foreign country for treatment, as well as about your application for prior authorization for planned treatment abroad;
  • in cooperation with your treating physician, make sure that the foreign medical institution has expressed its readiness to provide the requested healthcare service;
  • in cooperation with the treating physician, make sure that the foreign medical institution accepts the letter of guarantee or S2 form issued by the Health Insurance Fund.

 

Requirements for a council report

  • The criteria for prior authorization for planned treatment abroad are assessed by at least two medical specialists, one of whom is a specialist providing health care services to the applicant.
  • The council report must be signed by all participants of the council.
  • All fields of the report must be completed. In case of an incomplete council report, you will be requested to add the missing information and this may prolong the application process.

 

Positive decision

If you meet the criteria of a prior authorization for planned treatment abroad, the Health Insurance Fund will issue you a respective decision and a letter of guarantee or S2 form.

The letter of guarantee is issued to the medical institution in a foreign country providing the requested health care service and forwarded by registered mail. A copy of this document will be sent to the applicant and their treating physician in Estonia by e-mail.

The S2 form is issued to the applicant and sent to them by registered post. You must personally deliver the S2 form to the foreign medical institution. A copy of this document will be forwarded to the applicant’s treating physician.

 

If the medical institution does not accept the letter of guarantee, then a contract for a partial assumption of the obligation for prepayment shall be signed between You and the Health Insurance Fund. The amount of the advance payment is to be agreed, but it cannot be more than 50% of the estimated total cost. A written agreement for the advance payment will be concluded within five working days after the decision to satisfy the application. The agreement can be signed only after the Health Insurance Fund has received the price offer on the basis of which the cost of the requested health care service is provided. After the contract has been signed by both parties, the Health Insurance Fund will transfer the funds for agreed proportion of the estimated total costs (not more than 50%) to your bank account at the agreed time. You will pay the total cost of the health care services to the foreign medical institution yourself. To verify that the health services were provided and paid for, you  must submit the original invoice (receipt) and the epicrisis (summary of medical history) to the Health Insurance Fund within 30 days from the provision of the health care services, after which the Health Insurance Fund will reimburse for the remaining amount of the actual cost of health care services. If the health care service is not provided or its cost is lower than the sum transferred to your bank account by the Health Insurance Fund, you are obliged to return the remaining amount to the Health Insurance Fund.

 

Expenses incurred in a foreign country that are not reimbursed by the Health Insurance Fund

The Health Insurance Fund assumes the obligation to pay for medical expenses abroad. The issued letter of guarantee or S2 form does not extend to possible non-medical expenses (patient’s self-liability, transportation costs, translation services, administrative or office expenses, accommodation outside the hospital, etc.). These are paid for to the foreign medical institution by the patient or the patient’s legal representative.

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.

 

Transport when going abroad for medical treatment

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.

 

Refusal 

Before making a refusal decision, the Health Insurance Fund explains in writing to the applicant why it is not possible to 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 the event of a refusal, a written notice to that effect will be issued to the applicant together with the decision.

 

Time required for the procedure of a prior authorization for planned medical treatment abroad

It takes up to 30 days to process an application received together with a council report. Applications received without a council report may take 2 to 3 months to process. 

 

Issue of a prior authorization for planned medical treatment abroad as a matter of urgency

Time resource for emergency cases is limited and reserved for 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. The patient’s treating physician will send a respective confirmation to the Health Insurance Fund. The precondition for the urgent application procedure is that both, the application for a 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.

The following reasons do not allow urgent processing of a prior authorization for planned medical treatment abroad:

  • the time of a surgery or consultation has already been booked at the foreign medical institution, but the application has not been submitted with 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.