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Reimbursement of treatment costs in the European Union

 Directive 2011/24/EU of the European Parliament and of the Council on the application of patients’ rights in cross-border healthcare in the EU

As of 25 October 2013, persons insured by the Health Insurance Fund can go to another European Union (EU) member state, as well as Norway, Iceland and Liechtenstein to receive health care services there and apply to the Health Insurance Fund for reimbursement.

In Switzerland, Directive 2011/24/EU does not apply, which means that in Switzerland, medical expenses are not reimbursed without prior authorization. 

 

  • In this case you do not need to apply for prior authorization from the Health Insurance Fund.
  • You can have your medical treatment in both public and private medical institutions.  
  • At first the patient has to cover all the costs by themselves and after receiving the health care service and submitting all necessary documents they can apply to the Health Insurance Fund for reimbursement. The Health Insurance Fund pays reimbursement based on the prices listed in the Health Insurance Fund’s list of health care services, not on the basis of the price list given by the foreign medical institution.
  • Referral letter from a medical specialist (incl. family physician) is required.

 

A referral from a medical specialist (incl. family physician) is also required when seeking treatment abroad on the same grounds as it would be when seeing a doctor in Estonia. The referral requirement does not apply in the following cases:

  • when seeing a psychiatrist, gynecologist, dermatologist, lung doctor (in case of suspected tuberculosis), ophthalmologist, surgeon, dentist or in case of a trauma.
  • the patient is a pupil or student studying in another member state and has submitted a respective certificate to the Health Insurance Fund;
  • the person has been issued one of the following forms: E112/S2, E106/S1, E109/S1 or E121/S1);
  • the patient is referred to another medical specialist during the stay abroad and he/she does not return to Estonia in the meantime;
  • the need for medical care arose while the person was already in another member state (necessary medical care under the Regulation (EC) 883/2004 of the European Parliament and of the Council).

Important to know

  • The Health Insurance Fund will only reimburse the costs of these health care services, pharmaceuticals and medical devices that the patient is also entitled to receive at the Health Insurance Fund’s expense in Estonia. 
  • Health care services that are available for Estonian insured persons only for a fee (such as adults’ laser operations to correct vision, vaccinations performed outside the national immunization plan) or are not indicated for a patient cannot be reimbursed.
  • The Health Insurance Fund pays reimbursement based on the prices listed in the Health Insurance Fund’s list of health care services, not on the basis of the price list given by the foreign medical institution. If the cost of a health care service received in a foreign country is higher than that of listed in the Health Insurance Fund’s list of health care services, then the patient will have to cover the price difference. The patient will also cover self-liability part, travel costs out-of-hospital accommodation and other costs which would not be reimbursed for the same health care service in Estonia. 
  • Cross-border health care benefits do not include additional fees and self-liability expenses that the insured person is subject to.
  • When processing cross-border health care benefits application, the Health Insurance Fund has the right to use the Internal Market Information System established under the European Parliament and Council Regulation (EU) No 1024/2012 concerning administrative cooperation through the Internal Market Information System (OJ L 316, 14.11.2012, pp. 1-11), in order to check the medical invoices.
  • To be able to apply for reimbursement of medical expenses, all health care service invoices and prescriptions have to be paid. The Health Insurance Fund does not handle unpaid invoices.
  • The Health Insurance Fund uses one bank account for each insured person at a time. If you have submitted to the Health Insurance Fund different bank account numbers while applying for benefits then all transactions that have not been made yet will be made to the account that was submitted last. Account data can be changed through the citizen’s portal or with a written application.

 

Reimbursement application

To claim reimbursement, you need to submit to the Health Insurance Fund the following documents:

1.     Reimbursement application
2.     Original invoices, copies of prescriptions, documents certifying the payment
3.     Summary of medical history / epicrisis (may be a copy) containing the following information:

  • patient's name and personal identification code; 
  • name of the medical institution and department;
  • the period of treatment, number of bed-days;
  • description of the health care services provided;
  • diagnosis (principal diagnosis, concomitant conditions, diagnostic reasoning, course of illness, patient’s condition at arrival);
  • examinations/analyzes performed, pharmacotherapy;
  • surgeries (date, name, anesthesia);
  • condition at discharge;
  • regimen and treatment, recommendations for rehabilitation;
  • prescribed drugs;
  • confirmation of the need for a certificate for incapacity for work;
  • name of the treating physician

4.     Referral (may be a copy). 

 

You can submit your reimbursement application:

  • by e-mail: info [at] haigekassa.ee
  • by regular mail to the address of the Estonian Health Insurance Fund, Lastekodu 48, Tallinn 10113. 

Please bring the original invoices and payment documents issued by the medical institution to the Health Insurance Fund's customer service office or send them by registered mail to Lastekodu 48, Tallinn, 10113.

The processing time for a reimbursement application submitted under the European Union Free Movement of Patients Directive is up to 3 months and the Health Insurance Fund transfers the funds to the bank account specified in the application within 15 calendar days from the positive decision of reimbursement.

 

Information request

If you have any additional questions (e.g. whether the treatment that you want to receive abroad is listed as reimbursable service in Estonia and if so, in what amount you are entitled to subsequent reimbursement, is a referral require, etc.), you can submit a INFORMATION REQUEST based on the application to the Health Insurance Fund.  Please include in the request an exact description of the health care services that you want to receive abroad, as well as estimated costs of the service abroad, if possible.

You can submit your request: 
- by email: info [at] haigekassa.ee
- by regular mail to the customer service department at Lastekodu 48, 10113 Tallinn. 

Reimbursement based on the rates of the country where health care was provided in case of necessary health care (Regulation (EC) No 883/2004)

  1. Only possible in case of necessary health care during a temporary stay in another member state i.e. in a situation where the necessity arose while already being in another member state. The decision about the necessity of the service is made by the doctor in the other member state, considering the medical justification, presumable duration of the stay and the nature of the health service. Reimbursement might be necessary for example in case you have forgotten your European Health Insurance Card.
  2. Reimbursement under this provision is not possible if the purpose of the stay was to receive health care.
  3. The right for reimbursement only covers medical institutions of the public health care system.
  4. The EHIF sends an enquiry to the member state where you were treated and based on the reply, transfers the reimbursable amount to your bank account.
  5. The decision on reimbursement is made by the member state where you were treated and it is based on their legislation. The reimbursement is calculated on the basis of that member state’s tariffs.
  6. Since the request for reimbursement rates is sent to another member state, the processing of your claim might take at least 6 months.