General Information for Amending the List

In the framework of the health insurance package, the Health Insurance Fund compensates for a large number of various medical services, procedures, medicinal products, etc. The list of health services brings together these services, their prices and the conditions for payment. The Health Insurance Fund pays the medical institution for a particular patient covered by health insurance after the provision of the service.

The list is updated annually according to the need and to the Health Insurance Act. Proposals to amend the list can be submitted by professional medical associations, the Estonian Hospital Association, as well as the Health Insurance Fund. On the Health Services list and for amending thereof.

The list of health services is amended under the Health Insurance Act, section 31, and the process is described in the following regulations:
- Government Regulation No. 301 of 24.09.2002 “The criteria for amendment of the list of the health care services of the Estonian Health Insurance Fund and their evaluation procedures."
- Minister of Social Affairs Regulation No. 9 of 19.01.2007 “Assumption of the payment obligation by the Estonian Health Insurance Fund from the insured person and the methodology for calculating the fee payable to the health care provider."

In case of each new service, the experts evaluate four criteria:

1. The effect on the patient's health or the medical evidence base. This means that the new service must have a greater positive impact on the health of the patient than the current service evidenced by studies. The assessment is given by an expert recommended by the Faculty of Medicine at the University of Tartu or the State Agency of Medicines.
2. The cost-effectiveness is mostly assessed by health care economists of the Health Insurance Fund. The aim is to estimate the size of the health benefits arising from the use of the new service and the cost required for achieving it, compared to the existing alternatives. Therefore, it is possible to assess the balance of the additional benefits and the necessary additional cost.
3. The effect on the budget of health insurance is mostly evaluated by health care economists of the Health Insurance Fund.
4.The impact on society and healthcare policy is evaluated by the Ministry of Social Affairs. The Ministry considers the need for the services to the community (e.g., the compliance with the development plans, the availability of the infrastructure necessary for provision of the service and personnel training facilities) and appoints the health care policy priorities.

The process for amending the list with proposals for amendments in the form of a figure:

PROFESSIONAL ASSOCIATION OF HEALTH CARE PROVIDERS, or

THE ESTONIAN HEALTH INSURANCE FUND

submits an application for amendment of the list of health care services

THE HEALTH INSURANCE FUND checks the applications.

If necessary, the applicants submit additional information

EXPERT IN THE FIELD

evaluates the medical evidence-based nature of the service

THE HEALTH INSURANCE FUND

evaluates the cost-effectiveness and the compliance of the treatment of the financial possibilities of the insurance

THE MINISTRY OF SOCIAL AFFAIRS

evaluates the need for the service and compliance with the national health care policy priorities

THE MANAGEMENT BOARD OF THE HEALTH INSURANCE FUND

shall submit to the SUPERVISORY BOARD

proposals for amending the list

THE HEALTH INSURANCE FUND

gives an opinion regarding the list

THE MINISTER OF HEALTH AND LABOR

shall submit the list for approval to

THE GOVERNMENT OF THE REPUBLIC

THE GOVERNMENT OF THE REPUBLIC

shall confirm the list of health care services