Reimbursement of health care costs in EU

As of 25 October 2013, persons insured by the Estonian Health Insurance Fund can travel to another EU state to seek treatment and apply for reimbursement from the Health Insurance Fund afterwards. This means that you first have to cover all the costs on your own and you can apply for reimbursement of costs from the Health Insurance Fund after the provision of service and the submission of all necessary documents.

The Health Care Fund shall only reimburse the costs of the health services that the patient is also entitled to receive at the Health Insurance Fund’s expense in Estonia. Health services that are fee-charging for patients insured in Estonia (such as dental care for adults) or are not indicated for a patient on the basis of his/her state of health shall not be reimbursed for. It is also possible to apply for reimbursement for medicinal products and medical devices purchased from another state, if the purchased items are included in the list of pharmaceuticals compensated for or medical devices reimbursed for and for which the person would also have the right to receive benefits in Estonia.

If services are provided in another state (tests, analyses), which might be a part of the service package in that state but are not reimbursable for the given medical condition in Estonia, then unfortunately the Health Insurance Fund cannot reimburse for such costs. A referral from a family or private doctor is also necessary when seeking treatment abroad on the same grounds as it would be when attending a doctor’s consultation in Estonia.

The patient also has to consider that 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 foreign price list. If the cost of a health service received abroad is higher than in the Health Insurance Fund’s list of health care services, then the patient shall cover the price difference. The patient shall also cover co-payments, travel costs and other costs which would not be reimbursed for on the receipt of the same health service in Estonia.

Upon processing of 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.

Cross-border health care benefits do not include the additional premium and additional cost-sharing for the insured person.

The procedures for applying for benefits, processing applications and payment of benefits are located in sub-menu "Procedure and Forms".

There are two possibilities for applying for reimbursement:

1. Reimbursement based on the rates of the country where health care was provided in case of necessary health care (Regulation (EC) No 883/2004)
 2. Reimbursement according to the price list valid in Estonia, based on the Health Insurance Act §662 (Directive on the application of patients rights 2011/24/EU)

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.

1.     Right for reimbursement in case of planned as well as necessary care provided either by public or private health care providers after 25 October 2013.

2.       Only those services that are also available and reimbursable by the Health Insurance Fund in Estonia are reimbursed for on the same grounds as they would be in Estonia.

3.     Reimbursement is based on Estonian legislation and the prices set out in the Health Insurance Fund’s list of health care services. For more precise information, consult the following pieces of legislation:

- EHIF’s list of health care services;

- EHIF’s list of pharmaceuticals;

- Reference prices of pharmaceuticals;

- Estonian Health Insurance Fund’s list of medical devices and the procedure for assumption of the obligation to pay for medical devices entered in the list of medical devices

4.     Processing a claim takes 3 months on average.

In order to get reimbursement on your medical expenses, all health care invoices and prescriptions have to be paid. The Estonian Health Insurance Fund does not handle unpaid invoices.

For  claiming reimbursement  the following documents must be presented to the EHIF:

1. Application for reimbursement can be found here.

2. Original invoices, copies of prescriptions, documents certifying the payment

3. Case summary (may be a copy). It should contain the following information:

-         Patient’s name and ID code
-         Name of the medical institution and department
-         The period of treatment, number of bed days
-         Description of the health care service that was provided
-         Diagnosis (principal diagnosis, accompanying conditions,  justification of  the diagnosis, course of illness, patient’s condition at admission)
-         Examinations and analyses, medicamental treatment
-         Operations (date, name, anaesthesia)
-         Condition  at time of discharge
-         Instructions for patient, recommendations for rehabilitation.
-         Duration of temporary incapacity for work
-         Name of the treating doctor

4. Referral (may be a copy).
NB! Referral is not necessary in the following cases:

- In the specialities of ophtomology, dermatovenerology, gynecology, pshyciatry, or in case of trauma or tuberculosis
- You are a pupil or student who is studying in another EU member state and has presented the EHIF a certificate  proving  it
- Y
ou have  been issued one of the following E-forms: E112/S2, E106/S1, E109/S1, E121/S1 (i.e  persons insured on the basis of art 17, 18, 24 or 26 of Regulation 883/2004)
- Y
ou are referred to another specialist while you are abroad and you do not return to Estonia in between the two appointments
- The need for health care arose while you were already in another member state (necessary healthcare on the basis of Regulation 883/2004)

EHIF will transfer the amount of the reimbursement to your given bank account in fifteen days after making a positive  decision.

NB! EHIF stores only one bank account per person. We would like to draw your attention to the fact that if you have given the EHIF different bank account numbers while applying for benefits in cash then all transactions that have not been made yet will be made to the account that you last gave us. Account data can be changed through the citizen’s portal or with a  written application.