Specialised medical care
A person needs specialized care if the family doctor determines that their health concern requires the involvement of a more specialized doctor.
A referral is needed to turn to a specialist, which is issued by the family doctor. No referral is needed to turn to a(n):
- dermatologist or venereologist;
The insured person has the right to choose the specialist that is suitable to them and an appointment time in any health care institution which is under contract with the Health Insurance Fund. The fund’s contract partners serve all insured individuals, regardless of their place of residence.
Specialized healthcare is divided into three:
- ambulatory care- doctor visit in the course of which a person is examined, some procedures are done (blood test, EKG, etc.) and if needed, further treatment is determined. The patient does not remain in the hospital.
- outpatient care- when the patient is kept for longer than a simple visit but does not spend the night in the hospital.
- stationary care- given at a hospital and the patient must stay overnight or even longer.
When visiting a specialist, treatment facilities have the right to charge a patient up to 5 euros for a visit fee.
- for children below the age of 2,
- in cases related to pregnancy and childbirth,
- in the case of intensive care.
- if the patient is to be referred to another doctor at the same facility,
During a hospital stay, a patient may be charged €2.50 per day for their room, up to a maximum of €25 per hospital stay.
Planned treatment abroad
Starting from 25 October 2013, all European Union (hereinafter EU) Member States had to transpose the directive on patients' rights in cross-border healthcare into their legal system. For a patient insured by Estonian Health Insurance Fund, this Directive has a significant additional value: patients may go to another EU Member State in order to receive regular treatment and thereafter seek financial compensation from the health insurance fund. In case of planned treatment, the patient visits another state with objective to seek treatment, i.e. the person's need for treatment arises in one state and he or she receives the treatment in another state.
The patient should keep in mind that the health insurance fund reimburses only the cost of such health services, for which the patient has health insurance coverage in Estonia. In other words, the compensation is not paid for health services for which the patient has to pay in Estonia (such as adult dental care) or is not indicated for the patient according to his or her health status. Also, the patient should take into account that the health insurance fund pays compensation according to price list of health services of health insurance fund, rather than the foreign price list.
If the cost of health service received abroad is greater than the cost of health service in the price list of health services of the health insurance fund, the patient shall pay for the price difference by his or herself. The cost-sharing, travel and other expenses, which are not reimbursed to patients receiving the same health care services in Estonia, shall not be reimbursed.
See also: table comparing treatment options and benefits; your rights pursuant to the directive
To receive planned treatment abroad, you must first apply for prior authorisation from the Health Insurance Fund to fund the healthcare service (see application procedure for prior authorisation). Prior authorisation ensures that the Health Insurance Fund will pay for the healthcare service abroad, prior to when the healthcare service is provided. If authorisation is granted, corresponding documents are issued: letter of guarantee, E112 form, and contract.
In addition, current treatment possibilities abroad remain valid, meaning that in some cases, the Estonian Health Insurance Fund will continue reimbursing healthcare services abroad in countries that are not EU members. This is the case if the necessary healthcare service is not provided in Estonia and there are no alternative indicated healthcare services, and if the necessary treatment has been prescribed for the patient. The treatment must also be proven to be medically effective and the probability of achieving the objective must be at least 50 per cent. This treatment option is regulated by subsection 271 (1) of the Health Insurance Act.