Specialised medical care
Specialized medical care is needed when a person's health concern requires the intervention of a specialist in a narrower field, as assessed by their family doctor.
Insured individuals have the right to choose a suitable specialist and an appointment at any healthcare institution with a contract with the Health Insurance Fund. Contractual partners serve all insured individuals, regardless of the insured person's place of residence.
When seeking specialized medical care, a referral is required. Without a referral, individuals can consult an ophthalmologist, dermatologist, gynecologist, and psychiatrist.
Specialized medical care is further divided into three categories – outpatient, day, and inpatient treatment.
Outpatient treatment involves a doctor's appointment during which the patient is examined, any necessary tests (blood analysis, electrocardiogram, etc.), procedures, or surgeries that do not require a prolonged stay in a healthcare institution are performed, the patient is counseled, and, if necessary, further treatment is prescribed. The patient does not stay in the healthcare institution for an extended period.
In day treatment conditions, assistance is provided when the patient's health condition, following examinations or medical procedures (including surgeries), requires monitoring but does not necessitate an overnight stay in the hospital.
Inpatient medical care is provided in a hospital, and the patient must stay overnight or for an extended period.
Individuals in need of specialized medical care are placed in a treatment queue based on the severity of their health problem. Those with serious health issues gain faster access to a specialist. The maximum waiting time for an outpatient visit is six weeks, for planned inpatient treatment and day surgery procedures, it is up to eight months. The waiting time may be extended if a person prefers a specific doctor or healthcare institution, if the institution has a shortage of doctors or other resources (equipment, space), or if the patient is awaiting a follow-up appointment, etc.
The Health Insurance Fund has entered into agreements with healthcare institutions, according to which these institutions must maintain queues for people with referrals in specialized fields for at least four months, and in fields without referrals (dermatologists, ophthalmologists, gynecologists, psychiatrists) for at least three months. The aim of such an agreement is to reduce situations where a person calls a healthcare institution and is informed that there are no available slots, and they should call back after a certain period. The Health Insurance Fund regularly monitors compliance with this requirement.
People in need of specialized medical care are placed in the treatment queue based on the seriousness of the health problem. Those with a severe health problem are granted quicker access to a specialist. The maximum waiting time for an outpatient visit is six weeks, for planned inpatient treatment and day surgery procedures up to eight months. The waiting time may be extended if the person prefers a specific doctor or healthcare facility, the facility has a shortage of doctors or other resources (equipment, rooms), or the patient is waiting for a follow-up appointment, etc.
The Health Insurance Fund has entered into agreements with healthcare facilities, according to which the facilities must keep queues open for people in specialized fields with a referral for at least four months, and for specialties without a referral (dermatologist, ophthalmologist, gynecologist, psychiatrists) for at least three months. The purpose of such an agreement is to reduce situations where a person calls a healthcare facility and is told that there are no available slots and to call again after some time. The Health Insurance Fund regularly checks compliance with this requirement.
If you already have an appointment with a specialist:
If you still need to visit a specialist, the Health Insurance Fund has sent guidelines to healthcare institutions, requesting them to contact the patient at least two days before the planned appointment. However, each healthcare institution organizes its work independently. The healthcare institution has three options:
Firstly, to offer a remote consultation via phone or video call. Remote consultations are available for all specialties, and the Health Insurance Fund covers the costs.
The doctor still has the right and the option, based on the patient's health condition, to invite the patient to an in-person appointment. For this, the patient or their close contacts must not have virus symptoms to protect both themselves and the doctor's health.
Thirdly, the doctor or healthcare institution may choose to postpone the appointment. If the appointment is postponed, the healthcare institution (if possible) is advised to either give the patient a new appointment immediately or take the patient's contact details and inform them of a new appointment when the state of emergency eases, and new appointment times (doctors' schedules) are known. When new slots become available, patients whose appointments were postponed during the state of emergency will be prioritized for regular specialist appointments.
If your appointment was canceled during the state of emergency:
If your appointment was canceled during the state of emergency, you don't need to arrange a new appointment with the healthcare institution yourself. A healthcare institution employee will contact you by 14.05.2020 at the latest and arrange further treatment.
Patients whose appointments were canceled or postponed during the state of emergency have priority when booking new appointments.
If your condition worsens during the waiting period, please contact your family doctor and describe your condition. The family doctor can arrange an e-consultation with a specialist if necessary.
If you have a new need for a specialist appointment during the state of emergency:
Contact your family doctor because they are your first point of contact for health concerns.
The family doctor has several options. Firstly, they can communicate with the patient, clarify the health concern, and, in most cases, help the patient with their health issues.
If the family doctor has additional questions for the specialist, they can conduct an e-consultation, covered by the Health Insurance Fund. Currently, e-consultations are available in 23 specialties.
If the specialist and family doctor deem a specialist appointment necessary, the specialist who conducted the e-consultation can take over the treatment.
Then, considering the criticality of the patient's health concern, the specialist decides whether to invite the person for an in-person appointment or conduct a remote consultation.
Planned medical treatment abroad
Persons insured by the Estonian Health Insurance Fund are entitled to receive health care services abroad based on certain criteria and to claim from the Health Insurance Fund for both monetary and non-monetary benefits for this.
Options for planned medical treatment abroad:
A. Under Article 271(1) of the Health Insurance Act
This option is intended for insured persons for whom medically indicated healthcare services or alternative healthcare services cannot be provided in Estonia. This option constitutes non-monetary compensation. Based on the criteria of the Health Insurance Act, healthcare services provided in a foreign country must also have proven medical effectiveness, be cost-effective, and be within the budget of the health insurance system. Required documents:
When processing the application, the Health Insurance Fund bases its decision on the individual’s application, the council’s assessment, and the criteria set forth in § 271 (1) of the Health Insurance Act.
In the event of a positive decision, the Health Insurance Fund issues a document (letter of guarantee or Form S2) whereby the Health Insurance Fund assumes the obligation to pay for medical expenses incurred in a foreign country. The Health Insurance Fund may give preference to a Member State of the European Union. The issued letter of guarantee or Form S2 does not cover potential non-medical expenses (patient copayment, transportation costs, translation costs, administrative or office costs, insurance, accommodation outside the hospital, etc.). These are paid to the foreign healthcare facility by the patient or their legal representative.
B. Under Article 20 of Regulation (EC) No. 883/2004 of the European Parliament and of the Council
This option is intended for insured persons who have been medically prescribed a healthcare service that is provided in Estonia but which cannot be provided within a medically justified timeframe. This option constitutes non-monetary compensation. Required documents:
When processing the application, the Health Insurance Fund bases its decision on the individual’s application, the consilium’s assessment, and the criteria set forth in Regulation (EC) No. 883/2004 of the European Parliament and of the Council.
In the event of a positive decision, the Health Insurance Fund issues a document (letter of guarantee or Form S2) whereby the Health Insurance Fund assumes the obligation to pay for medical expenses incurred in a foreign country (European Union member states, European Free Trade Association member states). The issued letter of guarantee or Form S2 does not cover potential non-medical expenses (patient copayment, transportation costs, translation costs, administrative or office costs, accommodation outside the hospital, insurance, etc.). These costs are paid to the foreign healthcare facility by the patient or their legal representative.
Read more about applying for prior authorization for planned treatment abroad.
C. Directive 2011/24/EU of the European Parliament and of the Council (Free Movement of Patients)
This option is intended for insured persons who wish to receive healthcare services—which patients are entitled to receive at the expense of the Estonian Health Insurance Fund (EHIF)—in another European Union member state, Norway, Iceland, or Liechtenstein. Directive 2011/24/EU does not apply in Switzerland, which means that medical expenses incurred in Switzerland are not reimbursed without prior authorization.
This option involves financial reimbursement. Reimbursement is not paid for healthcare services that are subject to a fee for the insured person in Estonia (e.g., laser eye surgery for adults, vaccinations performed outside the national immunization schedule, etc.) or are not indicated for the patient based on their health condition.
No prior authorization is required when seeking treatment abroad under this directive. Initially, the patient must cover all costs for the healthcare services received themselves; financial reimbursement from the EHIF can be requested after the healthcare services have been provided and the necessary documents have been submitted. The EHIF reimburses the costs of healthcare services in accordance with the EHIF’s list of healthcare services, i.e., the price list; therefore, if services are more expensive in a foreign country, the patient must cover part of the cost.
To receive healthcare services abroad, a referral from a family doctor or specialist is required, on the same basis as when visiting a doctor in Estonia.
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