Riigikogu seadus terviktekst RaKSavaldamine avaldatud 2002-06-19 RT I 2002 62 377 181723 Entered into force in accordance with § 90 RT V2025-12-3020256530122025006 2026-01-01 2026-03-31 2012-07-02 tyviseadus_1_10.02.2010.xsd 530122025006 241 2025-12-30 Mari Peetris 100282 Tüviseaduse raamskeem XML struktuuri koostamiseks Health Insurance Act 1 2003-01-29 RT I 2003 20 116 260772 2003-03-10 2003-12-17 RT I 2003 88 591 690845 2004-01-01 2004-04-20 RT I 2004 37 253 745121 2004-05-01 , in part 01.08.2004 2004-06-02 RT I 2004 49 342 772862 2004-07-01 2004-06-28 RT I 2004 56 400 778828 2004-08-01 , in part 01.01.2005 and 01.04.2005 2004-10-13 RT I 2004 75 520 813527 2004-12-01 2004-12-08 RT I 2004 89 604 831323 2005-04-01 2004-12-16 RT I 2004 89 614 831409 2005-01-01 2005-04-06 RT I 2005 22 148 890243 2006-01-01 2005-06-15 RT I 2005 39 308 919178 2006-01-01 2005-10-12 RT I 2005 57 451 955779 2005-11-18 2005-11-24 RT I 2005 65 498 966190 2006-01-01 2005-12-15 RT I 2005 71 546 972416 2006-01-01 , 01.04.2006 2006-05-17 RT I 2006 26 191 1034665 2006-08-01 2006-12-21 RT I 2007 4 17 12776181 2007-01-29 2007-02-15 RT I 2007 24 127 12802623 2008-01-01 2007-12-19 RT I 2007 71 437 12902050 2008-10-01 2007-12-20 RT I 2008 3 22 12909773 2008-09-01 2008-06-19 RT I 2008 34 210 12997653 2008-08-01 2008-06-19 RT I 2008 34 210 12997653 2008-09-01 2008-06-19 RT I 2008 34 210 12997653 2009-08-01 2008-12-09 RT I 2008 56 313 13096356 2009-01-01 2008-12-10 RT I 2008 58 327 13096449 2009-01-02 2008-12-11 RT I 2008 60 331 13111040 2009-01-01 2008-12-17 RT I 2009 5 35 13120899 2009-07-01 2009-02-20 RT I 2009 15 93 13152060 2009-07-01 2009-05-21 RT I 2009 29 176 13186056 2010-04-01 , in part 19.06.2009 and 01.07.2009 2009-06-18 RT I 2009 35 232 13196585 2009-07-01 2009-09-30 RT I 2009 49 331 13225575 2010-01-01 , in part 01.04.2010 2009-12-17 RT I 2009 67 461 13252426 2010-01-01 2010-03-18 RT I 2010 15 77 13297358 2010-04-18 , in part 01.07.2010 2010-04-22 RT I 2010 22 108 13310847 2011-01-01 , will enter into force on the date specified in the decision of the Council of the European Union regarding the abrogation of the derogation established in favour of the Republic of Estonia on the ground provided for in Article 140(2) of the Treaty on the Functioning of the European Union, Decision No. 2010/416/EU of the Council of the European Union of 13 July 2010 (OJ L 196, 28.07.2010, pp. 24–26). 2011-01-26 RT I 2011-02-17 1 117022011001 2011-02-27 2011-06-07 RT I 2011-06-10 7 110062011007 2011-06-07 , the words “or insured persons who are at least 65 years of age” in subsection 6 of § 57 of the Health Insurance Act are declared unconstitutional and repealed by a judgment of the Supreme Court en banc. 2012-06-14 RT I 2012-07-02 8 102072012008 2012-08-01 2012-06-14 RT I 2012-07-05 14 105072012014 2012-10-01 2012-06-13 RT I 2012-07-06 1 106072012001 2013-04-01 2012-06-13 RT I 2012-07-10 2 110072012002 2013-04-01 2012-10-10 RT I 2012-10-25 1 125102012001 2012-12-01 2012-12-20 RT I 2012-12-31 6 131122012006 2013-01-10 2013-06-12 RT I 2013-07-02 1 102072013001 2013-09-01 , in part 01.01.2014 2013-11-15 RT I 2013-11-29 1 129112013001 2013-12-09 2013-12-18 RT I 2014-01-10 2 110012014002 2014-01-20 , in part 01.01.2015 2014-02-19 RT I 2014-03-13 2 113032014002 2014-03-23 , in part 01.01.2015, 01.01.2017 and 01.01.2019 2014-03-26 RT I 2014-04-16 4 116042014004 2014-04-26 2014-03-26 RT I 2014-04-16 3 116042014003 2014-07-01 2014-06-11 RT I 2014-06-21 8 121062014008 2015-01-01 2014-06-19 RT I 2014-06-29 109 129062014109 2014-07-01 , the ministers’ official titles have been replaced on the basis of subsection 4 of § 107³ of the Government of the Republic Act. 2014-09-17 RT I 2014-10-08 1 108102014001 2014-10-18 , in part 01.01.2015 2014-11-19 RT I 2014-12-05 2 105122014002 2015-09-01 2014-11-19 RT I 2014-12-13 1 113122014001 2016-01-01 , in part 01.01.2015 and 01.07.2016; date of entry into force amended in part to 01.07.2016 and 01.01.2017 [RT I, 17.12.2015, 1] 2015-01-29 RT I 2015-02-26 1 126022015001 2015-03-01 2015-02-18 RT I 2015-03-11 2 111032015002 2015-03-21 , in part 01.07.2015 and 01.01.2016 2015-02-11 RT I 2015-03-12 1 112032015001 2016-01-01 2015-02-18 RT I 2015-03-23 1 123032015001 2015-04-02 2015-02-18 RT I 2015-03-23 5 123032015005 2015-07-01 2015-11-25 RT I 2015-12-17 1 117122015001 2015-12-20 , in part 01.01.2016 and 01.07.2016 2015-12-09 RT I 2015-12-30 2 130122015002 2016-01-09 , in part 01.01.2016 and 01.03.2016 2016-03-16 RT I 2016-04-06 1 106042016001 2016-05-01 2016-04-20 RT I 2016-05-04 1 104052016001 2016-05-14 2016-12-13 RT I 2016-12-27 4 127122016004 2017-07-01 , in part 01.01.2018 2017-06-14 RT I 2017-06-29 1 129062017001 2017-07-09 , in part 01.01.2018 2017-06-14 RT I 2017-07-04 1 104072017001 2018-01-01 2017-06-19 RT I 2017-07-07 2 107072017002 2018-01-01 2017-12-06 RT I 2017-12-28 4 128122017004 2018-01-01 2017-12-06 RT I 2017-12-28 5 128122017005 2018-01-01 2018-06-13 RT I 2018-06-22 4 122062018004 2018-09-01 , in part 01.07.2018 2018-10-17 RT I 2018-10-26 1 126102018001 2022-04-01 , amended in part [RT I, 31.03.2022, 1] 2018-11-21 RT I 2018-12-07 1 107122018001 2018-12-17 2018-12-05 RT I 2018-12-21 2 121122018002 2019-01-01 , in part 01.09.2019 2019-02-13 RT I 2019-03-04 1 104032019001 2020-07-01 ‒ enters into force on 1 January in the year following the making of the decision of the European Commission in accordance with Article 4(3) or Article 9(3) of Council Regulation (EU) 2015/1589 laying down detailed rules for the application of Article 108 of the Treaty on the Functioning of the European Union (OJ L 248, 24.09.2015, pp 9–29). If the European Commission makes the decision after 1 October in the calendar year, then enters into force on 1 January in the second year following the year of the making of the decision of the European Commission; the date of entry into force has been amended in part [RT I, 28.02.2020, 2] 2019-02-20 RT I 2019-03-13 2 113032019002 2019-03-15 , the words “health insurance database” have been replaced with the words “Health Insurance Fund database” throughout the Act. 2020-02-18 RT I 2020-02-28 2 128022020002 2020-07-01 2020-04-15 RT I 2020-04-21 1 121042020001 2020-05-01 , implemented retroactively as of 12 March 2020 2020-05-13 RT I 2020-05-17 1 117052020001 2020-05-18 2020-11-25 RT I 2020-12-10 1 110122020001 2021-01-01 2020-12-09 RT I 2020-12-29 2 129122020002 2021-01-01 , in part 01.05.2021; entry into force amended in part [RT I, 21.04.2021, 1]; entry into force amended in part [RT I, 22.12.2021, 3] 2021-04-14 RT I 2021-04-21 1 121042021001 2021-05-01 2021-12-08 RT I 2021-12-17 2 117122021002 2022-01-01 2021-12-08 RT I 2021-12-22 3 122122021003 2022-01-01 , in part 01.01.2023 2021-12-15 RT I 2022-01-03 2 103012022002 2022-02-01 ‒ enters into force on the day when a period of six months has passed from the publication of a notice specified in Article 82(3) of Regulation (EU) No 536/2014 of the European Parliament and of the Council in the Official Journal of the European Union, Commission Decision (EU) 2021/1240 of 13 July 2021 (OJ L 275, 31.07.2021, pp 1–2). 2022-03-16 RT I 2022-03-31 1 131032022001 2022-04-01 2022-04-13 RT I 2022-04-29 1 129042022001 2022-05-09 2022-06-01 RT I 2022-06-20 3 120062022003 2022-06-30 2022-12-07 RT I 2022-12-22 2 122122022002 2023-01-01 2022-12-28 RT I 2023-01-11 1 111012023001 2023-01-12 , applied retroactively as of 1 January 2023; entry into force in part 01.07.2023 2023-02-15 RT I 2023-03-07 5 107032023005 2024-01-01 2023-02-22 RT I 2023-03-11 9 111032023009 2023-04-01 , the word “haigekassa” [Health Insurance Fund] is replaced throughout the Act with the word “Tervisekassa” [the Health Insurance Fund] in the appropriate case form 2023-06-20 RT I 2023-07-06 6 106072023006 2024-01-01 2023-11-23 RT I 2023-12-15 3 115122023003 2023-12-25 2023-11-23 RT I 2023-12-15 2 115122023002 2024-07-01 2024-04-16 RT I 2024-05-02 3 102052024003 2024-05-15 , in part 01.01.2025 and 01.02.2025 2024-06-04 RT I 2024-06-21 2 121062024002 2024-07-01 2024-11-06 RT I 2024-11-20 1 120112024001 2025-01-01 2024-11-20 RT I 2024-12-12 2 112122024002 2024-12-22 , in part 01.01.2025, 01.04.2025 and 01.01.2026 2025-05-14 RT I 2025-06-03 1 103062025001 2025-06-13 , in part 01.01.2026 2025-11-19 RT I 2025-12-03 3 103122025003 2025-12-13 , in part 01.01.2026 and 01.04.2026 1 GENERAL PROVISIONS 1 Scope of application of Act 1 This Act regulates solidarity-based health insurance (hereinafter health insurance). 2 In the event of a conflict between this Act and an international agreement ratified by the Riigikogu, the provisions of the international agreement apply. 2 Definition, principles and form of health insurance 1 Health insurance is a system for covering health care expenses incurred to finance the disease prevention and treatment of and purchase of medicinal products and medical devices for insured persons and to pay benefits for temporary incapacity for work and other benefits on the conditions and in accordance with the procedure provided for in this Act. RT I 2008 3 22 12909773 2008-09-01 2 Health insurance is based on the solidarity of and limited cost-sharing by insured persons and on the principle that services are provided according to the needs of insured persons, that treatment is equally available in all regions and that Health Insurance Funds are used for their intended purpose. 3 Health insurance is compulsory insurance, with the exception of the health insurance provided for in §§ 22–24 of this Act. 3 Insurer 1 For the purposes of health insurance, the insurer is the Health Insurance Fund. RT I 2023-03-11 9 111032023009 2023-04-01 2 Repealed - RT I 2016-12-27 4 127122016004 2017-07-01 3 Insured persons have equal rights and opportunities to receive health insurance benefits, unless otherwise provided for in this Act. RT I 2016-12-27 4 127122016004 2017-07-01 4 Development of health services and health promotion RT I 2017-12-28 4 128122017004 2018-01-01 1 The Health Insurance Fund may use Health Insurance Funds and funds allocated to the Health Insurance Fund from the state budget for paying for activities or projects improving the quality, availability and effectiveness of provision of health services and for health system development activities with the approval of the Ministry of Social Affairs. 2 The Health Insurance Fund participates in financing projects specifically aimed at promoting health to the extent of the amounts prescribed for such purpose in the budget of the Health Insurance Fund with the approval of the Ministry of Social Affairs. RT I 2017-12-28 4 128122017004 2018-01-01 2 CONDITIONS OF INSURANCE 1 Insured person 5 Insured Person 1 For the purposes of this Act, an insured person is a permanent resident of Estonia or a person residing in Estonia on the basis of a temporary residence permit or the right of residence or a person legally staying and working in Estonia based on a temporary ground for stay for whom a payer of social tax must pay social tax or who pays social tax for themselves in accordance with the procedure, in the amounts and within the time limits provided for in the Social Tax Act, or a person considered equal to such persons on the basis of this Act or on the basis of a contract specified in subsections 1 and 2 of § 22 of this Act. RT I 2015-03-23 1 123032015001 2015-04-02 2 The following are insured persons for whom a payer of social tax must pay social tax: 1 persons who work on the basis of an employment contract concluded for a term exceeding one month or for an unspecified term and for whom the employer must pay social tax; 2 officials, active servicemen, members of the Riigikogu, the President of the Republic, members of the Government of the Republic, judges, the Chancellor of Justice, the Auditor General, the Public Conciliator, members of councils of local authorities, members of city or rural municipality governments, mayors of rural municipality or city districts for whom the state or the local authority must pay social tax via its agencies; RT I 2012-07-06 1 106072012001 2013-04-01 3 persons for whom the state, local authority or, based on the Creative Persons and Artistic Associations Act, an artistic association (hereinafter artistic association) is required to pay social tax under § 6 of the Social Tax Act; RT I 2014-01-10 2 110012014002 2014-01-20 4 members of the management or controlling bodies of legal persons within the meaning of § 9 of the Income Tax Act for whom the legal person or legal persons pay social tax on the basis of clause 2 of subsection 1 of § 9 of the Social Tax Act in the monthly total amount calculated on the basis of at least the monthly rate established in the state budget for the given budgetary year (hereinafter minimum social tax obligation); RT I 2015-03-11 2 111032015002 2016-01-01 5 persons receiving remuneration or service fees on the basis of a contract for services, a mandate or another contract or other contracts under the law of obligations for the provision of services, who are not entered in the commercial register as self-employed persons and for whom the other party to the contract pays social tax on the basis of clause 2 of subsection 1 of § 9 of the Social Tax Act in the monthly total amount calculated on the basis of at least to the extent of the minimum social tax obligation; RT I 2015-03-11 2 111032015002 2016-01-01 5 1) ]]> a payer of business income tax who, under the Simplified Business Income Taxation Act, pays social tax at least to the extent of the minimum social tax obligation provided for in clause 4 of subsection 2 of this section or who pays social tax under the said Act or for whom social tax is paid under clause 5 of subsection 2 of this section at least in the total amount of the minimum social tax obligation per month; RT I 2017-07-07 2 107072017002 2018-01-01 6 persons receiving an unemployment insurance benefit on the basis of the Unemployment Insurance Act for whom the Estonian Unemployment Insurance Fund must pay social tax on the basis of clause 8 of subsection 1 of § 2 of the Social Tax Act. 2 1)]]> The term of a fixed-term employment contract provided for in clause 1 of subsection 2 of this section is not applied towards the emergence of an insurance cover in the case of an employment contract concluded for the period of the practical training of a doctor-resident. RT I 2018-12-21 2 121122018002 2019-01-01 3 An insured person who pays social tax for themselves, is a self-employed person, an enforcement agent or a notary who pays social tax on their business income in accordance with the Social Tax Act. RT I 2024-05-02 3 102052024003 2024-05-15 3 1)]]> An insured person for whom social tax is paid by a self-employed person registered in the commercial register is their spouse or registered partner who has been entered in the employment register as the spouse or registered partner participating in the activities of the undertaking of the self-employed person on the basis of § 20² of the Taxation Act (hereinafter spouse or registered partner participating in activities of undertaking of self-employed person). RT I 2023-07-06 6 106072023006 2024-01-01 4 The following persons for whom social tax is not paid are considered to be equal to insured persons on the basis of this Act: 1 pregnant women whose pregnancy has been identified by a doctor or a midwife; RT I 2009 29 176 13186056 2010-04-01 2 persons under 19 years of age; 3 persons who receive a state pension granted in Estonia; 3 1) ]]> persons who have been found to have partial work ability or no work ability under the Work Ability Allowance Act; RT I 2014-12-13 1 113122014001 2016-07-01 (entry into force amended – RT I, 17.12.2015, 1) 4 persons with up to five years left until attaining the retirement age who are maintained by their spouses or registered partners who are insured persons; RT I 2023-07-06 6 106072023006 2024-01-01 5 persons acquiring basic or general secondary education, persons acquiring formal vocational education and higher education students who are permanent residents of Estonia and study in an educational institution in Estonia founded and operating on the basis of legislation or in an equivalent educational institution abroad, except for doctoral candidates that receive the doctoral allowance; 2014-11-19 RT I 2014-12-05 2 105122014002 2015-09-01 6 a monk or a nun who is a member of a cloister registered in the register of religious associations. RT I 2017-12-28 4 128122017004 2018-01-01 2 Duration of Insurance Cover 6 Duration of insurance cover of officials, active servicemen, members of Riigikogu, President of Republic, members of Government of Republic, judges, Chancellor of Justice, Auditor General, Public Conciliator, members of councils of local authorities, members of city or rural municipality governments, mayors of rural municipalities or city districts 1 The insurance cover of the persons specified in clauses 1 and 2 of subsection 2 of § 5 of this Act will commence upon expiry of a waiting period of fourteen days from the date of commencement of work entered in the employment register specified in § 25¹ of the Taxation Act (hereinafter employment register). RT I 2014-04-16 3 116042014003 2014-07-01 2 If the date of commencement of work entered in the employment register remains within the term of validity of the valid insurance cover, the insurance cover will continue on the new ground without interruption. RT I 2014-04-16 3 116042014003 2014-07-01 3 The insurance cover of the persons specified in clauses 1 and 2 of subsection 2 of § 5 of this Act will terminate two months after the date of termination of work entered in the employment register. RT I 2014-04-16 3 116042014003 2014-07-01 4 The insurance cover of the persons specified in clauses 1 and 2 of subsection 2 of § 5 of this Act will be suspended two months after the date of commencement of the suspension of work entered in the employment register, except in the case of unpaid leave granted by agreement of the parties, provided that social tax is paid for the person in accordance with the Social Tax Act, and the insurance cover will continue as of the date following the date of termination of the suspension of work entered in the employment register. RT I 2014-04-16 3 116042014003 2014-07-01 5 Subsection 4 of this section does not apply in the period during which the insured person is entitled to the benefit for temporary incapacity for work, the mother's parental benefit or the adoptive parent's parental benefit under the Family Benefits Act. RT I 2018-10-26 1 126102018001 2022-04-01 , amended in part [RT I, 31.03.2022, 1] 7 Duration of insurance cover of persons for whom social tax is paid by state, local authority or artistic association 1 The insurance cover of a person specified in clause 3 of subsection 2 of § 5 of this Act will commence as of the making of an entry on commencement of the insurance cover in the Health Insurance Fund database. The documents necessary for the person to be entered in the Health Insurance Fund database must be submitted to the Health Insurance Fund by the agency through which the state or local authority pays social tax for the person or by an artistic association. 2 The insurance cover of a person specified in clause 3 of subsection 2 of § 5 of this Act will terminate one month after the termination of the obligation of the state, local authority or artistic association to pay social tax for the person. The agency through which the state or the local government paid social tax for the person and the artistic association are required to notify the Health Insurance Fund of termination of the obligation to pay social tax within ten calendar days. RT I 2014-01-10 2 110012014002 2014-01-20 8 Duration of insurance cover of member of management body and controlling body of legal person, person receiving remuneration and service fees based on contract under law of obligations, and payer of business income tax RT I 2017-07-07 2 107072017002 2018-01-01 1 The insurance cover of a person specified in clauses 4 and 5 of subsection 2 of § 5 of this Act will commence as of the making of an entry to the Health Insurance Fund database if social tax has been declared for the person to the extent of the minimum social tax obligation based on clause 4 of subsection 1 of § 9 of the Social Tax Act. The Health Insurance Fund will make an entry on the day following the day of receiving data on the declaration of social tax for the person from the Tax and Customs Board. RT I 2015-03-11 2 111032015002 2016-01-01 1 1)]]> The insurance cover of a person specified in clause 5¹ of subsection 2 of § 5 of this Act begins after an entry has been made in the Health Insurance Fund database following the accrual of social tax provided for in clause 2 of subsection 2 or clause 2 of subsection 3 of § 8 of the Simplified Business Income Taxation Act and declaration of social tax payable on personal remuneration or service fees provided for in clause 5 of subsection 2 of § 5 of this Act to the extent of the minimum social tax obligation. The Health Insurance Fund makes an entry on the day following the day of receipt of data from the Tax and Customs Board. RT I 2017-07-07 2 107072017002 2018-01-01 2 The Tax and Customs Board immediately submits to the Health Insurance Fund data on persons for whom, per month, social tax has been declared to the extent of the minimum social tax obligation or received to the extent of the same on the basis of the Simplified Business Income Taxation Act or for whom social tax has been declared to the extent of the minimum social tax obligation and received to the extent of the same on the basis of the Simplified Business Income Taxation Act. RT I 2017-07-07 2 107072017002 2018-01-01 3 The insurance cover of an insured person is suspended after a month has passed from the due date provided for in clause 4 of subsection 1 of § 9 of the Social Tax Act where by the due date social tax has not been declared to the extent of the minimum social tax obligation or received to the extent of the same on the basis of the Simplified Business Income Taxation Act for the person or social tax has not been declared to the extent of the minimum social tax obligation and received to the extent of the same on the basis of the Simplified Business Income Taxation Act for the person. RT I 2017-07-07 2 107072017002 2018-01-01 4 The insurance cover suspended on the basis of subsection 3 of this section resumes on the day following the receipt from the Tax and Customs Board of data certifying the declaration of the minimum social tax obligation or payment thereof by a payer of business income tax or certifying the declaration and payment of the minimum social tax obligation by a payer of business income tax. RT I 2017-07-07 2 107072017002 2018-01-01 5 Subsection 3 of this section does not apply in the period during which the insured person is entitled to the benefit for temporary incapacity for work, the mother's parental benefit or the adoptive parent's parental benefit under the Family Benefits Act. RT I 2018-10-26 1 126102018001 2022-04-01 , amended in part [RT I, 31.03.2022, 1] 9 Duration of insurance cover of persons receiving remuneration or service fees on basis of contract under law of obligations Repealed - RT I 2015-03-11 2 111032015002 2016-01-01 9 1. ]]> Duration of insurance cover of persons receiving unemployment insurance benefit 1 The insurance cover of a person specified in clause 6 of subsection 2 of § 5 of this Act will commence as of the making of an entry on commencement of the insurance cover in the Health Insurance Fund database. The documents necessary for the person to be entered in the Health Insurance Fund database must be submitted to the Health Insurance Fund by the Estonian Unemployment Fund. 2 The insurance cover of a person specified in clause 6 of subsection 2 of § 5 of this Act will terminate two months after termination of the obligation of the Estonian Unemployment Fund to pay social tax for the person. The Estonian Unemployment Insurance Fund must notify the Health Insurance Fund of termination of the obligation to pay social tax within ten calendar days. RT I 2004 56 400 778828 2004-08-01 10 Duration of insurance cover of self-employed persons entered in register RT I 2005 71 546 972416 2006-04-01 1 The insurance cover of a person specified in subsection 3 of § 5 of this Act will commence upon the expiry of a waiting period of fourteen days calculated as of the entry in the commercial register or registration in the the Chamber of Enforcement Agents and Trustees in Bankruptcy or the Chamber of Notaries. The Chamber of Enforcement Agents and Trustees in Bankruptcy, the Chamber of Notaries and the Registration Department of the Tartu District Court are required to submit to the Health Insurance Fund the data on the commencement of the insurance cover required for the entry of a person in the Health Insurance Fund database within seven calendar days as of the person’s entry in the commercial register or assumption of office. RT I 2024-05-02 3 102052024003 2024-05-15 2 If the data necessary for an entry on commencement of the insurance cover of a person to be made in the Health Insurance Fund database are submitted to the Health Insurance Fund during the period of validity of the insurance cover of the person, the insurance cover will continue on the new basis without interruption. RT I 2005 71 546 972416 2006-04-01 3 The insurance cover of a person specified in subsection 3 of § 5 of this Act will terminate two months after making of the deletion entry in the commercial register, release or removal from office. The Registration Department of the Tartu District Court, the Chamber of Enforcement Agents and Trustees in Bankruptcy and the Chamber of Notaries are required to inform the Health Insurance Fund of the termination of the activities, release or removal from office of a person specified in subsection 3 of § 5 of this Act within ten calendar days after making the deletion entry in the commercial register, release or removal from office. RT I 2024-05-02 3 102052024003 2024-05-15 4 The insurance cover of a person specified in subsection 3 of § 5 of this Act will be suspended after two months have passed from the suspension of activities, including from making an entry on the suspension of seasonal activities in the commercial register or suspension of the period or powers of office. Upon suspension of the period or powers of office, insurance cover is suspended only if the person does not pay social tax for themselves during the period of suspension. The Registration Department of the Tartu District Court, the Chamber of Enforcement Agents and Trustees in Bankruptcy and the Chamber of Notaries are required to inform the Health Insurance Fund of the suspension of activities, the suspension of the period or powers of office of a person within ten calendar days after making the suspension entry in the commercial register, or the suspension of the period or powers of office. RT I 2024-05-02 3 102052024003 2024-05-15 5 If a person specified in subsection 3 of § 5 of this Act recommences business activities after the suspension of their activities, period or powers of office, or the suspension of their activities, period or powers of office terminates, the Registration Department of the Tartu District Court, the Chamber of Enforcement Agents and Trustees in Bankruptcy and the Chamber of Notaries are required to submit to the Health Insurance Fund the details of recommencement of business activities within ten calendar days after the recommencement of business activities or the termination of the suspension of the activities, period or powers of office. Upon receipt of the data, the insurance cover will continue without a waiting period. RT I 2024-05-02 3 102052024003 2024-05-15 6 The provisions of subsection 4 of this section do not apply in the event of suspension of engagement in business for a period during which the insured person is entitled to receive the benefit for temporary incapacity for work, the mother's parental benefit or the adoptive parent's parental benefit under the Family Benefits Act. RT I 2018-10-26 1 126102018001 2022-04-01 , amended in part [RT I, 31.03.2022, 1] 10 1. ]]> Duration of insurance cover of spouse or registered partner participating in activities of undertaking of self-employed person RT I 2023-07-06 6 106072023006 2024-01-01 1 The insurance cover of the spouse or registered partner participating in the activities of the undertaking of a self-employed person will commence after the passing of the waiting period of fourteen days from the entry in the register of taxable persons. RT I 2023-07-06 6 106072023006 2024-01-01 2 If the documents necessary for an entry on commencement of the insurance cover of the spouse or registered partner participating in the activities of the undertaking of a self-employed person to be made in the Health Insurance Fund database are submitted to the Health Insurance Fund during the period of validity of the insurance cover of the spouse or registered partner participating in the activities of the undertaking of the self-employed person, the insurance cover will continue on the new basis without interruption. RT I 2023-07-06 6 106072023006 2024-01-01 3 The insurance cover of the spouse or registered partner participating in the activities of the undertaking of a self-employed person will terminate two months after making a deletion entry regarding the spouse or registered partner in the employment register or after making a deletion entry regarding the self-employed person in the commercial register. RT I 2023-07-06 6 106072023006 2024-01-01 4 The insurance cover of the spouse or registered partner participating in the activities of the undertaking of a self-employed person will be suspended after two months have passed from the suspension of the activities of the self-employed person, including after making an entry on the suspension of seasonal activities in the commercial register. RT I 2023-07-06 6 106072023006 2024-01-01 5 As of the receipt of data on the recommencement of the activities of a self-employed person, the insurance cover of the spouse or registered partner participating in the activities of the undertaking of the self-employed person will continue without a waiting period. RT I 2023-07-06 6 106072023006 2024-01-01 6 Subsection 4 of this section does not apply in the event of suspension of the activities of a self-employed person during the period when their spouse or registered partner is entitled to the benefit for temporary incapacity for work, the mother’s parental benefit or the adoptive parent’s parental benefit under the Family Benefits Act. RT I 2023-07-06 6 106072023006 2024-01-01 11 Duration of insurance cover of persons considered equal to insured persons 1 The insurance cover of a person specified in subsection 4 of § 5 of this Act will commence as of the making of an entry on commencement of the insurance cover in the Health Insurance Fund database. The documents required for entering a person in the Health Insurance Fund database must be submitted to the Health Insurance Fund by the person or by their legal representative. RT I 2014-04-16 3 116042014003 2014-07-01 2 The documents necessary for a person specified in clause 3 of subsection 4 of § 5 of this Act to be entered in the Health Insurance Fund database must be submitted by the Social Insurance Board and, in the events provided by law, by the Chancellery of the Riigikogu. 2 1)]]> The Estonian Unemployment Insurance Fund is required to submit the documents necessary for entering a person specified in clause 3¹ of subsection 4 of § 5 of this Act into the Health Insurance Fund database. RT I 2014-12-13 1 113122014001 2016-07-01 (entry into force amended – RT I, 17.12.2015, 1) 3 The documents necessary for a person studying in Estonia specified in clause 5 of subsection 4 of § 5 of this Act to be entered in the Health Insurance Fund database must be submitted by the Ministry of Education and Research. A person studying in a foreign state specified in clause 5 of subsection 4 of § 5 must submit the documents necessary for insurance cover to commence by themselves. 3 1)]]> The cloister where the person is a member is required to submit the documents necessary for entering a person specified in clause 6 of subsection 4 of § 5 of this Act into the Health Insurance Fund database. Within seven calendar days following the receipt of a relevant inquiry from the Health Insurance Fund the Ministry of the Interior certifies to the Health Insurance Fund the cloister's right to submit the data. RT I 2017-12-28 4 128122017004 2018-01-01 4 The insurance cover of the persons specified in clauses 1–6 of subsection 4 of § 5 of this Act terminates where the person no longer meets the conditions provided for in the relevant clause of subsection 4 of § 5, taking account of the variations provided for in § 12 of this Act. RT I 2017-12-28 4 128122017004 2018-01-01 5 The submitters of the documents specified in subsections 2 to 3¹ of this section are required to notify the Health Insurance Fund of the termination of the insurance cover of the persons specified in clauses 3, 3¹, 5 and 6 of subsection 4 of § 5 of this Act within ten calendar days as of its termination. RT I 2017-12-28 4 128122017004 2018-01-01 12 Specifications concerning duration of insurance cover of persons considered equal to insured persons 1 The insurance cover of a person who has been declared permanently incapacitated for work or as having partial work ability or no work ability will terminate upon expiry of a term of three months from the expiry of the period of the permanent incapacity for work or partial work ability or absent work ability. RT I 2014-12-13 1 113122014001 2016-07-01 (entry into force amended – RT I, 17.12.2015, 1) 1 1)]]> The insurance cover of a person specified in clause 1 of subsection 4 of § 5 of this Act will terminate three months after the estimated date of delivery as determined by a doctor or midwife. RT I 2009 29 176 13186056 2010-04-01 2 The insurance cover of a person specified in clause 5 of subsection 4 of § 5 of this Act will terminate three months after their graduation from the educational institution. RT I 2015-03-23 5 123032015005 2015-07-01 2 1)]]> If a student of at least 19 years of age acquiring general secondary education as specified in clause 5 of subsection 4 of § 5 of this Act is expelled from the educational institution before graduation within three consecutive academic years after commencement of acquisition of the general secondary education, their insurance cover will terminate one month after the expulsion. If a student of at least 19 years of age acquiring formal vocational education as specified in clause 5 of subsection 4 of § 5 of this Act fails to graduate from the educational institution within the standard period of study prescribed for completion of the curriculum (except for medical reasons) or is expelled from the educational institution before graduation, his or her insurance cover terminates one month thereafter. If a student specified in clause 5 of subsection 4 of § 5 of this Act fails to graduate from the educational institution within one year after the end of the standard period of study prescribed for completion of the curriculum (except for medical reasons) or is expelled from the educational institution before graduation, their insurance cover will terminate one month thereafter. RT I 2013-07-02 1 102072013001 2013-09-01 3 Insurance cover will be suspended for any period of academic leave. The conditions under which insurance cover is not suspended for a period of academic leave will be established by a regulation of the minister in charge of the policy sector. After expiry of the period of suspension, the insurance cover will continue without a waiting period. 4 The insurance cover of a person specified in clause 6 of subsection 4 of § 5 of this Act terminates after one month has passed from terminating membership in the cloister, including as of the date of moving to a cloister located abroad. RT I 2017-12-28 4 128122017004 2018-01-01 13 Submission of documents and information 1 Information required for the commencement, suspension or termination of the insurance cover must be submitted in writing or in an electronic form that is considered equal thereto. RT I 2014-04-16 3 116042014003 2014-07-01 1 1)]]> A person providing a person specified in clauses 1 and 2 of subsection 2 of § 5 of this Act with work must submit the information specified in these provisions, which serves as the basis for the commencement, suspension and termination of the person's insurance cover on the grounds and in accordance with the procedure provided for in the Taxation Act to the employment register and the latter will forward it to the Health Insurance Fund. RT I 2015-03-11 2 111032015002 2016-01-01 2 Documents and information necessary for insurance cover to commence, to be suspended or to terminate may, in addition to the person obligated to submit the documents or information, also be submitted by the person applying for insurance cover or by the insured person. 3 A person required to submit documents or information necessary for the commencement of the insurance cover must perform the obligation within seven calendar days as of the emergence of the obligation. The employment register will forward the information after the person having the registration obligation has entered it in the employment register. RT I 2014-04-16 3 116042014003 2014-07-01 4 Repealed - RT I 2014-04-16 3 116042014003 2014-07-01 5 The Health Insurance Fund will issue a certificate concerning the receipt of documents or information at the request of the person submitting the documents or information. 6 The following will be established by a regulation of the minister in charge of the policy sector: 1 a list of the documents necessary for insurance cover to commence, to terminate and to be suspended, and the composition of the information contained in such documents; 2 if necessary, the procedure for recognition of documents issued in foreign states. 13 1. ]]> Proof of insurance cover 1 A person's insurance cover commences, is suspended and terminates on the basis of data entered in the Health Insurance Fund database. 2 The entries of commencement, suspension and termination of the insurance cover of the persons specified in clauses 1 and 2 of subsection 2 and subsection 3¹ of § 5 of this Act are made in the Health Insurance Fund database on the basis of the data of the employment register. 3 The Health Insurance Fund may make an entry on termination or suspension of the insurance cover of a person on its own initiative where the fund has sufficient information that the conditions of insurance of the person are not complied with and the fund has, where possible, previously ascertained the insured person's opinion. The Health Insurance Fund must notify the insured person of the making of the entry on the same day in writing. The insured person has the right to submit objections against the making of the entry within ten days after the receipt of the notice. 4 A person who is entered in the Health Insurance Fund database must present an identity document in order to prove their insurance cover in Estonia. In order to prove their insurance cover in another Member State of the European Union, a contracting state of the European Economic Area or Switzerland, a person entered in the Health Insurance Fund database presents their European health insurance card or provisional replacement certificate of their European health insurance card (hereinafter provisional replacement certificate). 5 A person under the sage of 15 years who has been entered in the Health Insurance Fund database may present a European health insurance card instead of an identity document in order to prove their insurance cover in Estonia. 6 The conditions of and procedure for issuing European health insurance cards and provisional replacement certificates are established by a regulation of the minister in charge of the policy sector. 7 If a person's insurance cover is suspended or terminated, they must not use the European health insurance card or provisional replacement certificate. RT I 2019-03-13 2 113032019002 2019-03-15 14 Liability of persons obligated to submit documents 1 If a person applying for insurance cover would have had the right to receive health insurance benefits if a person obligated to submit documents necessary for insurance cover to commence had performed such obligation as required, the person who violated the obligation must compensate the person applying for insurance cover for the loss incurred due to the failure to receive the health insurance benefits. 1 1)]]> If a person applying for insurance cover would have had the right to receive health insurance benefits if a person obligated to submit documents necessary for insurance cover to commence had performed such obligation as required on the basis of subsection 1¹ of § 13 of this Act, the person who violated the obligation must compensate the person applying for insurance cover for the loss incurred due to the failure to receive the health insurance benefits. RT I 2014-04-16 3 116042014003 2014-07-01 2 Repealed - RT I 2005 39 308 919178 2006-01-01 3 Repealed - RT I 2005 39 308 919178 2006-01-01 4 In the event of violation of the obligation provided for in subsection 1¹ of § 13 of this Act, the Health Insurance Fund has the right to recover the health insurance benefits from the person who violated the obligation, which the Health Insurance Fund has paid for the person or to the person whose insurance cover was not terminated or suspended by the right time. RT I 2014-04-16 3 116042014003 2014-07-01 3 Health Insurance Database and Data Protection Repealed - RT I 2019-03-13 2 113032019002 2019-03-15 15 Health insurance database Repealed - RT I 2019-03-13 2 113032019002 2019-03-15 16 Controller and processor of health insurance database Repealed - RT I 2019-03-13 2 113032019002 2019-03-15 17 Information to be entered in health insurance database Repealed - RT I 2019-03-13 2 113032019002 2019-03-15 18 Right to collect information Repealed - RT I 2019-03-13 2 113032019002 2019-03-15 19 Entries in health insurance database Repealed - RT I 2019-03-13 2 113032019002 2019-03-15 20 Statutes for maintenance of health insurance database Repealed - RT I 2019-03-13 2 113032019002 2019-03-15 21 Proof of insurance cover Repealed - RT I 2019-03-13 2 113032019002 2019-03-15 4 Persons Considered Equal to Insured Persons on Basis of Contract 22 Persons considered equal to insured persons on basis of contract 1 The permanent residents of Estonia and persons residing in Estonia under a temporary residence permit or the right of residence are considered equal to insured persons on the basis of a contract.[RT I, 03.12.2025, 3 - entry into force 01.01.2026] 2 The contract specified in subsection 1 of this section may be concluded in favor of another person by the permanent residents of Estonia and persons residing in Estonia under a temporary residence permit or the right of residence.[RT I, 03.12.2025, 3 - entry into force 01.01.2026] 2 1)]]> [Repealed – RT I, 03.12.2025, 3 – entry into force 01.01.2026] 2 2)]]> [Repealed – RT I, 03.12.2025, 3 – entry into force 01.01.2026] 3 The Health Insurance Fund has the right, if it provides a reasoned explanation, to refuse to conclude a contract specified in subsection 1 of this section if the person has failed to duly perform contracts previously concluded with the Health Insurance Fund or to comply with legislation regulating health insurance or if they have knowingly submitted false information to the Health Insurance Fund. 23 Application of Acts 1 Unless otherwise provided by this Act, all the rights and obligations of insured persons provided by this Act extend to the persons considered equal to insured persons on the basis of a contract specified in subsection 1 of § 22 of this Act. 2 The provisions of the Law of Obligations Act that regulate insurance contracts apply to the contracts specified in subsection 1 of § 22 of this Act insofar as they are not in conflict with the provisions of this Act. The provisions of the Insurance Activities Act do not apply to such contracts. RT I 2005 39 308 919178 2006-01-01 24 Conditions under which person is considered equal to insured persons on basis of contract 1 The standard conditions of the contract specified in subsection 1 of § 22 of this Act will be approved by the supervisory board of the Health Insurance Fund on the proposal of the management board. 2 The term of the contract must be at least one year. 3 The size of an insurance premium payable in a calendar month on the basis of a contract is the product of the average gross wage of the previous calendar year as published by the Statistical Office, multiplied by 0.13 and rounded with the accuracy of 10 cents. The Health Insurance Fund has the right to change the size of an insurance premium payable in a calendar month once a year after the Statistical Office has published the average gross wage of the previous calendar year. RT I 2010 22 108 13310847 2011-01-01 4 Insurance cover will commence one month after entry into the contract. If an insurance contract is concluded during the period of validity of the compulsory insurance cover of a person, the insurance cover of the person will commence as of the termination of the currently valid compulsory insurance cover without interruption. 5 Repealed - RT I 2005 39 308 919178 2006-01-01 6 Repealed - RT I 2005 39 308 919178 2006-01-01 7 The contract will terminate once the insurance cover of the compulsory insurance becomes effective on the basis of this Act or once a person considered equal under the contract takes up residence abroad.[RT I, 03.12.2025, 3 – entry into force 01.01.2026] 3 HEALTH INSURANCE BENEFIT 1 General Conditions 25 Definition and types of health insurance benefit 1 Health insurance benefit is a high quality and timely health service, necessary medicinal product or medical device which is provided to an insured person under the conditions provided for in this Act by the Health Insurance Fund or a person who has concluded a corresponding contract with the fund (benefit in kind), or a sum of money that the Health Insurance Fund must pay to an insured person under the conditions provided for in this Act for the health care expenses incurred by the person or upon their temporary incapacity for work (pecuniary benefit). RT I 2008 3 22 12909773 2008-09-01 2 A health insurance benefit in kind is any of the following which is wholly or partially financed by the Health Insurance Fund: 1 a health service provided to prevent or treat a disease (health service benefit); 2 a medicinal product or medical device (benefit for medicinal products, benefit for medical devices, and additional benefit for medicinal products and medical devices). RT I 2024-05-02 3 102052024003 2025-01-01 3 The expenses incurred by the Health Insurance Fund to provide benefits for medicinal products must not exceed 20 per cent of the expenses prescribed for health service benefits in the annual budget of health care expenses. The funds of the risk reserve provided for in § 39¹ of the Health Insurance Fund Act may be used on the basis of a decision of the supervisory board of the Health Insurance Fund in order to cover the additional expenses incurred for benefits for medicinal products in the case of an unanticipated growth in disease contraction. RT I 2023-03-11 9 111032023009 2023-04-01 4 A pecuniary health insurance benefit is any of the following that is paid to an insured person by the Health Insurance Fund: 1 the benefit for temporary incapacity for work; 2 repealed - RT I 2016-12-27 4 127122016004 2018-01-01 3 repealed - RT I 2004 89 614 831409 2005-01-01 4 repealed - RT I 2017-12-28 5 128122017005 2018-01-01 5 the benefit for a health service provided outside the waiting list; RT I 2013-11-29 1 129112013001 2013-12-09 6 the benefit for a cross-border health service. RT I 2013-11-29 1 129112013001 2013-12-09 4 1)]]> A pecuniary health insurance benefit will be paid to the bank account of the recipient of the benefit, which has been entered into the Health Insurance Fund database or, on the basis of a written application of the recipient of the benefit, to the bank account of a third party. The account details saved in the Health Insurance Fund database can be updated by the insured person via the interface of the data exchange layer of information systems (hereinafter X-road) or on the basis of a written application. RT I 2014-10-08 1 108102014001 2014-10-18 5 An insured person does not have the right of recourse against the Health Insurance Fund in respect of the money or other assets spent on the services, medicinal products or medical devices classified as health insurance benefits in kind. RT I 2008 3 22 12909773 2008-09-01 26 Right of recourse of Health Insurance Fund 1 The Health Insurance Fund has the right of recourse against a person who is liable for the occurrence of an insured event due to which an insured person receives health insurance benefits, and against the insurers and the Estonian Motor Insurance Bureau who are required to provide benefits in connection with that insured event. RT I 2022-06-20 3 120062022003 2022-06-30 2 The Health Insurance Fund has the right of recourse to the extent of a health insurance benefit paid by the fund in accordance with the procedure provided for in the State Liability Act in the case of loss caused to an insured person by a public authority through damage to health or a bodily injury. 3 Based on § 1041 of the Law of Obligations Act, the Health Insurance Fund has the right of recourse concerning persons who use the European health insurance card or the provisional replacement certificate of the European health insurance card after the suspension or termination of their insurance cover to the extent of the health insurance benefit paid by the fund to such persons. RT I 2015-12-30 2 130122015002 2016-01-09 4 Repealed - RT I 2015-03-11 2 111032015002 2016-01-01 5 Repealed - RT I 2015-03-11 2 111032015002 2016-01-01 6 Repealed - RT I 2015-03-11 2 111032015002 2016-01-01 7 The Health Insurance Fund has the right of recourse against the sponsor of the scientific research where the insured person's need for the health insurance benefit stems from participation in scientific research, unless it is a clinical trial or a performance study of a medicinal product or device and the sponsor is exempt from the professional assessment remuneration under subsection 3 of § 99⁷ of the Medicinal Products Act. RT I 2022-12-22 2 122122022002 2023-01-01 27 Territorial effect of health insurance benefits 1 Except in the events provided for in subsection 2 of this section and subsection 3 of § 36 of this Act, an insured person has the right to receive health insurance benefits in kind only in Estonia. RT I 2013-11-29 1 129112013001 2013-12-09 2 If an insured person has been provided with a health service in a foreign state, the insured person may receive health service benefits in accordance with the procedure established in § 27¹ of this Act on the basis of a respective authorisation granted by the Health Insurance Fund or a written contract concluded beforehand between the insured person or their legal representative and the Health Insurance Fund. RT I 2013-11-29 1 129112013001 2013-12-09 3 The Health Insurance Fund will refuse to grant the authorisation or conclude the contract specified in subsection 2 of this section if the health service applied for can be rendered to the insured person in Estonia, but the Health Insurance Fund does not grant the insured person monetary health insurance benefits or health insurance benefits in kind in Estonia in the event of provisions of the health service applied for. RT I 2013-11-29 1 129112013001 2013-12-09 4 Repealed - RT I 2016-12-27 4 127122016004 2018-01-01 27 1. ]]> Health service benefit upon provision of health service in foreign state 1 The Health Insurance Fund may grant the authorisation specified in subsection 2 of § 27 of this Act or conclude a contract specified in the same section on the basis of an application of an insured person or their legal representative if: 1 the health service applied for or an alternative health service cannot be rendered to the insured person in Estonia; 2 provision of the health service applied for is therapeutically justified with regard to the insured person; 3 the medical efficacy of the health service applied for has been proved; 4 the average probability of the aim of the health service applied for being achieved is at least 50 per cent. 2 At least two medical specialists, one of whom is the medical specialist providing health service to the insured person, must assess the conformity of the insured person to the criteria specified in subsection 1 of this section. 3 At the request of the Health Insurance Fund, the insured person must undergo an additional evaluation of their state of health, which will be carried out by a doctor appointed by the Health Insurance Fund for the purpose of identifying the conformity of the state of health of the person to the criteria specified in subsection 1 of this section. 4 The Health Insurance Fund may give preference to the provision of the health service applied for upon granting the authorisation or concluding the contract specified in subsection 2 of § 27 of this Act in a Member State of the European Union. RT I 2013-11-29 1 129112013001 2013-12-09 28 Restrictions on receipt of health insurance benefits 1 If a person fails to follow the medically justified treatment prescribed by a doctor or a family nurse, they will lose the right to receive health insurance benefits in connection with the case of disease for the prevention of which or against which the particular treatment was prescribed. RT I 2009 67 461 13252426 2010-01-01 2 In the events provided for in subsection 1 of this section, the Health Insurance Fund will decide on the loss of a right to receive health insurance benefits in accordance with the procedure provided for in the Administrative Procedure Act, taking into account the specifications prescribed in this Act. 3 Intra-agency proceedings with regard to a decision made by the Health Insurance Fund on the basis of subsection 2 of this section may be initiated by an insured person within ten calendar days in accordance with the procedure provided for in the Administrative Procedure Act. 4 The provisions of subsection 1 of this section do not apply if: 1 the monetary value of the health insurance benefit concerned does not justify restriction of the insured person's right to bodily self-determination; 2 application of the provisions would constitute a significant breach of the insured person's right to bodily self-determination; 3 the insured person or their legal representative has good reason for refusing to grant consent to or follow the treatment prescribed by a doctor or family nurse; RT I 2009 67 461 13252426 2010-01-01 4 the health service prescribed is likely to cause a risk of serious health damage to the insured person or their death; 5 the health service prescribed causes great pain or a danger of prolonged pain to the insured person. 5 The insured person is not entitled to the health insurance benefit where the need for the benefit stems from participation in scientific research, except for a clinical trial or a performance study of a medicinal product or device or in the event of using a hospital-exemption medicinal product. RT I 2022-12-22 2 122122022002 2023-01-01 6 The right to receive a health insurance benefit expires within three years as of the creation of the right unless otherwise provided by this Act. 2 Health Service Benefit 1 Health Services 29 Scope of insurance cover 1 The Health Insurance Fund will assume the obligation of an insured person to pay for health services if the services are entered in the list of health services of the Health Insurance Fund and the provision thereof is therapeutically justified. 2 To the extent of the limit established for the calendar year, the Health Insurance Fund assumes the obligation of an insured person of at least 19 years of age to pay for dental care services. The limit is not applicable in the event specified in subsection 2 of § 33 of this Act. RT I 2016-12-27 4 127122016004 2017-07-01 2 1)]]> In addition to subsection 2, the Health Insurance Fund assumes the obligation of an insured person of at least 19 years of age to pay for the anaesthesia service required based on medical indications in accordance with the conditions set out in the list of health care services. RT I 2016-12-27 4 127122016004 2017-07-01 2 2)]]> The Health Insurance Fund assumes the obligation to pay for the denture service to the extent of the limit established for three years from: 1 an insured person of at least 19 years of age whom pension for incapacity for work or old-age pension has been granted in accordance with the State Pension Insurance Act or who has been found to have partial work ability or no work ability under the Work Ability Allowance Act; 2 an insured person of over 63 years of age. RT I 2016-12-27 4 127122016004 2018-01-01 2 3)]]> The restriction provided for in subsection 2² of this section is not applied in the cases provided for in subsection 2 of § 33 of this Act. RT I 2016-12-27 4 127122016004 2018-01-01 2 4)]]> In accordance with the procedure provided for in § 33³ of this Act, the Health Insurance Fund assumes the obligation to pay for health services involving in vitro fertilisation and embryo transfer from an insured woman of up to 40 years of age who has medical indications for the in vitro fertilisation and embryo transfer. RT I 2017-12-28 4 128122017004 2018-01-01 3 The Health Insurance Fund must also assume an obligation of a person to pay for health services if an insured event occurring during the period of validity of the insurance cover of the person directly causes the need for emergency medical care to be provided to the person after termination of the insurance cover. 30 List of health services of Health Insurance Fund 1 The list of health services of the Health Insurance Fund (hereinafter list of health services) will be established by a regulation of the Government of the Republic on the proposal of the minister in charge of the policy sector to which the written opinion of the supervisory board of the Health Insurance Fund concerning the proposal is appended. 2 The following is entered in the list of health services: 1 the name of the health service; 2 the code of the health service; 3 the reference price of the health service; 4 the limits for the payment obligation of an insured person assumed by the Health Insurance Fund; 5 the extent of cost-sharing by an insured person; 6 the conditions for application of the reference price of the health service, the limits for the payment obligation of an insured person assumed by the Health Insurance Fund, and the extent of cost-sharing by an insured person. 3 The extent of cost-sharing by an insured person is that part of the reference price of a health service for which the payment obligation is not assumed by the Health Insurance Fund. The same extent of cost-sharing applies to all insured persons and the extent must not exceed 50 per cent of the reference price of a health service, unless otherwise provided for in this Act. Cost-sharing does not apply to provision of emergency care. RT I 2016-12-27 4 127122016004 2017-07-01 4 A reference price set out in the list of health services covers all the expenses necessary for the provision of the health service, except for expenses on research, organisation practical training, and the training of pupils and students. RT I 2018-12-21 2 121122018002 2019-09-01 31 Amendment of list of health services 1 The following criteria are taken into account upon entry of a service in the list of health services: 1 the proven medical efficacy of the health service; 2 the cost-effectiveness of the health service; 3 the necessity of the health service in society and the compatibility of the service with national health policy; 4 correspondence to the financial resources of health insurance. 1 1)]]> Upon entry of a complex service in the list of health services and upon changes in information specified in clauses 2, 4, 5 and 6 of subsection 2 of § 30 of this Act and also upon deletion of a service from the list of health services, at least the criteria provided for in clauses 3 and 4 of subsection 1 of § 31 are taken into account. 1 2)]]> If the reference price of a health service is changed, at least the criteria provided for in clauses 2, 3 and 4 of subsection 1 of § 31 are taken into account. 1 3)]]> The Health Insurance Fund establishes a health services list advisory committee which renders an opinion to the management board of the Health Insurance Fund regarding amendment of the list of health services in accordance with the regulation of the Government of the Republic specified in subsection 2 of this section. RT I 2018-06-22 4 122062018004 2018-07-01 2 By a regulation, the Government of the Republic establishes: 1 more detailed contents of the health services list criteria set out in subsection 1 of this section and the persons assessing compliance with the criteria; 2 the conditions of and procedure for assessment of the list of health services; 3 the procedure for the establishment of, the rules of procedure of and the procedure for rendering an opinion by the health services list committee. RT I 2018-06-22 4 122062018004 2018-07-01 3 A health service may be entered in the list of health services subject to cost-sharing by the insured person if: 1 the aim of the provision of the health service can be achieved by other, cheaper methods which do not involve significantly greater risks or have any other significant adverse effects on the situation of the insured person; 2 the health service is directed more at improving quality of life than at treating or alleviating a disease; 3 insured persons are generally prepared to pay for the health service themselves and the decision of an insured person to conclude a contract for the provision of the health service depends primarily on the assumption of the obligation to pay for the health service by the Health Insurance Fund or on the extent to which the payment obligation is assumed. 4 A health service may be entered in the list of health services with a condition. 5 The making of a proposal for amendment of the list of health services may be initiated by the associations and professional associations of interested health care providers by entering into negotiations with the Health Insurance Fund. The making of a proposal for amendment of the list of health services may be initiated by the Health Insurance Fund by entering into negotiations with the associations and professional associations of interested health care providers. The addition or amendment of a service involving the administration of a medicinal product may be initiated by the holder of the marketing authorisation of the medicinal product. The Ministry of Social Affairs has the right to make a proposal to the Health Insurance Fund to commence negotiations with association of health service providers or professional associations in order to initiate a revision of the list of health services where it is required for implementing the health policy of the state. RT I 2022-06-20 3 120062022003 2022-06-30 6 An application submitted to the minister in charge of the policy sector for amendment of the list of health services must contain as annexes the positions of the initiator of the amendment and of the other party to the negotiations. RT I 2004 56 400 778828 2004-08-01 ; 01.01.2005 32 Payment to health care providers The procedure for the assumption of a payment obligation of an insured person by the Health Insurance Fund and the methods for calculation of the payments to be made to health care providers will be established by a regulation of the minister in charge of the policy sector on the proposal of the supervisory board of the Health Insurance Fund. 33 Dental care benefit for insured person under 19 years of age 1 The Health Insurance Fund will assume a payment obligation arising from a contract for the provision of dental care services concluded by or for the benefit of an insured person under 19 years of age, on the condition that the dental care service provided is entered in the list of health services. 2 Subsection 1 of this section applies to an insured person under 19 years of age and the provider of the dental care service must conclude a contract for the provision of dental care services with the insured person if: 1 provision of the dental care service to the insured person within one year after the person attains 19 years of age is based on therapeutic indications and if such indications were or should have been evident at the time of the insured person's last visit to the provider of the dental care service before the person attained 19 years of age; RT I 2008 34 210 12997653 2008-08-01 2 provision of the dental care service to the insured person is based on therapeutic indications and if such indications have arisen from the need to treat the effects of dental care services provided to the person before they attained 19 years of age or due to the fact that the expected recovery did not occur within one year after they attained 19 years of age. RT I 2004 56 400 778828 2004-08-01 3 The level of cost-sharing of an insured person set in the list of health care services does not apply to a person from whom the Health Insurance Fund assumes the obligation to pay for dental care services in accordance with subsections 1 and 2 of this section. RT I 2016-12-27 4 127122016004 2017-07-01 33 1. ]]> Dental care benefit for insured person of at least 19 years of age 1 By a regulation, the Government of the Republic will establish: 1 the list of the dental care services for which the Health Insurance Fund assumes the payment obligation of an insured person of at least 19 years in events other than those specified in subsection 2 of § 33 of this Act; 2 the limit of the assumed obligation of an insured person of at least 19 years of age to pay for dental care services provided to the person per calendar year; 3 the heightened limit of the assumed obligation of an insured person of at least 19 years of age whom pension for incapacity for work or old-age pension has been granted under the State Pension Insurance Act, who has been diagnosed with a partial or absent ability to work on the basis of the Work Ability Allowance Act, who is unemployed within the meaning of the Labour Market Measures Act, who receives the subsistence benefit under the Social Welfare Act in the period provided in a regulation established on the basis of § 32 of this Act, who is over the age of 63 years, pregnant or the mother of a child of less than one year of age or who, as a result of a health care service rendered to them or an illness that they have been diagnosed with, has an increased need for a dental care service, to pay for the dental care service provided to the person per calendar year; RT I 2023-03-07 5 107032023005 2024-01-01 4 the list of health services and diagnosed illnesses specified in clause 3 of this subsection; RT I 2017-06-29 1 129062017001 2018-01-01 5 the limit of assuming the obligation to pay for the denture service rendered to an insured person specified in subsection 2² of § 29 of this Act for a period of three years. RT I 2016-12-27 4 127122016004 2018-01-01 2 Upon provision of a person from whom the Health Insurance Fund assumes the obligation to pay for a dental care service to the extent of the heightened limit established on the basis of clause 3 of subsection 1 of this section with the dental care service, the cost-sharing rate of the insured person of up to 15 per cent, as set out in the list of health care services, is applied. RT I 2016-12-27 4 127122016004 2017-07-01 3 If the Health Insurance Fund did not assume to the extent of the limit or the heightened limit the obligation of an insured person of at least 19 years of age to pay for a dental care service per calendar year, the limit of the payment obligation to be assumed by the Health Insurance Fund in the next calendar year will not be increased. RT I 2016-12-27 4 127122016004 2017-07-01 4 Where the Health Insurance Fund did not assume the obligation to pay for the denture service over a period of three years from an insured person to the extent of the established limit, the limit of the payment obligation assumed by the Health Insurance Fund is not increased over the course of the next three years. RT I 2016-12-27 4 127122016004 2018-01-01 33 2. ]]> Rights of Health Insurance Fund upon assuming payment obligation of person of at least 19 years of age to pay for dental care service and denture service provided to person RT I 2016-12-27 4 127122016004 2018-01-01 1 Regarding the portion exceeding the limit of assuming the obligation of an insured person of at least 19 years to pay for a dental care service per calendar year on the basis of clauses 2 and 3 of subsection 1 of § 33¹ of this Act, the Health Insurance Fund may make a precept to the person along with a warning and recover the benefit to the extent exceeding the limit. 2 Regarding the portion exceeding the limit of assuming the obligation of an insured person of at least 19 years to pay for the denture service per three years on the basis of clause 5 of subsection 1 of § 33¹ of this Act, the Health Insurance Fund may make a precept to the person along with a warning and recover the benefit to the extent exceeding the limit. 3 In the event of failure to comply with a precept within the term set out in a warning specified in subsections 1 and 2 of this section, the Health Insurance Fund has the right to issue a precept for compulsory execution pursuant to the procedure provided in the Code of Enforcement Procedure. RT I 2016-12-27 4 127122016004 2018-01-01 33 3. ]]> Assuming of obligation to pay for in vitro fertilisation and embryo transfer health services 1 The Health Insurance Fund assumes the obligation of a person specified in subsection 2⁴ of § 29 of this Act to pay for the following health services: 1 the in vitro fertilisation and embryo transfer health services included in the list of health services; 2 health services provided in connection with in vitro fertilisation and embryo transfer within 90 days preceding the in vitro fertilisation and embryo transfer. 2 The health service provider is compensated for the costs of the health services specified in subsection 1 of this section where a treatment invoice is submitted to the Health Insurance Fund on the basis of a treatment financing contract. 3 Upon provision of the health services subsection 1 of this section outside Estonia, subsections 2 and 3 of § 27 of this Act are applied. RT I 2017-12-28 4 128122017004 2018-01-01 34 Disease prevention The Health Insurance Fund participates in financing projects specifically aimed at disease prevention to the extent of the amounts prescribed for such purpose in the budget of the Health Insurance Fund and with approval of the Ministry of Social Affairs. 2 Contract for Financing Medical Treatment 35 Contract for Financing Medical Treatment 1 By a contract for financing medical treatment, the Health Insurance Fund assumes the obligation of an insured person to pay for the provision of health services under the conditions provided for in the contract and in legislation. 2 A contract for financing medical treatment is an administrative contract. The provisions of Chapter 7 of the Administrative Procedure Act together with the specifications provided by this Act apply to contracts for financing medical treatment. 36 Entry into contract for financing medical treatment 1 The Health Insurance Fund concludes a contract for financing medical treatment with a health care provider or providers. 2 The Health Insurance Fund is not required to conclude a contract for financing medical treatment with all health care providers. 3 The Health Insurance Fund has the right to conclude a contract for financing medical treatment with health care providers located in foreign states. The reference prices and limits provided for in the list of health services apply to a contract for financing medical treatment which is concluded with a health care provider located in a foreign state if the Health Insurance Fund undertakes to assume the obligation to pay for the provision of a health service entered in the list of health services. 4 In order for a decision to be made on entry into a contract for financing medical treatment and on the term of the contract, the Health Insurance Fund takes into account the following circumstances: 1 the need of the insured persons for the service, and the availability of the service; 2 the quality of and conditions for the provision of the service; 3 the price of the service; 4 the possibility of the service being provided in accordance with the standard conditions of accommodation; 5 the maximum number of health care providers providing the health service; 6 figures regarding the average density of provision of the health service; 7 developments in national health policy; 8 whether the health care provider has performed previous contracts for financing medical treatment or other similar contracts as required; 9 the existence or absence of tax arrears and the general financial situation of the health care provider; 10 compliance with legislation regulating health insurance and health by the health care provider or the employer thereof. 4 1)]]> The Health Insurance Fund concludes contracts for financing medical treatment, taking into account the circumstances specified in subsection 4 of this section, with a term of at least three years. RT I 2004 56 400 778828 2005-04-01 4 2)]]> If the Health Insurance Fund, taking into account the circumstances specified in subsection 4 of this section, concludes a contract for financing medical treatment with a health care provider for the first time, the contract will be concluded for a term of at least three years. RT I 2004 56 400 778828 2005-04-01 5 The Health Insurance Fund will conclude a contract for financing medical treatment for a term of at least five years with a person who owns a hospital specified in the hospital network plan established by a regulation of the Government of the Republic in accordance with subsection 1 of § 55 of the Health Services Organisation Act. RT I 2014-03-13 2 113032014002 2019-01-01 5 1)]]> The Health Insurance Fund will conclude a contract for financing medical treatment for a term of at least five years with a person who provides family medical care based on the approved list of family doctors. RT I 2024-06-21 2 121062024002 2024-07-01 6 Repealed - RT I 2004 56 400 778828 2005-04-01 37 Conditions of contract for financing medical treatment The following conditions will be agreed upon in a contract for financing medical treatment: 1 the term of the contract; 2 the amount of obligations of insured persons assumed by the Health Insurance Fund during a specific period of time and the total amount of obligations, and, if necessary, amounts for each of the medical professions established by the minister in charge of the policy sector or amounts calculated on any other basis; 3 the price payable for the provision of the health service, taking into consideration the reference price and limit provided for in the list of health services; 4 the minimum volume of health services provided; 5 a list of health care professionals who provide health services for which the payment obligation is assumed by the Health Insurance Fund, and the procedure for giving notice of amendment of the list and for co-ordinating the amendments with the Health Insurance Fund; 6 the number of hours in a period of time during which the health care provider must provide health services to insured persons; 7 the term during which the health care provider must submit information to the Health Insurance Fund concerning the assumption of obligations to pay for health services provided to insured persons; 8 cases where assumption of the payment obligation of an insured person is contingent upon prior written approval from the Health Insurance Fund; 9 cases where the parties have the right unilaterally to terminate or amend the contract or to suspend performance of the contract in part or in full; 10 the frequency with which information is to be submitted to the Health Insurance Fund concerning waiting lists and the services provided, and the composition of the information to be submitted; 11 the procedure and term for giving notice of health services provided to insured persons outside the waiting list; 12 the scope of the reporting obligation of the health care provider and the obligation to submit information concerning insured persons, and the composition of the information to be submitted; 13 the indicators of the quality and efficacy of the health services; 14 the liability of the parties upon violation of the contract; 15 other conditions necessary for ensuring the efficient and sound use of Health Insurance Funds. 37 1. ]]> Conditions of conclusion of contract for financing treatment with provider of person of at least 19 years of age with dental care and denture services RT I 2016-12-27 4 127122016004 2018-01-01 1 To assume from the insured person the obligation to pay for the dental care service provided for in subsections 2 and 2² of § 29 of this Act, the Health Insurance Fund concludes a contract for financing treatment for a term of at least three years with a health service provider that holds a dental care services activity licence. 2 Where the Health Insurance Fund does not have a valid contract for financing treatment with a dental care or denture service provider, the contract specified in subsection 1 of this section is concluded with it for a term of one year. The term of the contract for financing treatment is renewed for at least two years where the health care provider has not breached the terms of the contract in the first year of validity of the contract. 3 The following terms and conditions are agreed on in the contract for financing treatment specified in subsection 1 of this section: 1 the term of the contract; 2 the conditions of ensuring the quality of the health service and the procedure for exercising supervision over it by the Health Insurance Fund; 3 a list of health care professionals who provide health services for which the payment obligation is assumed by the Health Insurance Fund, and the procedure for giving notice of amendment of the list and for coordinating the amendments with the Health Insurance Fund; 4 the term during which the health care provider must submit information to the Health Insurance Fund concerning the assumption of obligations to pay for health services provided to insured persons; 5 cases where the parties have the right unilaterally to terminate or amend the contract or to suspend performance of the contract in part or in full; 6 the frequency with which information is to be submitted to the Health Insurance Fund concerning waiting lists and the services provided, and the composition of the information to be submitted; 7 the scope of the reporting obligation of the health care provider and the obligation to submit data concerning insured persons, and the composition of the information to be submitted, and the closing date and procedure for the submission of data; 8 the liability of the parties upon violation of the contract; 9 other conditions necessary for ensuring the efficient and sound use of Health Insurance Funds. 4 Subsections 4–4² of § 36 and § 37 of this Act do not apply to the contract for financing treatment specified in this section. RT I 2016-12-27 4 127122016004 2018-01-01 38 Waiting list 1 A waiting list is a part of a database maintained by a health care provider which contains information concerning insured persons who are waiting for a regular health service benefit and which serves as the basis for the assumption of payment obligations by the Health Insurance Fund. 2 The Health Insurance Fund will conclude contracts for financing medical treatment only with health care providers who maintain waiting lists in accordance with clause 4 of subsection 1 of § 56 of the Health Services Organisation Act and enable entry into contracts for provision of health service through the health information system. RT I 2008 3 22 12909773 2008-09-01 3 The maximum length of a waiting list will be approved by the supervisory board of the Health Insurance Fund. Any extension of the maximum length of a waiting list does not apply to insured persons who have already been entered in the waiting list. 4 Repealed - RT I 2016-12-27 4 127122016004 2017-07-01 5 Only insured persons who, upon their entry in a waiting list, have a proven medical need for a health service may be entered in the waiting list. An insured person who no longer has a proven medical need for a health service will be deleted from the waiting list immediately. The Health Insurance Fund has the right to examine waiting lists at any time or to demand that a waiting list be submitted for examination. 6 An insured person has the right to obtain a health service outside the waiting list on the condition that this does not prejudice the opportunities of the insured persons in the waiting list to obtain the health service. 39 Assumption of obligations 1 The Health Insurance Fund is deemed to have assumed an obligation to pay for the provision of a health service if, within thirty calendar days after the receipt of the documents on which assumption of the obligation is based, the Health Insurance Fund has not notified the health care provider in writing of its refusal to assume the obligation. 2 If there is a waiting list for a health service, the Health Insurance Fund must assume the obligation to pay for the health service if the insured person has been on the list and waiting for the health service to be provided, together with assumption of the payment obligation by the Health Insurance Fund, until their turn or for longer than prescribed by the maximum length of the waiting list. 3 In the event of existence of a waiting list, the Health Insurance Fund will not assume the obligation to pay for a health service received outside the waiting list, unless otherwise provided for in this Act or legislation established on the basis thereof. RT I 2013-11-29 1 129112013001 2013-12-09 4 The assumption of an obligation to pay for the provision of a health service may be refused if: 1 provision of the heath service is unjustified or the therapeutic indications are insufficient; 2 the health service is provided to a standard below the general level of medical science; 3 the health service is not provided in conformity with the conditions provided by legislation or the contract for financing medical treatment; 4 the rights of the patient have been violated upon the provision of the health service; 5 the documents on which assumption of the obligation is based have been prepared incorrectly and the health care provider fails to eliminate the deficiencies within the term agreed upon in the contract for financing medical treatment; 6 upon provision of the health service, the health care provider violates this Act, other legislation or a contract concluded with the Health Insurance Fund. 5 The Health Insurance Fund has the right and a health care provider must notify an insured person in writing within one month of the refusal of the Health Insurance Fund to assume a payment obligation and of the reasons therefor. In the event of a violation of the notification obligation, the health care provider will lose the right to demand payment for the health service from the insured person. 6 An insured person has the right to submit the same objections to a claim for payment submitted by a health care provider as the Health Insurance Fund. 3 Second Opinion 40 Right to second opinion 1 For the purpose of this Act, ‘second opinion’ means an independent opinion of another medical specialist who is a health service provider or a medical specialist working for another health service provider (hereinafter provider of second opinion), which is aimed at evaluating the correctness of the diagnose given to the insured person by the medical specialist who gave the initial opinion or the necessity of the medical product or health service prescribed to the insured person, the explained alternatives and expected impact and the risks relating to the provision of the health service. 2 The doctor who gave the initial opinion to the insured person upon provision of a health service must send to the provider of a second opinion all the documents regarding the health services rendered to the insured person or copies thereof and give the insured person a letter referring the insured person to the provider of the second opinion. 3 The Health Insurance Fund will assume the obligation to pay for the second opinion once per treatment event to the extent specified in the list of the health services of the Health Insurance Fund. 4 On the conditions of and in accordance with the procedure provided for in § 66² of this Act, the Health Insurance Fund will compensate the insured person for the expenses of giving a second opinion of a health service provider operating in another Member State of the European Union. 5 On the conditions of and in accordance with the procedure provided for in § 66² of this Act, the Health Insurance Fund will compensate the insured person for the expenses of giving a second opinion of a health service provider operating outside the European Union. 6 In order to obtain a second opinion from a health service provider operating in Estonia who does not have a treatment financing contract with the Health Insurance Fund and from a health service provider specified in subsection 5 of this section, the insured person or their legal representative and the Health Insurance Fund will conclude a written contract in advance. RT I 2013-11-29 1 129112013001 2013-12-09 4 Benefits for Medicinal Products, Benefits for Medical Devices, and Additional Benefits for Medicinal Products and Medical Devices RT I 2024-05-02 3 102052024003 2025-01-01 41 Scope of insurance cover in case of benefits for medicinal products 1 The Health Insurance Fund will, to the extent and in accordance with the procedure provided by legislation, assume an obligation to pay for the retail sale of medicinal products, food for particular nutritional uses and food supplements used for treatment of congenital metabolism disorders (hereinafter medicinal products), which are necessary for the out-patient treatment of an insured person and are entered in the list of medicinal products of the Health Insurance Fund (hereinafter list of medicinal products). RT I 2014-04-16 4 116042014004 2014-04-26 1 1)]]> The amount payable on the basis of the obligation to pay assumed by the Health Insurance Fund is calculated based on the retail price of the medicinal product. For the purposes of this Act, the retail price of a medicinal products is the final sales price of one sales packaging of the medicinal product to the consumer, which comprises the wholesale and retail sales mark-ups of the medicinal product, value added tax and the reimbursements granted by the manufacturer or the holder of the marketing authorisation or the wholesale distributor or retailer. RT I 2010 15 77 13297358 2010-07-01 2 The Health Insurance Fund will assume an obligation to pay for a medicinal product only if the prescription issued for the medicinal product is in compliance with the conditions and form established by a regulation of the minister in charge of the policy sector on the basis of the Medicinal Products Act. Family doctors operating on the basis of the practice lists of the family doctors and nurses working together with such family doctors, licensed medical specialists, licensed dentists, licensed midwives, and nurses who have acquired nursing specialty according to subsection 2 of section 24 of the Health Services Organisation Act, doctors (except in events of provision of emergency medical care), dentists and midwives working for a health care provider holding an activity licence for providing specialised medical care, and nurses who have acquired nursing specialty according to subsection 2 of section 24 of the Health Services Organisation Act, and doctors and dentists registered with the Health Care Board and employed in the Defence Forces have the right to issue prescriptions. As of the third year of residency, doctors-residents have the right to issue prescriptions equal to that of doctors who have acquired the respective speciality of specialised medical care. RT I 2022-06-20 3 120062022003 2022-06-30 3 The Health Insurance Fund will not assume an obligation to pay for the following portions of the price of a medicinal product: 1 the basic rate of cost-sharing per prescription, and 2 in the event of a medicinal product specified in subsection 3 of § 44 of this Act, the amount exceeding the reference price or the price provided for in the price agreement; RT I 2012-07-05 14 105072012014 2012-10-01 3 in the event of a medicinal product intended for the treatment or alleviation of a disease entered in the list of diseases established on the basis of subsection 1 or 2 of § 44 of this Act, the amount exceeding the reference price or the price provided for in the price agreement or the price established in the European Commission's joint procurement for medicinal products. RT I 2022-04-29 1 129042022001 2022-05-09 4 in the case of a medicinal product specified in subsection 4¹ of § 44 of this Act, the amount exceeding the reference price or the price provided for in the price agreement or the price established in the European Commission's joint procurement for medicinal products; RT I 2022-04-29 1 129042022001 2022-05-09 4 The amount payable based on the payment obligation assumed by the health insurance fund is calculated in the event of the medicinal products specified in subsection 3 of § 44 of this Act in accordance with the reimbursement percentage specified in the list of medicinal products from the difference between the reference price or the price specified in the price agreement and the basic rate of cost-sharing. RT I 2012-07-05 14 105072012014 2012-10-01 5 The amount payable based on the payment obligation assumed by the Health Insurance Fund is calculated in the event of the medicinal products specified in subsections 1 and 2 of § 44 of this Act in accordance with the reimbursement percentage specified in the list of medicinal products from the difference between the reference price or the price specified in the price agreement or the price established in the European Commission’s joint procurement for medicinal products and the basic rate of cost-sharing. RT I 2022-04-29 1 129042022001 2022-05-09 6 The amount payable based on the payment obligation assumed by the Health Insurance Fund is calculated in the event of the medicinal products specified in subsection 4 of § 44 of this Act in accordance with the reimbursement percentage specified in subsection 4 of § 44 from the difference between the reference price or the price specified in the price agreement or the price established in the European Commission’s joint procurement for medicinal products and the basic rate of cost-sharing. RT I 2022-04-29 1 129042022001 2022-05-09 6 1)]]> The amount payable based on the payment obligation assumed by the Health Insurance Fund is calculated in the event of the medicinal products specified in subsection 4¹ of § 44 of this Act in accordance with the reimbursement percentage specified in subsection 4¹ of § 44 from the difference between the reference price or the price specified in the price agreement or the price established in the European Commission’s joint procurement for medicinal products and the basic rate of cost-sharing. RT I 2022-04-29 1 129042022001 2022-05-09 7 If the retail price of a medicinal product is lower than the reference price or the price specified in the price agreement or the price established in the European Commission's joint procurement for medicinal products, the amount payable on the basis of a payment obligation assumed by the Health Insurance Fund will be calculated on the basis of the difference between the retail price and the basic rate of cost-sharing. RT I 2022-04-29 1 129042022001 2022-05-09 8 With good reason and taking into account the criteria provided for in subsection 2 of § 43 and subsections 5 and 6 of § 44 of this Act, the Health Insurance Fund may, at the written request of an insured person or the legal representative thereof to which the written opinion of the doctor treating the insured person has been annexed, assume the obligation to pay a portion of the retail price of a medicinal product, except for the basic rate of cost-sharing, if the medicinal product concerned is necessary for the out-patient treatment of the insured person and is entered in the list of medicinal products or is unauthorised. RT I 2023-12-15 3 115122023003 2023-12-25 42 Reference price, price agreement and basic rate of cost-sharing RT I 2012-07-05 14 105072012014 2012-10-01 1 A reference price is the price that serves as the basis for assumption of the payment obligation for medicinal products that have the same active substance and route of administration and that are entered in the list of medicinal products. RT I 2010 15 77 13297358 2010-04-18 1 1)]]> Reference prices are established for medicinal products if another medicinal product with the same active substance and route of administration is entered in the list of medicinal products with a reimbursement rate of 100, 75 or 50 per cent from another manufacturer or marketing authorisation holder of the medicinal product or two or more medicinal products with the same active substance and route of administration from at least two manufacturers are entered in the list at the same time. RT I 2010 15 77 13297358 2010-07-01 1 2)]]> The wholesale purchase price of a medicinal product to which the maximum valid gross margins for wholesale and retail trade and the value added tax are added (hereinafter maximum retail price) is the basis for the calculation of a reference price. The calculation of reference prices for two medicinal products is based on the medicinal product the price of which is lower. In the case of three or more medicinal products, reference prices are calculated on the basis of the price of the medicinal product with the next lowest price after the medicinal product with the lowest price. RT I 2004 56 400 778828 2005-01-01 1 3)]]> A person holding an activity licence for the wholesale trade of medicinal products and a person engaged in the wholesale trade of medicinal products holding an activity licence for the manufacture of medicinal products are required to communicate the wholesale purchase prices of all medicinal products to the Health Insurance Fund. The persons who communicate the wholesale purchase prices of medicinal products, and the conditions and procedure for the communication are established by a regulation of the minister in charge of the policy sector. RT I 2017-12-28 5 128122017005 2018-01-01 2 The method for the calculation of reference prices, the terms for the establishment and the conditions and terms for the amendment of reference prices will be established by a regulation of the minister in charge of the policy sector, taking into account the provisions of subsection 3 of § 25 of this Act. RT I 2004 56 400 778828 2005-01-01 2 1)]]> Reference prices of medicinal products are established by a regulation of the minister in charge of the policy sector on a proposal of the supervisory board of the Health Insurance Fund. RT I 2017-12-28 5 128122017005 2018-01-01 3 Where the price level of a medicinal product is lower than or equal to the reference price or where only one medicinal product with a given active substance and route of administration has been issued a valid marketing authorisation in Estonia, the price of the medicinal product is determined by a price agreement or established as a result of the European Commission's joint procurement for medicinal products. RT I 2022-04-29 1 129042022001 2022-05-09 4 A price agreement is an administrative contract that is concluded for each particular case between the Health Insurance Fund and a manufacturer of medicinal products or a person holding marketing authorisation for a medicinal product and which determines the wholesale purchase price of a medicinal product with a retail price lower than or equal to the reference price or a medicinal product to which a reference price does not apply, and for which the reimbursement rate is 100, 75 or 50 per cent. RT I 2017-12-28 5 128122017005 2018-01-01 5 Upon purchasing a medicinal product from a pharmacy, the basic rate of cost-sharing is 3.50 euros per prescription. The basic rate of cost-sharing is applied only in the case of out-patient treatment of a person insured in the Health Insurance Fund. RT I 2024-12-12 2 112122024002 2025-01-01 6 Information concerning the valid reference prices and prices determined by price agreements must be available to consumers of health services on the website of the Health Insurance Fund, at the pharmacy and at the health service provider who issues a prescription. RT I 2017-12-28 5 128122017005 2018-01-01 43 List of medicinal products 1 The list of medicinal products is established by a regulation of the minister in charge of the policy sector on a proposal of the supervisory board of the Health Insurance Fund. RT I 2017-12-28 5 128122017005 2018-01-01 2 The following criteria are taken into account upon making a proposal to include a medicinal product in the list of medicinal products and establishment of the list of medicinal products: RT I 2017-12-28 5 128122017005 2018-01-01 1 the need of an insured person to obtain a medicinal product as a result of the provision of a health service; 2 the proven medical efficacy of a medicinal product and the need of an insured person to obtain other medicinal products in the course of their treatment; 3 the economic justification of the use of a medicinal product; 4 the existence of alternative medicinal products or means of treatment; 5 conformity with the financial resources of health insurance and with the principle provided for in subsection 3 of § 25 of this Act. 3 The procedure for drawing up and amending the list of medicinal products, the detailed contents of the criteria provided for in subsection 2 of this section and the persons to assess compliance with the criteria will be established by a regulation of the minister in charge of the policy sector. 3 1)]]> The Health Insurance Fund carries out the administrative procedure established on the basis of subsection 3 of this section for drawing up and revising the list of medicinal products. To carry out the procedure, the Health Insurance Fund establishes an advisory medicinal products committee the appointment of the members of which and the rules of procedure of which are established by a regulation of the minister in charge of the policy sector as specified in subsection 3 of this section. RT I 2017-12-28 5 128122017005 2018-01-01 3 2)]]> A request submitted by a manufacturer of a medicinal product for the entry of the medicinal product in the list of medicinal products or revision of the list constitutes public information, except for an annex to the request or other information that may compromise the impartiality of the procedure. RT I 2017-12-28 5 128122017005 2018-01-01 4 Only medicinal products which have been issued valid marketing authorisations in Estonia may be entered in the list of medicinal products. RT I 2004 56 400 778828 2004-08-01 5 The following information is entered in the list of medicinal products: 1 the active substances and the Anatomical Therapeutic Chemical codes (ATC codes) of the medicinal products​; 2 pharmaceutical preparations; 3 the manufacturers of the medicinal products; 4 diseases in the case of which medicinal products containing an active substance intended for the treatment or alleviation of the disease are sold at a reimbursement rate of 100 per cent; 5 diseases in the case of which medicinal products containing an active substance intended for the treatment or alleviation of the disease are sold at a reimbursement rate of 75 per cent; RT I 2004 56 400 778828 2004-08-01 6 the reimbursement rates for the pharmaceutical forms, strengths and packaging of medicinal products; 7 code of the medicinal product. RT I 2016-05-04 1 104052016001 2016-05-14 5 1)]]> The data specified in clauses 4–7 of subsection 5 of this section is binding, while the data specified in clauses 1–3 is informative. RT I 2010 15 77 13297358 2010-04-18 6 A medicinal product may be entered in the list of medicinal products with a condition the objective of which is to: 1 ensure that the entry in the list of medicinal products enters into force after a price agreement is concluded or a reference price is established; 2 ensure that the medicinal product is deleted from the list of medicinal products upon termination of the price agreement; 3 establish a lower reimbursement rate for a certain pharmaceutical form, strength or packaging of the same medicinal product; 4 restrict a right to issue prescriptions for medicinal products, imposed in the interests of the health of insured persons or in order to ensure that the issue of prescriptions for medicinal products is justified; 5 ensure the efficient and sound use of Health Insurance Funds. 44 Reimbursement rates for medicinal products 1 A list of the diseases in the case of which a medicinal product intended for the treatment or alleviation of the disease is, upon the existence of a valid reference price or price agreement, subject to entry in the list of medicinal products with a 100 per cent reimbursement rate will be established by a regulation of the Minister in charge of the policy sector. RT I 2022-04-29 1 129042022001 2022-05-09 2 A list of the diseases in the case of which a medicinal product intended for the treatment or alleviation of the disease is, upon the existence of a valid reference price or price agreement, subject to entry in the list of medicinal products with a 75 per cent reimbursement rate will be established by a regulation of the Minister in charge of the policy sector. Upon sale of medicinal products entered in the list of medicinal products with a reimbursement rate of 75 per cent, the 90 per cent reimbursement rate applies to children between 4 and 16 years of age and persons receiving a pension for incapacity for work or an old-age pension on the basis of the State Pension Insurance Act or who have been identified to have partial work ability or no work ability under the Work Ability Allowance Act and insured persons over 63 years of age. RT I 2022-04-29 1 129042022001 2022-05-09 3 Medicinal products that are not intended for the treatment or alleviation of diseases specified in a list of diseases established on the basis of subsection 1 or 2 of this section may be entered in the list of medicinal products with a 50 per cent reimbursement rate. RT I 2012-07-05 14 105072012014 2012-10-01 4 If a medicinal product that is entered in the list of medicinal products with a reimbursement rate of 100, 75 or 50 per cent is not used for the treatment or alleviation of diseases specified in a list of diseases established on the basis of subsection 1 or 2 of this section, a 50 per cent reimbursement rate will be deemed to be applicable to the medicinal product, taking into account the conditions established on the basis of subsection 6 of § 43 of this Act. RT I 2012-07-05 14 105072012014 2012-10-01 4 1)]]> In the event of medicinal products entered in the list of medicinal products, the 100 per cent reimbursement rate applies to children under 4 years of age. 5 the Minister in charge of the policy sector will establish the list of diseases specified in subsection 1 of this section on the basis of the following criteria: RT I 2022-04-29 1 129042022001 2022-05-09 1 the gravity and life-threatening nature of a disease; 2 the possibility of a disease spreading epidemically; 3 the need to ease the pain caused by a disease, and other humane considerations; 4 conformity with the financial resources of health insurance and with the principle provided for in subsection 3 of § 25 of this Act. 6 Upon establishment of the list of diseases specified in subsection 2 of this section, the Minister in charge of the policy sector will, in addition to the criteria provided for in subsection 5 of this section, take into consideration the objective to ensure the treatment or alleviation of chronic diseases which severely impair the quality of life. RT I 2022-04-29 1 129042022001 2022-05-09 7 A disease will not be entered in a list of diseases specified in subsection 1 or 2 of this section if the disease can be treated by other, cheaper methods which do not involve significantly greater risks or have any other significant adverse effects on the situation of the insured person. 8 A disease may be entered in the list of diseases with a condition the objective of which is to take into account the needs arising from gender, age or medical reasons. RT I 2004 56 400 778828 2004-08-01 45 Entry into price agreement RT I 2014-04-16 4 116042014004 2014-04-26 1 The interest of insured persons to obtain necessary medicinal products at a reasonable price, the budgetary funds of the Health Insurance Fund which are prescribed for the assumption of obligations to pay for medicinal products, and the principle provided for in subsection 3 of § 25 of this Act will be taken into account upon entry into and amendment of a price agreement. RT I 2014-04-16 4 116042014004 2014-04-26 2 The following conditions will be agreed upon in a price agreement: 1 the wholesale purchase price of a medicinal product in euros by each pharmaceutical form, active substance content and packaging subject to a 100, 75 or 50 per cent reimbursement rate; RT I 2010 22 108 13310847 2011-01-01 2 the estimated retail sale volume of the medicinal product during the term of validity of the price agreement if the medicinal product is the only medicinal product with a given active substance and route of administration entered in the list of medicinal products with a reimbursement rate of 100, 75 or 50 per cent; RT I 2010 15 77 13297358 2010-07-01 3 the term during which amendment of the price agreement by the parties is prohibited; 4 the conditions whereby a party has the right to demand that the price agreement be amended in addition to the provisions of subsection 3¹ of this section; RT I 2014-04-16 4 116042014004 2014-04-26 5 the due date by which the parties are required to submit requests for amendment of the price agreement in order to prevent automatic extension of the term of validity of the price agreement; 6 the term during which the manufacturer of a medicinal product must sell the medicinal product on the Estonian market and the Health Insurance Fund must assume the obligations of insured persons to pay for the medicinal product under the currently applicable conditions if the parties do not reach an agreement concerning amendment of the price; 7 other conditions and obligations necessary for ensuring the efficient and sound use of Health Insurance Funds and compliance with the conditions of the price agreement. 3 A proposal for a price agreement to be concluded is made to the Health Insurance Fund by a manufacturer of a medicinal product or a person holding marketing authorisation for a medicinal product. The Health Insurance Fund may initiate the proceedings for conclusion of a price agreement. RT I 2017-12-28 5 128122017005 2018-01-01 3 1)]]> Where a medicinal product is the only medicinal products with the same active substance and manner of administration entered in the list of medicinal products and where the price set out in a price agreement exceeds the highest price effective in the Member States of the European Union, as specified in the regulation established on the basis of subsection 6 of § 45 of this Act, the Health Insurance Fund or the manufacturer submits a request to amend the price agreement for the purpose of changing the price. RT I 2017-12-28 5 128122017005 2018-01-01 3 2)]]> It is possible to continue the price agreement if the price provided for therein exceeds the highest effective price of the same medicinal product in the Member States of the European Union specified in the regulation established on the basis of subsection 6 of § 45 of this Act and if the parties cannot agree to reduce the price of the medicinal product provided for in the price agreement, but after assessment of the criteria specified in subsection 2 of § 43 of this Act, it is justified to continue the existing price agreement. RT I 2023-12-15 3 115122023003 2023-12-25 4 Repealed - RT I 2010 15 77 13297358 2010-04-18 5 Repealed - RT I 2010 15 77 13297358 2010-04-18 5 1)]]> Where no agreement is reached on the conditions for entry into or amendment of a price agreement during a reasonable period of time, the Health Insurance Fund may, in accordance with the procedure established subsection 3 of § 43 of this Act, initiate proceedings for the exclusion of the medicinal product from the list of medicinal products. RT I 2017-12-28 5 128122017005 2018-01-01 5 2)]]> As of the termination of a price agreement, given the time-limit specified in clause 6 of subsection 2 of this section, or from the annulment of the reference price of a medicinal product until the exclusion of the medicinal product from the list or until the conclusion of a price agreement, the maximum retail price in force in the Member States of the European Union specified in the regulation established on the basis of subsection 6 of § 45 of this Act, which is calculated on the basis of the wholesale purchase price and is effective at the time of submission of the request for amendment or conclusion of the price agreement will be deemed by the Health Insurance Fund as the price of the price agreement of the medicinal product upon taking over the obligation to pay for the sale of the medicinal product. RT I 2014-04-16 4 116042014004 2014-04-26 6 The procedure for entry into price agreements will be established by a regulation of the minister in charge of the policy sector. 46 Assumption of obligations to pay for sale of medicinal products 1 The retailer of a medicinal product will submit to the Health Insurance Fund an invoice for the sale of the medicinal product for the purpose of assumption of the obligation to pay to the extent and on the conditions provided for in this Act via the Digital Prescription Centre specified in § 81 of the Medicinal Products Act. An obligation is deemed as assumed by the Health Insurance Fund if the Health Insurance Fund has not, within 30 calendar days as of the submission of the invoice, refused to assume the obligation to pay for the medicinal products indicated on the invoice. RT I 2010 15 77 13297358 2010-04-18 2 The Health Insurance Fund may refuse to assume an obligation to pay for the sale of a medicinal product if, upon the sale of the medicinal product, the requirements for the sale of the medicinal product were violated. 47 Additional benefit for medicinal products Repealed - RT I 2024-05-02 3 102052024003 2025-01-01 48 Scope of insurance cover in case of benefits for medical devices 1 The Health Insurance Fund will, to the extent and in accordance with the procedure provided by legislation, assume an obligation to pay for the medical devices which are necessary for an insured person and are entered in the list of medical devices of the Health Insurance Fund (hereinafter list of medical devices). 2 For the purposes of this Act, a medical device is an instrument, apparatus or device, or a material or other product that an insured person, as a member of the general public, can use separately or in combination for one or more purposes determined by the manufacturer and whose intended main effect to the insured person is neither pharmacological, immunological nor metabolic and that is needed for: 1 monitoring, alleviating or treatment of a disease; 2 alleviating or treatment of an injury. 2 1)]]> For the purposes of this Act, 'medical device' also means a skin care device used for the treatment of a skin disease involving a congenital disorder of the horny layer of the skin. RT I 2014-04-16 4 116042014004 2014-04-26 3 The following is not regarded as a medical device for the purposes of this Act: 1 a surgically invasive device; 2 an implantable device; 3 an active device for diagnostics. 4 The list of medical devices and the procedure for assumption of the obligation to pay for medical devices entered in the list of medical devices will be established by a regulation of the minister in charge of the policy sector on proposal of the supervisory board of the Health Insurance Fund. 5 The following information is entered in the list of medical devices: 1 the name of the group of medical devices; 2 code of the medical device; 3 name of the medical device: 4 number of medical devices in the sales packaging; 5 reference price of the medical device or sales packaging of medical devices which will be the retail price agreed upon in the price agreement; 6 the limits for the payment obligation of an insured person assumed by the Health Insurance Fund; 7 the extent of cost-sharing by an insured person; 8 the conditions for application of the reference price of the medical device or sales packaging of medical devices, the limits for the payment obligation of an insured person assumed by the Health Insurance Fund, and the extent of cost-sharing by an insured person. 6 The limits for the payment obligation of an insured person assumed by the Health Insurance Fund will be 90% or 50% of the reference price of the medical device or sales packaging of the medical device entered in the list of medical devices, except in the case specified in subsection 3 of § 48¹ of this Act. The limit for the payment obligation of an insured person assumed by the Health Insurance Fund will be 50 % if there is an alternative method of treatment cheaper than the reference price of the medical device or sales packaging of the medical device, or a cheaper medical device belonging to another group of medical devices or another cheaper medical device available in Estonia. 7 For the purposes of this Act, a group of medical devices joins medical devices with the same effect and intended purpose in the list of medical devices. 8 Only medical devices with regard to which the Health Insurance Fund and the manufacturer or the representative thereof have concluded a price agreement may be entered in the list of medical devices. 9 A medical device may be entered in the list of medical devices with a condition with the objective to regulate the prescription of the medical device, taking into account the criteria provided in subsection 1 of § 48¹ of this Act. RT I 2008 34 210 12997653 2008-09-01 48 1. ]]> Amendment of list of medical devices 1 The following criteria are taken into account upon entry of medical devices in the list of medical devices or deletion of medical devices from such list: 1 the existence of medically justified indications for the use of the medical device by the general public and existence of alternative medical devices or treatment methods; 2 the optimal quantity of medical devices needed for treatment based on the diagnosis, severity of the disease or other circumstances influencing the course of treatment; 3 correspondence to the funds of health insurance, including the existence of another public source of financing; 4 cost effectiveness of the medical device; 5 conformity of the medical device with the Medical Devices Act and relevant European Union legislation, except in the event of a medical device specified in subsection 2¹ of § 48 of this Act. RT I 2022-12-22 2 122122022002 2023-01-01 2 Upon amendment of the reference price that is the basis for assumption by the Health Insurance Fund of an obligation of an insured person to pay for a medical device, the criteria provided in clauses 2 and 3 of subsection 1 of this section are taken into account. 3 If, in the list of medical devices, there are two comparable medical devices in a group of medical devices then, beginning from the third medical device entered in the list of medical devices, the basis for assumption by the Health Insurance Fund of the payment obligation will be the reference price of the comparable medical device that comes second in the list with regard to its reference price. 4 The possibility to use, instead of a medical device, an alternative method of treatment that is cheaper than the treatment provided for in the price agreement or the reference price of the medical device, a cheaper medical device belonging to another group of medical devices or a cheaper medical device available in Estonia will be assessed by a relevant association of medical specialists. RT I 2022-06-20 3 120062022003 2022-06-30 5 The detailed contents of the criteria provided for in subsection 1 of this section, the persons to assess compliance with the criteria and the procedure for assessment thereof will be established by a regulation of the minister in charge of the policy sector. 6 The manufacturer of a medical device or an authorised representative of the manufacturer may initiate a proposal for amendment of the list of medical devices by entering into negotiations with the Health Insurance Fund. State Agency of Medicines or the Health Insurance Fund may initiate a proposal for amendment of the list of medical devices by entering into negotiations with the manufacturer of a medical device or an authorised representative of the manufacturer. The applicant will make public all the circumstances known thereto which are relevant to the negotiations. RT I 2024-11-20 1 120112024001 2025-01-01 49 Assumption of obligation to pay for medical devices and contracts with sellers RT I 2008 34 210 12997653 2008-09-01 1 The retailer of a medical device will submit to the Health Insurance Fund an invoice for the sale of the medical device for the purpose of assumption of the obligation to pay to the extent and on the conditions provided for in this Act via the Digital Prescription Centre specified in § 81 of the Medicinal Products Act. An obligation is deemed as assumed by the Health Insurance Fund if the Health Insurance Fund has not, within 45 calendar days as of the submission of the invoice, refused to assume the obligation to pay for the medical device indicated on the invoice. RT I 2010 15 77 13297358 2010-04-18 2 The seller of a medical device, except for a pharmacy, will conclude a contract with the Health Insurance Fund in which the following conditions are agreed upon: 1 the term of the contract; 2 the circumstances under which a party has the right to terminate the contract unilaterally; 3 a term shorter than the term specified in subsection 1 of this section; 4 the circumstances under which assumption of an obligation is contingent upon prior written approval from the Health Insurance Fund; 5 the scope of the reporting obligation of the seller of the medical device and the obligation to submit information concerning insured persons to the Health Insurance Fund, and the composition of the information to be submitted; 6 other conditions necessary for ensuring the efficient and sound use of Health Insurance Funds. RT I 2008 34 210 12997653 2008-09-01 3 Assumption of an obligation to pay for the sale of a medical device may be refused if the sale of the medical device is not in conformity with the provisions of legislation or of a contract concluded with the Health Insurance Fund. RT I 2008 34 210 12997653 2008-09-01 49 1. ]]> Additional Benefits for Medicinal Products and Medical Devices 1 The Health Insurance Fund additionally assumes the obligation to pay from the insured person where the sum paid by the insured person for medicinal products entered in the list of medicinal products and necessary for the out-patient treatment of the insured person and for medicinal devices entered in the list of medicional devices and necessary for alleviating or treatment of an injury or a disease or for monitoring of a disease for a member of the general public of the insured person exceeds 100 euros during the calendar year (hereinafter supplementary benefit for medicinal products or medical devices). 2 The amount of the supplementary benefit for medicinal products or medical devices is calculated by the Digital Prescription Centre at the moment of the purchase of the medicinal product or medical device by the insured person, taking account of the information in the Digital Prescription Centre. 3 Where a discount cannot be given to the insured person to the extent of the prescribed supplementary benefit for medicinal products or medical devices for objective reasons, it is given to the insured person upon the next purchase or the lost supplementary benefit for medicinal products or medical devices is compensated for at the request of the insured person. 4 The procedure for application for and payment of the lost supplementary benefit for medicinal products or medical devices provided for in subsection 3 of this section is established by a regulation of the minister in charge of the policy sector. 5 Where the insured person does not make the next purchase or submit a request specified in subsection 3 of this section in the current calendar year, the supplementary benefit for medicinal products or medical devices not received by the person at the moment of the last purchase transfers to the next calendar year. 6 The amounts paid by the Health Insurance Fund, the amounts exceeding the reference price or the price established in the price agreement are not taken into account upon calculation of the supplementary benefit for medicinal products or medical devices. 7 Where an amount calculated in accordance with subsection 2 of this section is 100 to 300 euros, the Health Insurance Fund compensates 50 per cent of the portion exceeding 100 euros. 8 Where an amount calculated in accordance with subsection 2 of this section exceeds 300 euros, the Health Insurance Fund, in addition to the amount calculated in accordance with subsection 7 of this section, compensates 90 per cent of the portion exceeding 300 euros. RT I 2024-05-02 3 102052024003 2025-01-01 5 Pecuniary Benefits 1 Benefit for Temporary Incapacity for Work 50 Benefit for temporary incapacity for work, types thereof and events of payment RT I 2012-07-02 8 102072012008 2012-08-01 1 Benefit for temporary incapacity for work is financial compensation paid by the Health Insurance Fund to an insured person on the basis of a certificate of incapacity for work in cases where the person does not receive income subject to individually registered social tax due to a temporary release from the their duties or economic or professional activity. 1 1)]]> The benefit for temporary incapacity for work is paid to a person insured on the basis of subsection 3¹ of § 5 of this Act if a deletion entry or an entry on suspension of operations has not been made in the commercial register with regard to a self-employed person who pays social tax or if a work termination entry has not been made in the employment register with regard to the spouse or registered partner participating in the undertaking of a self-employed person by the start date of release from work specified on their certificate of incapacity for work. RT I 2023-07-06 6 106072023006 2024-01-01 2 The benefit for temporary incapacity for work will not be paid to persons covered by insurance on the grounds specified in clauses 3 and 6 of subsection 2 of § 5 or subsection 4 of § 5 of this Act or to persons considered equal to insured persons on the basis of a contract. 3 The types of the benefit for temporary incapacity for work are: 1 sickness benefit; 2 repealed - RT I 2018-10-26 1 126102018001 2022-04-01 3 repealed - RT I 2018-10-26 1 126102018001 2022-04-01 4 care benefit. RT I 2004 56 400 778828 2004-08-01 4 A person who receives income subject to individually registered social tax may be paid sickness benefit under the conditions provided for in this Act. RT I 2024-05-02 3 102052024003 2024-05-15 51 Insured event of temporary incapacity for work 1 Sickness benefit is paid to an insured person in the case of the following insured events: 1 a disease or injury of the insured person in respect of which the health care professional treating the person has diagnosed that the person is temporarily unable to work in their position or continue to perform their duties or their economic or professional activity due to the disease or injury; RT I 2022-06-20 3 120062022003 2022-06-30 2 quarantine established with regard to the insured person; 3 working of the insured person the basis of subsection 1 of § 12⁵ of the Occupational Health and Safety Act; RT I 2024-05-02 3 102052024003 2024-05-15 4 refusal of the insured person from work on the basis of subsection 3 of § 12⁵ of the Occupational Health and Safety Act; RT I 2024-05-02 3 102052024003 2024-05-15 4 1)]]> working of the insured person the basis of subsection 1 of § 12⁴ of the Occupational Health and Safety Act; RT I 2024-05-02 3 102052024003 2024-05-15 5 the removal of an organ or blood stem cells from the insured person in order to transfer the organ or the cells to another person for treatment purposes whereby the treating doctor has diagnosed that the person is temporarily unable to work in their position or continue to perform their duties or their economic or professional activity due to such removal. RT I 2015-02-26 1 126022015001 2015-03-01 2 Repealed - RT I 2018-10-26 1 126102018001 2022-04-01 3 Repealed - RT I 2018-10-26 1 126102018001 2022-04-01 4 The care benefit is paid to an insured person in respect of the following insured events: 1 nursing a child of under 12 years of age or a disabled insured person of under 19 years of age; RT I 2016-12-27 4 127122016004 2017-07-01 2 nursing a family member who is ill at home; 3 caring for a child of under three years of age or for a disabled child of under 16 years of age when the person caring for the child is themselves ill or is receiving obstetrical care. 52 Certificate of incapacity for work 1 A certificate of incapacity for work is a document certifying the temporary incapacity for work of an insured person and their temporary release from the performance of their duties, which the health care professional treating the person or providing services to the person issues to the insured person electronically and which, upon opening and termination of the certificate of incapacity for work, is immediately sent to the Health Insurance Fund database via the X-road interface. RT I 2022-06-20 3 120062022003 2022-06-30 1 1)]]> A certificate of incapacity for work may be issued on paper if the data cannot be sent to the Health Insurance Fund database via the X-road interface due to technical reasons. In such an event the issuer of the certificate of incapacity for work will sent the details of the certificate to the Health Insurance Fund database via the X-road interface as soon as possible. RT I 2014-10-08 1 108102014001 2014-10-18 2 Health care professionals have the right to issue certificates of incapacity for work. The issuer of a certificate of incapacity for work is liable for the correct assessment of the insured event of temporary incapacity for work and for ensuring that the temporary incapacity for work is justified. The right to issue certificates of incapacity for work does not apply in cases of the provision of emergency medical care or to the persons referred to in subsections 4 and 6 of § 3 of the Health Services Organisation Act. RT I 2024-05-02 3 102052024003 2024-05-15 2 1)]]> A midwife has the right to issue a certificate for sick leave only for the purpose of the temporary easing of the working conditions or refusal from work of a pregnant woman or a person who has the right to maternity leave on the basis of § 12⁵ of the Occupational Health and Safety Act. RT I 2024-05-02 3 102052024003 2024-05-15 2 2)]]> A nurse has only the right to issue and terminate a certificate for sick leave and the certificate for care leave for the purpose of disease, injury, quarantine or nursing an insured person. RT I 2022-06-20 3 120062022003 2022-06-30 3 The types of the certificate of incapacity for work are the certificate for sick leave and the certificate for care leave. RT I 2018-10-26 1 126102018001 2022-04-01 3 1)]]> A certificate for sick leave may contain proposals for working conditions corresponding to the state of health during the period of release from the performance of employment or service duties. Only a doctor has the right to issue a certificate for sick leave containing proposals for the temporary provision of work corresponding to the state of health the basis of § 12⁴ of the Occupational Health and Safety Act. RT I 2024-05-02 3 102052024003 2024-05-15 4 By a regulation, the Minister in charge of the policy sector enacts: 1 the composition of the data of the certificate of incapacity for work; 2 the conditions and procedure for the opening, termination and revocation of the certificate of incapacity for work; 3 the conditions and procedure for forwarding the certificate of incapacity for work from the health care provider to the Health Insurance Fund; 4 the extent of access of the health care provider and the employer to the composition of the data of the certificate of incapacity for work. RT I 2024-05-02 3 102052024003 2024-05-15 53 Procedure for grant and payment of benefit for temporary incapacity for work 1 The benefit for temporary incapacity for work is paid on the basis of a certificate of incapacity for work. Where an insured event specified in clause 1 of subsection 1 or subsection 4 of § 51 of this Act occurs when the insured person is in a foreign state, the certificate of incapacity for work is replaced by a paper certificate issued by the doctor or dentist who treated the person in the foreign state. At the request of the Health Insurance Fund, the certificate must be accompanied by a translation into Estonian prepared by a person specified in subsection 1 of § 2 of the Sworn Translators Act; the costs of such translation are covered by the insured person. RT I 2018-10-26 1 126102018001 2022-04-01 1 1)]]> Repealed - RT I 2014-10-08 1 108102014001 2014-10-18 2 Repealed - RT I 2009 15 93 13152060 2009-07-01 3 Repealed - RT I 2014-10-08 1 108102014001 2014-10-18 3 1)]]> Repealed - RT I 2022-06-20 3 120062022003 2022-06-30 4 The employer of the insured person or the self-employed person must make their entries in the certificate of incapacity for work within seven calendar days as of learning of the termination of the certificate from the insured person. RT I 2014-10-08 1 108102014001 2014-10-18 4 1)]]> The payer of business income tax makes their entries on a certificate of incapacity for work within seven calendar days following the ending of the certificate, but not later than by the due date and in accordance with the procedure specified in subsections 5 and 5² of this section. The Health Insurance Fund pays the benefit for temporary incapacity for work in accordance with subsection 6 of this section. RT I 2017-07-07 2 107072017002 2018-01-01 4 2)]]> The former employer of the insured person of the insured person or the self-employed person do not have the obligation to make their entries in the certificate of incapacity for work if the certificate of incapacity for work following the previous certificate of incapacity for work begins after the termination of the employment or service relationship. RT I 2024-05-02 3 102052024003 2025-02-01 5 The benefit will be granted and paid if the employer of the insured person or the self-employed person has made their entries in the electronic certificate of incapacity for work not later than by the 90th calendar day after the date following the termination of the certificate of incapacity for work. The benefit will not be granted or paid if the entries were not made in the certificate of incapacity for work within the time limit provided for in this subsection. RT I 2024-05-02 3 102052024003 2024-05-15 5 1)]]> If the insured person submits to the employer or the self-employed person a certificate of incapacity for work on paper, the employer or the self-employed person will make their entries in the respective electronic certificate of incapacity for work of the insured person via the X-road interface within seven calendar days after the date of receipt of the paper certificate from the insured person. RT I 2014-10-08 1 108102014001 2015-01-01 5 2)]]> If the insured person submits to the employer or the self-employed person the paper certificate issued by a doctor or dentist who treated the person abroad (hereinafter certificate), the employer or the self-employed person will, within seven days after the date if receipt of the certificate from the insured person, submit to the Health Insurance Fund the certificate and other documents required for granting and payment of the benefit. RT I 2014-10-08 1 108102014001 2015-01-01 5 3)]]> The insured person may submit to the Health Insurance Fund the certificate and other documents necessary for the granting and payment of the benefit themselves. RT I 2014-10-08 1 108102014001 2015-01-01 5 4)]]> The benefit will be granted and paid on the basis of the certificate if: 1 the insured person's certificate along with other documents required for granting and paying the benefit has been submitted to the Health Insurance Fund not later than by the 90th calendar days following the date of commencement of the employment or service duties or resuming the economic or professional activities, or 2 the insured person's certificate along with other documents required for granting and paying the benefit has been submitted to the Health Insurance Fund not later than by the 90th calendar days following the date of resuming participation in the activities of the undertaking of the self-employed person. RT I 2014-10-08 1 108102014001 2015-01-01 5 5)]]> The benefit will not be granted or paid if the certificate was not submitted within the time limit provided for in subsection 5⁴ of this section. RT I 2014-10-08 1 108102014001 2015-01-01 6 The Health Insurance Fund will pay the benefit for temporary incapacity for work within 30 calendar days following the date when the employer of the insured person or the self-employed person has made the required entries in the electronic certificate of incapacity for work or if, in the event of the certificate, the properly compiled documents have reached the Health Insurance Fund. In the event of a delay in payment, the Health Insurance Fund must pay a fine for delay in accordance with law. RT I 2014-10-08 1 108102014001 2015-01-01 7 The composition of the documents and information necessary for the grant and payment of the benefit for temporary incapacity for work, and the procedure for the grant and payment thereof will be established by a regulation of the minister in charge of the policy sector. 54 Size of benefit for temporary incapacity for work 1 The Health Insurance Fund will pay the benefit for temporary incapacity for work to an insured person per calendar day as a percentage of their average income per calendar day, taking into account the cap specified in this Act:[RT I, 12.12.2024, 2 – entry into force 01.01.2026] 1 70 per cent in the event of refusal from the provision of in-patient and out-patient health services and from work that does not correspond to the state of health and in the event of the temporary release from the performance of service duties and in the event of a quarantine; RT I 2009 35 232 13196585 2009-07-01 1 1) ]]> 80 per cent in the event of taking care of a child under three years of age or of a disabled child of under 16 years of age if the person providing care is ill or being provided with childbirth assistance, is taking care of an ill family member at home or if a child of under 12 years of age or a disabled insured person of under 19 years of age is nursed in a hospital or at home; RT I 2016-12-27 4 127122016004 2017-07-01 2 repealed - RT I 2009 35 232 13196585 2009-07-01 3 repealed - RT I 2009 35 232 13196585 2009-07-01 4 repealed - RT I 2018-10-26 1 126102018001 2022-04-01 5 repealed - RT I 2018-10-26 1 126102018001 2022-04-01 6 100 per cent in the event of an illness or injury caused as a result of an occupational disease or an accident at work; RT I 2004 56 400 778828 2004-08-01 7 100 per cent in the event of preventing a criminal offence, protecting national or public interests or saving a human life; 8 100 per cent in the event of the removal of an organ or blood stem cells in order to transfer the organ or cells to another person for treatment purposes. RT I 2015-02-26 1 126022015001 2015-03-01 1 1)]]> The Health Insurance Fund will pay the benefit for temporary incapacity for work to an insured person per calendar day up to the benefit cap calculated on the basis of § 55² of this Act.[RT I, 12.12.2024, 2 – entry into force 01.01.2026] 1 2)]]> The cap on the benefit for temporary incapacity for work is not applicable in the event specified in clauses 3, 4¹ and 5 of subsection 1 of § 51 of this Act.[RT I, 12.12.2024, 2 – entry into force 01.01.2026] 2 Upon calculation of the amount of the benefit, the sum is rounded with the accuracy of one cent. RT I 2010 22 108 13310847 2011-01-01 3 If the insured person has been temporarily provided with work corresponding to their state of health on the basis of subsection 1 of § 12⁵ of the Occupational Health and Safety Act, the Health Insurance Fund will pay the insured person sickness benefit. The benefit along with the wages or salary to be received for the period (hereinafter wages) is equal to the wages in force on the day preceding the day on which the release from the performance of employment or service duties stated on the certificate for sick leave begins. RT I 2024-05-02 3 102052024003 2024-05-15 3 1)]]> Where an insured person has more than one employer and is entitled to sickness benefit for working for at least one employer on the basis of clause 3 of subsection 1 of § 51 of this Act, if the employer is unable to provide the working conditions corresponding to the person’s state of health or the person renounces the work offered, the benefit is 70% of the wages in effect on the day preceding the date of commencement of the release from the performance of employment or service duties indicated by the employer on the certificate for sick leave.[RT I, 03.12.2025, 3 – entry into force 01.01.2026] 4 The Health Insurance Fund continues to pay the insured person sickness benefit on the basis of clause 4¹ of subsection 1 of § 51 of this Act as of the first day of working on the basis of the certificate for sick leave, if the insured person is entitled to sickness benefit on the basis of clause 1 of subsection 1 of § 51 of this Act and has been temporarily provided with work corresponding to their state of health on the basis of subsection 1 of § 12⁴ of the Occupational Health and Safety Act. Payment will not be continued beyond the term provided for in subsection 1 of § 57 of this Act. The benefit along with the wages to be received for the period is equal to the wages in force on the day preceding the day on which the release from the performance of employment or service duties stated on the certificate for sick leave begins. RT I 2024-05-02 3 102052024003 2024-05-15 5 If an insured person has more than one employer and is entitled to sickness benefit for working for at least one employer on the basis of clause 4¹ of subsection 1 of § 51 of this Act, if the employer is unable to provide the working conditions corresponding to the person’s state of health, the benefit is 70% of the wages in force on the day preceding the day on which the release from the performance of employment or service duties stated on the certificate for sick leave begins. RT I 2024-12-12 2 112122024002 2024-12-22 55 Calculation of average income per calendar day 1 Average income per calendar day is calculated on the basis of the information concerning social tax calculated or paid to the insured person, as submitted by the Tax and Customs Board, and the information certifying the right to receive the benefit as submitted by the persons specified in clauses 1, 2, 4, 5 and 5¹ of subsection 2 of § 5 and subsections 3 and 3¹ of § 5 of this Act. Social tax paid by the state, rural municipality, city or artistic association under clauses 1 to 3, 3³ and 6¹ to 15 of subsection 1 of § 6 and subsections 1¹ and 1² of the same section of the Social Tax Act is not taken into account upon calculating the average income per calendar day.[RT I, 03.06.2025, 1 – entry into force 01.01.2026] 1 1)]]> In the case of social tax paid from a business account, the average income per calendar day is calculated on the basis of the tax rate provided for in the Social Tax Act. RT I 2017-07-07 2 107072017002 2018-01-01 2 The average income of a person insured on the basis of clause 1 or 2 of subsection 2 of § 5 of this Act per calendar day is deemed to be equal to the income calculated on the basis of the social tax calculated for the insured person during the calendar year preceding the calendar year of the date on which release from the performance of their duties commenced as specified in the certificate of incapacity for work, divided by 365. RT I 2009 29 176 13186056 2009-07-01 3 If social tax was not paid for a person insured on the basis of clause 1 or 2 of subsection 2 of § 5 of this Act during the calendar year serving as the basis for calculation of their average income per calendar day, the average income per calendar day will be deemed to be equal to the negotiated wage of the employee divided by 30, but not more than the amount of the minimum monthly wage established by the Government of the Republic and divided by 30. Calculation of average income per calendar day is based on the negotiated wage of the employee or the minimum monthly wage established by the Government of the Republic as applicable on the date preceding the date on which the release from the performance of duties commenced as specified in the certificate of incapacity for work. RT I 2009 15 93 13152060 2009-07-01 3 1)]]> In the case of insured events provided for in clause 4 of subsection 1 of § 51 of this Act, the average income per calendar day provided for in subsection 3 of this section will be equal to the average remuneration calculated in accordance with the procedure established in subsection 8 of section 29 of the Employment Contracts Act divided by 30. This may not exceed the amount of the minimum monthly wage established by the Government of the Republic and divided by 30.[RT I, 03.12.2025, 3 – entry into force 01.01.2026] 4 If average income per calendar day calculated in accordance with the procedure provided for in subsection 2 of this section is lower than average income per calendar day calculated in accordance with the procedure provided for in subsection 3 of this section, average income per calendar day will be calculated in accordance with the procedure provided for in subsection 3 of this section. 5 The average income of a person insured on the basis of clause 4, 5 or 5¹ of subsection 2 of § 5 or subsection 3 of § 5 of this Act per calendar day is deemed to be equal to the income calculated on the basis of the social tax paid by or for the insured person during the calendar year preceding the calendar year of the date specified in the certificate of incapacity for work as the date on which release from performance of the duties arising from a contract specified in clause 4, 5 and 5¹ of subsection 2 of § 5 of this Act or from economic or professional activity commenced, divided by 365. RT I 2017-07-07 2 107072017002 2018-01-01 5 1)]]> The average wage of a person insured on the basis of subsection 3¹ of § 5 of this Act per calendar day equals the income calculated on the basis of the social tax paid for the insured person in the calendar year preceding the calendar year of the start date of the release of the person from participating in the activities of the undertaking of a self-employed person, divided by 365. RT I 2012-07-02 8 102072012008 2012-08-01 6 Where social tax was not paid for a person insured on the basis of clause 4, 5 or 5¹ of subsection 2 of § 5 or subsection 3 or 3¹ of § 5 of this Act during the calendar year serving as the basis for calculation of their average income per calendar day, the average income per calendar day is deemed to be equal to the monthly rate provided for in § 2¹ of the Social Tax Act, divided by 30. The average income per calendar day is calculated on the basis of the monthly rate provided for in § 2¹ of the Social Tax Act in force on the date preceding the date of the release of the person from performing duties, engaging in economic or professional activities or participating in the activities of the undertaking of a self-employed person. RT I 2017-07-07 2 107072017002 2018-01-01 7 The provisions of subsection 6 of this section do not apply if, on the date preceding the date on which release from the performance of duties commenced as specified in a certificate of incapacity for work, the insured person did not have the obligation to make advance payments of social tax. 7 1)]]> The provisions of subsection 7 of this section do not apply to a person insured on the basis of subsection 3¹ of § 5 of this Act. RT I 2012-07-02 8 102072012008 2012-08-01 8 If an insured person has the right to receive the benefit for temporary incapacity for work on more than one ground specified in subsections 2, 5 and 5¹ of this section, their average income per calendar day will be calculated on the ground that is more favourable for the insured person. RT I 2012-07-02 8 102072012008 2012-08-01 9 In the case of insured events provided for in clauses 3 and 4¹ of subsection 1 of § 51 of this Act, the wages in force on the day preceding the date of commencement of the release from the performance of employment or service duties indicated on the certificate for sick leave will be calculated in accordance with the procedure established in subsection 8 of § 29 of the Employment Contracts Act.[RT I, 03.12.2025, 3 – entry into force 01.01.2026] 55 1. ]]> Calculation of average income per calendar day for a person who has received parental benefit 1 In the case of an insured person to whom parental benefit under the Family Benefits Act has been paid in the three calendar years preceding the calendar year of the date on which release from the performance of employment or service duties commenced as specified in the certificate of incapacity for work, and for whom social tax has been paid by the State in the same period under clause 1 of subsection 1 of § 6 of the Social Tax Act, the average income per calendar day is calculated in accordance with the procedure laid down in § 55 of this Act, taking into account the specifications provided for in this section. 2 The specifications for the calculation of average income per calendar day provided for in this section apply to an insured person who is paid the benefit for temporary incapacity for work on the basis of a certificate of incapacity for work according to which the insured person has been on parental leave in the calendar year preceding the calendar year of the commencement of the exemption from the performance of his or her duties indicated on the certificate of incapacity for work. 3 The Social Insurance Board forwards to the Health Insurance Fund the amount of average income per calendar day of the shared parental benefit (hereinafter income per calendar day of the parental benefit) of an insured person entitled to receive parental benefit in the meaning of § 33 of the Parental Benefits Act, calculated in accordance with the procedure provided for in § 39 of the Family Benefits Act. 4 The Health Insurance Fund compares the income per calendar day of the parental benefit of the insured person to the average income per calendar day calculated for the same person on the basis of § 55 of this Act and bases the payment of the benefit for temporary incapacity for work to the insured person on the income per calendar day which is more favourable to the person. RT I 2023-12-15 2 115122023002 2024-07-01 55 2. ]]> Calculation of the cap on the benefit for temporary incapacity for work 1 The cap on the benefit for temporary incapacity for work for one calendar day is twice the average income subject to social tax in Estonia for one calendar month of the year before the previous calendar year divided by 30, taking into account the calendar year of the beginning of the insured event. 2 In order to calculate average income subject to social tax in Estonia for one calendar month for the following calendar year, the average amount of the pension insurance part of individually registered social tax approved by the Government of the Republic for the previous calendar year, based on subsection 3 of § 13 of the State Pension Insurance Act, is multiplied by five and the result is divided by 12. When calculating the average monthly income subject to social tax in Estonia, the amount is rounded to the nearest cent. 3 The Health Insurance Fund publishes the benefit cap calculated on the basis of subsections 1 and 2 of this section for one calendar day of the following calendar year on its website not later than on 1 December.[RT I, 12.12.2024, 2 – entry into force 01.01.2026] 56 Right to receive benefit for temporary incapacity for work 1 The right to receive sickness benefit arises as of the ninth day of release from the performance of employment or service duties as specified in the certificate of incapacity for work, unless otherwise provided for in this Act. RT I 2023-01-11 1 111012023001 2023-07-01 1 1)]]> If the sickness benefit is paid on the basis of refusal from work on the basis of subsection 3 of § 12⁵ of the Occupational Health and Safety Act, the insured person obtains the right to receive sickness benefit calculated on the basis of clause 1 of subsection 1 of § 54 of this Act as of the second day on which the person refused from performance of employment or service duties. RT I 2024-05-02 3 102052024003 2024-05-15 1 2)]]> In the event of pregnancy, the persons specified in clauses 1, 2, 4, 5 and 5¹ of subsection 2 of § 5 and subsections 3 and 3¹ of § 5 of this Act are entitled to the sickness benefit as of the second day of release from the performance of the employment or service duties or from engaging in economic or professional activities or from participating in the activities of a self-employed person specified in the certificate of incapacity for work in the event of occurrence of an insured event specified in clause 1 of subsection 1 of § 51 of this Act. RT I 2017-07-07 2 107072017002 2018-01-01 1 3)]]> If the sickness benefit is paid on the basis of clauses 6 and 7 of subsection 1 of § 54 of this Act, the right to receive the benefit will arise as of the second day of release from performance of the employment or service duties or from engaging in economic or professional activities specified in the certificate of incapacity for work in the event of occurrence of an insured event specified in clause 1 of subsection 1 of § 51 of this Act RT I 2009 29 176 13186056 2009-07-01 1 1)]]> If the sickness benefit is paid on the basis of clause 8 of subsection 1 of § 54 of this Act, the right to receive the benefit will arise as of the first day of release from performance of the employment or service duties or from engaging in economic or professional activities specified in the certificate of incapacity for work in the event of occurrence of an insured event specified in clause 5 of subsection 1 of § 51 of this Act. RT I 2015-02-26 1 126022015001 2015-03-01 2 If the sickness benefit is paid on the basis of the temporary provision of work corresponding to the state of health on the basis of subsection 1 of § 12⁵ of the Occupational Health and Safety Act, the insured person obtains the right to receive sickness benefit calculated on the basis of subsection 3 of § 54 of this Act as of the day on which the person commended the performance of employment or service duties corresponding to the state of health. RT I 2024-05-02 3 102052024003 2024-05-15 2 1)]]> If the sickness benefit is paid on the basis of the temporary provision of work corresponding to the state of health on the basis of § 12⁴ of the Occupational Health and Safety Act, the insured person obtains the right to receive the sickness benefit calculated on the basis of subsection 4 of § 54 of this Act as of the day on which the person temporarily commenced work corresponding to the state of health but at the earliest from the 61st day of release from the performance of employment or service duties. RT I 2024-05-02 3 102052024003 2024-05-15 3 The right to receive the care benefit arises as of the first day of release from the performance of duties as specified in the certificate of incapacity for work. RT I 2018-10-26 1 126102018001 2022-04-01 57 Period of time serving as basis for calculation of sickness benefit 1 In the event of a disease or injury, an insured person has the right to receive sickness benefit until the date on which their work ability is restored as specified in the certificate for sick leave, but not for more than 240 consecutive calendar days in the event of tuberculosis or 182 consecutive calendar days in the event of any other disease. RT I 2014-12-13 1 113122014001 2016-07-01 (entry into force amended – RT I, 17.12.2015, 1) 2 Repealed - RT I 2014-12-13 1 113122014001 2016-07-01 (entry into force amended – RT I, 17.12.2015, 1) 3 In the event of quarantine, the insured person has the right to receive the sickness benefit until the date of termination of the quarantine. RT I 2020-12-29 2 129122020002 2021-01-01 4 Repealed - RT I 2009 5 35 13120899 2009-07-01 5 Repealed - RT I 2015-12-30 2 130122015002 2016-01-01 6 Repealed - RT I 2014-12-13 1 113122014001 2016-07-01 (entry into force amended – RT I, 17.12.2015, 1) 7 Repealed - RT I 2014-12-13 1 113122014001 2016-07-01 (entry into force amended – RT I, 17.12.2015, 1) 58 Period of time serving as basis for calculation of maternity benefit or adoption benefit Repealed - RT I 2018-10-26 1 126102018001 2022-04-01 59 Period of time serving as basis for calculation of care benefit 1 The insured person has the right to receive care benefit on the basis of a certificate for care leave for up to 60 calendar days in the event of nursing a child under 12 years of age or a disabled insured person of under 19 years of age or for up to seven calendar days in the event of nursing another family member at home. RT I 2024-05-02 3 102052024003 2024-05-15 1 1)]]> Repealed - RT I 2024-05-02 3 102052024003 2024-05-15 2 On the basis of a certificate for care leave, an insured person has the right to receive the care benefit for up to ten calendar days in the event of caring for a child of under three years of age or for a disabled child of under 16 years of age if the person caring for the child is ill or is receiving obstetrical care. 3 If a certificate for care leave is issued to several persons caring for one and the same person, the persons will have the right to receive the care benefit for not more than the total number of the calendar days specified in subsections 1–2 of this section. RT I 2015-03-11 2 111032015002 2015-07-01 60 Restriction on right to receive benefit for temporary incapacity for work 1 The insured person does not have the right to receive the benefit for temporary incapacity for work if: RT I 2004 56 400 778828 2004-08-01 1 the illness or injury of the insured person or the person being nursed is caused by the intent of the person; 2 the illness or injury of the insured person or the person being nursed is caused by a state of intoxication ascertained in accordance with the procedure established on the basis of the Traffic Act or by an examination conducted by a doctor; 3 the insured person or the person being nursed fails to comply with the medically justified treatment prescribed by a health care professional, as a result of which the recovery of the person is hindered; RT I 2022-06-20 3 120062022003 2022-06-30 4 the insured person fails to appear at a health care professional's consultation at the prescribed time without good reason; RT I 2022-06-20 3 120062022003 2022-06-30 5 the insured person receives income subject to social tax specified in clause 1 or 3 of subsection 1 of § 2 of the Social Tax Act for the period of temporary incapacity for work or income taxable under the Simplified Business Income Taxation Act. RT I 2017-07-07 2 107072017002 2018-01-01 6 repealed - RT I 2004 89 614 831409 2005-01-01 1 1)]]> The restriction specified in clause 5 of subsection 1 and in subsection 2 of of this section does not apply where the insured person obtains wages on the basis of § 12⁴ or § 12⁵ of the Occupational Health and Safety Act. RT I 2024-05-02 3 102052024003 2024-05-15 2 If the insured person or the person being cared for performs their duties or is engaged in business during their temporary incapacity for work, the person will lose the right to receive the benefit for temporary incapacity for work as of the date on which they commenced performing the duties or engaging in business. 3 If the insured person or the person being cared for fails to appear at a health care professional's consultation at the prescribed time without good reason, the person will lose the right to receive the benefit for temporary incapacity for work as of the date of their failure to appear at the consultation. RT I 2022-06-20 3 120062022003 2022-06-30 4 The insured person does not have the right to receive the benefit for temporary incapacity for work if the insured person is: RT I 2014-10-08 1 108102014001 2014-10-18 1 on holiday; 2 on care cleave during a holiday. RT I 2009 5 35 13120899 2009-07-01 5 In the events listed in subsection 4 of this section, the insured person obtains the right to receive the benefit as of the day when they interrupt their holiday and assume or must assume their employment or service duties. RT I 2009 5 35 13120899 2009-07-01 6 The insured person who has the right to receive the sickness benefit does not have the right to receive the care benefit for the same period. RT I 2018-10-26 1 126102018001 2022-04-01 61 Prohibition on permitting insured person who is temporarily incapacitated for work to assume employment or service 1 The employer must not permit the insured person specified in clause 1 or 2 of subsection 2 of § 5 of this Act to assume their duties at a time when they are released from the performance of their duties as specified in the certificate of incapacity for work. 2 In the event of a violation of the prohibition specified in subsection 1 of this section, the insured person will lose the right to receive the benefit for temporary incapacity for work as of the date of the violation. 3 An employer may allow a person to perform employment or service duties on the basis of § 12⁴ or 12⁵ of the Occupational Health and Safety Act at the time of release from the performance of their employment or service duties, provided that the employee and the employer follow the proposals of the health care professional for working or service conditions corresponding to the state of health as indicated in the certificate for sick leave. RT I 2024-05-02 3 102052024003 2024-05-15 62 Rights of Health Insurance Fund upon payment of benefit for temporary incapacity for work 1 The Health Insurance Fund may, by a decision, extend the term for payment of the benefit for temporary incapacity for work by up to 30 calendar days if there is reason to suspect that the person does not have the right to receive the benefit. If such doubt is not confirmed, the Health Insurance Fund must pay late interest as of the expiry of the term provided for in subsection 6 of § 53 of this Act. 2 Before making the decision specified in subsection 1 of this section, the Health Insurance Fund must grant the insured person a term of at least five calendar days to submit their opinion on and objections to the matter. 3 The Health Insurance Fund may issue a precept together with a warning concerning unjustified payment of the benefit for temporary incapacity for work and recover the benefit from the insured person or withhold the unfounded benefit from the payments of subsequent periods. 4 If unfounded payment of the benefit for temporary incapacity for work occurs due to the submission of incorrect information by the employer of the insured person or due to a violation of the prohibition specified in subsection 1 of § 61 of this Act, the Health Insurance Fund may issue a precept together with a warning and recover the unfounded benefit from the employer of the insured person. 5 The Health Insurance Fund will recover from the employer the difference between the benefit paid at the rate of 100 per cent on the basis of clause 6 of subsection 1 of § 54 of this Act as a result of an accident at work or an occupational disease and the benefit calculated at the rate of 70 per cent on the basis of clause 1 of subsection 1 of § 54 of this Act. RT I 2016-12-27 4 127122016004 2017-07-01 6 In the event of failure to comply with a precept within the term set out in a warning specified in subsection 3 or 4 of this section, the Health Insurance Fund will have the right to issue a precept for compulsory execution in accordance with the procedure provided in the Code of Enforcement Procedure. RT I 2005 39 308 919178 2006-01-01 2 Other Pecuniary Benefits 63 Adult denture benefit Repealed - RT I 2016-12-27 4 127122016004 2018-01-01 64 Reimbursement for travel expenses Repealed - RT I 2004 89 614 831409 2005-01-01 65 Underlying documents of adult denture benefit Repealed - RT I 2016-12-27 4 127122016004 2018-01-01 66 Connection between adult denture benefit and specific period of time Repealed - RT I 2016-12-27 4 127122016004 2018-01-01 66 1. ]]> Reimbursement for health service provided outside waiting list 1 On a proposal of the supervisory board of the Health Insurance Fund, the minister in charge of the policy sector may establish a regulation setting out the list of health services, except dental services, and the procedure for reimbursement of the costs of such health services, which have been rendered to insured persons outside the waiting list by health service providers operating in Estonia and holding a treatment financing contract with the Health Insurance Fund at the time of provision of the health service (hereinafter contracting partner of Health Insurance Fund). 2 The proposal of the supervisory board of the Health Insurance Fund may be based on: 1 the need to ensure sufficient access to high-quality health services, or 2 the need to control expenses and prevent wasting financial, technical or human resources. 3 The regulation specified in subsection 1 of this section may set out health services that: 1 considerably affect the quality of life of the patient, preventing the development of a disability or permanent damage to health; 2 cause the hospitalisation of the patient for at least one night, or 3 call for using specialised medical infrastructures and equipment. 4 On the conditions and threshold prices set out in the list of health services established on the basis of subsection 1 of § 30 of this Act and without exceeding the sum paid for a health service by an insured person, the Health Insurance Fund will reimburse the costs of provision of the health service provided for medical reasons by a contracting partner of the Health Insurance Fund outside the waiting list to the insured person entered in the waiting list by a health service provider. 5 Upon reimbursement of a health service provided outside the waiting list, the insured person will not be reimbursed for the additional fee or additional cost-sharing established in this Act or on the basis thereof. 6 If the maximum length of the waiting list of a health service established in Estonia on the basis of subsection 3 of § 38 of the Health Insurance Act is at least one year, the reimbursement for health services provided outside the waiting list will be paid out on the date specified in the reimbursement decision taken by the Health Insurance Fund, but not later than on the last day of the appropriate maximum term of the waiting list of provision of the health service. RT I 2013-11-29 1 129112013001 2013-12-09 66 2. ]]> Reimbursement for cross-border health service 1 The insured person has the right to obtain reimbursements provided in this Act in connection with the provision of a cross-border health service specified in § 50³ of the Health Services Organisation Act in a Member State of the European Union other than Estonia. 2 The Health Insurance Fund will reimburse the costs of provision of a cross-border health service provided for medical reasons on the conditions and based on the threshold prices set out in the list of health services established on the basis of subsection 1 of § 30 without exceeding the sum paid by the insured person for the cross-border health service. 3 The Health Insurance Fund will reimburse the sum paid for medicinal products dispensed to the insured person for medical reasons in the course of provision of the cross-border health service and entered in the list established on the basis of subsection 1 of § 43 of this Act on the conditions established in the list, taking into account the threshold prices established on the basis of subsection 2¹ of § 42 of this Act and based on the medicinal product prices set under the price agreements made on the basis of subsection 4 of § 42 of this Act, without exceeding the sum paid by the insured person for the medicinal product. RT I 2023-12-15 3 115122023003 2023-12-25 4 The Health Insurance Fund will reimburse the sum paid for medical equipment dispensed to the insured person for medical reasons in the course of provision of the cross-border health service and entered in the list established on the basis of subsection 4 of § 48 of this Act on the conditions and threshold prices established in the list, without exceeding the sum paid by the insured person for the medical equipment. RT I 2023-12-15 3 115122023003 2023-12-25 5 Upon reviewing an application for reimbursement of a cross-border health service, the Health Insurance Fund has the right to use the Internal Market Information System established on the basis of Regulation (EU) No 1024/2012 of the European Parliament and of the Council on administrative cooperation through the Internal Market Information System (OJ L 316, 14.11.2012, pp. 1–11). 6 Upon reimbursement of a cross-border health service, the insured person will not be reimbursed for the additional fee or additional cost-sharing established in this Act or on the basis thereof. 7 The procedure for application for reimbursement for cross-border health services, reviewing applications and payment of reimbursements will be established by a regulation of the minister in charge of the policy sector. RT I 2013-11-29 1 129112013001 2013-12-09 66 3. ]]> Prior authorisation for provision of health service 1 On a proposal of the supervisory board of the Health Insurance Fund, the minister in charge of the policy sector may establish, by a regulation, the prior authorisation requirement for provision of cross-border health services in a Member State of the European Union other than Estonia for the purpose of: 1 ensuring sufficient and stable access to a balanced selection of high-quality medical services, or; 2 controlling expenses and preventing the wasting of financial, technical or human resources. 2 The prior authorisation requirement specified in subsection 1 of this section may be established for the provision of health services that: 1 depend on the need for planning; 2 cause the hospitalisation of the patient for at least one night; 3 call for using highly specialised and expensive medical infrastructures and equipment; 4 pose a special risk for the patient or population. 3 The regulation specified in subsection 1 of this section will set out the health service for which the prior authorisation requirement will be established, the purpose of establishment of the prior authorisation requirement and the period of reassessment of the prior authorisation requirement. 4 The prior authorisation requirement can be established nationwide or for obtaining a health service provided by a certain health service provider. 5 In the event of a health service the provision of which is subject to the prior authorisation requirement, the Health Insurance Fund will pay the cross-border health service remuneration only if the insured person has obtained a relevant prior authorisation. 6 The established prior authorisation requirement will be published on the websites of the Ministry of Social Affairs, Health Insurance Fund and national contact point of cross-border health services. 7 The Ministry of Social Affairs will inform the European Commission about the establishment of the prior authorisation requirement and about the commencement and termination of applying the requirement. 8 The Health Insurance Fund will grant prior authorisation to the insured person. 9 The Health Insurance Fund must not refuse to grant prior authorisation if the insured person is entitled in Estonia to a health service whose prior authorisation is applied for and if the health service cannot be provided in Estonia within a medically justified term, given the objective medical evaluation of the status of health of the person, their medical history and the possible progress of the disease, the strength of pain and the type of the disability at the time of filing the application. 10 The Health Insurance Fund may refuse prior authorisation for the following reasons: 1 according to a clinical evaluation, it has been identified with reasonable certainty that there is a risk to health, which cannot be deemed acceptable, given the possible benefits of the cross-border health service to the person; 2 it has been identified with reasonable certainty that the cross-border health service poses a considerable threat to public safety; 3 the health service is provided by a health service provider with regard to whom there are serious and concrete doubts about following the provisions on the quality of the health service, patient safety standards and guidelines, including supervisory provisions, provided that these standards and guidelines are established in the legal provisions or accreditation systems of the Member State providing the health service; 4 the health service can be provided in Estonia within a medically justified term, taking into account the status of health and possible progress of the disease of the person. 11 If the insured person applied for prior authorisation for a cross-border health service, the Health Insurance Fund will identify whether the terms and conditions of obtaining the prior authorisation set out in Regulation (EC) No 883/2004 of the European Parliament and of the Council on the coordination of social security systems (OJ L 166, 30.04.2004, pp. 1–123) have been fulfilled. If the terms and conditions have been fulfilled, prior authorisation will be granted in accordance with the Regulation, unless the person explicitly requests otherwise. 12 Upon reviewing an application for prior authorisation, the Health Insurance Fund has the right to use the Internal Market Information System established on the basis of Regulation (EU) No 1024/2013 of the European Parliament and of the Council for verifying health service providers operating in the Member States of the European Union and circumstances pertaining to health care professionals. 13 Upon reviewing an application for prior authorisation, the Health Insurance Fund has the right to request and expert evaluation in order to identify the need for provision of the health service applied for and the term of provision of the service. 14 The conditions of and procedure for obtaining prior authorisation for cross-border health services in a Member State of the European Union other than Estonia and for application and granting of prior authorisation will be established by a regulation of the minister in charge of the policy sector. RT I 2013-11-29 1 129112013001 2013-12-09 66 4. ]]> Restrictions on reimbursement for cross-border health service 1 In the event of provision of a cross-border health service without a referral by a provider of family medical care or special medical care holding an activity licence for provision of health services in Estonia, the Health Insurance Fund will not reimburse the cross-border health service, except in the events specified in subsection 3 of § 70 of this Act and to the insured persons specified in clause 5 of subsection 4 of § 5 of this Act. RT I 2024-06-21 2 121062024002 2024-07-01 2 The insured person who has insurance cover on the basis of Article 17, 24 or 26 of Regulation (EC) No 883/2004 of the European Parliament and of the Council or whose need to receive a cross-border health service arises during their stay in a Member State of the European Union other than Estonia will receive reimbursement for the cross-border health service on the basis of a referral issued by a health service provider of the Member State of the European Union. RT I 2013-11-29 1 129112013001 2013-12-09 6 Additional Fee and Additional Cost-sharing by Insured Person 1 General Conditions 67 Additional fee and prohibition on extension of additional fee 1 For the purposes of this Act, 'additional fee' means expenses that are incurred by the insured person in addition to the amount of cost-sharing in order to receive the health insurance benefit and with regard to which the payment obligation is not assumed by the Health Insurance Fund. Additional fees are the visit fee and the in-patient fee. 2 The Health Insurance Fund does not compensate for additional fees. 3 A health care provider that has concluded a contract for financing medical treatment with the Health Insurance Fund must not demand that the insured person participate in paying for a health service entered in the list of health services in any other manner than on the grounds and to the extent provided for in this Subchapter in addition to the cost-sharing specified in the list of health services, the list of medicinal products or the list of medical devices. RT I 2008 3 22 12909773 2008-09-01 68 Obligation to provide health service in standard conditions of accommodation 1 A health care provider with which the Health Insurance Fund has concluded a contract for financing medical treatment must provide the insured person with accommodation in standard conditions for any period during which the person is receiving in-patient health services. 2 The standard conditions of accommodation will be established by a regulation of the minister in charge of the policy sector. 3 If health services are provided in conditions better than the standard conditions of accommodation, the health care provider may charge a fee corresponding to the value of the additional benefits from the insured person in accordance with the price list established by the health care provider. The health care provider must submit such price list to the Health Insurance Fund upon conclusion of a contract for financing medical treatment and to make insured persons aware of the price list before health services are provided. 4 The insured person has the right to demand that the health care provider provide health services in the standard conditions of accommodation. If a health care provider that has concluded a contract for financing medical treatment with the Health Insurance Fund is only able to provide health services in conditions better than the standard conditions of accommodation, the health care provider must not charge the fee specified in subsection 3 of this section from the insured person. 2 Visit Fee, Additional Cost-sharing, In-patient Fee and Fee for Issue of Documents 69 Fee for home visit 1 A person providing family medical care may charge a fee from an insured person for a home visit. RT I 2024-06-21 2 121062024002 2024-07-01 2 A fee for a home visit must not exceed the maximum rate of visit fees set out in subsection 1 of § 72 of this Act, regardless of the number of insured persons per one home visit. 3 The visit fee for a home visit cannot be charged from a pregnant woman and from an insured person who is less than two years of age. RT I 2009 29 176 13186056 2009-07-01 70 Visit fee and additional cost-sharing upon payment for out-patient specialised medical care 1 If out-patient specialised medical care is provided on the basis of a referral from a person providing family medical care, a person providing specialised medical care or a person providing independent nursing or, in the event provided for in subsection 3 of this section, without a referral, the person providing the specialised medical care will have the right to charge the visit fee from the insured person. RT I 2024-12-12 2 112122024002 2024-12-22 2 If out-patient specialised medical care is provided without a referral from a person providing family medical care, a person providing specialised medical care or a person providing independent nursing who holds an activity licence to provide health services in Estonia, the Health Insurance Fund will not assume the obligation to pay for the health services (additional cost-sharing), except in the events specified in subsection 3 of this section. RT I 2024-12-12 2 112122024002 2024-12-22 3 If out-patient specialised medical care is provided without a referral from a person providing family medical care or a person providing specialised medical care who holds an activity licence to provide health services in Estonia, the Health Insurance Fund will assume the obligation to pay for the health services if the specialised medical care is provided in connection with a trauma, tuberculosis, eye disease, dermatosis or venereal disease or if gynaecological or psychiatric care is provided or if the provider of specialised medical care leaves the patient under observation or treatment by the provider of specialised medical care due to the state of health of the patient. RT I 2024-06-21 2 121062024002 2024-07-01 4 If the insured person is referred to a person providing out-patient specialised medical care to a health care professional working for the same health care provider but in another speciality or to a health care professional working for another health care provider but providing the same health service, the insured person must not be charged the visit fee. 4 1)]]> When the provider of out-patient specialised medical care leaves an insured person under observation or treatment by the provider of specialised medical care due to their state of health, the insured person may be charged a visit fee once a year. RT I 2024-12-12 2 112122024002 2025-04-01 5 The visit fee must not be charged if: 1 out-patient specialised medical care is provided in connection with pregnancy or childbirth; RT I 2024-12-12 2 112122024002 2025-04-01 2 repealed - RT I 2024-12-12 2 112122024002 2025-04-01 3 provision of emergency out-patient specialised medical care is directly followed by the provision of in-patient health services. 6 If the patient terminates a contract for provision of health services less than 24 hours before the time agreed upon for the provision of the health service or fails to appear at the place of performance of the contract by the time agreed for the provision of the service, the provider of the health service will have the right to charge the double visit fee from the patient upon performance of the next contract for the health service. RT I 2008 3 22 12909773 2008-09-01 70 1. ]]> Visit fee upon payment for the service of a person treated as a health care professional 1 If a person treated as a health care professional under subsection 6 of § 3 of the Health Services Organisation Act independently provides out-patient health services on the basis of a referral from a provider of family medical care, specialised medical care or a independent nursing holding an activity licence for the provision of health services, the person has the right to charge a visit fee from an insured person. 2 If a person treated as a health care professional independently provides health services without a referral from a provider of family medical care, specialised medical care or independent nursing, the Health Insurance Fund will not assume the obligation to pay for the health services (additional cost-sharing). 3 An insured person may not be charged a visit fee if the person is referred to a person treated as a health care professional by a health care professional of the same health care provider or the same health centre, or if health services are provided in connection with pregnancy or childbirth. 4 When a person treated as a health care professional leaves an insured person under observation or treatment due to their state of health, the insured person may be charged a visit fee once a year. 5 If the patient terminates a contract for the provision of health services less than 24 hours before the time agreed upon for the provision of the health services or fails to appear at the place of the performance of the contract by the time agreed for the provision of the service, the provider of the health services has the right to charge the double visit fee from the patient upon the performance of the next contract for the health services. RT I 2024-12-12 2 112122024002 2025-04-01 71 In-patient fee 1 A person providing in-patient specialised medical care or a provider of an independent in-patient nursing assistance service may charge an in-patient fee from the insured person for the services provided in standard conditions of accommodation. An in-patient fee may be charged for each calendar day which has commenced during the time spent by a person in hospital, but not for more than ten calendar days for one case of disease. RT I 2014-04-16 4 116042014004 2014-04-26 2 The in-patient fee must not be charged for a period when intensive care is provided, upon provision of in-patient specialised medical care in connection with pregnancy or delivery, or upon provision of in-patient specialised medical care to a minor. 3 The supervisory board of a health care provider has the right to establish the in-patient fee. 72 Maximum rate of visit fee and in-patient fee 1 The maximum rate of visit fee for a home visit is five euros and the maximum rate of visit fee for out-patient specialised medical care is 20 euros. RT I 2024-12-12 2 112122024002 2025-04-01 1 1)]]> The maximum rate of visit fee for out-patient specialised medical care is five euros if out-patient specialised medical care is provided to an insured person who is: 1 under 19 years of age; 2 pregnant, except in the case specified in clause 1 of subsection 5 of § 70 of this Act; 3 the mother of a child of less than one year of age; 4 over the age of 63 years; 5 a recipient of a pension for incapacity for work or old-age pension; 6 has partial work ability or no work ability identified on the basis of the Work Ability Allowance Act; 7 unemployed within the meaning of the Labour Market Measures Act; 8 is a recipient or the family member of a recipient of the subsistence benefit under the Social Welfare Act, if a subsistence benefit has been paid to the person or their family during the month of the provision of out-patient specialised medical care or during the two months preceding it. RT I 2024-12-12 2 112122024002 2025-04-01 1 2)]]> The maximum rates specified in subsections 1 and 1¹ of this section are also applied to the visit fee of an out-patient health services provided independently by a person treated as a health care professional. RT I 2024-12-12 2 112122024002 2025-04-01 2 The maximum rate of in-patient fee is five euros. RT I 2024-12-12 2 112122024002 2025-04-01 3 Repealed - RT I 2024-12-12 2 112122024002 2025-04-01 4 Repealed - RT I 2024-12-12 2 112122024002 2025-04-01 5 [Repealed - RT I, 03.12.2025, 3 - entry into force 13.12.2025] 73 Fee for issue of documents 1 A health care provider may charge a reasonable fee from the insured person for the documents issued. 1 1)]]> Repealed - RT I 2012-07-10 2 110072012002 2013-04-01 2 A health care provider must not charge a fee from the insured person for the issue of a certificate of incapacity for work or a prescription. RT I 2014-10-08 1 108102014001 2014-10-18 3 A health care provider cannot charge a fee from the insured person for the issue of a document that is necessary for the Health Insurance Fund, a law enforcement authority or another health care provider in connection with the performance of a contract for the provision of health services, expert assessment concerning incapacity for work, assessment of the work ability or determination of the degree of severity of a disability, or in any other events provided by law. RT I 2014-12-13 1 113122014001 2017-01-01 (entry into force amended – RT I, 17.12.2015, 1) 4 A health care provider has the right to charge a fee for the issue of a document concerning a patient who is a minor if the size of the fee does not exceed the average expenses incurred upon the issue of the document. RT I 2004 49 342 772862 2004-07-01 4 AMENDMENT OF ACTS 74 § 74. – 87 § 87. [Omitted from this text.] 5 IMPLEMENTATION AND ENTRY INTO FORCE OF ACT 88 Calculation of average income per calendar day until entry into force of § 55 of this Act 1 The average income of persons insured on the basis of clause 1 or 2 of subsection 2 of § 5 of this Act per calendar day is deemed to be equal to the income subject to social tax calculated for the insured person by their employers during the six calendar months preceding the date on which release from the performance of duties commenced as specified in the certificate of incapacity for work, divided by the number of calendar days in the six months preceding the date on which the release from work commences. The number of days for which the insured person was temporarily released from the performance of their duties on the basis of a certificate for incapacity for work, was on holiday for more than 28 calendar days on the basis of clause 1 or 2 of subsection 2 of § 9 of the Holidays Act or was on holiday on the basis of § 30 of the Holidays Act will be deducted from the number of calendar days in the six month period. 2 If the person insured on the basis of clause 1 or 2 of subsection 2 of § 5 of this Act did not receive income subject to social tax during the period serving as the basis for calculation of their average income per calendar day, the average income per calendar day is deemed to be equal to the basic wages of the employee divided by 30, but not more than the minimum monthly wage established by the Government of the Republic and divided by 30. Calculation of average income per calendar day is based on the basic wages of the employee or the minimum monthly wage established by the Government of the Republic as applicable on the date preceding the date on which release from the performance of duties commenced as specified in the certificate of incapacity for work. 3 If the average income per calendar day calculated in accordance with the procedure provided for in subsection 1 of this section is lower than average income per calendar day calculated in accordance with the procedure provided for in subsection 2 of this section, average income per calendar day will be calculated in accordance with the procedure provided for in subsection 2 of this section. 4 The average income of a person insured on the basis of clause 4 or 5 of subsection 2 of § 5 or subsection 3 of § 5 of this Act per calendar day is, in the event of a release from work beginning in the period lasting from July 1 to June 30 of the following calendar year, deemed to be equal to the income calculated on the basis of the social tax paid by or for the insured person during the calendar year (January 1 to December 31) preceding the aforementioned period, divided by 365. The number of days for which the insured person was temporarily released from the performance of their duties or economic or professional activity on the basis of a certificate of incapacity for work will be deducted from the figure 365 before the division. 5 If social tax was not paid for a person insured on the basis of clause 4 or 5 of subsection 2 of § 5 or subsection 3 of § 5 of this Act during the calendar year serving as the basis for calculation of their average income per calendar day, the average income per calendar day is deemed to be equal to the monthly rate provided for in subsection 5 of § 2 of the Social Tax Act, divided by 30. Average income per calendar day is calculated on the basis of the monthly rate provided for in subsection 5 of § 2 of the Social Tax Act which was applicable on the date preceding the date on which the person was released from the performance of their duties or from economic or professional activity. 6 The provisions of subsection 5 of this section do not apply if, on the date preceding the date on which release from the performance of duties commenced as specified in a certificate of incapacity for work, the insured person did not have the obligation to pay social tax or make advance payments of social tax. 7 If the insured person has the right to receive the benefit for temporary incapacity for work on the basis of both subsection 1 and subsection 4 of this section, their average income per calendar day will be calculated on one of the grounds provided for in this section as chosen by the insured person. 8 Calculation of the average income per calendar day of persons insured on the basis of clause 1 or 2 of subsection 2 of § 5 of this Act is based on the information certifying their right to receive the benefit and submitted by the payer of social tax. 9 Calculation of the average income per calendar day of persons insured on the basis of clause 4 or 5 of subsection 2 of § 5 or subsection 3 of § 5 of this Act is based on the information submitted by the Tax and Customs Board concerning income subject to social tax. RT I 2003 88 591 690845 2004-01-01 89 Transitional provisions 1 If release from work as specified in a certificate of incapacity for work commences before 1 October 2002, but the certificate is submitted for the grant and payment of the benefit for temporary incapacity for work after 1 October 2002, the provisions of this Act apply to the granting and payment of the benefit. 2 If the pregnancy and maternity leave of a person insured on the basis of the Republic of Estonia Health Insurance Act ends after the entry into force of this Act, the insured person will have the right to demand extension of the leave in accordance with this Act. 3 Until 1 January 2003, the Health Insurance Fund may conclude a contract with a person specified in clause 1 of subsection 1 of § 22 of this Act without the restriction concerning insurance by the Health Insurance Fund. 4 Until 1 January 2003, the dependent spouse of an insured person is also deemed to be a person considered equal to insured persons in accordance with law and social tax is not paid for them. 5 Until the entry into force of subsection 4 of § 30 of this Act on 1 July 2003, a reference price set out in the list of health services covers all expenses necessary for the provision of a health service, except expenses on research, the training of pupils and students and the construction or renovation of buildings. 6 The provisions of Division 2 of Subchapter 2 of Chapter 3 of this Act do not apply to contracts regulating payment for health services which have been concluded between the Health Insurance Fund and health care providers before the entry into force of this Act. 7 Until a price agreement is concluded, the maximum retail price in force on 31 December 2008 is deemed the price agreement price of a medicinal product. RT I 2010 15 77 13297358 2010-07-01 8 Repealed - RT I 2010 15 77 13297358 2010-07-01 9 Repealed - RT I 2010 15 77 13297358 2010-07-01 10 Until the entry into force of clause 1 of subsection 1 of § 54 of this Act on 1 April 2003, the Health Insurance Fund will pay the benefit for temporary incapacity for work to an insured person per calendar day in the amount of 60 per cent of the average income per calendar day in the event of the provision of in-patient health services or caring for a child of under 10 years of age in a hospital. 11 The following students admitted to educational institutions before the academic year 2003/04 are not deemed to be persons considered equal to insured persons under this Act: 1 students in distance learning (except for students enrolled in this form of study for medical reasons); 2 students of at least 24 years of age acquiring vocational education on the basis of secondary education in the form of distance learning or evening courses (except for students who reach 24 years of age within the standard period of study prescribed for completion of the curriculum). 12 Subsection 7 of § 57 of this Act does not apply to a person whose release from their duties or economic or professional activity as specified in the certificate of incapacity for work commences after 31 July 2004. RT I 2004 56 400 778828 2004-08-01 13 After 1 January 2009, the insurance cover of a self-employed person registered with a regional structural unit of the Tax and Customs Board will end two months after notification of the Tax and Customs Board of the termination of the business activities of the person or deletion of the self-employed person from the register of taxable persons after 31 December 2009 for the reason that the person has not applied for their entry in the commercial register as a self-employed person or their application for registration in the commercial register was not granted. The Tax and Customs Board must inform the Health Insurance Fund of the termination of the business activities of a person or deletion of a person from the register within ten calendar days. RT I 2008 60 331 13111040 2009-01-01 14 Until the end of the release from employment or service duties or economic or professional activities, the provisions of the Health Insurance Act in force until 1 July 2009 are applied to a person whose release from the employment or service duties or economic or professional activities commenced before 1 July 2009. RT I 2009 29 176 13186056 2009-07-01 15 For the purposes of this Act, an insured person also means a student acquiring vocational education without the basic education requirement or a student acquiring vocational education based on secondary education on the conditions established in this Act to persons acquiring formal vocational education. RT I 2013-07-02 1 102072013001 2013-09-01 16 The Health Insurance Fund will pay the insured person the cross-border health service benefit for the health services provided, prescription drugs prescribed and medicinal products dispensed in the course of provision of the health services as of 25 October 2013. RT I 2013-11-29 1 129112013001 2013-12-09 17 In the event of medicinal products issued to the insured person before 1 January 2015, the Health Insurance Fund applies the provisions of § 47 of this Act in force until 31 December 2014 upon calculation of the amount of the additional benefit for medicinal products. RT I 2014-12-13 1 113122014001 2015-01-01 18 In the event of medicinal products issued to the insured person before 1 July 2017, the Health Insurance Fund applies the version of the Health Insurance Act in force until 30 June 2017 upon calculation of the amount of the additional benefit for medicinal products. RT I 2016-12-27 4 127122016004 2017-07-01 19 For the health care services provided before 1 July 2017 the adult dental care benefit is paid out on the basis of the version of the Health Insurance Act in force until 30 June 2017 if the application for the benefit has been submitted by 1 October 2017 at the latest. The total amount of the benefit granted to an insured person in 2017 does not exceed the heightened limit of the dental care service established on the basis of subsection 3 of § 33¹ of this Act. The Health Insurance Fund transfers the benefit to the current account of the insured person or to that of a third party indicated by the insured person not later than by 25 January 2018. RT I 2016-12-27 4 127122016004 2017-07-01 20 The adult denture benefit is paid out for a denture service provided before 1 January 2018 on the basis of the version of the Health Insurance Act in force until 31 December 2017, provided that the service provider submits an aggregate invoice or the insured person submits an application not later than by 31 January 2018. RT I 2016-12-27 4 127122016004 2018-01-01 21 Upon assuming the obligation to pay for a denture service provided for in subsection 2² of § 29 of this Act, the Health Insurance Fund takes into account the adult denture benefit to be paid to a person specified in the version of the Health Insurance Act in force until 31 December 2017 per three years, which has already been paid to the person which the person applies for in accordance with subsection 20 of this section. The calculation of the three-year period that started on 1 January 2018 with regard to the insured person continues until the end of the period. RT I 2016-12-27 4 127122016004 2018-01-01 22 In vitro fertilisation and embryo transfer health services provided and costs incurred on prescription medicinal products before 1 January 2018 are compensated for in accordance with § 35¹ of the Artificial Insemination and Embryo Protection Act in force until 31 December 2017. RT I 2017-12-28 4 128122017004 2018-01-01 23 The rights and obligations of the minister in charge of the policy sector, which are set out in an administrative contract concluded between the manufacturer of a medicinal product and the minister in charge of the policy sector on the basis of subsection 4 of § 42 of the Health Insurance Act in force before 1 January 2018 transfer to the Health Insurance Fund as of 1 January 2018. RT I 2017-12-28 5 128122017005 2018-01-01 24 Upon payment of a benefit for sums paid until 31 December 2017 in a justified and certified manner for purchasing medicinal products entered in the list of medicinal products, which were necessary for the out-patient treatment of the insured person, the Health Insurance Fund applies the version of this Act in force until 31 December 2017 when calculating the size and processing the benefit for the medicinal product. RT I 2017-12-28 5 128122017005 2018-01-01 25 The Health Insurance Fund applies the version of this Act that entered into force on 1 January 2018 to the processing of applications submitted on the basis of subsection 3 of § 43 of the Health Insurance Act before 1 January 2018. RT I 2017-12-28 5 128122017005 2018-01-01 25 1)]]> With regard to a person entitled to the benefit for incapacity for work under subsection 1 of § 56 of this Act whose discharge from the employment or service duties or from the economic or professional activity indicated on the certificate of incapacity for work started before 1 January 2021 the wording of this Act in force until 31 December 2020 is applied. RT I 2020-12-29 2 129122020002 2021-01-01 25 2)]]> With regard to a person entitled to the benefit for incapacity for work under subsection 1 of § 56 of this Act whose discharge from the employment or service duties or from the economic or professional activity indicated on the certificate of incapacity for work started before 1 January 2023 the version of this Act in force until 31 December 2022 is applied. RT I 2021-12-22 3 122122021003 2023-01-01 26 To a person who became entitled to the maternity benefit or adoption benefit before 1 April 2022, the maternity benefit or the adoption benefit is paid on the basis of the version of this Act in force until 31 March 2022. RT I 2018-10-26 1 126102018001 2022-04-01 27 With regard to a person entitled to the benefit for incapacity for work under subsection 1 of § 56 of this Act whose discharge from the employment or service duties or from the economic or professional activity indicated on the certificate of incapacity for work started before 1 July 2023, the wording of this Act in force until 30 June 2023 is applied. RT I 2023-01-11 1 111012023001 2023-07-01 28 The amendments to this Act that entered into force on 15 May 2024 will be applied to new certificates for sick leave opened in respect of insured events occurring as of 15 May 2024. RT I 2024-05-02 3 102052024003 2024-05-15 29 If a certificate for sick leave is issued to a pregnant woman or a person who has the right to maternity leave due to refusal from work or the provision of work corresponding to the state of health before 15 May 2024, the version of this Act in force before 15 May 2024 will be applied to their insured event. RT I 2024-05-02 3 102052024003 2024-05-15 30 Upon payment of a benefit for sums paid until 31 December 2024 in a justified and certified manner for purchasing medicinal products entered in the list of medicinal products, which were necessary for the out-patient treatment of the insured person, the Health Insurance Fund applies the version of this Act in force until 31 December 2024 when calculating the size and processing the benefit for the medicinal product. RT I 2024-05-02 3 102052024003 2025-01-01 31 The amendments to this Act concerning the cap on the benefit for temporary incapacity for work that entered into force on 1 January 2026 will be applied to new certificates of incapacity for work opened in respect of insured events occurring as of 1 January 2026.[RT I, 12.12.2024, 2 – entry into force 01.01.2026] 32 If a certificate for sick leave is issued to a pregnant woman or a person who has the right to maternity leave due to refusal from work before 1 January 2026, the version of this Act in force before 1 January 2026 will be applied to their insured event.[RT I, 03.12.2025, 3 – entry into force 01.01.2026] 89 1. ]]> Issue of paper certificate of incapacity for work 1 Until 31 December 2014, doctors, dentists and midwives authorised to issue certificates of incapacity for work may issue certificates of incapacity for work to insured persons on paper. 2 As of 1 January 2015, doctors, dentists and midwives authorised to issue certificates of incapacity for work may issue certificates of incapacity for work to insured persons on paper only in the event specified in subsection 1¹ of § 52 of this Act. RT I 2014-10-08 1 108102014001 2014-10-18 89 2. ]]> Health insurance in emergency situation During the emergency situation declared by the Government of the Republic on 12 March 2020, the insured persons specified in clauses 4–5¹ of subsection 2 of § 5 of this Act for whom social tax is not paid to the extent of the minimum social tax obligation during the emergency situation, are considered insured persons as well. The insurance cover of these persons will not end in accordance with subsection 3 of § 8 of this Act and remain in force until the tenth date of the second month following the end of the emergency situation. RT I 2020-04-21 1 121042020001 2020-05-01 , implemented retroactively as of 12 March 2020 89 3. ]]> Ex-post evaluation of the system of prevention of incapacity for work On the basis of the Occupational Health and Safety Act, the Ministry of Social Affairs will analyse the temporary provision of work corresponding to the state of health and the impact and effectiveness of the payment of benefits during this period at the latest in 2029. RT I 2024-05-02 3 102052024003 2024-05-15 90 Entry into force of Act 1 This Act will enter into force on 1 October 2002. 2 Subsection 3 of § 25 and §§ 47 and 63 of this Act will enter into force on 1 January 2003. 3 Clause 1 of subsection 1 of § 54 and § 55 of this Act will enter into force on 1 April 2003. 4 Subsection 4 of § 30 of this Act will enter into force on 1 July 2003. 5 Repealed - RT I 2004 89 614 831409 2005-01-01 1 Directive 2010/41/EU of the European Parliament and of the Council on the application of the principle of equal treatment between men and women engaged in an activity in a self-employed capacity and repealing Council Directive 86/613/EEC (OJ L 180, 15.07.2010, pp. 1–6);Directive 2011/24/EU of the European Parliament and of the Council on the application of patients’ rights in cross-border healthcare (OJ L 88, 04.04.2011, pp. 45–65). RT I 2013-11-29 1 129112013001 2013-12-09