Universal Healthcare Programme: who gets what, how much the patient pays and how the approval letter works

Who is covered by Universal Healthcare?

The programme's beneficiaries are citizens of Georgia, holders of a neutral identity card or neutral travel document, registered persons with a personal number legitimately living in Abkhazia and the Tskhinvali region, and stateless persons with status in Georgia, asylum seekers, refugees and persons with humanitarian status.

Two groups are excluded from the programme. The first is an accused or convicted person held in a detention or prison facility. The second is a person enrolled in a private insurance scheme, identified using data from the State Insurance Supervision Service; this rule has exceptions, which we discuss separately below.

Since 1 January 2021 the programme has been run by the National Health Agency (a legal entity of public law), and services are provided by clinics and outpatient facilities registered in the programme. A person can use the programme on only one basis. If you belong to several categories, the order of priority is: first the socially vulnerable and equivalent groups, then pension age, severe disability status, veteran status, children with disabilities and finally everyone else.

Which category are you in and which package are you entitled to?

Your package depends on which group you fall into. The table is based on the current version of the programme and summarises the main civilian categories; veterans, pregnant women and certain diagnoses have their own annexes.

Annual income is calculated from Revenue Service data: for salaried employees on taxable income for the last 12 months, for those who file a tax return on the previous year's data. Monthly income is the average of the last three months. A change takes effect from the first day of the month after the information is received.

One detail often changes the category: if your annual income included a one-off payment, including charitable assistance or compensation, or a funded pension paid to a person with disabilities, it can be deducted on documentary proof to the Agency. This rule is used by families who ended up in the "high income" category because of money raised for treatment.

How much does the patient pay: how co-payments work

The co-payment is the share of the amount reimbursable under the programme that remains for the patient to pay. It depends on two things: the type of service and your category. The table compares the three most common packages.

Exceptions: in the standard package, cardiac and cancer surgery for patients under 18 is free of co-payment. In the second-column group, neonatal cases, as well as cardiac and cancer surgery for children aged 0-5 and children with disabilities, are not subject to a co-payment. For computed tomography, the same group pays a 20% co-payment and pensioners 10%.

What matters is what the programme counts as 100%. Since November 2022 much of inpatient care has been funded using the DRG method, meaning the cost of a case is set by the programme rules. For programme services, a clinic may not make the patient pay more than the set co-payment or any other additional amount, including in a DRG-funded case. The exception is additional services permitted by the Minister's normative act, such as a chosen doctor or ward. If, under the final DRG, your share turns out to be less than you paid, the clinic refunds the difference within 30 calendar days, and overcharging costs the clinic a fine of three times the amount.

The practical conclusion: before you sign, ask in writing how much is the programme's share and how much is your co-payment, and if any other amount is requested, ask which rule permits it. To cover the co-payment you can then apply to the municipality or the referral commission.

What does the programme not cover?

The annex to the basic package names, in a separate list, the costs that are not reimbursed. This is the list to check when a clinic tells you that "the programme doesn't cover this":

• services provided abroad and sanatorium and spa treatment;
• cosmetic surgery, treatment of sexual dysfunction and infertility, bariatric operations;
• organ transplantation, external prosthetics and orthopaedic joint replacement, except for an injury less than 3 months old that cannot be treated conservatively;
• PET/CT scans and extracorporeal lithotripsy;
• refractive and laser eye surgery (except for diabetic eye disease), surgical treatment of strabismus, corneal transplantation;
• specific antiviral treatment for viral hepatitis, which has a separate programme;
• hospitalisation for internal medicine conditions, except for emergency conditions specified by the Minister's act;
• services funded in the same year under another state or local budget programme.

"Not covered" does not mean there is no route to funding at all. For example, joint replacement has a separate Tbilisi municipal sub-programme, and treatment abroad is considered through the referral commission. This list applies to the basic package; the package for families with a score of up to 70,000 and for protected groups has its own, slightly different list.

Emergency and planned care: who does what?

Emergency care

In an emergency the patient does not need to submit anything. The clinic must notify the Agency of the case through a special electronic programme immediately, and no later than 24 hours. If the patient's identity or insurance status needs to be checked, the clinic still makes the notification and records the patient temporarily as "unknown"; final identification must take place before the case is closed. One piece of advice for the family here: give the clinic the patient's ID details as early as possible.

Planned surgery and the approval letter

Planned surgical care is funded on the basis of an approval letter (a materialised voucher) issued by the Agency, which in everyday language is called a guarantee letter or "the paper". To be recognised as a beneficiary, the patient or their authorised representative has two options: submit Form IV-100/a, a copy of the ID (a birth certificate for a person under 18) and an invoice or cost estimate to the Agency themselves, or apply to a clinic that takes part in the programme. In both cases the application is completed in a special electronic system.

In Form IV-100/a the diagnosis must be given using the ICD-10 classification and the intervention with a procedure code. The Agency issues the approval letter within no more than 60 calendar days of receiving the application, or informs you in writing of any obstacle. Once the letter has been issued, the clinic makes an additional notification for the planned intervention no later than 12 hours before hospitalisation.

1. Get a complete Form IV-100/a

   Ask the doctor for the ICD-10 diagnosis and the procedure code. Without these two, the electronic application is incomplete.

2. Check the clinic

   Ask whether the clinic takes part in the planned surgery component and request a cost estimate that shows the programme's share and your share separately.

3. Submit the application

   Either the clinic enters it in the electronic system, or you submit the documents to the Agency. Write down the date of submission so that you can keep track of the 60-day period.

4. Get a copy of the letter or the refusal

   Whether it is an approval letter or a refusal, take it in writing: the municipality and the referral commission ask for exactly this document.

The programme also protects freedom of choice: a voucher holder can receive the service from any of the programme's providers, unless the voucher names a specific provider. For planned outpatient care, you can change your family doctor registration once every two months.

What happens if you have private insurance?

A person enrolled in a private insurance scheme, as a rule, cannot use Universal Healthcare. The Agency establishes this using data from the State Insurance Supervision Service, so having insurance is reflected automatically. However, the rule has important exceptions:

• Insured people with an income below GEL 1,000 a month still receive emergency outpatient care, management of critical conditions, cancer treatment and surgery for a cancer diagnosis.
• Insured people with an income of GEL 1,000 or more a month keep cancer treatment and surgery for a cancer diagnosis.
• When insurance ends, for 6 months from the end date the person is entitled to part of the services defined by the programme, and after that period moves to the full package for their category.
• Veterans receive cancer care regardless of private insurance.

In practice this means it is easy to fall into the "gap" between the two systems: the insurance excludes the operation, and you are not entitled to Universal Healthcare because you are insured. In that case get a written reply from both sides. An insurance company's refusal can be reviewed and is often open to dispute, as we explain on the insurance disputes page.

How does Universal Healthcare combine with other sources?

Universal Healthcare is almost always the first link in the chain, and its written reply is the pass to the next links. Municipalities often calculate co-funding precisely on the basis of the co-payment amount, and the referral commission takes into account a Universal Healthcare refusal or partial funding. Medicines for chronic conditions (cardiovascular, lung and thyroid disease, type 2 diabetes, glaucoma, Parkinson's disease, epilepsy) are covered by a separate annex to the programme for socially vulnerable people with a score of up to 100,000, pensioners, children with disabilities, persons with severe or significant disabilities and certain other groups; the details are in the guide to funding for medicines. The cancer patient's route, from chemotherapy to surgery, is described separately in the guide to funding for cancer treatment.

If your category depends on your social status, check in advance that it is correct: we explain how the rating score is obtained and reviewed in the guide to social status. If you have received a refusal from the Agency, or no reply within 60 days, what to do is in the guide to appealing a refusal. And the funding search service can help you prepare documents and applications.

Frequently asked questions about Universal Healthcare