State programme or private insurance: who pays for what and which to approach first

State programme and private insurance in one table

The table compares the two systems on the criteria that directly affect the patient's pocket. The figures, where the programme sets them, are in the Universal Healthcare guide; here we compare the logic.

One thing stands out clearly from the table: the limits of a state programme are written the same way for everyone and published openly, while those of insurance depend on your specific policy. So assessing insurance always starts with the full text of the policy, not with an advertising brochure. The terms of state programmes, in turn, may change every year, because the government approves each year's programmes by a separate resolution; for 2026 this is Resolution No. 655 of 31 December 2025.

Can you use both at the same time?

The Universal Healthcare Programme (Government Resolution No. 36 of 2013), as a rule, excludes people enrolled in a private insurance scheme from its beneficiaries. The National Health Agency establishes whether you are insured from its own data, so this is reflected without any application from you. A corporate policy taken out for you by your employer is no different from an individual one in this respect.

The exclusion is not total. The programme still keeps cancer treatment and surgery for a cancer diagnosis for insured people, and additionally emergency services for insured people on a low income. After insurance ends, a transitional period applies. The exact thresholds and periods are listed in the Universal Healthcare guide, in the chapter on private insurance; what matters here is the principle: for an insured person the policy is the main source, and the programme is only additional support in specific areas.

Cancer care is where the two systems meet most often, and here it is especially important to establish in writing, before treatment starts, which part the insurer pays and which part the programme pays. How this cost is split in practice is described in our guide to funding cancer treatment.

Who pays what: co-payment, excess and limit

In both systems part of the cost remains with the patient, but that part is calculated differently and goes by different names.

In a state programme

In Universal Healthcare the patient's share is the co-payment: a percentage of the amount reimbursable under the programme, which has an upper cap and varies by category. Importantly, the percentage is calculated from the price set by the programme, not from the clinic's price list, and for programme services the clinic may not charge anything beyond the co-payment, except for additional services permitted by a regulatory act. The second restriction is an annual or per-case limit, above which costs fall outside the programme.

In private insurance

In a policy the patient's share takes three forms. The excess is a fixed amount you pay yourself for each case before the insurer steps in. The co-payment is a percentage that may remain even after the excess. Limits and sub-limits are annual or service-specific caps, for example on inpatient care, medicines or diagnostic tests. In addition, many policies vary the reimbursement percentage by clinic: one rate at a partner clinic, a lower one elsewhere.

The practical conclusion is the same for both: before any procedure, ask the clinic for a written cost estimate that states separately how much the programme or the insurer pays and how much remains for you. You will also need this document later when you approach other sources.

Which should you approach first?

The order depends on whether you are insured and what kind of service you need. Below is the general rule, broken down into five steps.

1. Establish your status

   Find out whether you are enrolled in a private insurance scheme, including through your employer, and which Universal Healthcare category you fall into.

2. Approach your main source

   For an uninsured person this is Universal Healthcare, for an insured person the policy. In cancer care an insured person needs an answer from both sides, because both may contribute.

3. Get a written answer

   A letter of approval, the insurer's guarantee letter or a refusal, all in writing. A verbal "it isn't covered" means nothing at the next stage.

4. The remaining difference

   For the co-payment and the uncovered part you approach the municipality and the referral commission. Both ask for the answers from the first two sources, and the municipal service also asks an insured person for a certificate from the insurance company.

5. The last link

   Charitable sources and fundraising only after that. Some of them also ask for the state and insurance answers.

In an emergency the rule is simple: treatment first, paperwork later. The clinic notifies the Agency itself, while an insured person should notify the insurer as quickly as possible, because many policies set a notification deadline. The full route for cases with a large co-payment is in the guide to funding surgery.

Refusal: an administrative act or a contract dispute?

Refusals from the two systems are legally different things and are therefore challenged in different ways. Confusing them often costs families a missed deadline.

A state programme refusal is an administrative act of the National Health Agency. Under the General Administrative Code, the deadline for filing an administrative complaint is one month, the deadline for a court claim is also one month, and a failure to answer within the statutory period counts as a refusal. The steps are described in the guide to appealing a refusal.

An insurer's refusal is a dispute arising from a private contract. The instruction approved by Order No. 18 of 2017 of the State Insurance Supervision Service requires the insurer to give the customer the full list of exclusions before the contract is signed, and to consider a customer's complaint and notify the outcome in writing or electronically. If the company's answer does not satisfy you, the next step is the supervisory service and, ultimately, the court. What to check in a refusal letter and when it can be challenged is covered on our insurance disputes page.

Corporate policy: what happens when you change jobs?

Employer insurance is the most common private policy, and it is also the one that most often ends unexpectedly: when you leave your job, when the company switches insurer or when the contract expires. At that moment three things happen at once. The old policy ends, and with it every approval not yet completed. Universal Healthcare returns gradually, through a transitional period. And the new policy may treat your existing condition as pre-existing or impose a waiting period.

• Planned surgery: if you are planning to change jobs, ask the insurer whether it will cover an already approved procedure if it takes place after the policy ends. Ask for the answer in writing.
• Termination document: get a certificate showing the date on which the insurance ended. This date matters for counting the Universal Healthcare transitional period.
• New policy: before signing, read the exclusions, the definition of a pre-existing condition and the waiting period. For a family member with a chronic diagnosis these are often the most important clauses.

If the texts of the old and new policies differ and one of them is in a foreign language, you can order a translation on our financial documents translation page.

Treatment abroad: which system covers what?

The basic Universal Healthcare package names services provided abroad in its list of exclusions. State help of this kind is requested under the Referral Services Programme, through the commission, while for children's cancer treatment abroad the Solidarity Fund of Georgia works through a separate mechanism. The details are in the guide to funding treatment abroad.

Under private insurance, planned treatment abroad is funded only when the policy expressly provides for it: these are usually policies with international cover, and they often require prior approval. Travel insurance, on the other hand, is for emergencies and as a rule does not cover planned treatment. In both cases reimbursement is claimed with the foreign invoice, proof of payment and the discharge summary, so keep all the originals and plan the translation in advance.

Which papers to keep so that both systems answer you?

When the two systems meet, the decision often turns on a single sheet of paper: a date, an amount or the grounds for a refusal. Keep the documents listed below in one folder and attach copies to every new application.

• the full text of the policy with its annexes, not just the insurance card or a short summary;
• the insurer's guarantee letter, reimbursement statement or refusal stating the policy clause;
• the Agency's approval letter or refusal and the date the application was filed;
• the clinic's cost estimate showing the programme's, the insurer's and the patient's shares separately;
• the final bill and payment receipts, the discharge summary and Form IV-100/a;
• the certificate of termination of insurance, if the policy changed during treatment.

This set serves three purposes: appeals, applications to the municipality and the referral commission, and, if necessary, a court dispute. If any document is in a foreign language, for example an international policy or a foreign clinic's invoice, prepare the translation in advance so that you do not miss a deadline because of it.

Is private insurance worth it if you have Universal Healthcare?

There is no single answer to this question, and we do not recommend any particular product or company. The decision depends on your category, your health and your budget, and four questions will help you make it:

• What are you entitled to under Universal Healthcare now, and what will you lose if you take out insurance?
• Does the policy cover exactly the services your family is likely to need, including medicines and the management of a chronic condition?
• What excess, co-payment and limit does the policy have, and how do they compare with the programme's co-payment?
• At which clinics is the policy valid, and what happens if the specialist you need works outside the network?

If the answers to these questions are unclear, or you have already been refused by both sides, our funding search service analyses the answers from both systems together and recommends the next source.

Frequently asked questions about state programmes and private insurance