Access to Belgian Health Care (PDF - 1018 KB) - COOPAMI

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Access to Belgian Health Care

Measures for an accessible and affordable Health Care for all

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Table of Contents

• Basic Principles - General Access to Belgian

Health Care

• Accessibility Measures for Low-income Patients

• Accessibility Measures for patients with high

Health Expenses

• Monitoring & Supervision

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Basic Principles

General Access to Belgian Health Care

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Basic Principles of Belgian Health Care

• Compulsory vs. Supplementary System

• The Compulsory System

• Insurability vs. Health Care

• Beneficiary vs. Dependent

• General Regime vs. Independent Regime

• Different Qualities

• Ways to pay Contribution

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Basic Principles of Belgian health Care








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• Compulsory Health Care Insurance

– Governmentally initiated, organized & monitored

– Payed by Social Security Contributions & Taxes

– Public Insurance Companies

• Supplementary Health Care Insurance

– Privately initiated & organized, but Governmentally

monitored

– Payed by the ‘Clients’

– Private Insurance Companies

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• Actors in the Compulsory System

– Patient

– Health Care Provider

– Public Insurance Companies = Mutualities (Mutual

insurance fund)

– The National Institute for Health and Disability

Insurance (NIHDI)

• One, Integrated Compulsory System

• The Patient has 2 Roles: the Patient & the

Insured

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• Payment of Medical Care

– The patient pays the Health Care Provider

– Reimbursement of the Tariff by the Mutualities

– Patient Contribution (ca. 25%)

• Doctors: reimbursement of the tariff via a

certificate

• Hospitals/Pharmacies: third-party payment

• The Mutualities are Reimbursement by the NIHDI

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Belgian reimbursement system

Fees

tariff -

Health Care

Provider

Patient

Mutual

Insurance

Fund

affiliation

patient contribution

Reimbursement

=


• Before the Patient can become a ‘Patient’ with

Reimbursement of the tariff he has to become an

insured in the Compulsory System

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• Insurability:

– Rules to become Insured

– Supporting Documents

– Accessibility Measures for:

• Low-Income Patients

• Patients with High Health Expenses

• Health Care:

– Medical Service Rules

– Medical Certificates

– The Insured becomes a Patient

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• Rules of Insurability are:

– Initiated in the Workgroup Insurability

– Voted by the Insurance Comity

– Voted and published the Government

– Since 2012 Observatory for Chronic Diseases

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• Workgroup Insurability has Representation of

– The NIDHI

– The Mutualities

– The Federal Public Service Social Security

– The Crossroads Bank for Social Security

– The Federal Public Service Economy

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• Beneficiary =

– Insured Person who is personally entitled

– Contributions

– Own Status and Quality

• Dependent =

– Insured Person with derived Rights

– Residual Possibility

– Conditional: Low-income & Affiliation with the

Beneficiary (Spouse, Cohabitant, Child,¨Parent)

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• Beneficiaries & Dependents:

– get the same Health Care,

– for the same price

– Just the system to open their Right to

Reimbursements is different

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• Number of Insured per Type of Right

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Type Insured

Total Beneficiary Dependent

7.438.089 3.514.321 10.952.410









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• Division in 2 Regimes: Reneral & Independents

• ≤ 2008 : important Difference on insured medical

Care & Contributions

– General: big risks, small risks

– Independent: big risks, small risks

• ≥ 2008 lasting influence on

• Contributions

• Qualities

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Small

risks

Big risks


• Independent regime

– Independents

– Professions (pharmacists, lawyers, accountants ..)

– Members of a religious community

• General regime

– Employees

– Public servants

– Unemployed

– Others

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• Numbers insured per regime (31/12/2012)

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Regime Number insured

Non-Insured 92.115

GR 9.758.030

IR 1.102.265

Total 10.952.410









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• Qualities are related to the types of contributions

• In both regimes:

– Actives

– Invalids/Disabled

– Widows/Widowers

– Orphans

– Pensioners

• In the general: Residents & Students

• In the Independent: Members of a religious

Community

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• Numbers by Quality (31/12/2012)

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Active employee 6.831.399 Active independent 917.907 Pensioners* 1.933.928 Invalid* 443.578 Member of a religious community 1.691 Handicapped* 93.429 Not Insured 92.115 Resident 264.471 Student 1.214 Widow(er)* 371.739 Orphan* 939 Total 10.952.410

* Quality for both regimes


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Active employee 62% Active

independent 8%

Pensioners* 18%

Invalid* 4%

Member of a religious community

0% Handicapped* 1%

Not Insured

1% Resident

3%

Student 0%

Widow(er)* 3%

Orphan* 0%

Insured by Quality









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• Contributions

– Employed workers - deducted at source (40% of

gross salary goes to Social security, 7% specific to Health

Care.).

– Independents - quarterly contribution

– Retired & disabled people - free

– Widows/Widowers - free

– Orphans - free

– Residents - specific contributions

– Students - specific contributions

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Low-Income Patients

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Accessibility Measures for Low-income patients

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Accessibility Measures for Low-income Patients

• Selection Low-income Patients

• Insured without Contribution

• Increased Insurance Intervention

• Third-party Payment System

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• Selection Low-income Patients




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Selection Low-income patients

• Family Income

• Income = gross annual Income

• Low-Income =

– Singles income ≤ ca.16.000 Euro/year

– Per extra family member + ca. 3.000 Euro/year

• Need for a Declaration of Honor or indication for

low-income (social benefit)

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• Selection Low-income patients




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Insured without Personal Contribution

• Dependents

• Qualities Beneficiaries with no Contribution

– Retired, unemployed & disabled People

– Widows/Widowers

– Orphans

– Unaccompanied Minors

→ Mostly Welfare Benefactors

• Some Residents: dependent on the Income

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Residents

• Different Amounts of Trimestral Contribution:

• 680€: Gross annual Income > 25.000 €

• 342€: Gross annual Income < 25.000 €

• 60€ : beneficiaries of the Increased Insurance

Intervention

• 0 € : Income is ≤ Minimum Wage

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Residents

• Residents per Contribution

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Insured without Personal Contribution

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Reason lack of Contribution Number Insured

Dependents 3.514.321

Residents without Contribution 182.453

On some kind of pension 2.843.613

Total 6.540.387






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Increased Insurance Intervention

• Increased Insurance Intervention beneficiaries

pay lower patient contributions

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• 3 roads, with 3 different sets of conditions

– Possession of a Specific Quality

– Possession of a Social Benefit

– Low Household Income for min. 1 year

• Beneficiaries of all 3 categories have Low-

incomes

• The same intervention is applied

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1. Based upon an entitled Quality/status of 1 family

member

• Examples of Qualities:

– Widows, disabled people, retired people, orphans

– Long-term unemployed people

– Single parent family

• Family = person + spouse + their dependants

• Declaration of current family income

• Prolongation after income verification

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2. Based upon a Social Benefit of 1 Family Member

• Examples of Social Benefits:

– Minimum Wage

– Increased Child Support

– Integration Allowance for the Handicapped

• Automatically for the whole Family

• Family = Person + Spouse + their Dependents

• Without Declaration

• Without Verification of Income for Prolongation

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3. Low Household income for min. 1 year (OMNIO)

• Household= all People enrolled in the National

Register at the same address on January 1st

• The Income of the previous Calendar Year must

be below a Certain Limit

• Declaration

• Prolongation after Income Verification

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Granted to ..?

Status Social benefit income

Person entitled

to the status +

spouse / life

partner +

Their

dependents

= Family

Person entitled to

the status +

spouse / life

partner +

Their dependents

= Family

All members of the

household as

composed in the

national register

=Household

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Family

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Household


• Number of beneficiaries of the Increased

Insurance Intervention

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Increased Insurance Intervention No Increased

Insurance Intervention

Quality + Social Benefit OMNIO

1.561.861 279.522 9.111.279

1.841.383 9.111.279

10.952.410


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Quality 41%

Social Benefit 44%

OMNIO 15%

Division between the types of Increased Insurance Intervention


• Evolution Increased Insurance Intervention (2006-

2012)

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0

200.000

400.000

600.000

800.000

1.000.000

1.200.000

1.400.000

1.600.000

1.800.000

2.000.000

1-1-2006 1-1-2007 1-1-2008 1-1-2009 1-1-2010 1-1-2011 1-1-2012

1.300.882 1.426.918

1.527.273 1.601.811 1.710.785 1.797.519 1.841.113


• Yearly Income Verification by the Mutualities

• Through the NIHDI and the FPS Finances

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• From 1st of January 2014 the 2 systems with

Declaration become 1 system

• With:

– Use of family

– Period of reference of 1 year AND low current

income

– Prolongation after income verification

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Social Third-party Payment System

• Third-party Payment System= Patient is only due

patient contribution

• Forbidden for GP consultations

• Social Third-party Payment System overrules this

for:

– Beneficiaries of the Increased Insurance

Intervention

– For insured who are unemployed six months (with

a family or single)

– case of an individual financial emergency

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Accessibility Measures for patients with high health expenses

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Accessibility Measures for patients with high Health Expenses

• Maximum Billing

• Measures in favor of chronically sick people

• The Special Solidarity Fund

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Maximum billing

A household that reaches a certain level of

patient contributions in a year, in relation to

it’s income, doesn’t have to pay patient

contribution for that year.

Maximum Billing

• 3 Types of Maximum Billing:

– Maximum billing income

– Social maximum billing

– Maximum billing children

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Maximum Billing Income

• General Principles:

• Household= all people enrolled in the National

Register at the same address on January 1st

(OMNIO)

• A year = a calendar year

• Income = net taxable Income of the household

• patient contributions in a counter

• Certain level of patient contributions in relation to

it’s income (slide 38)

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Maximum billing Income

Income Patient contribution limit

< 17 523,66 € 450 €

>17 523,67 € < 26 939,35 € 650 €

> 26 939,36 € < 36 355,07 € 1.000 €

> 36 355,08 > 45 378,45 € 1.400 €

> 45 378,46 € 1.800 €

Maximum Billing Income

• Automatically granted

• Monthly procedure (slide 40)

• Income used:

– year X -3

– Deviation possible if income dropped

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Mutual Insurance Fund

calculating patient contribution communication of

income category

450 €

asking the household’s income

category reconstructing the

household’s income

NIHDI

asking for the communication of

individual income individual income

FPS Finances

Maximum billing Income - Procedure

Social maximum billing

• Granted to the members of the household who

benefit the increased intervention

• Patient contribution limit = 450 Euro

• No intervention of NIHDI

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Maximum Billing children

• Individual right

• Patient contributions reaching 650 €

• Until 18 years accomplished

• For Children with increased Child Support a Ceiling of

450 Euros applies

Maximum Billing

• Number of beneficiaries Maximum Billing Year

2010 (31/12/2012)

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Type Maximum Billing MAB 2010

Social Maximum Billing 289.343

Maximum Billing Income 814.974

Increased Child Support 595

Maximum Billing children 8.759

Total 1.113.671

Maximum Billing

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Social Maximum Billing 26%

Maximum Billing Income 73%

Increased Child Support 0%

Maximum Billing children 1%

Beneficiaries MAB 2010

Maximum Billing

• Amount of expenses for the Maximum Billing Year

2010 (31/12/2012)

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Type Maximum Billing Expenses Maximum Billing €

MAB 2010

Social Maximum Billing 62.939.943,86

Maximum Billing Income 247.009.762

Increased Child Support 225.627,38

Maximum Billing children 2.509.691,34

total 312.685.024,52

Maximum Billing

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Social Maximum Billing 20%

Maximum Billing Income 79%

Increased Child Support 0%

Maximum Billing children 1%

Expenses in € MAB 2010

Maximum Billing

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• Maximum Billing



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Measures in favor of Chronically Sick People

• Maximum billing Chronically ill: Deduction of

100 Euro of the limit for households where 1

person has payed in 2 consecutive years more

than 450 euro patient contributions

• Forfait Chronically ill: fixed sum attributed on a

yearly basis

• Observatory for Chronic Diseases in de NIDHI

decisionmaking Process since 2012

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Measures in favor of Chronically Sick People

• Other Reimbursement Rules or Fixed Sums:

– Protection against additional costs for rooms or

additional fees

– Intervention for bandages for patients with

chronically wounds

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• Maximum Billing



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The Special Solidarity Fund

• Exceptionally covers health care services which

– are not reimbursed by health insurance;

– performance that have to be repaid but that person

did not meet the conditions to obtain the refund;

– medical services provided abroad and travel and

accommodation there.

• The SSF provides an intervention:

– in case of a rare rare condition

– in case innovative medical devices and/or

treatments are needed

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Monitoring & Supervision

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Monitoring & Supervision

General Monitoring & Supervision

• Internal Audit Services Mutualities: Compulsory &

supplementary Health Care

• Control Service Mutualities (OCM/CDZ):

Compulsory & supplementary Health Care

• NIHDI : Compulsory Health Care

– Administrative control

– Medical Control and Evaluation

– Data Matching & Thematic Controls

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Questions?

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