access to belgian health care (pdf - 1018 kb) - coopami
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1
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
3
Basic Principles
General Access to Belgian Health Care
4
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
• 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
• 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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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
• 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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Basic Principles of Belgian Health Care
• 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
=
Basic Principles of Belgian Health Care
• 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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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
• 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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Basic Principles of Belgian Health Care
• 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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Basic Principles of Belgian Health Care
• 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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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
• 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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Basic Principles of Belgian Health Care
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Basic Principles of Belgian Health Care
• 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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Basic Principles of Belgian Health Care
• 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
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
22
Basic Principles of Belgian Health Care
• 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
Basic Principles of Belgian Health Care
• Independent regime
– Independents
– Professions (pharmacists, lawyers, accountants ..)
– Members of a religious community
• General regime
– Employees
– Public servants
– Unemployed
– Others
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Basic Principles of Belgian Health Care
• 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
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
• 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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Basic Principles of Belgian Health Care
• 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
Basic Principles of Belgian Health Care
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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
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
• 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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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
• 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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Accessibility Measures for Low-income Patients
• Selection Low-income patients
• Insured without Contribution
• Increased Insurance Intervention
• Third-party Payment System
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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
Accessibility Measures for Low-income Patients
• Selection Low-income patients
• Insured without Contribution
• Increased Insurance Intervention
• Third-party Payment System
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Increased Insurance Intervention
• Increased Insurance Intervention beneficiaries
pay lower patient contributions
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Increased Insurance Intervention
• 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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Increased Insurance Intervention
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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Increased Insurance Intervention
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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Increased Insurance Intervention
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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Increased Insurance Intervention
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
Increased Insurance Intervention
• 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
Increased Insurance Intervention
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Quality 41%
Social Benefit 44%
OMNIO 15%
Division between the types of Increased Insurance Intervention
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
Increased Insurance Intervention
• Yearly Income Verification by the Mutualities
• Through the NIHDI and the FPS Finances
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Increased Insurance Intervention
• 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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Accessibility Measures for Low-income Patients
• Selection Low-income patients
• Insured without Contribution
• Increased Insurance Intervention
• Third-party Payment System
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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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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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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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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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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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