access to belgian health care (pdf - 1018 kb) - coopami
Post on 25-Mar-2022
8 Views
Preview:
TRANSCRIPT
1
Access to Belgian Health Care
Measures for an accessible and affordable Health Care for all
2
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
5
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
6
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
7
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
8
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
9
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
10
11
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
12
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
13
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
14
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
15
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
16
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
17
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)
18
Basic Principles of Belgian Health Care
19
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
20
Basic Principles of Belgian Health Care
• Number of Insured per Type of Right
21
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
23
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
24
Basic Principles of Belgian Health Care
• Numbers insured per regime (31/12/2012)
25
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
26
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
27
Basic Principles of Belgian Health Care
• Numbers by Quality (31/12/2012)
28
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
29
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
30
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
31
32
Low-Income Patients
33
Accessibility Measures for Low-income patients
34
Accessibility Measures for Low-income Patients
• Selection Low-income Patients
• Insured without Contribution
• Increased Insurance Intervention
• Third-party Payment System
35
Accessibility Measures for Low-income Patients
• Selection Low-income Patients
• Insured without Contribution
• Increased Insurance Intervention
• Third-party Payment System
36
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)
37
Accessibility Measures for Low-income Patients
• Selection Low-income patients
• Insured without Contribution
• Increased Insurance Intervention
• Third-party Payment System
38
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
39
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
40
Residents
• Residents per Contribution
41
Insured without Personal Contribution
42
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
43
Increased Insurance Intervention
• Increased Insurance Intervention beneficiaries
pay lower patient contributions
44
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
45
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
46
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
47
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
48
49
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
50
Family
51
Household
Increased Insurance Intervention
• Number of beneficiaries of the Increased
Insurance Intervention
52
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
53
Quality 41%
Social Benefit 44%
OMNIO 15%
Division between the types of Increased Insurance Intervention
Increased Insurance Intervention
• Evolution Increased Insurance Intervention (2006-
2012)
54
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
55
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
56
Accessibility Measures for Low-income Patients
• Selection Low-income patients
• Insured without Contribution
• Increased Insurance Intervention
• Third-party Payment System
57
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
58
Accessibility Measures for patients with high health expenses
59
Accessibility Measures for patients with high Health Expenses
• Maximum Billing
• Measures in favor of chronically sick people
• The Special Solidarity Fund
60
61
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
62
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)
63
64
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
65
66
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
67
68
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)
69
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
70
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)
71
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
72
Social Maximum Billing 20%
Maximum Billing Income 79%
Increased Child Support 0%
Maximum Billing children 1%
Expenses in € MAB 2010
Maximum Billing
73
Accessibility Measures for patients with high Health Expenses
• Maximum Billing
• Measures in favor of chronically sick people
• The Special Solidarity Fund
74
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
75
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
76
Accessibility Measures for patients with high Health Expenses
• Maximum Billing
• Measures in favor of chronically sick people
• The Special Solidarity Fund
77
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
78
Monitoring & Supervision
79
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
80
Questions?
81
top related