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European Observatory on Health Systems and Policies

Belgium


Health Systems in Transition (HiT) profile of Belgium

3.4 Out-of-pocket payments

3.4.1 Cost-sharing (user charges)

For outpatient care, patients are in principle required to pay upfront the full fee and then claim reimbursement from their sickness fund. For inpatient care and medicines purchased in pharmacies, the third-party payer system applies and patients only pay user charges. User charges can be either official and provided by law, or supplements charged on top of official user charges, which are allowed under certain conditions (see in particular Subsection Patient contributions at the end of Section 3.6.1 Paying for health services).

Co-payments vary from service to service but are equal for everyone, with the exception of patients with preferential reimbursement who pay reduced co-payments. Co-payment rates are about 25% for GP consultations, 35% for GP home visits and 40% for specialist consultations, physiotherapy, speech therapy, podology and dietetics. The co-payment for preferential reimbursement rate beneficiaries depends on the type of service and amounts to about 10% for GP consultations, about 15% for specialist consultations, and about 20% for physiotherapy, speech therapy, podology and dietetics.

Before July 2007, in order to qualify for preferential reimbursement, a patient had to belong to a socioeconomically vulnerable group and earn less than a minimum income threshold. People and their dependants defined as socioeconomically vulnerable groups are: pensioners, widowers/widows, orphans, disabled people receiving a disability benefit, long-term unemployed aged 50 years and older with at least one year of full unemployment, civil servants who are made redundant because of illness or infirmity for at least one year, disabled children entitled to increased child allowance, and people entitled to one of the following allowances: integration or income replacement for disabled persons, income guarantee for the elderly, disability benefit, subsistence level income (leefloon-revenue d’intégration), support from the public municipal welfare centre (OCMW-CPAS) and allowance for assistance for the elderly.

On 1 July 2007, the system was extended (now called the OMNIO system) and the socioeconomic group criterion was abolished. In 2009, in order to qualify for preferential reimbursement the gross annual taxable income of the household (or isolated person) must not exceed €14 339.94 + €2654.70 per dependant (NIHDI 2009c).

Concerning medicines, about 2500 pharmaceuticals are reimbursable in Belgium. In the case of pharmaceuticals obtained from a pharmacy, the patient pays co-insurance (i.e. the patient pays a certain fixed proportion of the cost of a service and the third-party payer covers the remaining proportion).17 The percentage is determined by the pharmaceutical category, which reflects the social importance of the pharmaceutical, pharmacotherapeutic criteria and price criteria. A distinction is made between category A (pharmaceuticals for serious and long-term illnesses), B (socially and medically useful pharmaceuticals), and C (socially and medically less useful pharmaceuticals). The different rates are given in Table3.7.

Moreover, a system of reference reimbursement has been developed. With this system, the basis of reimbursement of an original pharmacological product for which there is a less expensive version (often a generic or a “copy”) is decreased. From 1 July 2005, the decrease is 30%. This implies that the patient will pay a reference supplement when the more expensive medication is prescribed. From 1 January 2009, the basis of reimbursement for original pharmaceutical products which have been in the system of reference reimbursement for two years undergoes a further decrease of 2.5% (NIHDI 2009c).

For inpatient care, a patient’s out-of-pocket payments consist of:

  • a flat rate per day for hospitalization;
  • a room supplement when the patient has requested a single or double room;
  • the physician’s fee supplements for non-conventioned physicians or for conventioned physicians (conventioned physicians can only ask for a fee supplement when the patient has requested a single room);
  • costs of certain non-reimbursable medical products or pharmaceuticals; and
  • a flat rate charge per day for pharmaceuticals (€0.62/day), and flat rate charges per inpatient stay for biological tests (€7.44/stay), for radiology (€6.20/stay) and for technical acts (€16.40/stay).

17 It should be noted that in the rest of this report, the term “co-payment” is used to refer to both co-payment and co-insurance. Both are cost-sharing arrangements which require the individual covered to pay part of the cost of care. A co-payment refers to a fixed fee (flat rate) per item or service and a co-insurance refers to a fixed proportion of the total cost.

For hospital services, physicians can only request fee supplements if the patient is hospitalized in a single room (see section 3.4.1). To ensure that patients will receive the same (quality of) care irrespective their choice of room, a new bill (of law) is currently under discussion. The bill states that the patient is entitled to the same quality of care irrespective of the type of room. This concerns both the services provided by the hospital and the waiting time for these services.
For more details see:
https://www.lachambre.be/flwb/pdf/54/2154/54K2154009.pdf (in French and Dutch)

Since 1 January 2013, all physicians, including non-conventioned physician, were not longer to claim a supplemental fee for hospitalized patients in double rooms however this was still permitted for day hospitalizations. Since the new law of 17 July 2015, a supplemental fee can no longer be claimed for day hospitalizations.
For details see: http://www.ejustice.just.fgov.be/cgi_loi/change_lg.pl?language=fr&la=F&table_name=loi&cn=2015071738 (French) / http://www.ejustice.just.fgov.be/cgi_loi/change_lg.pl?language=nl&la=N&cn=2015071738&table_name=wet (Dutch)

From July 2015, the obligation of the social third party payer system for people with preferential reimbursement who consult their GP entered into force. Patient with preferential reimbursement status will only pay official co-payments for GP consultations. The implementation of this system will occur in a progressive way. GPs who are ready will begin in July 2015, and the system will only become mandatory in October 2015. Previously, this system was also anticipated to apply to chronic patients, but this only remains on a GP voluntary basis.
For details see: http://www.inami.fgov.be/fr/nouvelles/Pages/tiers-payant-obligatoire.aspx (French) / http://www.inami.fgov.be/nl/nieuws/Paginas/verplichte-derdebetalersregeling.aspx (Dutch)

From January 2015, the system of co-payments for medical specialist consultations was simplified, with a fixed amount of €3 for people with preferential reimbursement and €12 for people without preferential reimbursement, for every medical specialists. Previously this was calculated on a percentage basis.
For more details: https://www.fmsb.be/news/simplification-du-ticket-moderateur-chez-le-specialiste (French) / https://www.fsmb.be/news/vereenvoudiging-remgeld-bij-specialisten (Dutch)

People with granted social benefit (social integration revenue, etc.) will continue to be automatically entitled to preferential reimbursement for health care services (see section 3.4.1) and from January 2014, orphans will also be automatically entitled.
Other people will be entitled to preferential reimbursement on the basis of their taxable gross annual income (below €16 965.47+€3140.77 per dependent in 2013) under demand and after sickness funds have checked their income is below this thresholds. From January 2015, access will be proactively proposed by sickness funds, because some people are not aware of their rights.
For more details: http://www.presscenter.org/fr/pressrelease/20131024/reforme-de-lintervention-majoree-de-lassurance (French)/ http://www.presscenter.org/nl/pressrelease/20131024/hervorming-van-het-recht-op-de-verhoogde-tegemoetkoming-voor-500-000-bijkomend?setlang=1 (Dutch)

There are two systems of payments in Belgium: (1) a direct payment, where the patient pays for the full cost of the service and then obtains a refund from the sickness fund for part of the expense; and (2) a third-party payer system, where the sickness fund pays the provider directly and the patient is only responsible for paying any co-payments, supplements or non-reimbursed services.

Generally, the direct payment system applies to ambulatory care and the third-party payer system applies to inpatient care and pharmaceuticals. To improve access to health care, the social third-party payer system was developed for ambulatory care of the vulnerable population.

The social third party payer system can be applied for persons with an individual occasional financial distress, beneficiaries of preferential intervention status (BIM and OMNIO status), persons (and their dependents) exempted from contributions because the annual gross taxable income of their household does not exceed the integration income, complete unemployed people for at least 6 months and their dependents, persons having the medico-social conditions to be entitled to increased family allowances and their dependents.

With the national agreement between representatives of physicians and sickness funds of 2011, the social third party payer system was enforced:

  • Since July 2011, conventioned GP (i.e. GPs having adhered to the agreement) have committed to not refuse the application of the social third party payer system for each consultation (not for home visit) if a patient satisfying the conditions ask for such a system. With this agreement, the social third party payer system becomes the rule rather than the exception. However, it should be noted that in case of suspected abuse or irregularities from the patient or if the patient's actual situation appears to be inconsistent with the above conditions, the application of the system may be refused.
  • Administrative procedures of the system were improved: (i) Physicians are paid by the sickness funds in the 30 days with the use of a simplified form; (ii) The payment is guaranteed at the rate of increased intervention even if the references on the vignette of sickness funds, allowing to identify the patient as having access to preferential reimbursement, are no longer valid (guarantee limited to consultation, not for home visit to the patient); (iii) Co-payment system for GP consultations was simplified (see reform of December 2011: modification of the co-payment system for GP consultations)

Source: NIHDI (2011) [web site]. Tiers payant. Brussels, National Institute for Health and Disability Insurance (http://www.inami.be/care/fr/infos/thirdpayment/index.htm, accessed 24 June 2012).

 

After a long period of consideration by the NIHDI, two measures to modify the co-payment system entered into force on 1 December 2011.

Firstly, co-payments for consultations in the general practitioner’s office (NIHDI codes 101010, 101032, and 101076) or in the office of a doctor of dental sciences (NIHDI code 101054) will be limited as follows:

  • co-payments for people without preferential reimbursement will be €4 if they have a global medical file and €6 otherwise;
  • co-payments for people with preferential reimbursement will be €1 if they have a global medical file and €1.5 otherwise.

As part of the social third-party payer system, the GP may directly charge the balance of the fees to the sickness funds (see the reform log of July 2011 on the strengthening of the social third party payer system). In this case, it enables low-income patients to pay no more than €1 and therefore increases accessibility to primary care. It should also be noted that no index mechanism of co-payments have been set and no reduction in co-payments is foreseen for services provided by a medical student.

Secondly, co-payments for additional fees due to consultations in the GP office during the night, weekend and public holidays (NIHDI codes 102410, 102432, 102454 and 102476) are removed, i.e. the health insurance will cover 100% of these additional fees.

Source: NIHDI (2011) [web site]. Consultation chez le généraliste. Brussels, National Institute for Health and Disability Insurance (http://www.inami.be/care/fr/doctors/specific-information/social_paiement/20111019.htm, accessed 24 June 2012).

 

 

Two measures to modify the co-payment system for GP consultations entered into force on December 1, 2011. For more details, see the health policy update on this topic.

Since July 2011, conditions for preferential reimbursement with income limit have been extended to persons entitled to a fund for domestic oil of category 2 (people with a limited income) and 3 (indebted people) from a public social welfare centre (CPAS, Centre public d’action sociale – OCMW, Openbaar centrum voor maatschappelijk welzijn).
In Belgium, socially and economically vulnerable groups are entitled to a higher reimbursement. They are identified (Act of 14 July 1994 art.37, §§1,19):
• On the basis of a granted social benefit (without income condition), known as the BIM/RVV status (Bénéficiaires de l'intervention majorée / Rechthebbende verhoogde verzekeringstegemoetkoming): 
o persons entitled to a social integration revenue from the Public social welfare centre;
o persons entitled to social aid from the Public social welfare centre;
o persons who perceive the income guarantee for the elderly or an increased pension;
o persons entitled to one of the benefits accorded by the FPS Social security for disabled persons;
o persons entitled to increased child benefits (for children with a physical or mental incapacity of at least 66%);
• On the basis of a status as far as the gross annual taxable income does not exceed a certain limit (in February 2012: €16 306.33 + €3018.74 per dependent; after having completed a honor declaration form), also known as BIM/RVV status:
o orphans, invalids, pensioners or widows (VIPO);
o disabled people (not entitled to a benefit for disabled);
o members of a religious community;
o residents over 65 years;
o civil servants who are made redundant because of illness or infirmity for at least one year;
o unemployed people for at least 1 year (without any age limitation: since July 1, 2010);
o members of single-parent families (since July 1, 2010)
o persons entitled to a fund for domestic oil of category 2 (people with a limited income) and 3 (indebted people) from the Public social welfare centre (since July 1, 2011); or
• On the basis of the gross annual taxable income of the family determined after control of this income by the insurance institution, known as the Omnio status: includes families with modest incomes (€15 606.71 + €2889.22 per dependents in 2012).
People must submit an Omnio or BIM/RVV request file to their sickness fund to get access to preferential intervention.
Source:
NIHDI (2011) [web site]. Statut BIM. Brussels, National Institute for Health and Disability Insurance (http://www.inami.fgov.be/citizen/fr/medical-cost/SANTH_4_4.htm, accessed 24 June 2012).
Mutualité Socialiste (2011) [web site]. Fonds mazout. Personnes concernées. Tubize, Mutualité Socialiste, Brabant Wallon (http://www.mutsoc.be/Mutsoc/MaSituation/Argent/Tarifs-sociaux/fonds-mazout/mazout-personnes-concernees.htm, accessed 25 July 2012).
Mutualité Socialiste (2011) [web site]. Les personnes qui ont droit au statut BIM (VIPO). Tubize, Mutualité Socialiste, Brabant Wallon  (http://www.mutsoc.be/Mutsoc/MaSituation/Argent/Mesures-cout-soins/Tarif-preferentiel/Statut-bim/categories-sociales.htm, accessed 25 July 2012).

Introduction

In Belgium, cost-sharing mechanisms differ for inpatient and outpatient drugs. Modifications of cost-sharing mechanisms performed since April 2010 only concerns outpatient drugs. For pharmaceuticals dispensed to hospitalised patients (inpatient drug), patients continue to participate in drug costs by means of a co-payment per person per day of €0.62.

Cost-sharing mechanism for outpatient drugs before 1st April 2010

In the case of pharmaceuticals obtained from a pharmacy (outpatient drugs), the patient pays co-insurance (i.e. the patient pays a certain fixed proportion of the cost of a service and the third-party payer covers the remaining proportion). The percentage is determined by the drug category, which reflects the therapeutic importance of the pharmaceutical. A distinction is made between category A (vital drugs for serious and long-term illnesses: 0%), B (socially and medically useful pharmaceuticals: 25%), and C (socially and medically less useful pharmaceuticals; 50%). Non-reimbursed drugs (“comfort drugs”: 100%) are grouped in category D.

In addition, patient share per drug package is capped to avoid unaffordable out-of-pocket payments (for categories B and C). It should also be noted that cost-sharing mechanisms differ with the status of the insured. Socially and economically vulnerable groups are entitled to a higher reimbursement (see section 3.4.1 of the HiT 2010).

Cost-sharing mechanism for outpatient drugs after April 2010

To reinforce the intellectual role of the pharmacist and partly disconnect its remuneration from the price of drugs, a new system of remuneration of the pharmacists was introduced in April 2010. They no longer receive a percentage of the retail price of pharmaceuticals but rather a basic fee of €4.05 (since 01 April 2012) per reimbursed product (per pack), and an economic margin of 6.04% of the ex-factory price (€3.62+ 2% for ex-factory prices above €60). With this new remuneration system, formulas defining the level of cost-sharing for outpatient drugs supplied in community pharmacies had to be adapted. The objective is to avoid the new remuneration system of pharmacist from affecting patients by keeping the cost-sharing level of patients constant. Because this new remuneration mechanism is only applied for reimbursed drugs in community pharmacies, a distinction is now made between outpatient pharmaceuticals supplied in community pharmacies and those supplied in hospital pharmacies (see table below).

 

Table 1: Cost- sharing mechanisms for outpatient pharmaceuticals on 1 January 2012

Sources

  • NIHDI (2012) [web site]. Remboursement. Brussels, National Institute for Health and Disability Insurance (http://www.inami.be/drug/fr/drugs/general-information/refunding/index.htm, accessed 24 June 2012).
  • NIHDI (2012) [web site]. Rémunération des pharmaciens et des grossistes : réforme au 1er avril 2010. Brussels, National Institute for Health and Disability Insurance (http://www.inami.be/drug/fr/pharmacists/modification-20100401/index.htm, accessed 24 June 2012).

 

 

3.4.2 Maximum billing (MAB-MAF)

In 1993, within the context of the economic recession, it was decided that there should be a significant increase of the legal co-payments. Because of the increase in the financial burden for patients and the induced (short-term) volume decrease, especially for visits to and consultations with GPs, the government decided in 1994 to introduce a “social and fiscal exemption”, in order to put a ceiling on the total amount of co-payments to be paid. However, although access has been improved, there were still certain categories of people for whom costs for health care remained a problem. The system did not meet the needs of two high-risk groups in society: people with chronic illnesses and people who belong to a family with a low or modest income and who do not belong to a specific social category with protective measures.

On 5 June 2002, MAB was therefore introduced alongside the existing preferential reimbursement levels. The MAB is set according to the family’s net income, such that each household has an annual out-of-pocket maximum for all “necessary health care expenses” (see Table3.8). As soon as expenses reach the set ceiling, any further health care costs are covered in full by the health insurance fund for the remaining part of the year. This measure therefore improved the out-of-pocket maximum, already introduced under the social and fiscal exemption mechanism for certain vulnerable categories, by extending the scheme to all households and to other types of user charges.

MAB covers the following health care costs:

  • non-refundable health care expenses, up to the officially agreed fee, relating to physician consultations and visits, and those relating to all technical treatments by GPs and/or specialists, physiotherapists, nursing staff and paramedics;
  • non-refundable health care expenses relating to necessary pharmaceuticals (i.e. categories A, B and C) and personal contributions towards costs for pharmaceuticals in hospitals;
  • personal contributions towards the per diem rate paid for inpatient care, limited to the first year in a psychiatric hospital; and
  • non-refundable medical expenses relating to certain types of expensive medical devices (NIHDI 2009c).

There are currently three types of MAB:

  • social MAB: a threshold of €450 is applied at the household level for specific vulnerable groups; it is applicable to households with at least one individual with preferential reimbursement or who is entitled to an allowance for disabled persons; as soon as the limit of €450 is exceeded, the co-payments are reimbursed;
  • MAB for children: a threshold of €650 is applied at the level of the child; all children under 19 years with total co-payments of €650 become individually entitled without taking into account family income; and
  • income MAB: the principle of MAB is applied in a gradual way according to net family income (see Table3.8).

3.4.3 Fixed payments to patients

In order to protect people who can be expected to have high medical expenditure, for example chronically ill patients, fixed payments systems have also been introduced by Royal Decree. These have included those for chronically ill patients (Royal Decree of 2 June 1998), for incontinence material (Royal Decree of 2 June 1998), for palliative treatment at home (Royal Decree of 2 December 1999) and for patients in a persistent vegetative state (Royal Decree of 18 November 2005). Additional measures taken after 2007 are described in Chapter 6.

3.4.4 Solidarity fund

From 1990, the Special Solidarity Fund was established at the NIHDI in order to grant additional reimbursement for patients with a rare illness or who need a very specific treatment. Additional reimbursement is possible for: (a) a rare indication or (b) rare disorder, (c) a rare disorder which needs continuous and complex care, (d) the application of innovative medical aids or treatments (excluding pharmaceuticals), (e) chronically ill children and (f) some treatments abroad (NIHDI 2006). For each case, specific conditions must be fulfilled and the total reimbursement is set according to the availability of funds.

The status of "chronic illness" has been adopted in September 2013 by the government.  Three categories of patients are concerned (see the health policy update on new measures to improve health care access, 27 December 2012). The following rights will automatically be associated with this status:
• Maximum billing for chronically ill patients, i.e. a reduction of €100 in the maximum ceiling applied for the maximum billing (MAB) calculation (from January 2014 with a retroactive effect for the MAB 2013);
• Third-party payment system for all health services from January 2015.
More information available here: http://www.mc.be/actualite/articles/statut_malades_chroniques.jsp