Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

KCE Reports 133 Special Solidarity Fund 91
8.5.1 Patient initiative (SSF) versus automatic entitlement (compulsory health
care insurance)
The SSF system implies the initiative of the patient, supported by his treating medical
doctor, submitting an application for reimbursement without an a priori guarantee of
actual reimbursement. Such an approach has the major disadvantage that not all patients
potentially eligible to benefit from reimbursement will be reached. This might be due to
various reasons such as a lack of information on the existence of the SSF, insufficient
comprehension of the eligibility criteria, etc. Individuals entitled to the compulsory
health care insurance on the other hand have an automatic right to the services that are
covered in the nationally established fee schedule (the so-called nomenclature). Sickness
funds are legally bound to reimburse any claim from their insured members for care
delivered by any recognized health care provider at the agreed fee levels.
Hence it is primordial to (re)consider if the categories currently represented in the SSF
system can be introduced into the benefit package of the compulsory health care
insurance. A precondition for a similar shift is that realistic budget estimates can be
made and that reimbursable items can be defined in advance. Each item needs a new
(pseudo)nomenclature number.
8.5.2 Revision of the Categories
8.5.2.1 Reimbursement of extra medical costs for chronically ill children: shift back to
the compulsory health care insurance?
Although there are arguments to consider the group of chronically ill children as a
specific target population for the SSF, it can be questioned whether the differentiation
according to age groups does not create a discriminatory situation Moreover the
limitation of this category to children can be problematic since reimbursement of cost
for the treatment of chronically ill children would abruptly stop once they become
adults (>19 years old). As soon as the individual is adult, a maximum annual personal
share will be calculated. The costs for Epidermolysis Bullosa however are reimbursed in
full, irrespective of individual’s age.
8.5.2.2 Reimbursement of expenses for medical treatment abroad: suppress the
discrimination?
The SSF refunds costs for non-reimbursable medical treatment abroad, as well as travel
and accommodation expenses for the patient and for his/her companion, if “worthy of
consideration”. The SSF itself indicates in the annual report 2007 that reimbursed costs
in this category mainly include travel costs to neighboring countries. This may lead to a
possible discrimination of the patients treated in Belgium for whom the costs of
accommodation or the travel cost are not reimbursed although the distance between
the domicile and the respective hospital approaches the distance to a hospital in a
neighboring country.