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

154 Special Solidarity Fund KCE Reports 133
• The category of “chronically ill children” should be extended to “all
chronically ill patients”.
• The off label use of drugs.
• The social and financial situation of the patient should be taken into
account in the reimbursement amount. Otherwise the SSF doesn’t cover
what the term suggests.
• For some “social” categories no limitation in the reimbursement may be
applied.
• The restriction to “one parent guidance” to other countries is
problematic and emotionally unacceptable.
9.10.6.2 Limitation of the SSF intervention domains
On the question “Which elements should to your opinion be excluded from the
current SSF system?” all respondents answered that there was no reason to reduce the
existing intervention domains of the SSF. On the contrary, the suggestion was given to
include current SSF cases as much as possible into the regular health insurance system
and to look for solutions for all medical treatments not covered by the current system.
The SSF has a role to play in the identification, the communication and formulation of
suggestions for inclusion of treatments into the regular health system.
Five respondents explicitly suggested including the category of “chronically ill children”
into the regular health insurance coverage. The inclusion of costs for medical treatment
abroad was mentioned once.
9.10.7 Experience with the SSF/knowledge of the SSF procedure
The respondents described their view on the different steps and parties involved in the
SSF procedure.
• Many respondents reported that the complete file (declaration on honor,
scientific articles, medical information, invoice, …) is submitted to the
local sickness fund of the patient. One interviewee reported that the SSF
files are submitted directly to the national level (medical director) of the
sickness funds. One social worker indicated the possibility to send the SSF
file directly to the SSF.
• Among respondents knowing that files are submitted in a first step to the
local sickness funds, some reported the internal transfer from the local
sickness funds (advisory physician) to the national level (medical director).
Consequently, many respondents believe that the local advisory physicians
submit the files directly to the SSF and are not aware of the intermediate
step within the sickness funds.
• It is not clear who the deciding authority is for SSF files: the advisory
physician of the local sickness fund decides, or a committee of advisory
physicians that meets once every two to three months; Some
respondents refer also to a committee without further specification.
• Almost all respondents indicate that they are not involved or informed on
the outcome and further follow-up of a SSF file. There is only feedback
and communication with the local sickness funds when documents are
missing. Contacts with the SSF or the sickness funds at national level
(medical directors) don’t exist.
• Social services are not informed about the final outcome of a SSF file
unless the patient informs them that the SSF file is rejected and the
patient is still confronted with the financial problem linked to the cost of
the medical treatment.
• One respondent received the information from the sickness funds that
the financial cost needs to exceed €2000 before a SSF reimbursement can
be accepted.