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

8 Special Solidarity Fund KCE Reports 133
1 INTRODUCTION
The Special Solidarity Fund (SSF) was established by law as part of the National Institute
for Health and Disability Insurance (NIHDI) and is operational since 1990. The Fund
complements the compulsory health insurance coverage and serves as a social care net
covering high cost rare diseases excluded from the universal insurance system. One can
make an appeal to the SSF if all other possible sources of reimbursement have been
exhausted. Additionally, several criteria have to be met in order to be eligible for
reimbursement. Reimbursement can be granted for certain costs related to rare
diseases, rare indications or the application of innovative techniques, which are not (yet)
covered by the compulsory health insurance system in Belgium or any other channel
(private insurance – reimbursement abroad). The target population of the SSF are
seriously ill patients for whom an expensive but not (yet) reimbursed treatment is
essential. Chronically ill children (children below 19 years suffering from cancer, renal
insufficiency or any other life threatening disease, requiring a continuous or repetitive
treatment of at least 6 months) are a specific target group of the SSF. In this case the
SSF can reimburse additional costs as soon as €650 out-of-pocket payments have been
paid on a yearly basis.
The current procedure requires patients – often through the treating physician or the
social service of the hospital where the treating physician works – to submit an
application to the advising physician of their local sickness fund. After its submission, the
application passes through the national sickness fund and is finally transferred to the
SSF. The “College of Medical Directors” is the decision-making body within the SSF.
This body assesses the individual application files and takes the final decision regarding
reimbursement. Then the SSF informs the local sickness fund and in case of a positive
decision, the patient is reimbursed within 15 days after the decision.
The Minister of Social Affairs determines the budget of the SSF on a yearly basis.