Belgium’s National Healthcare Insurance Fund: How is a public insurance fund organized in order to provide for 99% of the population?

Belgium has a strong government-led socially-inclusive benefits and welfare program, with an extensive national healthcare insurance scheme, providing coverage to 99% of the population.

Its national insurance fund pays close to 70% of the drugs used in its healthcare provisions, and together with other government funds and grants, the public-sector finances close to 80% of the entire healthcare system.

How does it work?

All working citizens in Belgium are obligated to contribute social security payments and to join a health insurance scheme (mutualité in French and mutaliteit or ziekenfonds in Dutch).  This monthly contribution is €8 per employed citizen.

5 public health insurance schemes

There are 5 public health insurance schemes in Belgium, that all operate not for profit. The organizations are the following, including the approximate number of employees and their subscribers:

  • Christian – 6514 employees and 42% of the subscribers of the total insured population
  • Socialist – 2864 employees, 28% of the subscribers
  • Independent – 11,300 employees, 19.5% of the subscribers
  • Neutral – 600 employees, 7% of the subscribers
  • Liberal – 109 employees, 3.5% of the subscribers

These public insurance providers are often directly linked to corresponding labor unions.

The requested monthly contribution asked by one insurance provider compared to another does not vary immensely. The providers attempt to differentiate themselves by offering additional services, like holiday camps or family deals, or separate insurance plans for particular dental or other specialty healthcare needs.

The competition is high between the 5 providers and this market is closed to newcomers. Within the RIZIV frame, the 5 insurance providers contribute collectively to discussions around patient fees, care coverage, and regulation. It is said that these discussions facilitate a balance between the insurance schemes, the care providers, the social partners, and the government.

Basic insurance package

The insurance scheme providers offer compensations for the following:

  • Consultations at a GPs and healthcare specialists
  • Treatments by physiotherapists
  • Care by nurses and services for home care
  • Dental care
  • Childbirth
  • Prosthesis, wheelchairs, bandages and implants
  • Hospital care
  • Care in senior residences
  • Rehabilitation

The Federal Institute for Illness and Disability Insurance (RIZIV) and tariffs

The Federal Institute for Illness and Disability Insurance (RIZIV) supervises the payments and tariffs of the healthcare reimbursements and coverage. In Belgium, a set -though continuously revised- nomenclature and codification scheme is used to categorize and price various diagnostic and curative procedures and the materials used in each intervention/consultation.

RIZIV’s codification and pricing can have a very direct impact on the procedures and materials that will be used, and also, how the care provider himself will codify the treatments that he/she applies. E.g. if a procedure being used is not catalogued, then the care provider may see himself forced to use another code in order to receive reimbursement. Or, a care provider may choose to perform an intervention in an operating room rather than his consultation room, as the tariff is higher for an OR service.

A new product or procedure cannot always clearly fall under an existing codification (due to being innovative or unprecedented) and it can require some time before a rational price and tariff can be provided for it in order to integrate it into the public healthcare insurance system.

Products and treatments can apply for inclusion into the catalogue with RIZIV.

Funded and non-funded medical providers

In Belgium, a medical practitioner can be funded, meaning they are recognized by health insurance providers and that they have agreed to adhere to set tariffs for the diagnoses and treatments that they provide. It is also possible to be partly-funded, or not to be funded.

Whether the doctor is funded or not does not affect the amount that the insurance fund will reimburse the patient. Since doctors practicing outside of the fixed tariffs and fund agreement can set prices as high as they wish, this generally results in a higher total out-of-pocket contribution to be paid by the consulting patient.

Doctors who are funded by the insurance fund must follow further educational programs annually in order to keep their accreditation. Without accreditation they are obliged to charge less per consultation.

RIZIV provides a financial incentive to doctors to adhere to the set tariffs and a compensation to manage their documentation and files in an excellent manner.

Reimbursement policies

The healthcare costs of a Belgian patient will be partially or fully reimbursed, depending on certain social and financial criteria which are established by law.

A public GP consultation, for example, costs €25. The majority of employed and contributing social insurance patients will receive around €21 reimbursement from their health insurance fund, after the patient sends in their consultation note as proof/verification to their insurance provider. A low to very low-income patient can get up to €24.5 compensation.

However, the price of a GP consultation can vary, depending on the insurance fund agreement, whether that doctor is insurance-covered or still in training, what specialty that doctor practices, whether the consultation is given at home or at the doctor’s practice, and the hour of the consultation. A home consultation on an official holiday for example can cost €80.

Policies include:

  • For GP and specialist consultation, medical expenses will be reimbursed around 75%.
  • If you earn less than €2,326 per quarter, you can sign up as a dependent upon your partner or with a close relative who is a paying health insurance subscriber, or rely upon the Public Center for Social Welfare (OCMW) to cover your medical expenses.
  • Prescription medication purchased at the pharmacy will be charged at a reduced rate of around 60%. This is part of the third-payer-regulation, which is a regulation that states that only the patient contribution is charged at the moment that the healthcare item is being requested, rather than expecting the patient to advance the total amount and reimbursing them later.
  • In the case of hospitalization, the patient pays a fixed amount for accommodation and services via an invoice at a later date, and will be reimbursed for the medical care by their selected insurance provider. Patients who qualify for the third-payer-regulation will not have to pay this fixed amount. Any comfort options, such as a single room or phone usage, are paid by the patient privately.
  • For those who are contributing to and registered with an insurance provider, there is also the MAF (Maximumfactuur) rule, which creates a high-cost ceiling to protect those patients incurring immense medical costs. Most commonly this is used to protect chronic or long-term patients.
  • With smaller medical costs, the common procedure is to ask the patient to pay the amount in full up front (specialist consultations such as gynecologist check-up, teeth cleaning, etc.). The patient must then send the details (of the procedure as codified and certified by the care provider) to their health insurance scheme. It is the responsibility of the patient in such cases to mail the doctor’s note for processing to the insurance office and wait for a reimbursement transfer to their account. The insurer will reimburse the patient to varying amounts, depending on the type of care it was and the social status of the patient.
  • Homeopathy, acupuncture, osteopathy and chiropractic care are recognized in Belgium as reimbursable alternative treatments.

Structured reimbursed care paths

For certain health conditions, primarily chronic conditions, a care path is delineated by RIZIV that draws a contract for 3 different parties: the patient, the GP and the specialist.

Currently such a care path exists for diabetic patients and for kidney-failure patients. Very specific conditions define the care path patient; for example, the diabetic patient type 2 with 1-2 injections per day or with maximum oral treatments, where insulin is under consideration, will have to consult the GP at least twice a year, and the specialist at least once a year. During the duration of the contract, the patient will have all the GP consultations fully reimbursed, and 2 consultations with a specialist (dietician, podiatrist or diabetes educator) partially reimbursed.

By creating a care-path, the patient has a greater guarantee that the GP and specialist will work in close coordination for the treatment and follow-up.

Private and additional health insurance

Some people in Belgium choose to take additional insurance policies to cover them for healthcare services that are not included in the public insurance packages. This can be done with the health insurer they are already subscribed to or with a different private entity. Typical complimentary insurance covers include the following:

  • Non-urgent hospital admittance
  • Purchase of lenses and glasses
  • Some types of dental care
  • Some vaccinations
  • Daycare for children when the parent is ill
  • Medical care abroad

Private insurance pays for approximately 4% of total healthcare costs.

For further quantitative and qualitative information on the Belgian healthcare system and the macroeconomic climate, please look into our Business intelligence platform or order the Belgian Healthcare Scan incl. Surgical Procedures Volumes (all specialisms) – product license containing volumes of 984 surgical procedures in 13 specialisms.
Other licenses to our business intelligence platform depending on your needs are also available.

 

About Laura Weynants

Performs primary and secondary market research to create country reports at TforG. Interviews KOLs and medical sector professionals to build on TforG’s healthcare market expertise and competence networks. Complementing five years of sustainability policy and CSR communication, she now focuses on grasping key medical market trends, structures and opportunities in medical sectors worldwide. Coming from an international background of living in Germany, Spain, USA, UK and Belgium, she has gained a keen insight in international organizations and language skills to perform first hand investigations. She graduated from Sussex University Brighton, UK with a BA English Literature and Sociology and achieved a Master Degree in Sustainability and Corporate Social Responsibility in EOI Business School in Madrid, Spain.