Policy responses for Belgium - HSRM


Policy responses for Belgium

4.2 Entitlement and coverage

About 99% of the Belgian population is covered by the compulsory health insurance for a large range of services. This compulsory health insurance is managed by the National Institute for Health and Disability insurance (NIHDI). Various measures related to the COVID-19 crisis have been taken by the NIHDI (1-2):

• PCR tests carried out by the Reference Centre of UZ Leuven  at the beginning of the crisis were fully covered by the NIHDI. For tests carried out in other laboratories, from March 9th the NIHDI asked the laboratories to temporarily suspend invoicing patients. Then on April 2nd, the reimbursement of these tests was agreed such that molecular tests are reimbursed if the procedures defined by Sciensano are followed and if the laboratory meets certain quality requirements (see NIHDI for details, https://www.inami.fgov.be/fr/covid19/Pages/conditions-remboursement-tests-detection-coronavirus-pandemie-covid19.aspx). These tests are fully reimbursed, the patient does not have to pay co-payments and extra-billings are not allowed. A maximum of 2 PCR tests per patient was allowed. This limit was removed from April 22th.
• Antigen tests are reimbursed since April 1th (also with a limit of maximum 2 tests, which was removed on April 22th) and according to the procedures defined by Sciensano. Negative or doubtful results must be followed by a molecular test. No molecular tests can be performed in case of a positive result. These tests are fully reimbursed (no co-payment and no extra-billings).
• Serologic tests are reimbursed since June 3th (maximum 2 tests per 6 months period) but only as complementary diagnosis or to assess the serologic status of health professionals working in care facilities with a high risk (such as hospitals, laboratories and nursing homes). In these conditions (see https://www.inami.fgov.be/fr/covid19/Pages/conditions-remboursement-tests-detection-coronavirus-pandemie-covid19.aspx for details), these tests are fully reimbursed (no co-payment and no extra-billings). Otherwise, people have access to serologic tests but have to pay a maximum amount of €9.60.
• The NIHDI is developing a global mechanism that allows different types of health professionals to provide care for their patients without physical contact, to bill these services to the sickness funds, and to allow patients to be reimbursed (see section 2.2). Specific codes in the national established fee schedule were created to allow physicians to give medical advice by phone during the COVID-19 crisis period. For these consultations by phone, the use of the third party payer system is also promoted (mandatory for vulnerable patients entitled to an increased reimbursement and strongly recommended for others patients) and there are no patient co-payments. 
• Additionally, because of the postponing of non-urgent consultations and care, the implementation of some pharmaceutical treatments, the renewal of reimbursement authorisations for some pharmaceuticals and health products, and the following of rehabilitation conventions could be impacted. Temporary measures were therefore taken to avoid interruptions in these types of care.
• Triage centres have been initiated to screen patients at risk of infection with COVID-19 so that patients do not have to go to a General Practitioner's (GP) waiting room or hospital emergency department, where they could infect others. Since March 23rd 2020, these initiatives have received funding from the NIHDI, i.e. the same fee for all physicians working in these centres, a flat rate for nurses, paramedics and care coordinators (per half day) and a flat rate for administrative staff.
• It is apparent that the health sector will suffer from this crisis, particularly financially. After the crisis, the NIHDI will assess all the issues with representatives of each profession.
• To support the mental health of the population, the reimbursement of psychological care has been extended: Since March 2019, to improve the accessibility of ambulatory psychological care, visits to a clinical psychologist have been reimbursed for adults aged between 18 and 64  years; who suffer from common mental health disorders (i.e. depression, anxiety, and alcohol abuse); and who are referred by a GP or psychiatrist. Since 2nd April 2020, this reimbursement has been extended to people < 18 years old and > 65 year old to cover the whole population. While such enlargement was already foreseen before the COVID-19 crisis (the decision of March 2019 was a first step); the measure has been accelerated to support the population during the crisis.
• Regarding user fees, no co-payment required from patients in the new financing mechanism allowing for teleconsultations during the crisis. Extra-billings to patients for protective equipment is also forbidden during this crisis (but specific fees paid by the NIHDI have been foreseen for protective equipment of health professionals).

Because all non-essentials and non-urgent interventions and consultations had to be either cancelled or postponed from 14 March 2020 (up to 4 May) and in order to guarantee the quality and continuity of care, a series of health care insurance rules have also had to be adapted, in particular with regards to the reimbursement conditions linked to the patient's age or to maximum time limits or follow-up period. Concerning hospitals, and in order to cope with the new working conditions, new health care insurance rules have also been defined for emergency departments, intensive care units and COVID-19 specific care units. An update of all measures taken by the NIHDI can be found on: https://www.inami.fgov.be/fr/covid19/Pages/default.aspx

Measures were also taken for self-employed people who would not be able to pay their social contributions: Self-employed workers may submit a written request to their social insurance fund to request a one-year deferral of payment of provisional social contributions. Other economic measures are described in section 6.

Uninsured people can be covered by the public centre for social assistance (OCMW – CPAS) of their municipality. Some categories of vulnerable people can also benefit from health care through other provisions: Undocumented migrants are entitled to receive care via Urgent Medical Aid (UMA). During the COVID-19 crisis, measures have been taken to facilitate the administrative procedures and all care provided to undocumented migrants - between 14 March and 31 May 2020 will be considered as UMA. For asylum seekers, health care costs are either covered by the Federal Agency for the Reception of Asylum Seekers (Fedasil) or by the Ministry of Social Integration via the local welfare centres (OCMW-CPAS), depending on where they are living. Refugees and Belgian residents born with a foreign nationality are covered by the compulsory health insurance. Concerning prisoners, they are covered by the Ministry of Justice but a reform that aims to integrate all prisoners into the compulsory health insurance system is underway (that already started before the COVID-19 crisis) (3-5).

(1) NIHDI (2020). COVID-19 : Mesures exceptionnelles de l’assurance soins de santé et indemnités. Brussels : National Institute For Health and Disability Insurance (https://www.inami.fgov.be/fr/covid19/Pages/default.aspx, accessed April 2020)
(2) Personal communication with NIHDI: Daubie Mickael and Meeus Pascal
(3) De Devos C, Cordon A, Lefèvre M, et al. (2019). Performance of the Belgian health system – Report 2019. Brussels: Belgian Health Care Knowledge Centre (https://kce.fgov.be/sites/default/files/atoms/files/KCE_313C_Performance_Belgian_health_system_Report.pdf).
(4) Service de lutte contre la pauvreté, la précarité et l’exclusion sociale (2020). Aperçu des mesures COVID-19, en soutien aux situations de pauvreté et de précarité. Bruxelles : Service de lutte contre la pauvreté, la précarité et l’exclusion sociale (https://www.luttepauvrete.be/wp-content/uploads/sites/2/2020/04/200409-aper%C3%A7u-covid-19-FR.pdf, Accessed April 2020) ;
(5) Personal communication with Dauvrin Marie (KCE).