Have you ever wondered how JSIS determines the maximum amount – the so-called “ceiling” – that you are reimbursed for your medical expenses? The answer is, as often, not a simple one but here we will try to explain the calculation.
The JSIS has a long list of treatments and pharmaceuticals in its system. It monitors their prices in Belgium and based on these prices, it determines ceilings for the reimbursable amount for all the different expenditures in Belgium. The financial sustainability of the scheme is another factor that plays a role for the amount of a ceiling.
As an example, the ceiling for a consultation of a general practitioner in Belgium is currently 35€. If you pay 45€ for a visit, JSIS will first calculate 85% of these 45€, equalling 38.25€. As this is higher than the ceiling of 35€, you will receive only 35€ from JSIS. As you see, the ceilings are applied to the reimbursement, not directly to the medical bill. The 85% mentioned above is the reimbursement rate for a visit to a general practitioner – so, in any case, you must pay at least 15% of the bill. If the bill is so high that 85% of it are higher than the 35€ ceiling, you have to pay more than 15% of it. In the example case with a bill of 45€, you end up paying (45€ – 35€) = 10€ out of your own pocket, equalling more than 22% of the original bill.
For the ceilings in other countries, JSIS uses your medical bills of the last two years to establish a ceiling. The process is a technical one, but JSIS calculates ceilings such that the actual rate of reimbursement in the Member State is the same as the one in Belgium in at least 8 out of 10 cases. For example, if colleagues in Belgium are reimbursed on average 70% of a specific treatment, than the ceiling in other Member States will be established such that in 8 out of 10 cases, you will also receive at least 70% of the costs incurred. JSIS does this comparison at least every two years. If prices in a Member State rise so quickly that the current ceiling can no longer guarantee the same rate of reimbursement as in Belgium, an intermediate comparison is made and the rates are updated after that.
For some Member States, there might not be enough data available for the just mentioned calculations. In these cases, JSIS compares the health cost indices as established by Eurostat. If the Member State has lower prices than Belgium, the ceiling for Belgium is used. In other words, the reimbursed amount is always at least as high as in Belgium.
The result of this calculation is the list of so called “parity coefficients”, which determine the ceiling for any given Member State. The table below shows an excerpt of the current parity coefficients, in force since 01/01/2019. As you can see, the parity coefficient for a visit to a general practitioner in Luxembourg is 1.26. So the ceiling for the reimbursable amount in Luxembourg is 35€ × 1.26 = 44.10€. The coefficient for France is 1.00, resulting in a ceiling of 35€ (the same as in Belgium).