Do you remember... the Maximum Invoice?

Only one in three Belgians is aware of the costs that healthcare brings for them. This is shown by a study by sector federation Assuralia from early 2022. So the question is... how much financial risk does your household run as a result of medical costs, and is it worth insuring yourself privately against this?

Of every 5 euro, 1 euro is paid out of pocket

Medical costs can have a heavy budgetary impact on a household. Assuralia calculated that in 2020 what the patient has to pay themselves, after intervention by RIZIV (the national health and disability insurance institute) and any private insurance, was still almost 18% of the total expenditure on healthcare. Almost 1 euro out of 5, then, and moreover after intervention from all insurances. In that light it is understandable that in 2018 almost 10% of households indicated that they postponed medical care for financial reasons. For a country where 99% of the population falls under statutory social security, this is nonetheless a fairly surprising figure.

The Maximum Invoice comes to the aid of financially weaker households

This problem is not new. In 2002, the Maximum Invoice was introduced primarily to give extra protection to households with a low income. Because of the Maximum Invoice, a patient from a low income household never pays more per year for medical care than a certain ceiling amount. Note that the Maximum Invoice has changed significantly since its introduction in 2002, and now consists of as many as 4 different formulas.aspx) of which the "income based Maximum Invoice" is the most important, and also applies to everyone. It is on this last formula that we focus here for a moment.

Every net taxable income has its own Maximum Invoice

That income is described as follows by the law of 2002, which introduced the Maximum Invoice:

"Taken into account are the net incomes referred to in article 6, second paragraph, of the Income Tax Code 1992, relating to the most recent year for which a tax assessment has been recorded. The income from 2 years earlier is taken into account." In other words, for 2022 the net taxable income of 2020 is looked at, for the household to which the person entitled to medical costs belongs. As follows:

The figures in this table are the figures for 2022 and are indexed. Suppose my household has a net taxable income of 30.000 EUR in 2020. I have a total medical cost (still to be paid myself after intervention by the health insurance fund) of 1.000 euro per year. In this case, the costs that qualify for the Maximum Invoice and that rise above 732,03 EUR will still be covered by social security, and that thanks to the Maximum Invoice. In the best case, what the household itself pays for medical costs (the so called "out of pocket money") is limited to 732,03 EUR.

Costs that qualify for the Maximum Invoice

Is hospitalization insurance superfluous, then? After all, if the maximum financial risk you run as a result of medical costs, even for the highest incomes, is limited to a modest € 2.000 per year thanks to the Maximum Invoice, why would you as a household pay the premium for hospitalization insurance on top of that? An attentive reader will of course have understood that the catch lies in the concept of "costs that qualify for the Maximum Invoice". We need to take a closer look at that. These costs are listed below:

- the personal share for services by doctors, dentists, physiotherapists, nurses and other care providers; - the personal share for reimbursed medicines and for magistral preparations (medicines made by the pharmacist themselves); - the personal share for technical services (e.g. operations, X-rays, lab tests, technical tests...); - the personal share in the bed day price in a general hospital (fully) and in a psychiatric hospital (only the first 365 days); - the flat rate personal share for medicines during hospitalization; - enteral feeding via tube or stoma for young people under 19 years old; - endoscopic material and viscerosynthesis material; - dispensing margins (supplements) for implants. .

Does that sound like Greek to you? That's normal, but above all remember two things:

1. The word "reimbursable".

Some costs that are not reimbursable by RIZIV do not fall under the Maximum Invoice.

2. Don't forget that this is a list.

It would have been different had this scheme been based on a "tout, sauf" principle. In other words: "Everything is included in the Maximum Invoice, except...". Now this is not the case, and as a result whatever is not on this list does not fall under the Maximum Invoice.

Is hospitalization insurance useful after all, then?

To ask the question is to answer it. Without going into detail, but as long as there are no fee supplements or non reimbursable medical costs in play, the Maximum Invoice will function perfectly well.

However, the Maximum Invoice has no effect if the aforementioned matters suddenly do arise. As soon as you, for example, choose a single room during a hospital admission, the so called non reimbursable fee supplements come into play, and the Maximum Invoice has no effect on those. This will also often be the case when it comes to serious treatments. You may still have some control over the choice of room, but we are mainly thinking of services or techniques that are not reimbursable by RIZIV. And perhaps you would rather not be faced with the choice of whether you can or want to pay extra personally for a specific treatment? A classic example: robotic surgery (also often called keyhole surgery), versus classic invasive surgery. The advantage of robotic surgery is that it is less taxing for the patient, resulting in faster recovery and also fewer days in bed. But this treatment is also often more expensive because the cost of the robot is partly charged. However... not for all treatments with robotic surgery is the cost of the robot reimbursed by RIZIV.

Let's say that a hospitalization insurance will spare you this kind of financial surprise after the operation, or in the best case, decision stress at a particularly difficult moment before the operation. You must not forget that the figure "1 euro out of 5 borne by the household" which we mentioned above, was determined including the contributions from private insurances. For these reasons and many other reasons, additional private hospitalization insurance is still a must.

Focus on dental care: of every 5 euro, 2,5 euro is paid out of pocket.

Of course the Maximum Invoice limits the total medical costs. This is not only about costs resulting from a hospital admission, but equally about so called outpatient costs, so outside the hospital. These are regular doctor visits, and for example costs for dental care. In 2018, 50,4% of dental costs were borne by the patient and were therefore not reimbursed by the health insurance fund. As a citizen, you had also better insure yourself privately for so called outpatient costs, such as for example costs for dental care.

Sources and further reading:

-https://www.tijd.be/politiek-economie/belgie-algemeen/Twee-op-de-drie-Belgen-onderschatten-kosten-gezondheidszorg/10364802(paywalled) -https://www.gezondbelgie.be/nl/performantie-van-het-belgische-gezondheidssysteem/toegankelijkheid-van-de-zorg/financiele-toegangkelijkheid-https://www.riziv.fgov.be/SiteCollectionDocuments/maximumfactuur-inkomensschijven-plafonds.docx-https://kce.fgov.be/nl/press-release/wat-te-denken-van-robotchirurgie(dated, but typifies the issue) -https://www.dkv.be/nl/blog/boom-collectieve-gezondheidsverzekeringen