Taking care of your health
Michael Steffens, Layla El Khadraoui
In Delegations, expatriate contracts are offered health coverage through the Joint Sickness Insurance (JSIS). While the coverage for most health costs under this scheme is generous in comparison to national schemes it looks complicated at times. JSIS does not always cover all costs incurred due to various reasons. In addition to the supplementary health coverage for colleagues working in Delegations, there are also commercially offered complementary health insurance schemes that can be advantageous under particular circumstances.
There are various reasons why you may pay out of your own pocket for health costs.
First of all, reimbursements under the Joint Sickness Insurance (hereinafter referred to as the “JSIS”) are linked to the General Implementing Provisions for the Reimbursement of Medical Expenses, which lay down the ceiling for each type of treatment or analysis. The standard reimbursement rate under the scheme covers 85% of the invoices. If you are based in Brussels or you have dependents that are not with you at your place of work outside the EU, you will already be aware of this. For colleagues and dependents based in Delegations, Article 24 of Annex X of the Staff Regulations establishes a supplementary sickness insurance. This insurance covers the difference between the costs actually incurred and the reimbursement received within the framework of the JSIS.
Still, most of you may have had occasions in which some costs were not reimbursed, e.g. if the treatment costs exceeded the ceiling. Depending on where you received the treatment or the practitioner you visited, this may weigh differently on your finances. However, less known by many colleagues but more important is the fact that ceilings exist also for surgical procedures or more costly treatments. Other examples are dental work, implants or dental surgeries, where costs often exceed the reimbursement as well.
JSIS offers reasonable coverage. However, it has some gaps that are hard to close without purchasing additional health insurance coverage.
How are reimbursements under the supplementary sickness insurance handled?
The treatment of the claims for reimbursement is always handled in two stages (i.e. two separate account sheets) according to the principle of 80/85% + 20/15%.
There are therefore also two account sheets issued, one marked “type of reimbursement = NOR” (for normal) and one marked “type of reimbursement = CHC” (Centre de gestion Hors Communautaire). In the JSIS reimbursement request, it is important to indicate yes under the question “currently serving or having served in a delegation (outside the E.U). In case you are based in a Delegation, this also applies to treatments you receive in Europe.
The ceilings are also applied differently for colleagues residing in Delegations. The first or NOR reimbursement sheet applies the ceiling for Belgium, while the supplementary reimbursement grants a maximum of 4 times this same ceiling. Beyond a total of 5 ceilings, the paid amounts are considered excessive pursuant to Article 5 of the GIP of Article 24 Annex X. The following example was provided by the administration:
Practical example: Dental crown with a ceiling of 350 €
· Art. 72: 80% with ceiling of 350 €
· Art. 24: difference up to 100% with a maximum of 4 ceilings = 1.400 €
· If the treatment costs for example the equivalent of 2.000 €:
· Reimbursement under Art. 72: 350 € (session 1 “NOR”)
· Reimbursement under Art. 24: refund of another 4 x 350 € (=1.400€), total refund 350 €+1400 €=1750 €
· Difference of 250 € (2.000 €-1.750 €) excluded from reimbursement
In case of the same treatment carried out in an EU country, the amount that is not covered by the first normal reimbursement is refunded within the limits of the excess threshold. That means that both reimbursement stages cannot exceed the excess threshold = 150% of the ceiling (taking into consideration the country coefficient for EU countries).
Practical example: Dental crown with a ceiling of 350 € (for Belgium)
· Art. 72: 80% with ceiling of 350 €
· Art. 24 ceiling: Reimbursement up to the excess threshold
Calculation taking the excess threshold into account
350 € = 80% of 437.50 € (ceiling exposed to 100%)
Excess threshold = 150% of 437.50 € = 656.25 €
· reimbursement article 24: 656.25 € – 350 € = maximum 306.25 € additional reimbursement with the CHC reimbursement sheet
It is therefore favourable to get dental treatments on location if proper medical facilities exist and this applies also to other treatments. In case of surgical operations performed in Europe, the same 150% of the ceiling limitation applies. In order not to lose flexibility as to the place of treatment, it is therefore advisable to look into complementary health coverage that is available at affordable costs.
Complementary Health Insurance: Hospitalisation coverage++
One solution could be to take out a complementary insurance with Afiliatys.eu, which has negotiated for a long time complementary health insurance group contracts to the JSIS with larger insurance companies such as Allianz or CIGNA. AFILIATYS is a non-profit organization under Belgian law, which has more than 37.000 members belonging to the EU Institutions, the diplomatic and consular corps of the Member States, international organizations and the European Schools.
The HospiSafe Sickness and Accident coverage provided by AFILIATYS offers ease of mind in terms of covering you and your dependents in case of a hospitalisation. This coverage is available at two different levels and it will pay out support in case of hospitalisation following an illness or an accident (depending on the options chosen). While this is relatively affordable, it is limited to all cases involving hospitalisation or accidents. Several expensive procedures fall into this category incl. surgery or other hospital treatments. In Belgium, the cost of an appendectomy can vary depending on the hospital and whether you have health insurance. Generally, the price ranges from €2,000 to €5,000. In case of the JSIS, the ceiling is set at 2.000 EUR, any cost above the 150% ceiling has to be covered by yourself.
You may want to choose this if you do not want to invest an excessive amount of money. Coverage for a family of four can be bought for less than 600 EUR per year. In comparison to the potential cost of hospitalisation this might actually be worthwhile, especially if you have dependents who live in Europe.
The benefits of the HospiSafe scheme are explained here. The HospiSafe Plus coverage adds to this a number of other health treatments including consultations and dental work but is also significantly more expensive and limited in its reimbursement level (maximum amounts per year). The scheme generally pays 80% of the costs not covered by the JSIS subject to yearly limites, e.g. €800 Euro for dental costs during the first two years in the policy or €3.200 per year from the third year onwards. The benefits and costs are explained here.
In case of retirement
In case you are about to retire it makes sense to consult the Afiliatys website well in advance (minimum 6 months before retirement) to ensure you can benefit and to ascertain that you have sufficient coverage during retirement since the CHC proportion of your reimbursement will no longer apply. You will only be reimbursed at a level of 85% under the JSIS.
Serious illness and elderly care under the JSIS
Another important risk to consider is that of elderly care, which you might face at older age. This can also be insured. However, colleagues would need to find suitable insurers in their national system – there is no Afiliatys insurance in place for this.
It is important to emphasize that getting a drawn-out illness recognised as a serious illness by the JSIS can increase the amount of reimbursements. First, all requests under JSIS are reimbursed at 100% regardless of where you are based. However, ceilings still apply and it may be wise to insure yourself against the risk of care in later years of your life.
Elderly care
Reimbursements for care and accommodation in a nursing home are reimbursable at the rate of 85% or 100% in the case of serious illness, with a ceiling of €36 per day for accommodation costs (max. 1.116 € per month). You might find yourself in a situation therefore where your partner or yourself are entering a nursing home, and you have to make up for the accommodation costs from your pension. In addition, if the illness of your partner is not recognised as a serious illness, you will also have to pay for 15% of the costs of care. Accommodation costs in nursing homes vary significantly and it is not a given that the amounts offered by the JSIS are sufficient.
In most member states, insurance providers allow to take out insurance packages that provide lump sumps according to the degree of dependence that exists when a claim is made. At the time of writing, in Germany, such an insurance costs about 80 EUR per month (per insured person) for a payment of up to 2.400 EUR monthly in case an insured person enters a nursing home. The insurance premium is higher if the risk of care at your own home are to be included.
An important consideration is also whether you can actually take out an insurance in your home country or in the European Union. This is explained in the following paragraph.
Insurances in your home country or in the European Union
If you decide for an insurance in your country of origin it is advisable to check the insurance conditions to ensure you are covered. There is case law that does not allow insurances to treat us differently to the ordinary customers because we are insured under the JSIS. However, keeping a written record of exchanges with the insurance is advisable and can be helpful when you process a claim.
In case your national insurance refuses to pay out because you are not insured in your national health or care insurance scheme, you can cite Case C-411/98 and the related judgement of the European Court of Justice from 3rd of October 2000. In addition, the conditions of the health insurance scheme under the JSIS are laid out in Article 72 of the staff regulations. These two pieces of information should be enough for a lawyer to unblock the situation. The case law basically stipulates that people insured under JSIS should not be treated differently from those insured under a national health scheme.
This is important because is many cases the conditions of complementary health insurances taken out in your home country stipulate that you have to be a member of the national health scheme.
Contact us anytime
While this USHU newsletter focusses on how to cope with extra medical costs, USHU has expertise in many questions linked to health insurance and we are more than happy to assist you with any queries you might have.
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