5 JUIN 2002. - The maximum bill for health care insurance

ALBERT II, King of the Belgians,
To all, present and to come, Hi.
The Chambers adopted and We sanction the following:
Article 1^er. This Act regulates a matter referred to in Article 78 of the Constitution.
Art. 2. In the Compulsory Health Care and Compensation Insurance Act, coordinated on 14 July 1994, a chapter IIIbis is inserted in Title III, consisting of sections 37quinquies at 37vicies, as follows:
« CHAPTER IIIbis - Maximum charge
Section I^re. - General provisions
Art. 37quinquies. Under the conditions set out in this chapter, the amount of the intervention of the insurance in the cost of the benefits referred to in section 34 is adjusted for a calendar year determined by the beneficiary's social class or by the income of the beneficiary's household, taking into account all personal interventions effectively supported by the beneficiary or household of which the beneficiary is a party.
Art. 37sexies. For the purposes of this chapter, "personal intervention" means the personal assessment of the beneficiary in the cost of a health benefit, referred to in section 34, as it appears in the regulations and taking into account the conventions, agreements and documents taking place or the fees fixed by the King pursuant to section 52 of the law of 14 February 1961 of economic expansion, social progress and financial recovery. Part of the cost of pharmaceutical specialties of categories A and B referred to in article 2, 2°, a) , 1^er and 2^e dashes, from the Royal Decree of 7 May 1991 establishing the personal intervention of beneficiaries in the cost of pharmaceutical supplies repayable under the compulsory health care insurance and allowances which, in accordance with section 35bis, is supported by beneficiaries, is considered to be personal intervention.
However, it is not considered for the calculation of the amount of personal interventions actually taken over by the recipient:
1st personal interventions concerning the benefits referred to in article 34, paragraph 1^er, 5°, except:
(a) pharmaceutical specialties of categories A and B;
(b) the lump-sum personal intervention for pharmaceutical specialties admitted to hospitalized beneficiaries in general hospital, referred to in section 2, 2°, 2(b) of the aforementioned Royal Decree of 7 May 1991;
(c) the lump-sum personal intervention for pharmaceutical specialties intended for hospitalized beneficiaries in psychiatric hospitals, referred to in Article 4, § 5, paragraph 2, of the National Convention of 12 March 1999 between psychiatric institutions and services and insurance agencies;
2° personal interventions relating to admissions referred to in article 34, paragraph 1^er, 6°, from 91^e day of hospitalization in a general hospital and from 366^e Hospital day in a psychiatric hospital.
The totalisation of the number of days of hospitalization is carried out by uninterrupted period of hospitalization within the meaning of Article 2, §§ 2 and 3, of the Royal Decree of 5 March 1997 setting the amount of the reduction of the intervention of insurance in the event of hospitalization or stay in a rehabilitation centre;
3° accommodation expenses related to benefits referred to in section 34, paragraph 1^er11° and 18°.
The King may, by order deliberately in the Council of Ministers, make amendments to this article.
Art. 37s. Although the amount of the insurance intervention in the cost of the benefits referred to in section 34 for a particular calendar year is adjusted under the conditions set out in sections 37octies, 37undecies or 37quindecies, the insurance intervention remains unchanged:
- for benefits under section 34, paragraph 1^er5°, with the exception of pharmaceutical specialties of categories A and B and pharmaceutical specialties admitted to hospitalized beneficiaries in general hospital or psychiatric hospital;
- for accommodation expenses related to benefits under section 34, paragraph 1^er11° and 18°;
- for personal interventions relating to admissions referred to in article 34, paragraph 1^er, 6°, from 91^e day of hospitalization in a general hospital and from 366^e day of hospitalization in a psychiatric hospital; the totalisation of the number of days of hospitalization is carried out by period of uninterrupted hospitalization within the meaning of Article 2, §§ 2 and 3, of the aforementioned Royal Decree of 5 March 1997.
The King may, by order deliberately in the Council of Ministers, make amendments to this article.
Section II. - Maximum billing
determined according to the social category of beneficiaries
Art. 37octies. For the household of one or more beneficiaries referred to in section 37novies, the intervention of the insurance in the cost of the benefits referred to in section 34 is set at 100 per cent of the refund base as soon as all personal interventions actually taken care of by the beneficiaries of that household, relating to the benefits made during the current year, reach EUR 450.
Art. 37novies . The beneficiaries referred to in section 37octies are:
1° the beneficiaries of the increased intervention referred to in Article 37, §§ 1^er and 19, 1°, 2°, 3° and 6°, as well as the holders referred to in article 32, paragraph 1^er, 13° and 15°, benefiting from the increased intervention, as long as they are not taken back to the 2° of this article;
2° the beneficiaries to whom is granted one of the allowances referred to in the Act of 27 February 1987 relating to the allowances of persons with disabilities, except for the beneficiaries of an integration allowance, belonging to categories 3 and 4, referred to in Article 6, § 4, paragraph 1^er, 3° and 4° of the above-mentioned Act of 27 February 1987, to which is effectively applied the slaughter referred to in Article 8, § 1^er, the Royal Decree of July 6, 1987 concerning the replacement income allowance and the integration allowance.
The King may, by order deliberately in the Council of Ministers, make amendments to this article.
Art. 37decies. § 1^er. The household, referred to in section 37octies, is constituted, either by a person usually living alone or by two or more persons who usually occupy the same dwelling and live in common. The composition of the household is determined according to the data contained in the National Register of Natural Persons.
§ 2. However, is not part of the household, constituted in accordance with § 1^erthe person in one of the situations listed below:
(a) be placed in a specified household in a regulated form of family placement;
(b) living in a community. However, if this person has the same principal residence as his or her spouse, the person with whom he or she forms a de facto household or dependants, he or she forms a household with those persons.
The person in one of these situations is considered to be usually living alone and forming a household alone.
may choose not to be part of the household constituted in accordance with § 1^er, according to the manner determined by the King, the person who is in a situation of dependency because of his state of health. However, if this person has the same principal residence as his or her spouse, the person with whom he or she forms a de facto household or dependants, he or she forms a household with those persons.
§ 3. The information contained in the National Register of Physical Persons is taken into account in 1^er January of a calendar year to determine the right of the household concerned within the maximum amount to be charged during that same year. However, if in the course of that same year, a person is registered in the National Register of Physical Persons for the first time, the change to the composition of the household is taken into account.
§ 4. The King specifies what is meant by "to be in a situation of dependency because of his state of health", by "community" and by "to form a household of fact".
§ 5. When the recipients of the same household are affiliated or registered with different insurers, the recipient of the household, with which the older person is affiliated or registered, manages the application of this section. The insurers concerned shall provide the information necessary for the application of this section, including the information relating to the composition of the household and the personal interventions effectively taken by the affiliate concerned.
Section III. - The maximum to be charged according to the income of the beneficiary's begging and executed by the insurers
Art. 37undecies . The intervention of insurance in the cost of benefits referred to in section 34 shall be set at 100 per cent of the reimbursement base as soon as all personal interventions actually taken in care by the beneficiaries composing the household constituted in accordance with section 37decies , relating to benefits made during a specified calendar year, exceeds a reference amount that varies according to the income of that household as follows:
Income
from 0 to 13 400,00 EUR 450,00 EUR
from 13 400.01 to 20 600,00 EUR 650,00 EUR
However, the intervention of insurance to 100 per cent is granted, regardless of the amount of the household income of which it is a part, to the child under the age of sixteen, as long as he has effectively supported, during the calendar year concerned, personal interventions in the amount of 650 EUR.
The King may, by order deliberately in the Council of Ministers, amend the above-mentioned age limit.
In this case, the personal interventions of this child are part of all personal interventions supported by the household concerned.
Art. 37duodecies. § 1^er. The King determines the procedure to be followed to determine the amount of household income referred to in section 37undecies, on the basis of information provided by the Administration of the Taxation of Companies and Revenues. The net income referred to in section 6, paragraph 2, of the Income Tax Code 1992, relating to the most recent year for which a tax was enlisted, shall be taken into consideration.
If the above-mentioned administration has no information on any of the members of the household concerned, the amount of the income of these persons shall be determined on the basis of other evidence specified by the King. In this case, the King determines which income is considered.
§ 2. The insurers communicate to the Institute's Administrative Control Service the identification data for the household referred to in section 37undecies. The Administrative Control Service transmits this information, via the Carrefour Bank of Social Security, to the Administration of Corporate and Revenue Tax. This administration communicates to the above-mentioned Administrative Control Service, via the Carrefour Bank of Social Security, information on the income of individuals whose identification data were transmitted to it.
The Administrative Control Service shall transmit to the insurers, by derogation from section 337, paragraph 4, of the Income Tax Code 1992, information allowing them to determine the grant of the intervention to 100 p.c., referred to in section 37undecies.
§ 3. When specific criteria, fixed by the King, show that since the year concerned by the information referred to in § 1^er, the income of one or more recipients of the specified household has undergone changes resulting in a significant decrease in household income, the right to intervention at 100 per cent will be reviewed by the insurer according to these elements on the basis of income and a procedure established by the King.
§ 4. The insurers are obliged to keep the secret of the information referred to in § 1^er and may not use the information obtained outside of the scope of this section.
Art. 37terdecies . In the event of an undue award of the intervention to 100 p.c. referred to in section 37undecies , resulting from the transmission of incorrect data by the members of the household concerned, an administrative fine may be imposed on each member concerned of the household from 90 to 370 EUR. This administrative fine is imposed by the officer of the Administrative Oversight Service or by the official designated by him. The King determines, by order deliberately in the Council of Ministers, the conditions in which he is, inter alia, taken into account the social and financial situation of the members of the household concerned and the procedure whereby the fine is imposed. In case of recidivism, the fine can be doubled.
Final determinations made with respect to fines referred to in the preceding paragraph are enforceable in full law. In the event of a failure of the debtor, the Administration of the cadastre, registration and domains may be responsible for recovering the administrative fine in accordance with the provisions of Article 94 of the Acts on State Accounting, coordinated on 17 July 1991.
The proceeds of this fine are paid to the Institute.
Art. 37quaterdecies . The income amounts referred to in section 37undecies are adjusted annually to a corrected index calculated in accordance with the following paragraphs.
The adaptation is made using the coefficient obtained by dividing the average of the price indices of the year preceding the year of taking into account personal interventions by the average of the price indices of the second year preceding that of taking into consideration personal interventions.
For the calculation of the coefficient, the rounding is carried out as follows:
1° the mean of the indices is rounded to the upper or lower centth of a point depending on whether or not the figure of the millimes is 5;
2° the coefficient is rounded to the ten upper or lower millimetres depending on whether or not the number of the cents reaches 5.
After applying the coefficient, the amounts are rounded up to the upper or lower centth depending on whether or not the figure of the millimes is 5.
The adaptation to the corrected index is for the first time for the maximum to be charged in 2002.
Section IV. - The maximum to be charged according to the income of the beneficiary's household and executed by the Administration of the Taxation of the Companies and Revenues
Art. 37quindecies. The Administration of the Taxation of Businesses and Revenues reimburses or imputes any income tax payable by the beneficiary or by the fiscal household of which it is a party, the share of the personal intervention of a year that exceeds, in the head of a fiscal household, a reference amount that varies according to the taxable income of that tax household during that year:
Taxable income Reference amount
from 0 to 13 400,00 EUR 450,00 EUR
from 13 400.01 EUR to 20 600,00 EUR 650,00 EUR
from 20 600.01 EUR to 27 800,00 EUR 1 000.00 EUR
from 27 800.01 EUR to 34 700,00 EUR 1 400,00 EUR
from 34 700.01 EUR to 49 600,00 EUR 1 800,00 EUR
starting at 49 600,01 EUR 2 500,00 EUR
Art. 37sedecies . For the purposes of this section, it is necessary to understand by "tax household": the person or all dependants of whom or whom a single tax contribution is made in respect of personal tax, in accordance with sections 126 and 128 of the Income Tax Code 1992. The personal interventions taken into account in this section must relate to the benefits refunded during the calendar year in question and have been effectively taken over by the recipient.
Art. 37septiesdecies . The Institute reimburses the amounts referred to in Article 37quindecies on the account of the Administration of the Taxation of Enterprises and Revenues, on a particular fund, which for the surplus is assimilated to a restitution fund within the meaning of Article 37 of the Acts on State Accounting, coordinated on 17 July 1991.
The King shall, by order deliberately in the Council of Ministers, establish the rules for the execution of paragraph 1^er, including the method of calculating the late interest and other administrative costs in the event of late payment by the Institute.
Art. 37duodevicies. The refund referred to in section 37quindecies is treated as a pre-payment surplus referred to in section 419, paragraph 1^er, 3°, of the Income Tax Code 1992. It is considered only as long as its amount reaches at least EUR 2.50. Part VII of the Code is applicable to this surplus.
Art. 37undevicies . The data required for the application of this section are transmitted electronically to the Carrefour Social Security Bank by insurers. The Carrefour de la sécurité sociale Bank transmits these aggregated data electronically to the Administration of Corporate and Revenue Tax.
A manual procedure is provided for electronic data that the Administration of Business and Revenue Tax has not been able to process. In this procedure, insurers send recipients a paper certificate containing the data required for the purposes of this section. Recipients transmit the said certificate to the above-mentioned administration.
This manual procedure is also applied for the correction of previously transmitted data, either electronically or through a paper certificate.
The manual procedure is not applied if the amount of personal interventions for benefits refunded in a calendar year does not reach EUR 12.40.
Art. 37vicies. The taxable income amounts referred to in section 37quindecies are adjusted annually to the corrected index in accordance with section 37quaterdecies . This adaptation is made by taxation year.
The adaptation is made using the coefficient obtained by dividing the average of the price indices of the year preceding the year of income by the average of the price indices of the second year preceding that of income.
For the calculation of the coefficient, the rounding is carried out as follows:
1° the mean of the indices is rounded to the upper or lower centth of a point depending on whether or not the figure of the millimes is 5;
2° the coefficient is rounded to the ten upper or lower millimetres depending on whether or not the number of the cents reaches 5.
After applying the coefficient, the amounts are rounded up to the upper or lower centth depending on whether or not the figure of the millimes is 5.
Adjustment to the corrected index for the first time comes to revenues for the year 2002 (2003 taxation year). »
Art. 3. Without prejudice to the provisions of the Act of 11 April 1995 to establish the Charter of the social insured, the King specifies the terms and conditions under which the beneficiaries, comprising the household concerned, are informed of their rights with respect to the granting of the maximum to be charged.
Similarly, the King specifies the rules and procedures for the transmission of information relating to the maximum amount to be charged to a beneficiary, to legal persons who take charge of personal interventions relating to the benefits provided to that beneficiary.
Art. 4. A disabled child who, as of the date of publication of this Act, is entitled to increased family allowances due to his or her disability, is entitled to the maximum charge referred to in section III of Chapter IIIbis of Title III of the Compulsory Health Care and Compensation Insurance Act, coordinated on July 14, 1994, for the calendar years in which the following conditions are met:
- the calendar year includes a period of benefit of the increased family allowances;
- personal interventions of EUR 450 are actually supported during the calendar year.
The personal interventions of this child are part of all personal interventions supported by the household of which it is part.
Art. 5. § 1^er. cease to produce their effects for benefits from 1 ^er January 2002:
1° Article 37, § 18, of the Compulsory Health Care and Compensation Insurance Act, coordinated on 14 July 1994;
2° the Royal Decree of 3 November 1993 enforcing section 37 of the Compulsory Health Care and Compensation Insurance Act, coordinated on 14 July 1994, amended by the Royal Decrees of 24 January 1994, 15 May 1995, 15 January 1997, 17 April 1997, 24 November 1997 and 19 October 2001;
3° the Royal Decree of 20 December 1993 enforcing Article 37, § 18, of the Compulsory Health Care and Compensation Insurance Act, coordinated on 14 July 1994, with respect to certain independent workers, as amended by the Royal Decrees of 15 May 1995 and 13 November 2001.
However, for the granting of the maximum to be charged according to the social category of beneficiaries and in respect of the benefits made in 2002, these provisions remain applicable to beneficiaries who, on the date of publication of this Act, are in the situation referred to in Article 2, § 2, 4°, of the royal decree of 3 November 1993 referred to above.
§ 2. The 100-per-cent coverage provided by the day before 1^er day of the month following the publication of this Act, on the basis of the regulatory provisions referred to in § 1^er and benefits in 2002 remain to the beneficiaries concerned.
§ 3. Section 43 of the Programme Act of 24 December 1993, as amended by the Acts of 21 December 1994, 29 April 1996, 24 December 1999, 12 August 2000, 2 January 2001 and 30 December 2001 and the Royal Decrees of 20 July 2000 and 11 December 2001, is repealed.
This article, however, remains applicable to social immunizations of personal intervention that are granted up to the year 2001 included.
§ 4. The King specifies the terms and conditions for the application of Chapter IIIbis of Title III of the Compulsory Health Care and Allowance Act, coordinated on 14 July 1994, by the Mariner Relief and Allowance Fund and the Overseas Social Security Office.
Art. 6. § 1^er. The provisions of this Act shall affect 1^er January 2002.
§ 2. By derogation from § 1^er, the provisions of section III of Chapter IIIbis of Title III of the same coordinated law shall affect 1^er January 2001, for households whose income amounts referred to in Article 37duodecies, § 1^erParagraph 1^er, is less than or equal to 13 730, 98 EUR.
The 100-per-cent intervention referred to in section 37 undecies of the same coordinated law, in the cost of benefits made during the year 2001, is granted on the basis of a procedure determined by the King. The household considered is the one that exists in 1^er January 2002 and the amount of actual personal interventions must exceed EUR 446.
For households referred to in paragraph 1^erthe provisions of section III above, however, produce their effects on 1^er January 2002
1° where an intervention of insurance at 100 per cent was granted on the basis of the Royal Decree of 3 November 1993 referred to in Article 5, § 1^erunless in the household concerned there is a beneficiary referred to in Article 2, § 2, 6°, of the royal decree of 3 November 1993 referred to above;
2° in all cases, if the members of the household concerned are affiliated with different insurers.
Promulgation of this law, let us order that it be clothed with the seal to the State and published by the Belgian Monitor.
Brussels, 5 June 2002.
ALBERT
By the King:
Minister of Social Affairs and Pensions,
F. VANDENBROUCKE
Minister of Finance,
D. REYNDERS
Seal of the state seal:
Minister of Justice,
Mr. VERWILGHEN