R.C.A.M.
 | Joint Sickness Insurance Scheme
Central Office |
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| Amendments to the interpretative rules |
| Informations: | spectacles, contact lenses
dental expenses
phytotherapy products |
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INTERPRETATION OF SICKNESS INSURANCE RULESANNEX I - SECTION VIII
Paragraph 4:
In the event of a home birth the nursing expenses referred to in this point also cover the expenses for medical auxiliaries. Where a number of medical and other services are provided by a single body comprising various service providers including medical auxiliaries, the scheme may reimburse the expenses for all the services combined without making any distinction according to the nature of the services.
ANNEX I - SECTION XV
Paragraph 2:
The cost of purchasing disposable corrective contact lenses is reimbursed at the rate of 80 %, with a maximum of EUR 300 reimbursable per period of 24 months.
Reimbursement is on the basis of a detailed, receipted bill provided that the first contact lenses reimbursed under the scheme were medically prescribed.
The reimbursement of disposable contact lenses cannot be combined with the reimbursement of contact lenses provided for in point XII of this Annex.
INFORMATIONSThese measures will apply, without retroactive effect, from the date of this publication. As regards disposable contact lenses, it is the first pair purchased after the date of this publication which will be reimbursed up to the amount specified above.
- REIMBURSEMENT OF SPECTACLE LENSES, CONTACT LENSES AND DISPOSABLE CONTACT LENSES
At its 232nd meeting held on 7 and 8 July 1999, the Sickness Insurance Management Committee reviewed the procedure introduced in 1996 with regard to the reimbursement of spectacle lenses and contact lenses and raised the thresholds in question.
The Central Office of the Joint Sickness Insurance Scheme reminds its members that the measures to be applied in respect of spectacles and contact lenses are temporary and subject to the amounts being updated, pending changes in the rules.
1.1. Spectacle lenses
Reimbursement of spectacle lenses is on the following basis:
- If the price of the lenses is the same as or less than the amounts shown below, reimbursement will be at the rate of 85% of the costs paid.
- If the price of the lenses is above these amounts, reimbursement will be at the rate of 85% of the threshold shown below unless a medical report accompanies the request for reimbursement and justifies the medical need for the special type(s) of treatment of the lenses.
| Threshold per lens
(costs incurred) | | Maximum reimbursable amount |
| EUR | BEF | EUR | BEF |
| Normal spectacle lenses: | | | | |
| - up to 4 diopt.100 | 4.034 | 85.00 | 3.429 |
| - from 4.25 to 6 diopt. | 130 | 5.244 | 110.50 | 4.458 |
| - from 6.25 to 8 diopt. | 160 | 6.454 | 136.00 | 5.486 |
| - above 8.25 diopt. | 320 | 12.909 | 272.00 | 10.972 |
| Progressive/multifocal lenses | 255 | 10 287 | 216.75 | 8.744 |
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Dioptres are, depending on the case, calculated as follows:
If the cylinder is positive, take the value of the sphere to obtain the dioptre:
Example:
| Sphere | Cylinder | Dioptre = |
| RE | - 0.50 | + 0.75 | - 0.50 |
| LE | + 0.50 | + 0.50 | + 0.50 |
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If the cylinder is negative, the dioptres are added up:
Example:
| Sphere | Cylinder | Dioptre = |
| RE | + 1.25 | - 0.75 | + 0.50 |
| LE | - 1.00 | - 1.5 | - 2.75 |
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1.2 Contact lenses
The threshold (costs incurred) per pair of lenses is fixed at EUR 350 (= BEF 14 119). Contact lenses are reimbursed at the rate of 85%, subject to a maximum reimbursement of EUR 297 50 (= BEF 12 001).
1.3 Disposable contact lenses
- Under Annex 1, point XV§2 of the rules, the cost of purchasing disposable corrective contact lenses will be reimbursed at the rate of 80% with a maximum of EUR 300 (=BEF 12 102) reimbursed per period of 24 months.
- Reimbursement is on the basis of a detailed, receipted bill provided that the first contact lenses reimbursed under the Scheme were medically prescribed.
- The reimbursement of disposable contact lenses cannot be combined with the reimbursement of contact lenses.
1.4 Renewal deadline - Reminder
The cost of a new pair of spectacle lenses or contact lenses, other than disposable contact lenses, will only be reimbursed - except where conditions of sight have changed and have been medically diagnosed - after a period of :
- 18 months for corrective spectacle lenses (12 months for children up to the age of 18), and
- 24 months for contact lenses,
starting from the date on which the previous pair of lenses were purchased.
- DENTAL COSTS
In the case of fillings, it is important for the calculation of the reimbursement that the dentist stipulate on the bill the number of areas treated.
The costs relating to the fitting of dental implants (the implant, the surgery involved, the anaesthesia, etc.) are not reimbursed. The cost of removable or fixed prostheses fitted on an implant are reimbursed in accordance with the conditions laid down in Annex III to the rules. An estimate must always be presented before such treatment is started. A bone graft, necessary in certain cases, is also reimbursed in accordance with the conditions laid down in Annex II.B.1 to the rules.
- PHYTOTHERAPY PRODUCTS
Following a new opinion issued by the Medical Council, certain phytotherapy products will from now on be reimbursed at the rate of 85%:
- Silymarine (Legalon): only in injectable form
- Fibre: for the treatment of constipation
- Horse chestnut extracts:
for the treatment of haemorrhoids
- Gingko biloba extracts (Tanakan and others):
for the treatment of vascular problems
- St John's wort (Hypéricine) extracts:
for the treatment of minor depressions
- Extracts with a sedative effect (Valériane, Passiflore)
- Phyto-oestrogens (Rémifemine, Ymea):
for the treatment of osteoporosis and the menopause
- Unsaponifiable extracts of soya (Piascledine):
for the treatment of osteoarthritis.
As in the case of any pharmaceutical product, the product has to be registered as a medicinal product or be used in a preparation made up by the pharmacy and has to be prescribed by a doctor.
Members are reminded that veinotonic products, treatment for vesicular/prostate problems and treatment for respiratory problems are also reimbursed. Products containing a mixture of homeopathic substances and of extracts of phytotherapy products not included in the above list may be reimbursed if at least three quarters of the components are homeopathic.
- INFORMATION
The Central Office makes every effort to keep the Sickness Insurance Scheme information updated on the Institutions internal net (Europateam?Personnel and Administration?Sickness Insurance and Accidents). A novelly is the list of reimbursable pharmaceutical products.
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