. consultations carried out on an Internet site;
. fees for appointments which the patient failed to attend;
. the costs of sending medical reports that are invoiced separately;
. consultations, examinations and technical procedures carried out for non-therapeutic or administrative reasons, such as:
o expert report ordered by the court;
o examination for insurance purposes;
o examination of professional competence;
o aptitude test for obtaining a pilot's licence;
o examinations carried out as part of occupational medicine (pre-recruitment medical, annual medical).

Hospitalisation is taken to mean stays in a hospital or clinic for the purpose of:


. undergoing treatment for medical conditions or surgery, or giving birth, including stays of one day;

. rehabilitation or functional re-education following a medical condition or surgical operation resulting in invalidity;

. undergoing treatment for psychiatric conditions;

. receiving palliative care.


The following are not considered as hospitalisation and do not qualify for any reimbursement:

. stays in an institution without a multidisciplinary medical, technical and logistical infrastructure;

. stays in sheltered housing, supervised or supported accommodation without a medical and/or paramedical infrastructure;

stays in a hospital or clinic or other type of establishment for fitness or rejuvenation treatment.

Prior authorisation based on a medical report is required for the following:

. stays of more than 6 months for the treatment of medical conditions or surgical operations;

. stays for plastic surgery;

. stays for rehabilitation or re-education which do not follow hospitalisation for a medical condition or a surgical operation (for example orthopaedic, neurological or rheumatological), or, if they do follow such a period of hospitalisation, stays of more than 2 months;

. stays of more than 12 months in a psychiatric hospital;

. stays in clinics specialising in health screening and diagnosis (general check-up);

. costs of person accompanying the patient.

Hospitalisation for a surgical operation or medical treatment is reimbursed at the rate of 85%.

The rate of reimbursement rises to 100%:

. in the case of serious illness;

. for stays of 3 or more consecutive days in intensive care, even if the stay is not directly connected with a serious illness and for the entire duration of the stay;

. for stays in a hospital palliative care unit;

in the event of prolonged hospitalisation, for accommodation costs beyond 30 consecutive days, after consultation of the Medical Officer.

In order to qualify for reimbursement, the hospitalisation must be the subject of a medical report to the Medical Officer of the Settlements Office.

. Accommodation costs

Accommodation costs relating to board and lodging, service and taxes are reimbursed on the basis of expenses actually incurred and according to the relevant invoicing rules applicable in the country of hospitalisation. If the accommodation costs are included in the all-in charge for a day in hospital, the reimbursement will be made as an aggregate amount.

Accommodation costs will depend on the type of room chosen. They will be reimbursed up to the price of the least expensive single room in the hospital.

Accommodation costs will be reimbursed only for the period of hospitalisation that is medically required to carry out the procedures or provide the treatment in the country of hospitalisation.

. Costs of diagnosis and treatment

In addition to the costs of surgical operations referred to in point 2 below, the costs of the following services will be reimbursed at the rate of 85%, or 100% in the case of serious illness:
o the costs of the operating theatre, plaster room and dressing room and other costs of treatment relating to the surgical operation;

o medical fees for visits and consultations;

o laboratory analyses and tests, x-rays;

o medicines, the costs of prostheses, orthoses and other orthopaedic instruments and appliances, provided that these expenses are directly related to the surgical operation and/or hospitalisation;

o diagnosis or treatment.


. Cost of stay for person accompanying the patient

The accommodation costs of an accompanying family member staying in the insured person's room or on the hospital premises may, exceptionally, be reimbursed at the rate of 85%, with a ceiling of €40 per day, if the patient is under the age of 14 or requires special assistance from a family member because of the nature of the condition or on other duly substantiated medical grounds. The reimbursement of the costs of an accompanying family member is subject to a prescription from the patient's doctor and prior authorisation.

The accommodation costs of a child who is being breastfed and has to accompany its mother in hospital may also qualify for such reimbursement.

2. Surgical operations

The costs of surgical operations are reimbursed at the rate of 85%, or 100% in the case of serious illness. These costs comprise all the fees of the surgeon, the surgeon's assistant(s) and the anaesthetist.

In the case of reimbursement at the rate of 85%, the costs are reimbursed up to the limit of the ceilings for each operation, with a ceiling according to the category of operation:

Category	Reimbursement at 85% Ceiling (€)
A1	535
A2	735
A3	1 350
B1	2 000
B2	2 600
C1	4 250
C2	5 350
D1	10 000
D2	Not applicable.

A list of surgical operations by category is given in Annex I.


Surgical operations that do not appear on this list may be treated as equivalent to operations of comparable importance and the costs thereof reimbursed on that basis after consultation of the Medical Officer.

In the case of an exceptionally difficult operation, reimbursement may be granted up to the ceiling for the category immediately above that fixed for the operation in question, after consultation of the Medical Officer.

Where the rules on invoicing provide for higher fees for emergency operations, the costs associated with such operations will be reimbursed at the rate of 85%, or 100% in the case of serious illness, subject to the proviso that the total reimbursement for the surgical operation in question may not exceed the ceiling provided for the category immediately above that of the operation in question.

Corrective or restorative plastic surgery may be reimbursed, particularly in the case of serious illness, deformity or accident, subject to prior authorisation granted after consultation of the Medical Officer. Plastic surgery which is considered to be purely cosmetic will not be reimbursed.

Chapter 3 - Services associated with dependence

The reimbursement of services associated with dependence - stays in an institution and the costs of carers - excluding residential drug rehabilitation, depends on the insured person's degree of dependence.

The degree of dependence is determined according to the following table, on the basis of the lowest score obtained on one of the two questionnaires in the Annex, to be completed by the patient's doctor:

Score	Degree of dependence
91-100	5
75-90	4
50-74	3
25-49	2
0-24	1

Values 1 to 4 on the dependence scale are taken into consideration for the purpose of reimbursing expenses, with 1 being the highest level of dependence. Level 5 dependence does not create any entitlement to reimbursement.

1. Permanent or long-term residence in paramedical and other establishments

The following are reimbursed under this heading:
a) residence in a convalescent or nursing home approved by the competent authorities and having a medical and/or paramedical infrastructure for the elderly and/or the disabled;

b) continuous and permanent residence in a psychiatric home approved by the competent authorities and having a medical and/or paramedical infrastructure;

c) residence in an establishment for rehabilitation or functional re-education in cases where the request for prior authorisation for reimbursement under the heading of hospitalisation has been refused (see Title II, Chapter 2, point 1.2);

d) continuous, long-term residence in a psychiatric hospital for more than 12 months where the request for prior authorisation for reimbursement as hospitalisation has been refused (see Title II, Chapter 2, point 1.2);

e) stays in a day centre;

stays in a non-hospital drug rehabilitation centre.

Prior authorisation based on a medical report to the Medical Officer, as specified in 1.3 below, is required in order for the costs of residence and treatment in any of the establishments listed at 1.1 to qualify for reimbursement.

The fact that authorisation under the heading of hospitalisation (see Title II, Chapter 2) has been refused does not affect whether or not authorisation is granted under the present heading.

Costs to be met by the beneficiary do not qualify for the special reimbursement provided for in Article 24 of the joint rules.

a) Convalescent and nursing homes

The request for prior authorisation must be accompanied by a medical report justifying the need for residence in the home and specifying the nature of the care required by the patient, and by the two forms in the Annex, duly completed by the patient's doctor.

Authorisations are granted for a maximum of 12 months and are renewable.

All of the costs of care and accommodation 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.

If all items are aggregated on the invoice so that it is not possible to separate the costs of care from the accommodation costs, the costs will be divided according to the degree of dependence in the proportions given in the following table:

Degree of dependence	Costs of care	Accommodation costs
4	0,3	0,7
3	0,5	0,5
2	0,6	0,4
1	0,7	0,3



In such cases the accommodation costs will be subject to the same ceiling of €36 per day.


b) Residence and care in a psychiatric home are reimbursable at the rate of 85%, or 100% in the case of serious illness, under the same conditions as those applying to convalescent and nursing homes.

Authorisations are renewable, subject to a detailed report by the patient's doctor, for periods determined by the Settlements Office.

c) Continuous residence and care in a rehabilitation or functional re-education establishment or psychiatric hospital are reimbursable at the rate of 85%, or 100% in the case of serious illness, under the same conditions as those applying to convalescent and nursing homes.

If all items are aggregated on the invoice so that it is not possible to separate the costs of care from the accommodation costs, the costs will be divided according to the proportions for level 1 degree of dependence.

d) Stays in a day-care centre and the care provided there are reimbursable under the following conditions:

. Daytime attendance only at a convalescent or nursing home for the elderly or a neurological or psychiatric day centre: the costs of accommodation and care are reimbursed under the same conditions as permanent residence in an establishment as referred to in a) above, with a ceiling of €18 per day for accommodation costs.

. Attendance at a child guidance clinic: care only is reimbursable as provided for in the relevant provisions.


e) Stays in a non-hospital drug rehabilitation centre, or equivalent establishment, and the medical care provided are reimbursed at the rate of 85% only, with a ceiling of €36 per day for the accommodation costs.

If all items are aggregated on the invoice so that it is not possible to separate the costs of care from the accommodation costs, the costs will be divided according to the proportions for level 1 degree of dependence.

Reimbursement is limited to a total stay of 6 months in a 12-month period.

2. Carers

The services provided by carers consist mainly of nursing care in the patient's home for several hours a day or the whole day and/or night.

Individual nursing tasks (injections, dressings, etc.) are reimbursed under the conditions laid down in Title II, Chapter 9.

The services of adults who look after children who are ill at home while their parents are away are not regarded as services provided by carers.

. Prior authorisation is required for the services provided by carers.

The request for prior authorisation must be accompanied by a medical report stating the duration of the services, the nature and frequency of the care to be provided and the two forms in the Annex, duly completed by the patient's doctor.

Authorisation will be granted if the services are deemed to be strictly necessary by the Medical Officer of the Settlements Office, who will evaluate them according to the degree of dependence of the insured person. The reimbursement of care services is authorised only for patients whose degree of dependence is rated as 1, 2, 3 or 4.

. Carers must be legally authorised to practise their profession.

In countries where the profession of carer is not regulated and/or if it is impossible to find an officially approved carer (e.g. approved by the Red Cross), the patient's doctor must specify on the prescription the name of the person who will provide the services and declare that this person is properly qualified to do so.

In the case of carers who are not attached to an official organisation (e.g. the Red Cross) or do not operate within an officially recognised private framework, proof of the contractual tie (a duly completed employment contract and/or insurance contract for the job of carer) must be sent to the Settlements Office.

The social charges relating to employment contracts and/or the insurance premiums are included in the costs of carers and are reimbursable under this heading.

. Invoices must comply with the law of the country in which they are issued.

Failure to produce the requisite documents will mean that prior authorisation cannot be granted and the corresponding services will not be reimbursed.

Costs are reimbursed at the rate of 80%, or 100% in the case of serious illness, up to a maximum amount (see below), regardless of the number of people providing care.

No reimbursement is made in respect of the carer's travel expenses, board and lodging, or any other ancillary costs.

The portion of expenses not reimbursed do not qualify for the special reimbursement provided for in Article 24 of the joint rules.

. Temporary home care

The costs of home care for a maximum period of 60 days are reimbursed at the rate of 80%, with a ceiling of €72 per day, or at the rate of 100% in the case of serious illness, with a ceiling of €90.

. Long-term home care

Beyond 60 days, the costs of home care are reimbursed at the rate of 80%, or 100% in the case of serious illness, subject to the ceilings set out in the following table, minus an amount equal to 10% of the member's basic income (salary, retirement pension, invalidity pension or disability allowance, allowance provided for in the fourth and fifth indents of Article 2(3) of the joint rules).



Degree of dependence	Ceiling for reimbursement
4 and 3	50% of the basic salary of an official in grade AST 2/1
2 and 1	100% of the basic salary of an official in grade AST 2/1

Authorisations are granted for a maximum of 12 months and are renewable.

. Services of carers in hospital

These costs are reimbursable only in public institutions where the healthcare infrastructure is insufficient to provide routine care. In such cases the costs of a carer employed on a prescription issued by the patient's doctor are reimbursed at the rate of 80%, subject to prior authorisation granted after consultation of the Medical Officer, with a ceiling of €60 per day. In the case of serious illness, such costs are reimbursed at the rate of 100%, with a ceiling of €75 per day.

Chapter 4 - Pharmaceutical products

1. Definition

For the purpose of the JSIS a pharmaceutical product is:
. a proprietary substance which is registered as a medicinal product and has a marketing authorisation; or
. a magistral formula produced under the responsibility of a pharmacist, the composition of which appears on the medical prescription or on the pharmacist's invoice and the components of which have been proved to be effective and safe; or
. a homeopathic preparation, proprietary herbal remedy or mother tincture that has been scientifically proved to be effective and safe.

2. Reimbursement

The pharmaceutical product must be prescribed by the doctor for a recognised medical indication and in doses consistent with normal therapeutic guidelines. It is dispensed by a pharmacist, a doctor or any other approved body or system authorised to dispense medicines.

If national legislation allows people with a qualification other than that of a doctor (e.g. a dentist, midwife, nurse, Heilpraktiker) to prescribe pharmaceutical products, these will also qualify for reimbursement under the conditions laid down by the Scheme in those countries where such practices are officially recognised and regulated by law.

The composition of a magistral formula must be shown on the medical prescription or the pharmacist's invoice and be included with the claim for reimbursement.

In the event of claims for reimbursement of products in doses which significantly exceed the normal therapeutic recommendations, the portion of the product regarded as excessive will not be reimbursed, after consultation of the Medical Officer.

3. Reimbursement conditions

Pharmaceutical products are reimbursed at the rate of 85%, or 100% if prescribed for a serious illness.

However, other reimbursement conditions apply to the following:
. narcotic drugs used during withdrawal treatment or substitution treatment for drug addicts qualify for reimbursement at the rate of 100% for a maximum of 6 months - see point 4.1;
. the special diet foods referred to in point 4.3b), for which reimbursement at the rate of 85% or 100% will apply to 40% of the expenses incurred, which corresponds on average to the price difference between these products and normal products;
. pharmaceutical products used for the treatment of nicotine dependency, where reimbursement will be limited to a total of €200 for all treatment during the insured person's lifetime.

4. Products reimbursable subject to prior authorisation

4.1. Prior authorisation based on a medical report is required for the following products:
. slimming products;
. anti-ageing hormonal treatment that is not justified by an objective hormonal deficiency;
. growth hormones;
. products used in the symptomatic treatment of male erectile disorders, when impotence is the result of a serious illness, accident or a prostate operation; the maximum amount reimbursed for this category of drugs in any 12-month period is €400;
. narcotic drugs used during withdrawal treatment or substitution treatment for drug addicts; these products qualify for a special reimbursement at the rate of 100% for a maximum of 6 months.

4.2. Prior authorisation based on a medical report is required for proprietary substances which are authorised for sale as pharmaceutical products but are used for a medical indication other than the recognised one (off-label use), for the same purposes as the products listed in point 4.1.

This provision also applies to hair loss treatments.

4.3. Prior authorisation based on a medical report is required for certain dietary and hygiene products if they are deemed to be essential for survival.

Such products are reimbursed even if they are not purchased in a pharmacy, from a doctor or from any other approved body or system authorised to dispense medicines.

The products in question are:
a) special products for enteral or parenteral feeding, which qualify for reimbursement at the rate of 85%, or 100% in the case of serious illness;
b) - high-calorie or high-protein liquid nutrition prescribed after radiotherapy, chemotherapy or major surgery;
    - special milk consisting of extensively hydrolysed semi-elemental formulas used in cases of prolonged diarrhoea associated with severe allergy to cow's milk or soya or in cases of anaphylactic shock, intestinal malabsorption or inflammatory bowel disease;
   - special foods used in the treatment of metabolic diseases.

The reimbursement rate for these 3 categories of product will apply to 40% of the expenses incurred, which corresponds on average to the price difference between these products and normal products.

disinfection or hygiene products essential for the treatment of certain serious illnesses, such as nosocomial infections.

5. Non-reimbursable products

The following products will not be reimbursed:

5.1. products for cosmetic, hygienic, aesthetic or dietary purposes or for personal comfort, with the exception of the situations referred to in point 4 above;

5.2. tonic wines and beverages, organotherapy products, trace elements in catalytic doses which are authorised for sale as pharmaceutical products but which have not been proved to be effective and/or safe.

6. Information for members

Two lists of the main pharmaceutical products that are and are not reimbursable will be updated regularly and notified to members.

Products that appear on neither list may be reimbursed after consultation of the Medical Officer.

Chapter 5 - Dental care, treatment and prostheses

1. Preventive care and treatment

The costs of preventive dental and oral hygiene care, x-rays, treatment and surgery are reimbursed at the rate of 80%, with a ceiling of €750 per calendar year per insured person, on condition that the treatment is provided by practitioners registered by the competent national authorities.

In the case of a serious illness such as cancer, insulin-dependent diabetes, valvulopathy (a remote consequence of dental infections) which affects or has repercussions for the buccal cavity, expenses will be reimbursed at the rate of 100%, subject to the joint approval of the Medical Officer and the Dental Officer, up to a ceiling of €1 500. This ceiling will also apply in the case of problems in treating hyperactive children or pregnant women.

The amount covers the following treatment:
. consultation
. intra-oral x-ray;
. panoramic x-ray and teleradiography performed in the dentist's surgery (*);
. fluoride treatment;
. sealing pits and fissures;
. descaling and polishing;
. fillings (**);
. reconstruction, core build-up (with screw or tenon), resin inlays and facets;
. devitalisation and root filling;
. normal extraction, incision of abscess, esquillectomy;
. surgical extraction, impacted tooth, apectomy, root amputation, frenectomy(***);
. local or loco-regional anaesthetic.

Treatment that is not included on this list may be reimbursed at the rate of 80%, or 100% in the case of serious illness, up to the amount of the annual ceiling, after consultation of the Dental Officer.


---

(*) The same examinations and maxillofacial scans performed in a hospital are reimbursed at the rate of 85%.

(**) The costs of systematically removing all silver amalgam fillings and replacing them will not be reimbursed unless the fillings are damaged or are a recurrent source of problems.

(***) The extraction of an impacted wisdom tooth carried out in hospital under general or local anaesthetic will be reimbursed subject to the limits and conditions laid down for surgical operations in category A2. If an additional extraction is performed during the same procedure, the reimbursement per tooth will be limited to half of the reimbursable amount for category A2 surgical operations.

2. Periodontal treatment

The costs of periodontal treatment which has been authorised by the Settlements Office after presentation of a detailed estimate and consultation of the Dental Officer will be reimbursed at the rate of 80%, with a ceiling of €350 per sextant, i.e. €2 100 for the whole mouth, over a period of 10 years. A second reimbursement may be authorised under the same conditions once 6 years have elapsed after the end of the 10-year period.

The costs of x-rays will be reimbursed separately, in accordance with point 1 above.

3. Orthodontic treatment

The costs of orthodontic treatment (dentofacial orthopaedics) are reimbursed at the rate of 80%, with a ceiling of €3 300 for the overall treatment (including cephalometric analysis, study models, photos, costs of retention), on condition that prior authorisation for the treatment has been obtained from the Settlements Office, on presentation of an estimate and after consultation of the Dental Officer. The costs of x-rays will be reimbursed separately, in accordance with point 1 above.

Orthodontic treatment must start before the patient's 18th birthday, except in the case of serious disease of the buccal cavity, maxillofacial surgery, maxillofacial trauma or serious problems of the temporomandibular joint diagnosed by x-ray and clinical examination.

Authorisation may be granted for a second course of treatment under the same conditions as above, in the following cases:
. if the patient moves to another country and has to use another practitioner who is unable to continue the current treatment using the same therapeutic technique; authorisation will only be granted if documentary evidence of the patient's change of place of residence is provided and if the new treatment immediately follows the previous one;
. if the patient's practitioner dies or closes down the practice;
. agenesis of 5 or more teeth in the upper jaw or 5 or more teeth in the lower jaw (excluding wisdom teeth);
. major maxillofacial surgery with osteosynthesis (trauma or tumours);
. serious problems of the temporomandibular joint.

Chapter 7 - Pregnancy, confinement and infertility

If the confinement takes place at a "birthing centre" or at a non-hospital centre approved by the competent health authorities,

. the fees for the confinement are reimbursed on the same conditions as a home confinement;

. additional costs relating to follow-up and accommodation are reimbursed for a maximum of 24 hours after the confinement.


Expenses following the confinement for services provided at home by nurses and medical auxiliaries are reimbursed at the rate of 100% for a maximum of ten days including the stay away from home.

If there are medical complications for mother and/or baby directly connected with the confinement, the period of reimbursement is extended, after consultation of the Medical Officer. If such complications require a stay in hospital, the costs of accommodation and care are reimbursed at the rate of 100%.

Excessive costs within the meaning of Article 20(2) of the joint rules of a stay at a birthing centre or non-hospital centre will be determined by comparison with the costs of a hospital stay in the country where the confinement took place.

a) surgical operations subject to a ceiling corresponding to the category of the surgical operation:

. vaso-vasostomy: category B1

. epididymo-deferential anastomosis: category B1

. ejaculatory duct resection: category B1

. varicocele repair: category A2


b) artificial insemination with sperm from the patient or from a donor,

c) in vitro fertilisation including with intra-cytoplasmic sperm injection (ICSI) subject to the conditions laid down in paragraph 3.1.

d) removal of sperm (deferential, epididymal or testicular) and preparation for ICSI, subject to a ceiling corresponding to category A2 surgical operations.


NB: Improving sperm quality is dealt with in the chapter on medicines and penile implants are dealt with in the chapter on prostheses.

Chapter 8 - Miscellaneous treatments

1.1. The costs of the treatments listed under point 2 below, prescribed by a doctor or, in the case of psychotherapy or similar treatments, by a psychiatrist, neuropsychiatrist or neurologist, are reimbursed at the rate of 80%, up to the ceiling for each type of treatment, or 100% in the case of serious illness, up to twice the ceiling normally applied.

1.2. The maximum number of sessions that can be reimbursed over a calendar year is specified for each type of treatment. Unless stated otherwise, the costs of a higher number of sessions may be reimbursed, subject to prior authorisation, in the case of recognised serious illness, post-operative or post-traumatic rehabilitation or reduced mobility.

1.3. Medical prescriptions must be drawn up before the start of treatment and dated less than six months before the date of the first treatment. They must include at least the following information:
. the patient's name,
. the reason for the treatment,
. the type of treatment and the number of sessions prescribed.


Other specific information or conditions listed under point 2 may be required, depending on the treatment.

1.4. Treatments must correspond to the treatments specified on the medical prescription and must be carried out by professionally qualified and legally recognised practitioners.

1.5. Invoices must be drawn up by the practitioners themselves, except in the case of treatment at a hospital, rehabilitation centre or thermal cure centre if prior authorisation has been obtained for such a cure.

Invoices from establishments such as beauty salons, fitness centres, hotels, and thalassotherapy and balneotherapy centres are not reimbursed.

1.6. The following are not reimbursed: treatment for aesthetic purposes, swimming pool subscriptions, enrolment fees for sports or fitness centres.

1.7. Any treatment not listed under point 2 is subject to prior authorisation.

2. Special provisions

MP: Medical prescription required

PA: Prior authorisation required

Chapter 9 - Medical auxiliaries

Section 1 - Convalescent and post-operative cures

A thermal cure is a stay of not less than ten days and not more than 21 days at a specialist establishment providing treatment under medical supervision using water taken from a spring before it has lost its biological and pharmacodynamic properties which derive from its richness in ions and oligoelements.

A stay in a paramedical centre approved by the national health authorities and specialising exclusively in the treatment of chronic illnesses can be considered to be equivalent to a thermal cure.

To qualify for reimbursement, the cure must be authorised in advance by the Settlements Office after consulting the Medical Officer and take place in a centre approved by the national health authorities.

Authorisation for a cure is limited to:
. one cure a year, up to a maximum of eight cures in the lifetime of the beneficiary, for each of the following categories of pathology:
1. rheumatism and sequellae of trauma to bones or joints
2. phlebology and cardio-arterial diseases
3. neurological diseases
4. disorders of the digestive tract and related structures, and metabolic disorders
5. gynaecological disorders and disorders of the kidneys and urinary tract
6. dermatology and stomatology
7. diseases of the respiratory tract

. one cure a year provided that it is taken in connection with the treatment of a serious illness or in the case of severe psoriasis which does not respond to conventional treatment.

Cures such as thalassotherapy and fitness cures are not considered to be thermal cures qualifying for reimbursement.

Reimbursement of the cost of spectacles is limited to two pairs, consisting of a frame and corrective lenses regardless of type:
. either one pair of spectacles with single vision lenses for near vision and one pair of spectacles with single vision lenses for distance vision,
. or one pair of spectacles with multifocal or progressive lenses and, if necessary, one pair of spectacles for correcting short or long sight.

The Scheme will not reimburse the following:
. spectacles with non-corrective lenses,
. sun-glasses,
spectacles for work on a computer screen for staff in active employment.

Except in the case of a medically attested change in dioptre or axis of 0.50 or more, the renewal period for reimbursement is two years (one year for children under 18) from the date on which the previous pair of spectacles in the same category was purchased.

The cost of spectacles with corrective lenses prescribed by an ophthalmologist or an ophthalmic optician is reimbursed at the rate of 85%, subject to the following ceilings:
. frames: €120
. lenses:
€110 per single vision lens up to 4 dioptres
€140 per single vision lens from 4.25 to 6 dioptres
€180 per single vision lens from 6.25 to 8 dioptres
€300 per single vision lens of 8.25 dioptres or above
€350 per lens for multifocal or progressive lenses.

The cost of an examination by an ophthalmic optician, in the absence of a prescription or examination by an ophthalmologist, is reimbursed at the rate of 85%, subject to a ceiling corresponding to that for a consultation or visit by a general practitioner.

Costs relating to tests of central vision or measurements using electronic equipment carried out by an optician or an optometrist are included in the ceiling for lenses.

In the case of loss of or damage to the frame or lenses before the end of the minimum period for renewal, the cost of repair or replacement is reimbursed up to the value of any previously unused portion of the ceiling for that period.

The original receipted invoice must specify:

. the type of vision to be corrected (distance - near - multifocal),

. a description of the lenses (strength of each corrective lens/dioptres),

the price of the lenses and frame, indicated separately.

a) General
. Reimbursement of the cost of corrective contact lenses does not rule out reimbursement of a pair of spectacles with single focus corrective lenses for near or distance vision or of a pair of spectacles with multifocal or progressive lenses.

. In the case of loss or tearing of the contact lenses before the end of the minimum period for renewal, the cost of replacement is reimbursed only up to the value of any previously unused portion of the ceiling for that period.

The scheme will not reimburse the cost of non-corrective coloured contact lenses.

b) Reimbursement conditions

The cost of purchasing conventional and/or disposable corrective contact lenses, prescribed by an ophthalmologist or ophthalmic optician, and of products for use with them, is reimbursed at the rate of 85%, with a ceiling of €500 per period of 24 months.

Costs associated with adaptation and supply of trial lenses by the ophthalmologist or ophthalmic optician are included in the ceiling for contact lenses.

The cost of an examination by an ophthalmic optician, in the absence of a prescription or examination by an ophthalmologist, is reimbursed at the rate of 85%, subject to a ceiling corresponding to that for a consultation or visit by a general practitioner.

c) Submission of invoices

The original receipted invoice must specify:
. the type of vision to be corrected (distance - near - multifocal),
. a description of the contact lenses (strength of each corrective lens/dioptres),
. the type of lenses: disposable or conventional,
. the cost of the lenses.

A derogation may be granted from the reimbursement conditions laid down for each category of lens or contact lens, subject to prior authorisation, in the case of recognised serious eye disease, supported by a medical report, or if the cost of purchasing lenses or contact lenses is greatly in excess of the maximum reimbursable amounts as a result of very limited sight or extreme dioptres.

The cost of purchasing artificial eyes is reimbursed at the rate of 85%, or 100% in the case of serious illness.

The amount of the allowance towards funeral expenses payable under Article 25 of the joint rules is €2 350.

This allowance is paid only on presentation of a copy of the death certificate.

In the case of a still birth, the allowance is granted provided that the foetus had reached at least 22 weeks.

In the case of the death of a person with top-up insurance, the allowance will be reduced by the amount of the allowance of the same type received from another source.

This allowance is separate from the reimbursement of the costs involved in transporting the body of an official in active employment, or of his or her spouse, dependent children or persons treated as dependent children, which by virtue of Article 75 of the Staff Regulations are borne by the institution to which the official belongs.

ANNEX I - LIST OF SURGICAL OPERATIONS

a) "normal" reimbursement;

b) reimbursement for an "accident or occupational disease" (giving the corresponding references);

c) reimbursement for "serious illness" (giving the corresponding references);

d) reimbursement for "staff serving outside the European Union".

. the patient's full name
. the nature of the treatment
. the dates and fees paid for each medical treatment
. the name and official references of the healthcare provider.

. the name of the prescribing practitioner
. the patient's full name
. the name of the prescribed medicine or, for generic medicinal products, the product supplied, or the composition of the preparation for magistral preparations (the preparation number will not suffice)
. the price of each product
. the full price and, for persons with top-up insurance, the price actually paid . the date on which the medicines were supplied
. the chemist's stamp and signature.

2.1. Members, as defined in Article 2 of the joint rules, who voluntarily choose a different legal or statutory sickness insurance scheme as their primary cover.

2.2. The member's spouse or recognised partner who is not gainfully employed or in receipt of income deriving from previous gainful employment but is eligible for cover by another legal or statutory sickness insurance scheme and voluntarily chooses such a scheme.

2.3. A spouse or recognised partner who is in gainful employment or in receipt of income deriving from previous gainful employment, as defined in Article 13(2) of the joint rules, provided that his or her annual income before tax is less than the basic salary of an official in grade AST2/1 multiplied by the correction coefficient for the country in which the income is received, and that he or she is covered by a sickness insurance scheme for all the treatment covered by the JSIS.

2.4. In order to maintain his or her spouse or partner's eligibility for top-up reimbursement, the member must send the Settlements Office each year the latest official documentary evidence of their pre-tax income (such as a tax certificate or other document drawn up by the competent national authorities).

Eligibility may then be extended on the basis of such documents from 1 July of the current year to 30 June of the following year.

If a spouse or partner enters gainful employment in the course of the year, eligibility for top-up cover is determined on the basis of the actual amount earned (before tax) during the fraction of the year in question, starting from the date on which the first income was received. If the income from gainful employment of the spouse or partner changes in the course of the year, this is taken into account only for establishing entitlement for the following year.

2.5. Member's children who are dependent within the meaning of Article 2 of Annex VII to the Staff Regulations, provided the scheme of the spouse or partner referred to above has agreed to provide them with primary cover without additional contributions.

. hospitalisation and surgical operations
. treatment and tests in hospitals or clinics
. convalescent and nursing homes
. home carers
. thermal cures and convalescence

. In the event of hospitalisation, direct billing covers the main invoices and the surgeon's fees.

If they are invoiced separately, invoices from the anaesthetist and the assistant may also be covered by direct billing.

The duration of direct billing of this type is 60 days. If the stay in hospital exceeds 60 days, an application for an extension should be submitted to the Medical Officer, together with a medical report explaining the need for the extension.

. Intensive out-patient care as part of a serious illness, (e.g. radiotherapy, chemotherapy or dialysis).

. Expensive medicines that must be bought repeatedly, such as growth hormones, repeated use of a standard or light ambulance, or expensive tests, if the monthly cost exceeds 20% of the member's pension or basic salary.

In the event of direct billing, after the reimbursement rates have been calculated the costs to be met by the member are, as a rule, deducted from later reimbursements, or from the salary, pension or other sums owing from the institution. At the request of the Settlements Office, the balance may be reimbursed by a transfer to the JSIS bank account.

. a shortened life expectancy
. an illness which is likely to be drawn-out
. the need for aggressive diagnostic and/or therapeutic procedures
the presence or risk of a serious handicap.

. medical costs which appear, in the light of current scientific knowledge, to be directly linked to the diagnosis, treatment or monitoring of the development of the serious illness, or any complications or consequences it causes;

costs eligible for reimbursement associated with dependence caused by the serious illness.

. the date of the diagnosis
. the exact diagnosis
. what stage the illness is at, and any complications
. the treatment required.

. how the illness has developed
. the treatment and/or care still required.

. Unqualified opinion: the auditor certifies the regularity and bona fide nature of the JSIS annual accounts and that they give a true and fair view of the previous year's financial transactions and of the Scheme's financial position and assets at the end of the year.

. Qualified opinion: in this case the auditor

a) has noted errors, anomalies or irregularities in the application of accounting principles; the effect of these is significant, but does not warrant the rejection of the annual accounts as a whole;

b) has been unable to scrutinise the accounts with the rigour he or she deemed necessary, although the imposed limitations have not been sufficient to warrant an adverse opinion.


In either case, the auditor must clearly indicate in the report either the nature of the errors or the limitations that led to the qualification. Moreover, figures should be included whenever possible for any qualified opinion under (a) above. Such figures should show the effect on the entry in the annual accounts, on the profit or loss for the financial year, and, if the error affects it, on the opening balance sheet.

If the qualification is entered under (b) above, the amounts in the annual accounts that might be affected by the limitations should be indicated.

a) has noted errors, anomalies or irregularities that are sufficient to compromise the validity and reliability of the annual accounts as a whole; and/or

b) has worked under limitations or in circumstances such that he or she is unable to form an opinion on the annual accounts as a whole.