One of the main principles of long-term care insurance is that the keeping of dependent persons in their own home is preferable to accommodation in a care and assistance facility.
This priority comes from the desire to enable everyone to live comfortably in their own home for as long as possible. In order to meet this objective, long-term care insurance covers the following benefits:
- benefits in kind;
- cash benefits;
- the lump sum for incontinence products;
- assistive technology;
- home adaptations;
- pension contributions for informal carers.
Persons who wish to benefit from long-term care insurance in order to receive home care should send their application to the National Health Fund (Caisse nationale de santé - CNS).
If the applicant receives the dependent person status based on the evaluation carried out by the Administration for Evaluation and Controls (Administration d'évaluation et de contrôle - AEC) of the long-term care insurance, all assistance and care provided by a care and assistance network (benefits in kind) is covered from the date of submission of the application.
Who is concerned
Each person registered with the health insurance and their co-insured family members are entitled to long-term care insurance. Each person is entitled to long-term care insurance, regardless of income, provided they have been recognised as dependent.
Persons who take out voluntary health insurance must have been affiliated with their health insurance fund for at least one year.
For individuals registered with the Luxembourg health fund (Caisse Nationale de Santé - CNS) who have been recognised as dependent persons, but who do not reside in Luxembourg (e.g., cross-border workers), Luxembourg is competent for covering cash benefits. Persons concerned must address the health fund in their country of residence with respect to benefits in kind.
Within the framework of home care, this means that the CNS can cover assistance and care services provided by a carer. The insured person should contact the health fund in the country of residence with regard to care services provided by a health care provider.
Persons affiliated with a health fund in another Member State of the European Unionbut residing in Luxembourg may be eligible for coverage in Luxembourg for care services provided by a home assistance and care network.
A person is deemed to be a dependent person if the following conditions are met:
- a person who, owing to a physical, mental, psychiatric or similar illness, requires significant help and regular assistance from another person to carry out basic day-to-day tasks (actes essentiels de la vie - AEV);
- basic day-to-day tasks refer to personal hygiene (e.g., bathing), assistance to go to the toilet, to eat, to dress and mobility issues;
- the level of assistance needed to carry out basic day-to-day tasks must be of a certain level and represent at least 3 ½ hours of care per week in the aforementioned areas;
- the need for assistance must be required for a minimum of 6 months or be permanent.
How to proceed
Applying for coverage
A person who wishes to benefit from long-term care insurance must submit their application for long-term care benefits by post to the National Health Fund (CNS) at the following address:
Caisse nationale de santé - Assurance dépendance
B.P. 1023 - L-1010 Luxembourg
The application consists of 2 parts:
- the form to be completed by the applicant;
- the medical report (R20) attached to the second part of the form and completed by the applicant's general practitioner.
The medical report (R20) is free of charge for the applicant: the physician is paid directly by the long-term care insurance.
In this report which is for the attention of the Administration for Evaluation and Controls, the doctor provides information on the applicant's state of health. While the role of the doctor is important, they are not the ones who decide whether the person is dependent.
The application will only be considered complete when both documents (the form and the report) have been submitted to the National Health Fund (CNS).
A return receipt confirms receipt of the application.
Evaluation and determination of the assistance and care services required
The National Health Fund (CNS) forwards the application file to the Administration for Evaluation and Controls (AEC) of the long-term care insurance which is responsible for determining the dependence and to evaluate the level of dependence.
The evaluation of the state of dependence is performed by a health professional from the AEC, in the applicant's home, the premises of the AEC or the care and assistance facility. The applicant will be informed of the upcoming evaluation.
In principle, the health professional is responsible for the application file and also guarantees its follow up. Their contact details will be communicated to the applicant at the time of the evaluation.
During the evaluation, the dependent person's capacity to perform basic day-to-day tasks will be examined. The person applying for the benefits will be asked questions, and if needed, also a person in their immediate environment.
After the evaluation, the health professional draws up a summary of the assistance and care services to which the dependent person is entitled during one week, which will then allow to see if the help required reaches the minimum of 3.5 hours/week for basic day-to-day tasks (AEV).
Communication of the decision to cover care services
The President of the National Health Fund (CNS) takes the decision based on the AEC's opinion. The decision is submitted, where applicable, together with the summary of assistance and care services that will be provided. Both the dependent person and the service provider (care and assistance network or facility) will be informed of the decision.
The summary will inform the dependent person of:
- the different services to which the dependent person is entitled (basic day-to-day tasks, measures to support the person's independence, care services to keep the person at home, support activities in the care and assistance facility, lump sum to purchase incontinence products);
- the weekly amount of care and assistance services;
- a detailed description of the care and services to be provided;
- the distribution of the assistance and care services provided by the informal carer and the assistance and care network, and where applicable, the costs covered;
- assistive technology and adaptations to housing to be granted after the evaluation.
The benefits will be granted at the earliest from the day the complete application is submitted.
Assistance and care networks and day or night care centres (benefits in kind)
Dependent persons wishing to receive home care can contact an assistance and care network. These are health professionals who can provide the help and care required within the framework of long-term care insurance.
The cost of the assistance and care services provided by the network is covered directly by long-term care insurance (benefits in kind).
The care and assistance network is also responsible for carrying out nursing tasks.
As a consequence, the dependent person may be entitled to:
- aid and care to carry out the basic day-to-day tasks;
- activities to support an independent life;
- home care services.
The help networks coordinate their work in order to ensure that dependent persons receive all the care that they need. For group support activities, they may also collaborate with day or night care centres.
Informal carer (cash benefits)
A person providing help and care services on a regular basis at least once a week may be recognised as a caregiver under certain conditions.
This may be:
- a close friend or a family member (spouse, child, even a neighbour); or
- a hired help declared to the Joint Social Security Centre (Centrecommun de la sécurité sociale – CCSS) (in this case, cash benefits can contribute to the payment of the carer's salary).
The carer must have been identified and evaluated so that the benefits in kind (help provided by the care and assistance network) can be replaced by cash benefits.
Depending on these criteria and the findings of the health professional from the AEC, the latter will decide if the person providing help and care can be retained as a carer.
If this person is maintained as the carer, he/she will provide help and care on his/her own or in collaboration with the care and assistance network (réseau d'aides et de soins - RAS). If help from the care and assistance network becomes necessary, the dependent person has freedom of choice with respect to the selection of the care provider.
In the case where the carer provides care services (whether alone or in collaboration with the care and assistance network - RAS), the dependent person is entitled to a lump sum to cover the expenses in relation with the services provided to carry out basic day-to-day tasks and/or the household services provided by the carer.
The lump sum granted is in euros per week (cash benefits) and is paid to acknowledge the care provided by the carer. There are 10 different levels of cash benefits which depend on the amount of help and care provided by the carer.
If the carer is unavailable, the dependent person can request help from a care and assistance network of their choice in order to receive assistance and care.
If home care is no longer guaranteed, the dependent person may receive these services in a care and assistance facility.
Combination with other benefits
Beneficiaries of long-term care benefits may not receive the following at the same time:
- a health insurance benefit of the same nature (health insurance takes priority in this case, except for coverage of assistive technologies);
- benefits of the same kind provided for by the accident insurance, the legislation relating to disabled persons or the differentiated education, all of which take priority where appropriate;
- a housing benefit, which is suspended up to the amount covered by long-term care insurance for home adaptations. Costs exceeding the amount covered by the insurance may still be covered by the housing benefit.
Review of the file
If the degree of required assistance and care changes, the dependent person may request that their situation be re-evaluated. The re-evaluation may also be requested by:
- family members;
- care providers;
- the CNS;
- the AEC.
In principle, a re-evaluation can only be requested one year after the last decision, except if the medical report states that there has been a fundamental change in circumstances since then.
The person submits the request for re-evaluation with the same form used to submit the initial application.
When the new evaluation gives rise to an increase in benefits, this increase will, in theory, take effect on the first day of the week in which the application was submitted. If the benefits are reduced, the reduction will be effective on the first day of the week following notification of the decision to reduce the benefits.
Revocation of benefits
If the conditions that resulted in the benefits being granted disappear, long-term care insurance benefits will be discontinued.
Benefits paid in error must be repaid, notably when the beneficiary's situation changes without the long-term care insurance management body being notified.
If the applicant does not agree with the CNS's initial decision, they may oppose it before the CNS's executive committee. To do so, they need only send a letter to the executive committee of the CNS within 40 days of the decision. The procedure is described in the decision that the person receives.
When the applicant lodges an opposition to the decision, their file is re-evaluated by the Administration for Evaluation and Controls (AEC) in order to assess the merits of the opposition.
If the applicant does not agree with the decision of the CNS's executive committee, they may file an appeal, within 40 days of receiving notification of the decision, with the Social Security Arbitration Tribunal (Conseil arbitral de la sécurité social - CASS) located in Luxembourg. A simple petition on plain paper submitted to the CASS will suffice.
CASS decisions can, themselves, be appealed if the amount in dispute is in excess of EUR 1,250. Applicants have to address the High Council of Social Security (Conseil supérieur de la sécurité sociale) within 40 days of the notification of each decision.