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In existence since 1 January 2013, the third-party payer system (tiers payant social - TPS) was introduced to facilitate access to medical and dental care for people with modest incomes, by sparing them from having to pay healthcare expenses in advance and then applying for reimbursement. Under the system, healthcare expenses are covered (paid) directly by the National Health Fund (Caisse nationale de santé - CNS).
Who is concerned
Any person with modest income who is a legal resident of Luxembourg.
Only the competent office can determine whether the applicant satisfies the conditions required for using the third-party payer system.
To use the third-party payer system, the applicant must be validly enrolled for health insurance.
If the applicant is not yet enrolled for health insurance, the social welfare office may be able to enrol them.
How to proceed
Applying to use the third-party payer system
People who wish to use the third-party payer system must apply to the competent social welfare office for the commune where they reside, which will first check that they are enrolled for health insurance and, if necessary, enrol them. The competent social welfare office depends on the commune where the applicant resides. Each social welfare office covers one or more communes.
The social welfare office has sole authority to determine, on a case by case basis, whether the applicant needs to use the third-party payer system.
If the application is approved, the social welfare office delivers a time-limited certificate to the applicant, accompanied by a book of yellow labels.
The certificate and the book of labels are made out in the name of the beneficiary and mention:
- the beneficiary's national identification number;
- the expiry date of the third-party payer certificate.
Separate labels are prepared for each family member. For example, bills for care provided to a child are not accepted by the third party payer system if the label affixed to the bill bears the name of the mother or father. The label affixed to the bill must bear the child's name.
Duration of validity of the third-party payer certificate
In general, the third-party payer certificate is valid for no more than 3 months. Exceptionally, access to the third-party payer system may be granted for 6 months.
Services provided outside the period of validity stated on the certificate, and on the labels, will not be covered by the third-party payer system.
The right to make use of the third-party payer system expires automatically at the end of the period of validity mentioned on the certificate and the labels.
After that expiry date, the right to use the third-party payer system may be extended or renewed, at the beneficiary's request, and with the approval of the social welfare office, under the agreed terms and conditions.
The social welfare office may revoke the right to use the third-party payer system before the expiry date. In that event, the social welfare office is responsible for recovering the certificates and the remaining labels from the beneficiary, if possible.
Obligations of the beneficiary
Beneficiaries sign a commitment statement, which is attached to their file. This statement may be used in the event that the social welfare office objects to amounts charged by the CNS.
When visiting their doctor or dentist, a beneficiary of the third-party payer system must bring:
- the third-party payer certificate provided by the social welfare office in their name;
- the book of labels prepared in their name;
- a valid ID document;
- their social security card.
In addition, beneficiaries must comply with the same rules applicable to anyone wishing to use the health insurance system, including avoiding excessive visits by seeking the services of more than 2 different doctors in the same speciality within a period of 6 consecutive months without a reason accepted by the Social Security Medical Board (Contrôle médical de la sécurité social - CMSS).
Types of services covered
The third-party payer system currently applies to services provided by doctors and dentists.
For certain dental services, double approval (or prior approval) by the social welfare office is mandatory. This is the case for services for which an estimate is prepared in advance, such as certain orthodontic procedures or care relating to dental prostheses.
In those cases, the dentist affixes a label to the estimate and gives it to the beneficiary, who in turn forwards it to the social welfare office for prior approval. The social welfare office determines the amount it will cover and states that amount on the estimate.
Where authorisation by the CMSS is required, the beneficiary forwards the estimate to the CNS for authorisation. Approval by the social welfare office will be given only after the CNS authorisation.
Payment of costs for care received
The healthcare provider affixes on their bill a label bearing the name of third-party payer beneficiary who received the care and sends it directly to the CNS, to the attention of the department "Tiers payant social (Third-party Payer Department). As a reminder, for all matters concerning the third-party payer system, the CNS is the competent body for all insured patients, even those covered by the 3 public-sector health insurance funds.
The CNS pays the healthcare provider the full rate for the service being covered, in accordance with the classification of procedures carried out by doctors, the classification of procedures carried out by dentists, and the classification of procedures carried out by medical laboratories and biological clinics, covered by health insurance and the respective agreements.
The CNS then contacts the competent social welfare office to recover the patient's share of the cost, in accordance with CNS rules. The social welfare office pays the patient's share to the CNS and then checks whether the beneficiary is able to repay them the patient' share.