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Sickness and maternity insurance provides insured individuals and their families with coverage for healthcare services (hospital, doctor's visits, pharmacy, etc.) delivered by providers legally established in Luxembourg.
Both residents and non-residents are entitled to healthcare coverage through one of several national health insurance funds. The fund with which the insured is enrolled depends on their socio-professional status. It is:
Enrolment with social security confers entitlement to the coverage of costs incurred in the event of an illness, for:
The healthcare services must be provided by approved providers, in other words, providers that have entered into an agreement with the National Health Fund, and have agreed to apply pre-determined rates (note that in Luxembourg, contractual agreement is automatic for any provider authorised to establish a practice).
Insured individuals are free to contact the care providers of their choice. However, only those procedures, services and supplies listed in the Luxembourg classification of procedures and rates (nomenclature), or in similar such lists provided for by Luxembourg laws, regulations, agreements and statutes, and delivered by persons or institutions authorised to practice their profession in Luxembourg, are covered by health insurance.
In exceptional cases, medical procedures that are not listed in the classification of procedures may be covered, on condition that (i) a detailed medical certificate is provided by the treating physician, and (ii) a favourable opinion is obtained from the Social Security Medical Board (Contrôle médical de la sécurité sociale), which sets a rate for reimbursement by analogy.
The reimbursement of certain benefits in kind (travel expenses, etc.) are subject to conditions.
'Benefits in kind' notably means:
1. the insured or co-insured individual goes to see a health professional;
2. the insured person pays the the health professional immediately or by bank transfer at a later moment;
3. the insured person sends the bill or statement of fees together with, where applicable, a proof of payment (notification of debit) to the competent health insurance fund in order to be reimbursed;
4. the insured person must attach the medical prescription where applicable.
The application for reimbursement must specify:
Note that no postage (stamps) is required for mail being sent in Luxembourg. Bills or statements of fees for costs paid in advance by persons insured by the National Health Fund may also be submitted in person at a local CNS agency.
5. the reimbursement is made via bank transfer. The reimbursed amount depends on the contractual rate or, where applicable, certain statutory conditions. As such, certain services are subject to prior authorisation from the Social Security Medical Board, without which the fund will not cover the delivered care.
Additional costs incurred for reasons of 'personal convenience' (convenance personnelle - CP) (CP codes) or first-class hospital accommodation (individual room) are fully borne by the insured.
Insured individuals who have taken out supplementary insurance (CMCM or similar) may send the relevant bills to their insurer for additional reimbursement.
Insured individuals who are experiencing financial problems may apply for direct coverage of their healthcare costs through the social security third party payer system.
Each local agency in the CNS agency network may issue checks for the purpose of reimbursing healthcare costs, provided that the relevant bills had been paid no more than 15 days before the date of application, and that their amount is as least EUR 100. Checks issued in this way may be cashed, with no cost or withholding, at any POST Luxembourg post office.
In certain cases, such as for the costs of hospitalisation, pharmaceutical drugs or laboratory services, a part of the costs covered by health insurance is paid directly by the fund. This system of direct payment is known as the third party payer system. For this system to operate, a social security card is required.
In this case, the insured pays the provider only their contribution to the healthcare costs (e.g. upon being released from the hospital).
In the calendar year, an insured individual's contribution to their healthcare costs is capped. In the case of payment for care exceeding 2.5 % of the annualized contributory income, the insured individual is entitled to an additional reimbursement from their health insurance fund for contributions exceeding the threshold in question. To determine the amount exceeding the threshold, the contributions made by both the insured and the co-insured parties are added.
For each reimbursement, the competent health insurance fund will send the insured person a detailed statement of reimbursement by post.
In order to simplify the procedure, the insured person can subscribe to the service "eDelivery" on MyGuichet.lu. This service allows to receive the detailed statement of reimbursement in the form of an electronic document ("eDocument"). Once this feature has been activated, the insured person receives a notification by email each time a statement of reimbursement is posted in his or her private eSpace on MyGuichet.lu.
By activating the eDelivery service, the insured person waives the right to receive a detailed statement of reimbursement by post.