EU, EEA and Switzerland
What do I need to look out for when receiving healthcare abroad (EU, EEA and Switzerland)?
A distinction must be made between emergency (essential) treatment and planned treatment. The terms of coverage depend on whether the treatment abroad is urgent (essential treatment) or planned.
Emergency treatment (essential treatment during the stay)
If you are staying abroad (holidays, studies, detachment etc.), any essential treatment is paid for on the basis of the European Health Insurance Card (EHIC).
Upon presentation of the EHIC or a replacement certificate, you can receive treatment in the country where you are staying under the same conditions as a resident.
It is possible to deliberately decide to seek treatment abroad before leaving Luxembourg.
Inpatient care (at least one overnight stay) requires prior authorisation from Luxembourg in order for the treatment to be covered. Upon presentation of a transfer request issued by a specialist doctor and following a favourable opinion from the CMSS, two types of agreement are possible.
- Either the CNS issues an S2 form, which guarantees coverage for planned care in the treatment country according to the rates and tariffs in force there.
- Or the CNS issues a "directive" authorisation, i.e. a letter of coverage that tells you the treatment is authorised and that the invoices paid will be reimbursed at Luxembourg tariffs. (Naturally, the reimbursement cannot exceed the costs actually paid.)
Outpatient care (hospital care with no overnight stay or outside of the hospital, for instance in a medical practice...)
For outpatient treatment (hospital treatment with no overnight stay or treatment outside hospital, e.g. at a doctor's practice etc.), prior authorisation is not required. However, if the treatment provided involves highly specialised and costly medical infrastructure or equipment, authorisation is necessary. Planned outpatient treatment is reimbursed by Luxembourg according to Luxembourg rates and tariffs.
Which country's legislation applies in cases of emergency care received in a EU Member State, Switzerland, Iceland, Liechtenstein or Norway?
If immediate access to healthcare proves necessary during a temporary stay in a EU Member State, Switzerland, Iceland, Liechtenstein or Norway, regardless of the purpose of the stay (holiday, studies, detachment etc.), treatment will be paid for based on your European Health Insurance Card.
The European card certifies that you are entitled to any health treatments necessary from a medical point of view in the country where you are staying, subject to the nature of the treatment and the planned length of your stay. This means that you are entitled to care from a medical viewpoint in order to ensure that you do not have to interrupt your stay to seek treatment.
The European Health Insurance Card entitles you to the same treatment as residents of the country where you are staying. This applies equally to procedures/conditions as to the price of the care received.
When and how can I use the European Health Insurance Card?
The European card can be used in all the Member States of the European Union as well as in Iceland, Liechtenstein, Norway and Switzerland when you need healthcare, whether you are on holiday, studying or travelling for work, subject to the length of your stay. Under a bilateral agreement with the respective countries, the European Health Insurance Card is also valid for stays in Macedonia, Serbia and Montenegro.
Your European Health Insurance Card is issued in your name and cannot be used by anyone else. If you are no longer insured in the country that issued the card, it can no longer be used. The card certifies that you are entitled to the necessary healthcare in the Member State where you are staying in order to continue your stay under safe medical conditions rather than having to interrupt your stay to seek treatment at home. Presenting the card entitles you to payment or subsequent reimbursement of medical costs incurred in the country you are visiting. This means you can be reimbursed directly for the costs incurred by the health insurance fund in the country where you are staying.
When and how am I not allowed to use the European Health Insurance Card?
The card cannot be used for planned treatment, i.e. when the only reason for your travel is to receive healthcare or medical treatment.
The European Health Insurance Card can only be used with approved healthcare providers, i.e. providers associated with the country's social security system. However, if the treatment is delivered by a non-approved or private provider, the costs can still be reimbursed under the terms of directive 2011/24 according to Luxembourg conditions and tariffs.
What can I do if my European Health Insurance Card is not accepted?
For necessary treatments, you must pay the costs for the medical care received and apply for reimbursement either from a health insurance fund in the country where you are staying or from your competent fund.
- If invoices are sent/given to the fund in the country you are visiting, you will be reimbursed according to the rates and tariffs of that country.
- If invoices are sent/given to the competent fund, it will ask the fund in the country visited for the tariffs applied (using form E126/S067). As soon as a response is received, you will be reimbursed according to the rates and tariffs of the country you visited. In addition, when the invoices are sent/given to your competent fund you can expressly request to be reimbursed based on Luxembourg rates and tariffs.
With an approved healthcare provider and for necessary treatment, the card can normally not be refused.
If I fall ill abroad and I do not have my European Health Insurance Card, what can I do?
If you do not have your European Health Insurance Card with you, the cover for medical treatment according to the same conditions and prices as residents does not apply. For example, even if certain emergency/necessary treatments are free (paid for directly by the foreign health fund) for residents, you may have to pay a fee.
You will have to advance all the costs for the treatment received and ask your competent health fund for a refund on your return.
However, if you are hospitalised urgently during a temporary stay abroad, your competent fund can - upon request - send you, the hospital or the foreign health insurance fund a temporary replacement certificate which guarantees the same level of protection as your European Health Insurance Card. On the basis of this certificate, treatment will be covered as if you were insured in the country where the care is provided.
If I fall ill abroad, where should I send my medical certificate of incapacity for work?
An insured person in Luxembourg should send all medical certificates of incapacity for work to the CNS within 3 days. This means that if you fall ill in your country of residence or during a temporary stay abroad and you receive a medical certificate of incapacity for work, the certificate should always be sent to the health insurance fund in your country of affiliation rather than your country of residence.
If you are staying in a country that does not issue medical certificates of incapacity for work, the health insurance fund in the country you are visiting will still be able to issue a form certifying your illness. This form should be sent to the CNS.
Under what circumstances can a refund at Luxembourg tariffs be refused?
A refund may be refused, partially or in full, because of:
- Treatment not provided for in Luxembourg;
- Limits specified by the classification system (e.g. reductions, combinations of treatments, more than three actions, actions that cannot be combined with a consultation etc.);
- Medication not included on the positive list of medications;
- Analyses with no prior medical prescription attached;
- Analyses invoiced by a medical clinic (grand ducal regulation restrictive list);
- Physiotherapy, speech therapy, hearing aids without entitlement;
- Physiotherapy by a provider other than a physiotherapist, e.g. a midwife;
- Services that are non-refundable in Luxembourg (dental crowns with no prior quotation, adult orthodontics, orthosis over €125 etc. with no quotation and the prior authorisation of the CMSS);
- Psychomotor treatment without the prior authorisation (APCM) of the CMSS;
- Renewal interval not respected;
- Requirement for entitlement to cover for physiotherapy, speech therapy and hearing aids;
- Requirement to entitlement for medication not included on the positive list (following a request from a doctor);
- Prior authorisation from the CMSS for psychomotor treatment...
This is not an exhaustive list.
Any medical technique or diagnostic method used by a foreign specialist doctor involving hospital infrastructure and inpatient or partial inpatient accommodation costs not covered by prior authorisation from the CMSS (S2 form) will not be reimbursed and must be paid for in full.
What is the normal waiting time for the reimbursement of medical costs incurred abroad?
For emergency treatment abroad, the reimbursement time depends on the timeliness of the response provided by the foreign health insurance fund. When emergency treatment is provided, Luxembourg requests the tariff from the fund in the country where you were staying. This means that the reimbursement time varies depending on the time the various foreign funds take to respond.
In the case of planned outpatient treatment (without prior authorisation) in a country of the EU, EEA and Switzerland, Luxembourg issues the refund according to Luxembourg conditions, rates and tariffs. The normal waiting time is a few weeks.
Scheduled treatment abroad
Is prior authorisation needed to consult a doctor in a EU Member State?
No, for consultations with a doctor (in a foreign health centre, clinic or hospital) you do not necessarily need prior authorisation. The reimbursement is made according to Luxembourg rates and tariffs. It is important to remember that no reimbursement will be made if the terms specified by the CNS statutes are not respected.
However, authorisation is required if the doctor uses highly specialised medical equipment specified in the restrictive list (Table of equipment and devices subject to planning/Annex 3) or the consultation requires the use of hospital infrastructure.
Prior authorisation can still be applied for if a prescribing doctor directs the patient to a colleague abroad. In this case, the procedure for requesting prior authorisation should be respected.
If prior transfer authorisation is granted, the insured person is entitled to request a travel allowance, which is not the case without prior transfer authorisation.
I would like to travel to a EU Member State, Switzerland, Iceland, Liechtenstein or Norway for treatment. What rules do I need to observe?
The conditions of cover depend on whether the care you want to receive abroad will be administered on the basis of an authorised treatment/transfer or not.
1. There are certain types of treatment that can only be provided abroad if prior authorisation is given. The treatments that require prior authorisation from the competent country are:
- inpatient treatment (at least one night in hospital)
- treatment requiring the use of hospital infrastructure
- treatment requiring highly specialised medical equipment
- treatment subject to APCM (prior authorisation from the CMSS)
2. In the case of outpatient treatment that does not require prior authorisation (e.g. doctor's surgery, single consultation with a specialist doctor in a foreign health centre or clinic etc.), reimbursement is possible without prior authorisation according to the tariffs in the competent country on presentation of the paid invoices.
What form does an authorisation for treatment/transfer abroad take?
There are two types of authorisations for a transfer abroad:
The S2 form is governed by the regulations (EC) 883/2004 and (EC) 987/2009. It is issued in the case of a positive opinion from the CNS and enables cover at the tariffs of the country where treatment is provided. In the best case, cover can be provided in the treatment country through the third-party payment system. If specifically requested, an additional refund may be applied for in the competent country (Luxembourg).
Given that the invoicing/reimbursement of treatment abroad may be different from invoicing/reimbursement in Luxembourg, it is important to remember to complete all the formalities with a possible additional fund (copies of the request + CNS S2 authorisation).
Authorisation based on article 20 of CSS
Following transposition into Luxembourg Law of directive 2011/24.
With a directive agreement, you pay the costs of the treatment in full and are refunded by your competent fund in Luxembourg according to the conditions and tariffs in force in Luxembourg (see question 11). If authorisation is granted, the insured person will receive a certificate of coverage (titre de prise en charge) explaining the reimbursement terms (costs to be advanced, reimbursement to be requested from the competent fund in Luxembourg according to the tariffs or fixed amounts specified). Given that the costs invoiced may be high, and far higher than the amount refunded by the fund in Luxembourg, the insured person is advised to ask the specialist centre abroad for a quotation for the costs of the treatment.
The procedure for requesting authorisation remains the same for both types of authorisation.
In the case of inpatient treatment or any other treatment that requires prior authorisation, no reimbursement will be made without an S2 or a directive agreement.
What is the S2 form?
This form certifies your right to planned treatment abroad. With the S2 form, you can expect the same conditions of cover at the same rates as people insured in the country of treatment. In the ideal case, it enables cover for the treatment costs through the third-party payment system via a local health insurance fund in the country of treatment.
If the third-party payment system does not apply, reimbursement is provided for at the rates of the treatment country by the health insurance institution in the country of treatment. If specifically requested, an additional refund may be applied for from the competent fund in Luxembourg.
How is authorisation obtained for treatment/transfer abroad?
Authorisation must be requested from the CNS before the planned treatment begins. The application is made based on a written, reasoned request from a doctor. The authorisation of the CNS is required in order to claim a refund later. Each request is evaluated and the insured person is notified of the decision.
There is a standard form which doctors use to make the request. This form "demande d'autorisation préalable d'un transfert à l'étranger" is defined by annex L of the CNS statutes. The request can be sent to the CNS by post, fax or e-mail or submitted in person to CNS desk 14 in Hollerich.
What is the validity period of the S2 form? Can it be renewed? If so, under what conditions?
The S2 is valid for the period mentioned under point 2.3.1 of the form. In general, the validity period corresponds to the duration requested by the prescribing doctor, which is the basis on which the CNS gives its opinion. If necessary, an extension may be requested by the patient's doctor for sound medical reasons.
A renewal can be requested by the patient's doctors under the same terms as the initial request.
If authorisation for a transfer abroad is granted, what do I do with the S2 form? Who do I give it to?
It is not clearly defined whether the foreign doctor offering the treatment is required to accept the S2 form. It is therefore advisable to ask the specialist centre abroad beforehand whether they agree to accept the S2 form and to carry out the formalities required in relation to the legal health insurance fund abroad.
If the specialist centre does not carry out these formalities, you will have to ask a local health insurance fund of your choice about the procedure to follow with the S2 form.
If consultations or outpatient examinations are all that is required, you can also advance the costs yourself and apply for a reimbursement from your insurer in Luxembourg.
For treatments that use highly specialist medical equipment or other treatments subject to special authorisation procedures involving the health insurance fund in the country of treatment, it is important that the S2 form and the request for authorisation to cover the medical care are submitted to the foreign health insurance fund for approval. In general, the specialist centre abroad will take care to comply with the procedures.
Which country's legislation applies in cases of planned care received in a EU Member State, Switzerland, Iceland, Liechtenstein or Norway?
If you want to seek treatment from a doctor, physiotherapist or other healthcare provider in a foreign surgery, health centre, clinic or hospital, you do not need prior authorisation from the CNS.
You must pay the costs of the treatment in full and apply for reimbursement from the Luxembourg health fund. You will be refunded according to the conditions and tariffs in force in Luxembourg.
If the treatment involves an overnight inpatient stay or highly specialised medical facilities (on the list of treatments subject to prior agreement), prior authorisation is necessary.
- If authorisation is granted for a transfer abroad, you will receive an S2 form, issued by the CNS, as specified by regulation 883/2004. This form certifies your right to planned treatment in another European Union Member State, Iceland, Liechtenstein, Norway or Switzerland. On presentation of the S2 to the health insurance institution in the country where the treatment will be provided, you will receive healthcare under the same conditions as people insured in that country. The treatment covered by the authorisation is thus paid for according to the conditions and tariffs in the country where it is provided.
- In addition, payment can take place under the terms of directive 2011/24/EU on the application of patients' rights in cross-border healthcare. The provisions of the directive apply if an S2 form cannot be issued because the treatment does not fall within the scope of application of the health insurance (e.g. rare illnesses), the treatment is provided in a private institution or you choose to apply the provisions of the directive. In this case, you pay the costs of the treatment in full and are refunded by your competent fund in Luxembourg according to the conditions and tariffs in force in Luxembourg.
NB. Make sure you keep detailed invoices so that the refund can be made at Luxembourg tariffs.
In the event of treatment in a EU Member State, can I receive treatment in the establishment of my choice, or are there restrictions?
In the context of the 883/2004 Regulation, treatment is only covered at the establishment mentioned on the S2. The transfer request necessarily refers to a specific treatment at a specific establishment and is authorised by the CNS.
If the request concerns a non-approved private establishment that does not accept the S2, the 2011/24 directive applies. Here again, if authorisation is granted, the entitlement to cover only applies to the specific establishment mentioned on the request.
How are the costs of authorised treatment in a foreign hospital covered? Do I have to pay the foreign clinic directly?
- If you have S2 authorisation, the cost of treatment is covered by a health insurer in the country of treatment at the rates and tariffs of that country. Ideally, cover is provided through the third-party payment system, i.e. the fund in the treatment country covers the treatment and you are responsible only for the proportion payable by the patient and any supplements.
If third-party payment does not apply, you must advance the costs and apply to your insurer in the treatment country or the Luxembourg fund for a reimbursement. The reimbursement is provided at the rates of the treatment country. On express request, an additional refund may be applied for from the competent fund in Luxembourg.
- In the case of a 2011/24 directive agreement, you must advance the costs in all cases and apply for reimbursement from the Luxembourg health fund. The reimbursement will be made at the rates, tariffs and conditions in force in Luxembourg.
What is covered?
- The S2 authorisation only allows for coverage under the same conditions and at the same rates and tariffs of the country of treatment. The S2 form does not guarantee full coverage of the medical costs incurred.
For example, fee supplements and other personal arrangements are not covered (e.g. Chefarztbehandlung, Wahlleistungen, supplement for a room with one bed or two beds, etc.) You can request an additional refund from the competent insurer. If the costs payable by you, excluding any supplements, are higher than the costs theoretically payable in your competent country, you can receive the difference within the limit of the reimbursement rates and tariffs in the competent country.
- With an authorisation under article 20 of the CSS (following transposition of directive 2011/24 into Luxembourg Law), healthcare is covered at the rates and tariffs of the competent country.
What can I do if the S2 is not taken into consideration by the provider and I receive an invoice to pay the total amount?
It is important to obtain as much information as possible about the coverage through the S2 form before treatment begins. The healthcare professional or even the health insurance fund in the country of treatment can provide you with information.
If the provider refuses coverage based on the S2, you must pay the invoice and request a refund.
In the case of inpatient treatment, approved centres should invoice the treatment directly to the insurer in the country of treatment. They may sometimes request a coverage form/certificate issued by this local health insurer. This is why it is important to seek information beforehand.
In the case of inpatient treatment, if you receive an invoice from the establishment even though you provided the S2 form, it is advisable to contact the establishment and try to arrange direct coverage. The CNS International Department can also assist; they will try to convince the provider to accept the S2 form and withdraw the invoice.
I would like to receive treatment in a country outside the European Union, Switzerland and the EEA. What rules do I need to observe?
Countries bound by bilateral agreement with Luxembourg should be distinguished from countries with no agreements.
All medical treatment planned before departure is subject to prior authorisation from the CNS. The same procedure for requesting authorisation applies here and in the other EU and EEA countries as well as Switzerland.
- For countries linked to Luxembourg by an agreement in terms of social security, the principles laid out by the respective agreement apply. If authorisation is granted, some agreements provide for a specific form allowing for coverage according to the rates and tariffs in force in the country of treatment. The specific details of each agreement must be checked on a case-by-case basis.
The countries are:
- For third-countries not linked to Luxembourg by an agreement in terms of social security, if authorisation is granted, you receive a certificate of coverage (titre de prise en charge) from the CNS. You must pay the costs of the treatment in full and apply for reimbursement on their return. The CNS sets the refund amount or decides whether any increase may be granted.
What reasons might lead to authorisation for treatment abroad being refused?
- No affiliation;
- Non-compliance with the APCM (prior authorisation from the CMSS);
- Non-compliance with the authorisation request procedure;
- The treatment falls outside the scope of health insurance;
- The treatment is not covered or the conditions for coverage are not fulfilled;
- The healthcare can be provided in Luxembourg within a time limit that is medically justifiable, taking into account his current state of health and the probable course of the condition;
- A clinical examination shows with sufficient certainty that the patient will be exposed to a safety risk that cannot be considered acceptable given the potential advantage for the patient of seeking healthcare abroad;
- There are valid reasons to think that the general public will be exposed to a considerable safety risk if the patient seeks healthcare abroad;
- The healthcare must be provided by a foreign healthcare provider that arouses serious specific concerns with regard to compliance with standards and approaches relating to the quality of care and patient safety.
What can be done if authorisation for treatment abroad is refused (appeal process)?
If authorisation is not granted, the parties may send a written objection to the Council of Administration of the CNS within forty days of receiving the decision.
To be valid, the objection must be signed by yourself, your legal representative or your proxy. The proxy may be a lawyer or a representative of a professional association or trade union of which you may be a member and must have a special written power of attorney.
It is advisable to send the objection by registered post to the address of the Council of Administration of the CNS.
Where can the S2 authorisation form be found?
The S2 authorisation form can be found under the section Forms.