A prior authorisation from Luxembourg is required for inpatient hospital care or if health care is provided, using highly specialised medical equipments (included in the list of treatments subject to prior authorisation) in a Member State of the EU, the EEA and Switzerland.
Germany, Austria, Belgium, Bulgaria, Croatia, Cyprus, Denmark, Spain, Estonia, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Malta, The Netherlands, Poland, Portugal, The Czech Republic, Romania, Slovakia, Slovenia, Sweden
Iceland, Liechtenstein, Norway
Types of authorisation
Upon presenting a request for prior authorisation issued by a doctor and following a favourable opinion from the Medical Board of the Social Security (CMSS), two types of authorisations are possible.
If the request concerns a contracted (non-private) establishment or hospital in the country, where treatment is provided, the insured person receives a S2 form, provided for by regulation 883/2004. This form is issued following a favourable opinion from the CMSS and certifies the right to planned treatment in another European Union Member State, Iceland, Liechtenstein, Norway or Switzerland.
Directive 2011/24 Authorisation
Coverage 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 the insured person chooses to apply the provisions of the directive.
For outpatient health care (health care in a hospital without an overnight stay or healthcare outside a hospital, for instance a medical practice), prior authorisation is not necessary, unless the doctor uses highly specialised and costly hospital infrastructure or medical equipments.
Choice of establishment
In the context of the regulation 883/2004, treatment is covered only, if it is provided in the establishment mentioned on the S2 form. This establishment must be contracted in the country of treatment. The transfer request necessarily refers to a specific treatment in a specific establishment and is authorised by the CNS, based on a favourable opinion from the CMSS.
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.
Procedure for requesting authorisation
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.
There is a standard form which doctors use to make the request. The request can be sent to the CNS by post, fax or e-mail.
Each request is evaluated in administrative and medical terms and the insured person is notified of the decision.
The procedure for requesting authorisation remains the same for both types, S2 authorisation and directive 2011/24.
In the case of inpatient treatment or any other treatment which requires prior authorisation, no reimbursement will be made without an S2 or a directive authorisation.
Period of validity
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 CMSS 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.
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.
For treatments which involve highly specialised medical equipments 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 ensures that the procedures are complied with.
Refusal of the S2 abroad
If the provider refuses coverage based on the S2, the insured person 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, issued by this local health insurer. This is why it is important to seek information beforehand.
In the case of inpatient treatment, if the insured person receives an invoice from the establishment even though they received an 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.
Terms of coverage
Upon presenting the S2 form to the health insurance institution in the country where the treatment will be provided, the insured person will receive healthcare under the same conditions and at the same rates 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. The S2 form does not guarantee full coverage of the medical costs incurred. 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.
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.).
The insured person can request an additional refund from the competent insurer. If the costs payable by the insured person, excluding any supplements, are higher than the costs theoretically payable in their competent country, the insured person will receive the difference within the limit of the reimbursement rates and tariffs in the competent country.
Directive 2011/24 Authorisation
With an authorisation under directive 2011/24, healthcare is covered at the rates and tariffs of the competent country. If authorisation is granted, the insured person receives 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 treatment costs.
In this case, the insured person pays the costs of the treatment in full and is refunded by their competent fund in Luxembourg according to the conditions and tariffs applicable in Luxembourg.
Reasons for refusing an authorisation request
- 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.
Appealing a refusal
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.