Third-party social payment

From 1^st January 2013, individuals with a low-income will be entitled to request assistance under the third-party social payment. Such requests should be made to the presiding social welfare office. The purpose of this scheme is to enable people in economic hardship to access medical and dental treatments.

Upon presentation of a time-limited certificate issued by the presiding social welfare office, the individual concerned will no longer be required to pay for their healthcare expenses upfront and apply for a refund at a later date. Instead, these costs will be paid directly by the National Health Fund.

Article 24.2 of the Social Security Code

"Direct payment shall further be granted to individuals in economic hardship, as duly documented by a certificate issued by the presiding social welfare office, pursuant to the terms of the relevant statutory and conventional provisions."

Pursuant to the provisions of the law of 18 December 2009 concerning social assistance, any person who is a legal resident of the Grand Duchy of Luxembourg may submit such a request to the social welfare office of their commune.

The social welfare office has sole authority to determine whether the request meets the necessary conditions for eligibility for the third-party social payment.

There are 30 social welfare offices responsible for providing social assistance throughout the country. The presiding social welfare office is determined by the commune in which the individual is resident. Each social welfare office presides over residents of one or more communes.

The list of social welfare offices and the communes that each office covers may be found here.

In order to be eligible for third-party social payment, the individual concerned must be a member of the health insurance scheme. When a request is received, the social welfare office will first check that the individual is a member of the scheme and, where applicable, sign them up to the scheme.

The social welfare office will then have sole authority to determine whether or not to grant third-party social payment to the individual. This decision is made on a case-by-case basis.

The third-party social payment currently covers medical and dental services.

Our tool "Invoices explained" can be consulted on our website.

• Time-limited certificate
• Book of labels

Where the social welfare office decides that the individual is eligible for the third-party social payment, it will issue the individual concerned with a time-limited certificate and a book of labels, by hand.

The certificate and the book of labels are issued in the beneficiary's name.

They feature the beneficiary's ID number and the validity period of the third-party social payment.

Separate labels are issued for each family member. In other words, invoices for treatment provided to a child are not covered by the third-party social payment if they feature a label bearing the mother's or father's name. The invoice must feature a label bearing the child's name.

The third-party social payment validity period is determined by the social welfare office. As a general rule, it is limited to a maximum of 3 months. In exceptional cases, the validity period may be extended to 6 months.

The validity period is the period between the start and end dates of the third-party social payment. These dates are shown on the third-party social payment certificate, along with the accompanying labels.

Any service performed on a date outside the third-party social payment validity period, as indicated on the certificate and the labels, will not be covered by the third-party social payment.

The third-party social payment ends automatically on the end date of the validity period as indicated on the label and the certificate.

Once this date has passed, the third-party social payment may be extended or renewed at the beneficiary's request, subject to the approval of the social welfare office in line with the relevant procedures.

The social welfare office may withdraw the third-party social payment before the end of the validity period. In this case, and wherever possible, the social welfare office will recover the certificate and any remaining labels from the beneficiary.

Any person who wishes to apply for the third-party social payment must submit a request to the social welfare office responsible for the commune in which they are resident.

The social welfare office will determine whether the individual meets the third-party social payment eligibility criteria.

Where the social welfare office decides that the individual is eligible, it will issue the individual concerned a time-limited certificate and a book of labels.

The social welfare office agent then informs the individual how the third-party social payment works, and reminds them of their obligations as a beneficiary. These include an obligation to present their social security card or other identity document to the service provider and to provide the certificate and labels.

The person then signs a formal statement, which is included in their file. This statement is used as evidence in the event that the social welfare office contests the amounts paid by the CNS.

Where the beneficiary presents a valid third-party social payment certificate and label to the doctor or dentist, covering the date on which the services are delivered, they are then entitled to receive the medical and dental services under the third-party social payment.

NB: for some dental services, double approval is required by the social welfare office

The beneficiary of the third-party social payment must give their doctor or dentist the third-party social payment certificate issued by the social welfare office, along with the book of labels, both of which must feature their name. They must take along an ID document and their social security card for identification purposes.

The beneficiary must abide by the same rules that apply to any person seeking services under the health insurance scheme.

Example:

To avoid abusive consumption, without justification approved by the Medical Board of the Social Security (Contrôle médical de la sécurité sociale CMSS), from more than two different doctors from the same medical discipline within any consecutive six-month period.

Where the beneficiary wishes to receive medical and dental services under the third-party social payment, they must prove their identity with an ID document and their social security card and must present the necessary documentation demonstrating their eligibility for the third-party social payment, i.e. the time-limited certificate and labels.

When an individual covered by the third-party social payment visits a doctor or dentist, they must present the certificate and labels issued by the social welfare office.

Where the beneficiary presents a valid third-party social payment certificate and label to the doctor or dentist, covering the date on which the services are delivered, they are then entitled to receive the medical and dental services under the third-party social payment.

The doctor then sends the invoice, bearing the beneficiary's label, directly to the CNS's TPS department.

Under the third-party social payment, the CNS acts as the relevant authority for all insured parties, including those covered by the three public sector health funds.

The CNS pays the service provider at the full rate for the service provided, pursuant to the medical codes for medical services and activities and the medical codes for medical analysis and clinical biology laboratory services and activities, as covered by the health insurance scheme and this agreement.

The full rate corresponds to the rate for the service provided, including the contribution arising from the coverage rates as set out in the CNS's bylaws for the rate concerned.

It then contacts the presiding social welfare office to recover the portion of the costs payable by the patient, in accordance with CNS's bylaws.

The social welfare office pays the patient portion to the CNS, then checks whether the beneficiary is in a position to repay their personal portion to the social welfare office.

NB: additional fees for personal convenience (CP1-CP7) are excluded from the third-party social payment and must be paid by the beneficiary. The third-party social payment will only cover an additional fee (CP8) for dental services and supplies as agreed with the insured party, where such fees exceed the rates covered by health insurance.

Double approval by the social welfare office is required in the following cases:

• Prior quotation

Dental services that involve the provision of a prior quote (DSD - quotation exceeded) (e.g. certain orthodontic services or treatments involving dental prostheses) require double approval by the presiding social welfare office. The dentist issues the beneficiary with a quotation, including a label. The beneficiary then sends this quotation to the social welfare office for prior approval, i.e. the social welfare office determines the extent of its contribution and approves this value as stated on the quotation. Where approval from the Medical Board of the Social Security (CMSS) is required, the beneficiary sends the quotation to the CNS for authorisation. The social welfare office only assesses the quotation once this authorisation has been granted. The service may only be covered by the third-party social payment if the corresponding quotation has been double-approved by the social welfare office.

• Personal convenience (CP8)

CP8: An additional fee charged by dentists for equipment costs agreed with the insured party (e.g. porcelain, gold, etc.) that exceeds the rates as set out in the nomenclature and not covered by health insurance.

Where this personal convenience represents an additional cost exceeding €25 per session, it may only be covered by the third-party social payment if the corresponding quotation has been approved by the social welfare office. The social welfare office determines the value of its contribution, i.e. the excess amount above the amount covered by the CNS. This prior approval is not required if the excess amount is less than or equal to €25.

NB: additional fees for personal convenience (CP1-CP7) that may be charged by the doctor or dentist are excluded from the third-party social payment and must be paid by the beneficiary.