JOINT SICKNESS INSURANCE SCHEME

NOTICE FROM THE CENTRAL OFFICE

Reimbursement of nursing care expenses

The purpose of this notice is to explain the rules applied by the Settlements Offices concerning the grant of prior authorisation for nursing care and the conditions to be met to obtain reimbursement of the costs incurred.

Home nursing care:

This consists basically of nursing care provided at the home of a patient for a number of hours, or even for full days/nights.

Nursing care may include the services of medical auxiliaries (administering injections, applying bandages, etc.) depending on their qualifications.

Application for prior authorisation:

The medical prescription which must accompany applications for prior authorisation must include:

• a diagnosis of the ailment and condition of the patient; if the medical officer considers it necessary, he/she may ask the personal physician to complete a questionnaire;
   
• the number of hours’ care provided per day and/or night;
   
• the estimated overall duration.

Requirements:

• Carers must be legally entitled to practise their profession.
  
  In countries where the profession is not regulated and/or where it is impossible to find an officially approved carer, the personal physician must indicate on the prescription the name of the person who is to provide the services and specify that the person has the qualifications necessary to provide the care. The carer’s diploma may also be required.
   
• Invoices must comply with the law of the country in which they are issued.
  
  Where carers are not answerable to an officially recognised body (e.g. Red Cross) or do not operate within an officially recognised private framework, they must be registered with the competent national or regional authorities (e.g.: valid contract of employment and/or an insurance policy covering the employment of the carer) and evidence of this must be sent to the Settlements Office.
  
  In the case of people who have already received authorisation for nursing care, evidence of this registration must be sent to their Settlements Office by 1 July 2005 at the latest.
  
  The Joint Sickness Insurance Scheme cannot under any circumstances agree to reimburse the costs of the services of an undeclared worker.
  
  In the absence of the necessary documents, the cost of the relevant services can no longer be reimbursed.

Reimbursement:

These costs are reimbursed at the rate of 80% subject to fixed ceilings (regardless of the number of hours’ service which must correspond to that shown on the application for prior authorisation) which do not vary in the event of reimbursement at the rate of 100% and irrespective of the number of people providing the care.

The present rules provide for three types of home nursing care:

• Care following hospitalisation for a maximum period of 45 days which may be extended once for the same period. The ceiling is €59.87 for 12 hours and €74.37 for 24 hours (*);
   
• Care for a maximum period of 90 days. The ceiling is €59.87 for 24 hours (*);
   
• Care for a period not exceeding 12 months which may be renewed. The ceiling is calculated as follows: basic salary of a grade C*2/1 official (currently €2 441.45) less 10% of the basic salary or pension of the member. Invoices must be submitted monthly.
  
  (*) Without parity coefficient