Nursing and convalescent homes
Procedure to be followed, rates of reimbursement, and special cases.
|The joint sickness insurance scheme (JSIS) covers the costs of long-term residence in a convalescent home, nursing home, rehabilitation centre, psychiatric home, etc.|
Step 1: request prior authorisation
The dependence evaluation form must be duly completed by the doctor. The doctor must also write a medical report justifying the need for the stay and stating the nature of the care needed by the patient.
If you don’t have access to JSIS online, please follow the traditional procedure. Fill in a request for prior authorisation and the declaration form. Don’t forget to attach all the original documents. Send everything in a sealed envelope to your Settlement Office (the correct address is on the form).
Step 2: ask for direct billing
You have the right to request direct billing (for medical care only). This will allow the hospital to send the main invoice to the joint sickness insurance scheme (JSIS) for direct payment. Fill in the direct billing form for nursing homes .
Note : Direct billing is not possible for beneficiaries of a complementary insurance.
Step 3: get a statement
The settlements office will send you a statement. You can also find it in JSIS online . You may have to pay part of the costs yourself (e.g. the remaining 15 % when you have 85 % cover). That sum will be deducted from later reimbursements.
If you paid the invoice yourself, you can claim reimbursement. Don’t forget to attach the detailed invoice and a medical report.
Conditions for reimbursement
The following permanent or long-term residence costs are reimbursed :
- residence in a convalescent or nursing home approved by the competent authorities and having medical and/or paramedical facilities for the elderly and/or the disabled
- continuous and permanent residence in a psychiatric home approved by the competent authorities and having medical and/or paramedical facilities
- residence in an establishment for rehabilitation or functional re-education in cases where a request for prior authorisation for reimbursement of hospitalisation has been refused
- continuous, long-term residence in a psychiatric hospital for more than 12 months where a request for prior authorisation for reimbursement as hospitalisation has been refused
- attendance at a day centre
- stays in a non-hospital drug rehabilitation centre.
The member’s degree of dependence is determined on the basis of the lowest score on the dependence evaluation form, as in the table below (only degrees 1 to 4 are reimbursed) :
|Score||Degree of dependence|
|91 – 100||5|
|75 – 90||4|
|50 – 74||3|
|25 – 49||2|
|0 – 24||1|
All of the costs of care and accommodation are reimbursable at the rate of 85%, or 100% in the case of serious illness, with a ceiling of €36 per day for accommodation costs.
If all items are aggregated on the invoice so that it is not possible to separate the costs of care from the accommodation costs, the costs will be divided according to the degree of dependence in the proportions given in the following table :
|Degree of dependence||Costs of care||Accommodation costs|
|4||30 %||70 %|
For continuous residence and care in a rehabilitation or functional re-education establishment, psychiatric hospital, psychiatric home or drug rehabilitation centre, the costs will be divided according to the degree of dependence 1.
For stays and care in a non-hospital drug rehabilitation centre, or equivalent establishment, reimbursement is limited to a total stay of 6 months in a 12-month period.
Exception: day centre
For daytime attendance only at a convalescent or nursing home for the elderly or a neurological or psychiatric day centre, the ceiling for accommodation costs is lowered to 18€ per day.