How is the dependent person informed of the decision?
The decision concerning the allocation of benefits is taken by the President of the National Health Fund (Caisse nationale de santé – CNS) based on the opinion of the State Office for Assessment and Monitoring of the long-term care insurance (Administration d'évaluation et de contrôle – AEC). It is accompanied by the summary of care and assistance required by the dependent person.
This summary provides information on:
- the various benefits and allocations to which the dependent person is entitled (activities of daily living, activities to support independence and autonomy, home-care support activities, inpatient support activities, allocation for incontinence products);
- their weekly care and assistance requirements;
- detailed descriptions of the care and assistance to be provided, how the care and assistance is allotted between the caregiver and the care and assistance network and, where applicable, the lump-sum payments;
- the assistive technology or home adaptations allocated to the dependent person in light of their assessment.
The summary is sent to the dependent person and to the care and assistance provider (care and assistance network or establishment).
If the applicant disagrees with the decision
They may file an objection to the decision with the Administrative Board of the National Health Fund (CNS). To do so, they must send a letter to the President of the CNS within forty days of the decision. The letter must be signed by the applicant themselves (or their legal representative, if the applicant is a minor or under guardianship).
The procedure for filing an objection is described in the document informing the person of the decision. It is set out in French and in German.
When the person lodges an objection to the decision, their file is reviewed by the AEC to determine the merits of the objection.
If the person still disagrees with the decision returned by the Board of Directors of the CNS, they can lodge an appeal with the Social Security Arbitration Tribunal (Conseil arbitral de la sécurité sociale).
This must be done within forty days of the decision.
If the person disagrees with the decision of the Social Security Arbitration Tribunal, they can lodge an appeal with the High Council of Social Security (Conseil supérieur de la sécurité sociale).
Once again, the person has forty days to lodge the appeal.
If the person's need for care and assistance changes
The dependent person can request a reassessment of their situation. To apply for a reassessment, a dependent person would normally have to wait one year from the previous one, unless there is a fundamental change in their circumstances.
They can simply file another application for long-term care insurance benefits. If they reapply before one year has elapsed, the primary care physician must provide details of the fundamental change in circumstances in the R20 medical report.
The reassessment can also be requested by a member of the dependent person's family, the caregiver, the care and assistance provider, the National Health Fund (CNS) or the State Office for Assessment and Monitoring of the long-term care insurance (AEC). The AEC will decide whether it is sensible to reassess the dependent person before one year elapses.
Once the application for a reassessment has been filed, the person's dependency status is evaluated once again. A new decision will be taken and the dependent person notified accordingly.
The benefit allocations will be increased if the person has a greater need for assistance. The increase in benefit allocations will take effect on the first day of the week in which the application was filed.
The benefit allocations will be reduced if the person has a lesser need for assistance. In this case, the reduction in benefit allocations will only take effect on the first day of the week immediately after that in which the person was notified of the reduction.