2009年12月中国残疾人联合会（CDPF）会议演讲
卢森堡，L-2974
艾希公路125号
评估和指导小组
安德烈-克尔格尔
电子邮箱：andree.kerger@igss.etat.lu
概述
在过去五十年里，因私营部门和国家的资助，帮助人们居家生活的住房机构和服务得到了发展。社会保障事实上并没有介入对长期护理的资助，长期护理是由护理受益人和国家来处理的。
生活在卢森堡的人口的老龄化，已经使得这种随意的工作的缺点日益突出：变化不定的财政资助、因信息的缺乏导致难以获得健康保险等。
同时，各国政府注意到了管理长期护理费用的这种不均衡性，他们反复重申他们的第一要务是让人们呆在家里。
在1994-1999年的任职期间，对老年人和残疾人的长期护理发生了最重大的变化。
这个立法机构制定了几项法律，它们从根本上改变了需要长期护理的老年人和残疾人的健康保险：
-规定了国家和在社会、家庭和医疗领域工作的行政机关之间的关系的法律，它构成了卢森堡有关老年人和残疾人护理行政人员的审批法规的法律背景；
-允许国家基金（“Fonds national de solidarité”）向在针对综合家居、保健诊所和监督式住房住户的老年人护理保险框架内提供的福利缴款的法律；
-引入一项长期护理保险的法律；以及给予残疾人社会教育护理1福利的机构。
这些法律定义了针对老年人和残疾人的长期护理组织的现有框架。
自从1999年以来，除了社会保障的完善带来的各种好处之外，随着家庭部、青年部和社会团结部的完善，带来了有利于老年人和残疾人的整个政治方向；并且自从2009年以来，随着家庭和融合部的完善，也带来了有利因素。
涵盖长期护理保险的法律
1998年6月19日的法律引入了长期护理保险，它按社会保障原则运营，也就是说，缴纳义务的社会保障缴款能够无条件地让残疾人有资格享受长期护理保险服务，而无需考虑其财力及其年龄。
其目的在于弥补救助一名残疾人使之能够进行日常生活基本活动的需求所产生的费用。
正幸亏有了这一法律，长期护理才被看作一项社会保障风险，其风险承受能力与疾病、工伤事故、永久丧失工作能力和老龄相同。
涵盖长期护理保险的法律做了以下安排：
·建立一个义务性的社会保障制度；
·建立一种无条件的权利，使得受保护人群有权享受实物服务，并使得辅助者有权享受现金服务，从而使得他们能够从一名旁人那里，获得他们日常生活的基本活动所需的协助和护理；
·具有一个残疾人福利的评估、定位和和授予体系的机构；
·处理与协助和护理提供者的关系的组织，这取决于残疾人是住在家中还是住在一家护理 机构之中；以及具有稳定的财务制度的机构（社会保障税和国家捐款。参加健康保险的所有人群均同时参加长期护理保险 。）
1. 依赖状态的定义
在1998年6月颁布的法律的框架之内，依赖状态的定义是 “因身体或者精神疾病或者同样性质的缺陷，表现为其日常生活的基本活动明显并经常需要旁人的协助的一个人的状态”。
采用的这一定义的基础是需要旁人协助的概念。
这一中心概念自身的定义有四个因素：
·与医学上的原因有联系。协助需求必须是一种身体或者精神疾病，或者同样性质的缺陷的结果；
·对其目的限制。协助需求必须产生于日常生活的基本活动。日常生活的基本活动是与三个领域紧密相关的那些活动：个人卫生、营养和行动自由；
·强度下限，准入门槛。协助需求必须证明规定的重要性。这一所需的最低限度的帮助必须达到每星期至少3.5小时；
·时间下限，持续时间。协助需求必须延续一个规定的时长或者一种不可逆转的健康状况，并且必须呈现时间上的规律性。这一时长被设定为六个月。
2. 依赖状态和协助需求的评估。
依赖状态的评估具有两个基本特征：协助需求评估的专业跨学科性和护理计划的个体化。
2.1评估协助需求的跨学科性
依赖状态的评估被托付给依据案例而选择的一名医生和一名健康专业人员（心理医生、护士、物理治疗师、职业治疗师、社会工作者）。它包括体格检查，接着是与申请服务的人面谈。这种面谈的目的是描述影响此人日常生活的基本活动的各种限制。评估通常在此人的生活环境中进行。
2.2护理计划的个体化
在卢森堡的长期护理保险的框架之中，我们并不选择按他们的依赖程度来对残疾人进行分类，而是根据一套个人评估体系来进行分类，由此受益人有权享受适合于他们自己的需求的护理计划。为残疾人考虑的每项护理或者帮助，是按一个标准的时长来进行分配的。这个标准时长的总数客观地说明了对依赖状态的评估。它是服务款项和准入门槛（享受服务所需的最少帮助）的参考以及各种福利上限（保险所给予的最高福利）的基础。
3.长期护理保险的服务
被评估和倾向小组（the Evaluation and Orientation Unit）认定为处于依赖状态的人，有权按照他们自己的需求，获得以下服务：
·他们因日常生活的基本活动2而需要的协助和护理；
·帮助照料家务，比如清洁和洗涤；
·以辅助活动的形式给予的帮助。这些活动主要是为了激励残疾人的自理能力，并防止依赖状态的恶化。这些活动也是为了让非正式的护理员能有计划地休假34；
·以专业咨询的形式给予的帮助，其目的是防止限制残疾人的自理潜力，并让残疾人的亲人熟人学习合适的协助和护理动作。
该法律对其他服务作了规定。长期护理保险也考虑到了：
·为非正式护理员买养老金缴款保险。
·购买或者雇用技术辅助设备：轮椅、适用床（adaptable bed）、助行架，定位壳（positioning shell）等
·必须的住房改造，以便更便于活动，从而提高 受益人的自理能力，并让他们能在家生活。
·用于购买协助和护理所需的器材的财政补贴。
当残疾人待在家中时，可以用现金服务（一笔钱）来部分或全部替代实物服务（专业人员提供的协助和护理）
·现金服务的目的是让受益人自己购买他所需要的护理，方式是召唤旁人或者长期护理保险的提供者。可以是一位近亲或者朋友，也可以是残疾人直接付费的一名专业人员。
·但是，这种转换的可能性是有限的。头七个小时的协助和护理可以完全被现金服务所取代。在七个小时和十四个小时之间，只能替代一半。如果是十四个小时以上，就不允许替代。
3.3 服务的上限
一名受益人就日常生活的基本活动，每星期最多能享受24.5小时的协助。对于严重的或者例外的情形，这个上限可以提高到每星期38.5小时。
对于家务，提供的水准是每星期 2.5小时。对于因依赖状态所产生的特殊需求，这个每周水准可以提高到 4小时。
支持活动限于每星期 14小时。
在护理计划的开始阶段，需要咨询服务，会持续有限的一段时间。
4. 长期护理保险的组织
长期护理保险是由一个行政机构运营的，称为“Caisse nationale de santé”。它作出所有个人的决定，并管理长期护理保险的预算。关于个人决定的通知由评估和倾向小组（the Evaluationand Orientation Unit）表述，该小组评估依赖状态并确定残疾人所享受的服务。它也负责控制提供给残疾人的服务的数量和质量。
咨询委员会负责给出以下方面的意见：
·依赖状态评估的工具，也就是评估问卷和标准声明（或者护理计划）；
·长期护理保险框架中的有利于特定人群的试验性的措施的项目；以及
·长期护理保险所维护的技术辅助设备的清单。
质量委员会定义对服务所要求的质量标准。
5. 与服务提供者的关系
长期护理保险承认几种服务提供者
5.1护理机构的定义是向残疾人昼夜提供膳宿，并根据他们的依赖状态，向他们提供他们所需的所有协助和护理的机构。有两种护理机构：连续居留机构，可让残疾人永久居留，或者间歇逗留机构，可让残疾人定期地离开该机构。这种机构是专为残疾人预备的。
5.2护理网络的定义是一伙有组织的一个或一个以上的自然人或者法人，分散在一个既定的地理区域，各具有不同的并且互补的技能，从而能够提供和协调对残疾人的全球护理。其网络结构使得残疾人能够联系一名对话者。它也能够在残疾人正呆在家里时，确保协助和护理的持续性。该网络必须有一个半静态的中心，让残疾人可以在白天或者晚上到达。
5.3通过协助和护理合同实现框架协议的批准和会员资格（”框架公约（conventioncadre）”）。为被允许代表长期护理保险提供协助和护理，服务提供者必须获得监督部（thesupervising ministry）的批准。批准定义了服务提供者为履行其活动所必须满足的条件。
此外，他们还必须通过一份协助和护理合同，成为框架协议的一方。该框架协议是在长期护理保险行政机关和服务提供者之间协商的。它指明了各方的权利和义务，介入了长期护理保险。
6.长期护理保险的资助
资助保险所需的资源由以下各项构成：
·国家预算所支付的一笔缴款，占所有费用的45％；
·最大的电力消费者所支付的一笔特别缴款；以及一笔长期护理缴款。这最后一笔缴款是每个健康护理保险被保险人应交的：
·这笔缴款的计税基础包括职业收入，替代收入和资本收入；
·关于职业收入和替代收入，每月计税基础要减去等于受保障最低工资的.的一笔免税额；
·没有最低和最高缴款水平；并且固定税率为1.4％。
注：
1为认知残疾人护理的特殊性，监督部已经决定引入社会教育护理的概念，它包括照料残疾人所需的特殊和附加服务。其定义为“以支持残疾人达到并保持最佳的身体、知觉、智力和精神生活方式自理水平以及最佳的社会融入水平的想法和权利为目标的注册服务提供者的结构化的一套安排和活动”。
监督部以个人固定费用介入资助这种社会教育护理，“目的是让管理者能够面对没有参加长期护理保险的残疾人的特定需求所产生的特定费用”。
2在营养方面，它主要包括帮助准备食物，以促进吸收，还有帮助吸收。
在人体卫生方面，它包括 ，例如帮助清洗、清洁某人的牙齿、保证皮肤和体表护理，以及帮助排泄。在行动能力方面，例子有帮助移位、改变姿势、帮助残疾人保持一个合适的姿势、帮助穿衣和脱衣、帮助在家和在楼梯上移动，以及帮助外出和回家。
3非正式护理：不属于一个护理网络的、在家帮助并照料残疾人的社交圈中的一个成员（通常是一名家庭成员或者一名近亲）。他／她也可以是不属于一个正式护理网络的一名专业人员。
4支持活动可能包括让不能独处的某人在家处于专业监督之下，专门的个人监督，陪同外出、购物或者支持参与群体活动 ，特别是去专门的日托中心。
LONG-TERM CARE INSURANCE
SITUATION IN GRAND DUCHY OF LUXEMBOURG
PRESENTATION REGARDING THE CONFERENCE CDPF
DECEMBER 2009
Andrée Kerger
Cellule d’évaluation et d’orientation
125 route d’Esch
L-2974 Luxembourg
e-mail : andree.kerger@igss.etat.lu
Introduction
During the last fifty years, housing institutions and services helping people to stay at home have been developed with funds from both the private sector and the state. Social security virtually did not intervene in financing long-term care, which the care beneficiary and the state dealt with.
The ageing of the population living in Luxembourg has underlined the shortcomings of this arbitrary working: Highly variable financial aid, access to health cover made difficult by a lack of information, etc.
At the same time various governments noticed this disparity in the way that long-term care costs were taken care of, and they kept on reasserting that maintaining people at home was their priority.
IDuring the 1994-1999 term of office, the most significant changes regarding long-term care to elderly and disabled people occurred.
This legislature made several laws that have radically changed the health cover of elderly and disabled people requiring long-term care:
-the law setteling the relations between the State and the administrative bodies working in the social, familial and therapeutic fields which forms the legal background of regulations in Luxembourg regarding the approval of administrators of care for elderly and disabled people;
-the law allowing the National Fund (“Fonds national de solidarité”) to contribute to the price of benefits provided within the framework of the gerontological cover for inhabitants of integrated homes, health-care clinics and supervised housings;
-the law introducing a long-term care insurance; and
-the institution of granting of benefits for the sociopedagogic caring of disabled people1.
These laws define the current framework of the long-term care organization for elderly and disabled people.
Since 1999, with the exception of aspects coming within the competences of the social security, the whole political orientation in favor of the elderly and disabled people comes within the competences of the Ministry of Family, of Social Solidarity and of Youth; and since 2009 within the competences of Ministry of the Family and Integration.
The Law covering Long-term Care Insurance
The law of 19th June 1998 introduced long-term care insurance which operates on social security principles, that is to say that paying a compulsory social security contribution unconditionally entitles the dependent person to the services of the long-term care insurance, without any consideration of its financial resources and its age.
It aims at making up for the expenses generated by the need for aid of a dependent person in order to perform the essential activities of daily living.
Thanks to this law, long-term care is recognized as a social security risk in the same capacity as sickness, industrial accident, permanent invalidity and old age.
The law covering long-term care insurance puts the following disposition in place:
. Creation of a compulsory social security system;
. Creation of an unconditional right which entitles protected people to services in kind and subsidiary to services in cash in order to enable them to obtain from an outsider the assistance and cares they need for their essential activities of daily living;
. Institution of a system of assessment, orientation and granting of benefits for dependent people;
. Organization of the relations with assistance and care providers depending on whether the dependent person lives at home or in a care institution; and
. Institution of a stable financial system (social security contribution and State contribution.
All people covered by health insurance are covered by the long-term care insurance as well.
1. Definition of dependence state
In the framework of the 19th June 1998 Law, the state of dependence is defined as “the state of a person who, as a result of a physical or mental sickness or of a deficiency of the same nature, expresses a significant and regular need of assistance from an outsider for the essential activities of daily living”.
The adopted definition is based on the concept of need of assistance from an outsider.
This central concept is itself defined by four elements:
-a link with a medical cause. The need of assistance has to be a consequence of a physical or mental sickness, or of a deficiency of the same nature;
-a limit as for its purpose. The need of assistance has to results from an essential activity of daily living. Essential activities of daily living are the activities coming close to three fields: personal hygiene, nutrition and mobility;
-a lower limit in intensity, the threshold for entry. The need of assistance has to account for a defined importance. This minimum of help required has to reach a minimum of 3.5 hours per week;
-a lower limit in time, the duration. The need of assistance has to stretch over a defined period or to an irreversible health condition, and it has to present regularity in time. This period has been set to sixth months.
2. Assessment of the state of dependence and of the need of assistance.
Assessment of the state of dependence exhibits two fundamental characteristics: professional interdisciplinarity in the assessment of the need of assistance and individualization of care plan.
2.1 Interdisciplinarity in assessing the need of assistance
The assessment of the state of dependence is entrusted to a doctor and a health professional (psychologist, nurse, physical therapist, occupational therapist, social worker) chosen on the basis of the case. It consists of a medical examination, followed by an interview with the person applying for the services. This interview aims at describing the restrictions affecting the person in the essential activities of daily living. Assessment usually takes place in the living environment of the person.
2.2 Individualization of the care plan
In the framework of long-term care insurance in Luxembourg, one has not opted for a classification of dependent people according to their dependence level but for a system of individual assessment, for which each beneficiary is entitled to a care plan adapted to their own needs.
Each care or help considered for the dependent person is assigned for a standard duration. The sum of this standard duration objectively accounts for the assessment of dependence state. It is the basis for the payment of services and the references for the threshold of entry (the minimum help required to access to services) as well as for the various benefits ceilings (maxima benefits granted by the insurance).
3. Services of the long-term care insurance
A person recognized as dependent by the Evaluation and Orientation Unit is entitled to the following services according to their own needs:
-assistance and care which they need for the essential activities of daily living2;
-help to take care of household tasks such as cleaning and washing;
-help under the form of support activities. They are mainly intended to stimulate the dependent persons autonomy and to prevent a worsening of the state of dependence. They also aim at enabling a planned moment off for the informal carer34;
-Help under the form of professional counseling which is intended to prevent the limiting of the autonomy potential for the person and to enable the close circle to learn appropriate movements for the assistance and cares.
The law makes provision for other services. The long-term care insurance take also care of:
-The payment of the pension contribution insurance for the informal carer.
-The purchase or the hire of technical aids: wheelchair, adaptable bed, walking frame, positionning shell…
-The adaption of housing required for an easier accessibility in order to promote the beneficiaries autonomy and to enable them to stay at home.
-A financial allowance to buy items required for assistance and care.
When the person stays at home, services in kind (assistance and care provided by professionals) can be partly or fully replaced by a service in cash (sum of money)
-Services in cash are intended to enable the beneficiary to purchase himself the care he needs by calling outsiders or providers of the long-term care insurance. It could be a close relative or friend as well as a professional directly paid for by the dependent person.
-This conversion possibility is however limited. The first seven hours of assistance and care can be fully replaced by a service in cash. Between seven and fourteen hours can be only the half replaced.
Beyond fourteen hours, replacement is not allowed.
3.3 The ceiling of services
A beneficiary is at the most, entitled to 24.5 hours of assistance per week for the essential activities of daily living. This ceiling can be raised up to 38.5 hours every week in serious or exceptional cases.
Concerning household tasks, a weekly rate of 2.5 hours is provided for. This weekly rate can be raised to 4 hours in case of particular needs generated by the state of dependence.
Support activities are limited to 14 hours every week.
Counseling is required at the beginning of the care plan for a limited duration.
4. The Organization of the Long-term Care Insurance
The long-term care insurance is run by an administrative body called “Caisse nationale de santé”. It takes all the individual decisions and manages the budget of the long-term care insurance. Notices concerning individual decisions are expressed by the Evaluation and Orientation Unit, which assessed the state of dependency and determine the services for which the dependent person is entitled. It is also in charge of controlling the quantity and quality of the services provided to dependent people.
The consultative commission is destined to give advice on
-the tools of the assessment of dependency, namely the assessment questionnaire and the standard statement (or care plan);
-the projects of experimental initiatives to lead in the framework of the long-term care insurance to the benefit of specific groups; and
-the list of technical aids of which the long-term care insurance takes care.
The quality commission defines standards for the quality required from services.
5. The relations with service providers.
The long-term care insurance recognizes several kinds of service providers.
5.1 The care institution is defined as the institution which accommodates the dependent people day and night and provides them with all the assistance and care which is required by them according to their state of dependence. There are two types of care institutions: continuous stay institutions where a person stays permanently or intermittent stay institutions where the person leaves periodically the institution. This kind of institution is reserved for the disabled only.
5.2 The care network is defined as an organized set of one or more natural or artificial persons dispersed in a given geographical area, who show different and complementary skills such that it can provide and coordinate the global care of the dependent person. The network structure enables the dependent person to contact a single interlocutor. It also enables to ensure continuity in assistance and care when the dependent person is staying at home. The network has to take on a semi-stationary center to which dependent people can go during the day or night.
5.3 The approval and membership of the outline agreement (“convention-cadre”) through the contract of assistance and care. In order to be allowed to provide assistance and care on behalf of the long-term care insurance, service providers have to win the approval of the supervising ministry. The approval defines the conditions that the service provider has to fulfill in order to exercise its activities.
In addition, they have to become a party to the outline agreement through a contract of assistance and care. The outline agreement is negotiated between the administrative body of long term care insurance and the service providers. It specifies the rights and obligations of each, intervening in the long-term care insurance.
6.Financing the long-term care insurance
The resources required in financing the insurance are constituted of:
-a contribution payable by the state Budget accounting for 45% of all expenses;
-a special contribution payable by the biggest consumers of electricity; and
-a long-term care contribution.
This last contribution is due by everyone covered by the health care insurance:
-The tax base of this contribution is constituted of the professional income, the replacement income and the capital income;
-Concerning the professional income and replacement income, the monthly tax base is reduced by a tax allowance equal to . of the guaranteed minimum wage;
-There is no minimum and maximum contribution level; andThe fixed rate is 1.4%.
1.In order to recognize the specificity of the care for disabled people, the supervising ministry has decided to introduce the concept of sociopedagogic caring which covers specific and additional services required to take care of disabled people. It is defined as “the structured set of dispositions and activities of a registered service provider which aims at supporting disabled people in their projects and rights to reach and maintain an optimal level of autonomy in their physical, sensorial, intellectual and mental way of life as well as an optimal level of social integration”.
The supervising ministry intervenes in financing this sociopedagogic caring with an individual fixed rate “aiming at enabling administrators to face the specific cost generated by the specific needs of disabled people which are not covered by the long-term care insurance.
2.In the field of nutrition, it mainly consists in helping preparing the food with the aim of facilitating the absorption as well as the assistance for the absorption.
In the field of corporal hygiene, it consists e.g. in assistance in washing, cleaning one’s teeth, ensuring skin and integument cares as well as to help for elimination.
In the field of mobility, one can cite the assistance for shift execution, for changes of position, the help which aims at maintaining the person in an adapted posture, for dressing and undressing, for displacement inside the home, in the stairs, as well as the assistance to get in and out home.
3.Informal carer: a member of the social circle (often a family member or a close relation) who helps and carees for the dependent person at home, without belonging to a care network. He/she also may be a professional who does not belong to a formal care network.
4.Support activities may consist in keeping someone under professionnal surveillance at home for people who cannot stay alone, in a specialized individual supervision, in accompanying for an outing, for shopping or for support activities in groups, notably for attending a specialized day care center.
--(本文摘自《残疾人社会保障与服务国际论坛暨第三届中国残疾人事业发展论坛论文集》)
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