Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

188 Special Solidarity Fund KCE Reports 133
9.14.2.2 What is covered?
The public health insurance scheme covers hospital care, ambulatory care, prescription
drugs, as well as minimal coverage of outpatient eye and dental care.
Cost-sharing: The principle of cost-sharing, or ticket modérateur, is extensively applied
to public-financed health services in France. There are three forms of cost-sharing: coinsurance,
co-payments and extra billing.
Co-insurance rates are applied to all health services and drugs listed in the publiclyfinanced
benefits package and vary depending on:
• type of care: hospital care (20% plus a daily co-payment of €16), GP visits
(30%), dental care (30%);
• type of patient: e.g. patients suffering from chronic diseases and low
income patients are exempt from cost sharing;
• effectiveness of the prescription drug: 0% for highly effective drugs, 35%,
65% or 100% for drugs with a limited therapeutic value;
• level of compliance with the current gate keeping system (médecin
référent): co-insurance regulation tends to favour visits to people’s
‘médecin référent’ (30% co-insurance rate) to visits to other GPs (50%).
As mentioned, treatment costs are split between public health insurance (what the state
pays) and the patient (co-payment). However, payments by patients can be reimbursed
by complementary private health insurance, up to 100%. From 2008, some smaller copayments
ceased being eligible for reimbursement up to an annual ceiling of €50.
Reimbursement by the publicly financed health insurance scheme is based on a
reference price (tarif de convention). Although a patient may be treated by a
practitioner classed as ‘conventioné’, he can ask more than the tariff de convention
provided it is "reasonable and tactful" to do so. For example, a specialist who has extra
qualifications or experience in other countries could charge extra for its services. This
supplementary charge is called a ‘depassement’ or extra billing. The difference
between the extra billed amount and the reference price is not covered by public health
insurance, nor complementary private health insurance and is fully charged to the
patient.
Safety nets: France introduced some safety nets for people with invalidity or with
work injury, people with specific chronic illnesses and low income patients. These
groups of citizens are exempt from co-insurance regulations and are reimbursed at
100% of the “tarif de convention” if one of the following applies:
• A patient suffers from one or more of the 30 chronic or acute medical
conditions that are listed, including insulin-dependent diabetes, cancer and
heart disease;
• A patient requires long-term care or care for a long-standing condition
(called an ALD–affectation de longue durée);
• A patient is hospitalised beyond 30 days. From the 31st day hospital stays
are 100% reimbursable;
• A patient’s surgery costs are above €91.
Children and low income residents are exempt from paying non-reimbursable copayments.
Complementary private health insurance (police complémentaire), by most of the
patients obtained through their employer, covers patients’ statutory cost-sharing,
meaning the share of health care costs that is not reimbursed by the public health
insurance scheme. However, this is only the case for health services and prescription
drugs that are part of the publicly-financed benefit package.
Low income residents (for example, €10,768 for a couple) that cannot afford a police
complémentaire could rely on free complementary state-funded healthcare, called CMU
complémentaire. They cannot be extra billed by doctors.