France

Health systems in transition France 73
Initially, SHI focused on the coverage of curative care in case of
illness or accident. In practice, however, preventive care is increasingly
covered, particularly for services provided within doctors’ practices, such
as mammography or cervical smear tests. Compulsory or recommended
immunizations are also reimbursed, and care of pregnant women and newborn
babies is free. A lump sum of €50 per year is available to smokers for smoking
cessation products (€150 for pregnant women and young adults aged 20–25).
The range of services covered by SHI does not include cosmetic surgery
or most thermal spa treatments (unless prescribed by a physician for one of a
list of 12 specific conditions defined by SHI, such as rheumatic diseases, and
subject to frequency and duration limits), nor does it include some services
of uncertain effectiveness. The choices required in the allocation of scarce
resources may result in non-reimbursement for certain procedures (e.g. bone
densitometry performed in the private sector as a preventive measure) or limits
on the frequency with which they can be reimbursed (e.g. mammography for
screening purposes).
For most common health care or products, volumes of care are not specified.
However, for expensive procedures or devices, volumes may be explicit. This
is the case, for example, with respect to in vitro fertilization, for which four
attempts are fully covered (the counter is reset in the case of a successful
pregnancy) with an age limit of 42; or for drug eluting stents, with generally
only one stent covered up to a maximum of three per patient in the case of acute
occlusive artery dissection.
For certain kinds of care, such as physiotherapy and thermal spa treatments,
prescription by a doctor is not a sufficient condition for reimbursement.
Coverage for these kinds of treatment is subject to prior authorization by doctors
advising the SHI Medical Service Office (médecins conseil du service médical),
after examination of the patient’s case history and possibly a patient interview.
Cash benefits are also provided by SHI to compensate for sickness, maternity
and paternity leaves, as well as in case of incapacity.
Actors involved in defining the benefit package
The positive lists are defined at the national level and apply throughout
France in all regions. Drugs and medical devices are added to the list by the
Ministry in charge of Health, while procedures are added by SHI (UNCAM)
(see section 2.3.5) on the advice of designated committees of the HAS (see