Complementary Health Insurance
"Contrats Responsables"
Health Insurance in France
Outside the insurance industry itself, health insurance policies that are defined as contrats responsables are probably not well understood or even known. It is worth having some knowledge of such plans because it may affect your choice of provider for "top up" insurance.
Background
Legislation introduced in 2004 and subsequent decrees are measures to target the health budget deficit. It was this legislation which introduced the registration with a doctor thus establishing a médicin traitant and through whom treatment would be managed. This channelling of healthcare through the médicin traitant is referred to as the parcours de soins.
Treatment administered outside the parcours de soins (with certain exceptions) would result in a reduction of reimbursement rates from the CPAM. In addition, there was the introduction of 1€ payment for each medical act.
It was the intention of the government that the population should be hit directly in the pocket to emphasise healthcare does cost! It was concluded that if these penalties/payments were simply taken on by the complementary insurers then the effect of the measures would be diminished.
Contrats Responsables
The complementary insurers were approached to assist with these measures by not paying for care administered outside the parcours de soins and to not reimburse the 1€ forfait. In return the insurers would receive taxation benefits. The contrat responsable was born. For a contract to be defined as such, the policy had to fullfil the following conditions:
- Pay the difference between the reimbursement rate by the CPAM (70%) and the full cost. This difference is called the ticket modérateur.
- Pay at least 30% of the costs of white label prescribed medicines. (CPAM reimbursement 65%).
- Pay at least 35% of the costs of labaratory analyses. (CPAM reimbursement 60%).
- Pay for at least two from a list of seven preventative measures considered as priorities in the interests of public health.
- NOT to pay the 1€ "forfait" levied on most medical acts.
- NOT to pay the 8€ levied on a consultations outside the parcours de soins with a specialist applying a dépassement and not to pay at least 20% of the ticket modérateur.
Of the three providers of complementary health insurance the mutuelles seem to be the most fervent in persuading their clients to respect the parcours de soins by applying greater financial penalties than required by décret 2005-1126.
Conclusion
Contrats responsables is yet another factor to be taken into account on choice of provider - as if it was not difficult enough already. Professional advice should be sought.
Peter Owen
Health Topic Host www.frenchentree.com
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