Care reimbursed.
All medical, pharmaceutical, laboratory and hospital costs, whether or not resulting from pregnancy, childbirth and its consequences, can be reimbursed by health insurance. Only compulsory prenatal examinations and childbirth preparation sessions are covered by maternity insurance. From the 6th month until the 12th day after childbirth, care is 100% covered by maternity insurance, whether or not it is related to the pregnancy. This concerns in particular: childbirth fees, postnatal follow-up sessions, postnatal examination, abdominal rehabilitation and perineo-sphincteric rehabilitation sessions. Transportation costs to the hospital or clinic by ambulance, or any other means, are covered on medical prescription.
La reimbursement basis for medical fees is subject to the sector to which the consulted practitioner belongs.
The difference between the reimbursement base and the reimbursement amount constitutes what is called the co-payment. The third-party payment or the advance fee waiver. Since January 1, 2017, the third-party payment is covered by Social Security, only the user fee remains to be paid by the insured; this can be partially or totally covered by complementary health insurance.
The three medical sectors
Compulsory complementary health.
Since January 1, 2016, each employer must enroll employees who do not have collective health insurance.
• The three medical sectors:
– The sector 1 eis made up of doctors who adhere to the Social Security convention. These doctors are subject to tariff obligations. fixed by the agreement and reimbursements are made on the rate of the agreement. They can only exceptionally request an overrun of fees.
– The sector 2 includes contracted physicians whose fees are freely set (HL) or authorized overrun (DA). The rates for these practitioners are higher than the rates for doctors in sector 1, the reimbursement of costs is made on the basis of the reference rate of Social Security lower than that of the agreement.
– The sector 3 includes practitioners who have not adhered to the convention and who are therefore not
subject to the tariff obligation. Reimbursement of costs is made on an extremely low authority rate. Whatever the sector, doctors have a legal obligation to display their fees in their place of consultation or exercise their fees. Fee overruns are never covered by Social Security. They can be fully or partially covered by complementary health insurance.
This article is taken from Laurence Pernoud’s reference book: 2018)
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