Abandoning worries about the lack of financial resources is a reality that more and more people are facing. Assistance has been provided to ensure access for all.Puma (Universal Health Protection— Replacement of the Capital Markets Union — Universal Health Insurance),AME(State Medical Aid),CMU-C(Universal Health Insurance),ACS(supplementary health payment aid) are among the schemes that can be utilized by individuals with low resources or in precarious situations. In particular, these agreements allow for exemption from upfront costs, meaning the third party pays in full. A right that is sometimes not respected. Let’s return to possible means.
Paying Third-Party Requests
Regarding the Law on the Modernization of the Health System, much has been said about third-party payers, including the question of its generalization. Since July 1, 2015, holders of supplementary health payment aid (ACS) benefit from full third-party payment, exempting them from rising costs. This will apply starting next July to individuals suffering from long-term illnesses (ALD) and to all maternity care. As of November 30, 2017, the portion reimbursed by social security will be paid to all French citizens as a third party (the reciprocity share must continue to be paid to the healthcare professional).
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In fact, third-party payment already applies to some insured individuals. However, in 2015, human rights advocates and Doctors of the World warned: “37% of doctors refuse to care for holders of the Capital Markets Union – C (Complementary Universal Health Coverage). Their reasons: refusal of the exemption from costs to which CMU-C beneficiaries are entitled, discrimination, non-compliance with disease tariffs. “A refusal of care considered discriminatory under Article L1110-3 of the Public Health Code. Those who have been denied this right do not necessarily disclose it. There are few records of appeals due to a lack of knowledge or distrust.
Cases of Sanctioned Refusal of Care
Some refusals may be authorized. This is the case when a healthcare professional is asked to provide care for which they do not have the competence that does not fall within their specialty.
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Specialists may also sometimes refuse care because they do not have sufficient funds and make a choice based on regulatory criteria (for example, for transplants). In all cases, cases of refusal of care are heavily regulated. This framework is also explicit for unauthorized cases of refusal of care. Several codes list these cases: the Public Health Code, the law on social measures and families, the Consumer Protection Code, etc.
For a complaint to be admissible, it is not necessary for the patient to have expressed specific demands (request for care not covered by health insurance, appointment outside the usual business hours, unjustified home requests…).
It is also strongly advised that patients check the prices charged by the healthcare professional or health facility before the appointment. This helps, for example, to avoid cases of abusive refusal of treatment (non-compliance with the exemption from costs, non-compliance with price limits). Most healthcare professionals accept full payment by third parties, and some are also signatories to the access care contract. To check the type of fees charged, compare prices and reimbursement bases, consult the Health Ameli directory.
Possible Recourse
Several recourses are available to beneficiaries of aid in case of refusal or exemption from costs.
Parisian insured individuals can report it directly to the conciliator of the Paris Primary Health Insurance Fund, providing the names of the insured and the doctor as well as an exact description of the facts.
- By postal mail to the following address:
Paris Health Insurance
Attention: Conciliator
75948 PARIS CEDEX 19
There is a letter template available on ameli.fr.
- By email: [email protected]
- By phone at 3646 (€0.06/min call price)
The CPAM arbitrator will contact the concerned health expert to discuss the circumstances of the refusal of care or waiver of costs and to inform the concerned individual of the measures taken following their complaint.
Other means are possible. The insured can enter:
- The competent territorial council of the relevant professional code (www.conseil-national.medecin.fr www.ordre-chirurgiens-dentistes.fr www.ordre.pharmacien.fr…)
- The Defender of Rights electronically on the site http://www.defenseurdesdroits.fr by filling out the online form.
Due to its social fragility, the CMU Fund can also guide individuals who are victims of discrimination.
Access to the right to health in precarious situations is a fundamental condition that all actors in the system and, more generally, the authorities as guarantors of equality must uphold.
Tag: The risks of not having health insurance