Key Benefits:
Publics concerned: insured beneficiaries of assistance in the payment of supplementary health insurance (ACS); insurance companies insurance code, contingency institutions Social Security Codemutual funds and unions code of mutuality.
Subject: Determination of the competition procedure for supplementary health insurance contracts eligible for the CSA.
Entry into force: the text comes into force on the day after its publication.
Notice: theArticle L. 863-6 of the Social Security Code Amended by Article 56 of the Social Security Financing Act for 2014 provides a procedure for competition of complementary organizations proposing health care coverage to CSA beneficiaries, in accordance with the principles of transparency, objectivity and non-discrimination. This procedure is intended to select individual supplementary health insurance contracts eligible for the benefit of the tax credit referred to in theArticle L. 863-1 of the Social Security Code. This decree sets out the conditions under which the State may select contracts eligible for assistance. In particular, it provides for the publication of a notice of appeal to competition that will specify the conditions for the admissibility and eligibility of applications as well as a notice of application setting out the expected benefits and criteria for the evaluation of bids. The decree also introduces rules to ensure equal treatment of candidates throughout the procedure and impartiality in the choice of offers, including by prohibiting conflict of interest situations. The decree finally facilitates the use of aid in payment of supplementary health insurance by allowing beneficiaries to keep the benefit of the right in case of incomplete use of its aid to subscribe a new contract with the benefit of it until its initial term.
References: the provisions of Social Security Code Amended by this decree may be consulted, in their drafting, on the website Légifrance (http://www.legifrance.gouv.fr).
The Prime Minister,
On the report of the Minister of Social Affairs, Health and Women ' s Rights,
Vu le insurance code ;
Vu le code of mutuality ;
Vu le Social Security Codeincluding article L. 863-6;
Vu la Act No. 2013-1203 of 23 December 2013 the financing of social security for 2014, including its article 56;
Vu la Act No. 83-634 of 13 July 1983 the rights and obligations of civil servants, including article 26;
Considering the opinion of the Central Board of Directors of the Agricultural Social Mutuality of July 3, 2014;
Having regard to the advice of the National Health Insurance Union Board of 3 July 2014;
Having regard to the advice of the Board of the National Health Insurance Fund for Employees dated 8 July 2014;
The State Council (Social Section) heard,
Decrete:
Chapter III of Title VI of Book VIII of the Social Security Code is thus amended:
1° In the fifth paragraph of Article R. 863-1, the words: "Except in the case provided for in Article R. 863-4 shall be deleted;
2° Section R. 863-4 is replaced by the following provisions:
"Art. R. 863-4.-If the contract ends in the period defined in the first paragraph of section R. 863-3, the agency to which the contract was contracted shall give the beneficiary the certificate referred to in the last paragraph of section R. 863-1 and a certificate indicating the period during which he exercised his right to deduction. The recipient delivers these certificates to the organization to which it enters a new contract. » ;
3° Section R. 863-5 is amended as follows:
(a) The second is repealed;
(b) In the fourth paragraph:
-the 3° becomes the 2°;
-the words: "on its application, the certificate referred to in the last paragraph of section R. 863-1 and a certificate indicating the period in which it exercised its right to deduction. are replaced by the words: "the certificates provided by section R. 863-4. » ;
4° It is complemented by nine articles as follows:
"Art. R. 863-8.-For the selection of contracts provided for in Article L. 863-6, a preliminary competition was made by the applicant organizations.
"The Minister for Social Security is responsible for the competition procedure. As such, it ensures the implementation of the principles of transparency, objectivity and non-discrimination among the candidate bodies.
"It sets up a selection commission responsible for the implementation and control of the procedure as well as the monitoring of compliance with the commitments for the selected offers. It sets the composition by order.
"Can't be appointed as members of the selection board of persons who have, over the past three years, engaged in wage-earning activities or legislative or managerial functions within a complementary organization or group of such organizations, or who have maintained a professional relationship for profit with these organizations or groups.
"The members of the selection board may not participate in the work of the commission if they have a direct or indirect link of interest with the organization or group of organizations whose offer is reviewed.
"No member of the selection board may, for three years from the date on which the list of successful bids has been published pursuant to section R. 863-12, carry out legislative or managerial functions within organizations whose offer has been selected or within the group of which these organizations are members.
"The members of the commission are held incommunicado and professional discretion under the same conditions as those defined inArticle 26 of Act No. 83-634 of 13 July 1983 the rights and obligations of civil servants.
"Art. R. 863-9.-The competition procedure shall be governed by the following provisions:
« 1° The main features of the desired offer are defined in a notice of appeal to the competition to which is attached the specifications defined in article R. 863-11;
« 2° Candidates filed within a time limit set out in the Notice of Appeal to Competition shall not be less than fifty-two days from the later date of the publication of the notice provided for in article R. 863-9, and complying with the rules for the presentation of tenders set out in the notice of application;
« 3° Candidates of mutual funds or unions under the code of mutuality, companies governed by the insurance code or foresight institutions governed by the Social Security Code, having branch 2 approval “illness” mentioned in thearticle R. 211-2 of the mutuality code, to theArticle R. 321-1 of the Insurance Code and to theArticle R. 931-2-1 of the Social Security Code respecting all the criteria set out in the Notice of Appeal to Competition and the rules set out in the terms of reference.
"The application of several insurers on a joint offer is eligible to the extent that the conditions of this paragraph are met, as well as the provisions of competition law and the regulations specific to insurance organizations;
« 4° The criteria for the evaluation of bids that allow for the determination of their rating are, in a preponderant manner, based on a price criterion and, for the rest, on criteria for the quality of service defined in the Notice of Competition Appeal and on the proposed services and the means used for the distribution of the offer, according to a weight determined in the Notice of Competition Appeal;
« 5° The selection is made within the limits of a number of bids mentioned in the Notice of Appeal to Competition and a note established by reference to that of the best-notated offer, under conditions specified in the same notice. The minimum number of bids selected cannot be less than three.
"Art. R. 863-10.-The notice of appeal to competition referred to in article R. 863-9 is published in the Official Journal of the French Republic and in the Official Journal of the European Union.
"Art. R. 863-11.-I.-The terms of reference set out the guarantees requested, including the services available to subscribers as well as the conditions relating to the benefit of the exemption of costs by insured persons, the supervision of tariff practices and the prohibition of contractual clauses in order to question the objective of solidarity and the mutualisation of risks pursued by the selection procedure, as a result of the special terms of reimbursement of the contribution,
"It sets out the obligations of organizations whose offer is selected, particularly with regard to information to be delivered to insured persons.
"It provides that contracts must include a termination clause, at the request of the insured, in the event of the cancellation of the offer corresponding to the contract, of the list established under section R. 863-12. The clause specifies that, in the event of termination in that respect, the organization shall reimburse the insured the amount of the contributions corresponding to the current period of the date of termination on the original date of termination of the contract.
"It determines the conditions for periodic monitoring and review of selected contracts.
"II.-The terms of reference specify the characteristics of the three contracts corresponding to minimum levels of care required for each offer.
"These three contracts, known as A, B and C, guarantee, in accordance with the provisions of R. 871-1 and R. 871-2, the coverage of the expenses incurred by the insured under the following terms:
« 1° Full support for the participation of insured persons defined in section R. 322-1. However, this care is not mandatory for the health benefits mentioned in 10° and 14° of R. 322-1. Support is increased for certain costs under the conditions set out in 3° of this II;
« 2° Full coverage of the daily package referred to in Article L. 174-4, without limitation of duration;
« 3° Coverage of costs incurred by the insured for certain individual medical devices subject to reimbursement and certain fees of practitioners, at minimum amounts, including the participation of insured persons as defined in 1°, under the following conditions:
“(a) For medical optics devices:
"by single-handed glass equipment whose sphere is between 6.00 and 6.00 and whose cylinder is less than or equal to + 4.00, to 100 euros for contract B and to 150 euros for contract C;
"-by single-handed glass equipment whose sphere is outside the zone of-6,00 or 6,00 or whose cylinder is greater than 4,00 and with multi-focal or progressive lenses, 200 euros for the contract B and 350 euros for the contract C;
“by equipment with a glass mentioned in the second paragraph of a and a glass mentioned in the third paragraph of a, 150 euros for contract B and 250 euros for contract C;
"-for lentils, 100 euros for B and C contracts;
“(b) For the fees of dental surgeons, respectively for contracts A, B and C, 125%, 25% and 30% of the liability rate for dento-facial orthopaedics and dental prosthetics;
"(c) For hearing aids, up to 450 euros per prosthesis for contract C.
"Art. R. 863-12.-Seuls may be opened, by the selection commission referred to in R. 863-8, the folds that have been received no later than the expiry date of the filing period established in accordance with the provisions of 2° of R. 863-9.
"Applications that have not been rejected pursuant to the provisions of the first paragraph and that comply with the tendering rules set out in the terms of reference are considered, by the selection committee, in the light of the eligibility requirements mentioned in the 3rd of Article R. 863-9.
"The bids of eligible candidates are classified in accordance with the rules resulting from the 4th of Article R. 863-9. This classification is the advice of the selection commission to the Minister in charge of social security.
"The list of contracts entitled to the tax credit under section L. 863-6 is fixed by order of the Minister for Social Security. Registration of contracts on the list is issued for a period of five years.
"The list of selected contracts is published in the Official Journal of the French Republic.
"Art. R. 863-13.-A each of the stages of the competition procedure defined in the first two paragraphs of Article R. 863-12, the selection board shall, by a reasoned decision, notify the rejection of their offer to organizations whose offer is not admissible or eligible, by any means to determine the date of receipt of the decision.
"Candidates whose offer has not been included in the list referred to in section R. 863-12 may apply to the Minister for Social Security for reasons why their offer has not been retained.
"Art. R. 863-14.-The competition procedure provided for in Article R. 863-8 shall be renewed no later than nine months before the expiry of the five-year period referred to in Article R. 863-12.
"Art. R. 863-15.-I.-If it is found that an organization does not comply with the commitments to the selected offer, it may be deleted by the Minister responsible for social security of the list referred to in section R. 863-12, after the collection, within two months from the notification of this finding, written comments and, if so, on its request, oral comments The delisting decision takes effect four months after the publication of the order pronounces it.
"II.-In the event of the delisting of its offer, the organization shall, within one month of the delisting order, inform the subscribers or adherents of the consequences of this delisting in respect of the benefit of the assistance referred to in Article L. 863-2 to allow them to terminate their contract within three months of the date of sending of this information, pursuant to the third paragraph of Article I.
"III.-From the date of publication of the delisting order, the contracts for this offer may no longer result in a subscription or renewal with the benefit of the assistance referred to in Article L. 863-2.
"Art. R. 863-16.-If the number of bids on the list referred to in R. 863-12 is reduced to less than three in the five-year period provided for in the same article and if the remaining period is greater than twelve months, a competition procedure to complete the list is open. The offers are selected under the conditions set out in article R. 863-9 with the exception of the rule set out in the last sentence of 5° of the same article and are in addition to those on the list in force, for the remaining period to be run before the expiry of the period provided for in article R. 863-12. »
I. - By derogation from the provisions of articles R. 863-12 and R. 863-14 of the Social Security Code, the contracts retained on the list referred to in article R. 863-12 of the same Code at the end of the first competition procedure implemented pursuant to the provisions of this Decree shall be entered for a period of three years. The renewal of the procedure provided for in R. 863-14 shall take place no later than nine months before the expiry of this three-year period.
II. - The provisions of this Decree shall apply to contracts entered into as of the date mentioned in the first paragraph of Article 56 of the Social Security Financing Act, 2014.
The Minister of Finance and Public Accounts, the Minister of Social Affairs, Health and Women's Rights and the Secretary of State responsible for the budget are responsible, each with regard to him, for the execution of this decree, which will be published in the Official Journal of the French Republic.
Done on 8 October 2014.
Manuel Valls
By the Prime Minister:
Minister of Social Affairs, Health and Women ' s Rights,
Marisol Touraine
Minister of Finance and Public Accounts,
Michel Sapin
The Secretary of State in charge of the budget,
Christian Eckert
