Key Benefits:
Publics concerned: complementary health insurance organizations and their insured persons.
Subject: Determination of the rules to be followed by supplementary health contracts to benefit from the tax and social aids attached to the "responsive contracts" scheme.
Entry into force: the text comes into force as of April 1, 2015 with the exception of collective and mandatory contracts for which the amendment will have to intervene in the first amendment of the act that establishes them and no later than December 31, 2017.
Notice: This decree defines the new "book of charges" of so-called "responsible" contracts pursuant to the amendments introduced by section 56 of the Social Security Financing Act for 2014.
It therefore specifies the minimum basket of guarantees as well as the limits of guarantees applicable to certain health-care positions to be followed by supplementary health contracts in order to benefit from the tax and social assistance attached to this scheme.
As a result, these contracts will have to cover the full participation of the insured on the rates of coverage by compulsory health insurance for all health expenses, except for spa fees and medications that have been classified as low or moderate, as well as for homeopathy. They must also cover the entire daily hospital package.
The Order also sets out limits for care expenses in order to limit the solvabilisation by complementary bodies of excessive tariff practices of certain professionals. For example, the care for overpayments of fees for physicians who do not adhere to the access to care contract will be limited to 125% of the social security rate at first and then to 100% of that rate as of 2017 and must necessarily be less than the excesses of fees for physicians who adhere to this scheme.
In the same way, the management of optics expenses is governed by different ceilings and floors depending on the level of correction required. It is also limited to equipment every two years except for minors or in case of changes in the need for correction where equipment can be reimbursed every year.
Finally, it is created an observatory of prices and medical care in order to accurately monitor the evolution of this sector and ensure the impact of measures on access to care.
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 Social Security Codeincluding articles L. 863-1 and L. 871-1;
Vu la Act No. 2013-1203 of 23 December 2013 for 2014, as amended by Act No. 2014-892 of 8 August 2014 for 2014, including its article 56;
Having regard to the advice of the Council of the National Health Insurance Union dated 18 September 2014;
Having regard to the advice of the National Union of Supplementary Health Insurance Organizations Council dated 19 September 2014;
The State Council (Social Section) heard,
Decrete:
Aunt 1° of Article R. 871-1 of the Social Security Code, the reference to section L. 161-36-2 is replaced by the reference toArticle L. 1111-15 of the Public Health Code.
Section R. 871-2 of the Social Security Code is replaced by the following:
"Art. R. 871-2.-The guarantees referred to in Article L. 871-1 include:
« 1° Of the full participation of insured persons defined in section R. 322-1. However, this care is not mandatory for the health benefits mentioned in 6°, 7°, 10° and 14° of the same article;
« 2° If the contract, the membership bulletin or the regulation proposes this guarantee, the rate overruns of the physicians who have not entered into the contract of access to care provided for in the national agreement referred to in Article L. 162-5, within a double limit of 100% of the liability rate and the amount covered for the overtaking of the physicians who have acceded to the contract of access to care less than 20% of the rate of liability;
« 3° If the contract, the membership bulletin or the regulation proposes a coverage of the costs incurred by the insured in addition to the liability rates for the acquisition of medical optics devices for individual use subject to reimbursement, the acquisition expenses of these devices, to the minimum level and to the maximum limits set below including the participation of insured persons defined in 1° and under the following conditions:
“(a) At least 50 euros and at a maximum of 470 euros per single-handed glass equipment with a sphere between 6.00 and 6.00 dioptries and with a cylinder of less than or equal to + 4,00 dioptries;
“(b) A minimum of 125 euros and a maximum of 610 euros per equipment with a glass mentioned in a and a glass mentioned in c;
"(c) At least 200 euros and at a maximum of 750 euros per single-handed glass equipment whose sphere is outside the zone of-6,00 to + 6,00 dioptries or whose cylinder is greater than + 4,00 dioptries and multi-focal or progressive lenses;
"(d) A minimum of 125 euros and a maximum of 660 euros per equipment with a glass mentioned in a and a glass mentioned in f;
“e) A minimum of 200 euros and a maximum of 800 euros per equipment with a glass mentioned in the c and a glass mentioned in the f;
“(f) At least 200 euros and at a maximum of 850 euros per equipment for adult with multi-focal or progressive sphero-cylindrical lenses whose sphere is off-area from-8,00 to + 8,00 dioptries or multi-focal or progressive spherical lenses whose sphere is off-area from-4,00 to + 4,00 dioptries.
"For the application of the maxima mentioned above, the support of the frames within the equipment is limited to 150 euros.
"This guarantee applies, in the case of glasses, to the costs incurred for the acquisition of equipment consisting of two glasses and a frame, per two-year period. However, for minors or in the event of the renewal of the equipment justified by an evolution of the view, it applies for the costs exposed to the acquisition of equipment per one-year period;
« 4° A daily package of hospital facilities provided for in Article L. 174-4, without limitation of duration. »
It is established with the Minister for Health and Social Security, an observatory of prices and medical optical care.
This observatory is responsible for analyzing sales prices, characteristics and quality of optical equipment and their level of coverage by complementary health contracts. It assesses the developments in the optical equipment market, the access of the insured to these equipment and the industry in which their production and distribution are registered. He shall submit to the Ministers responsible for health and social security, no later than 30 June of each year, a report on the practices observed and, where appropriate, make preconizations on the evolution of the sector supervision and supplementary insurance contracts.
The observatory includes representatives:
1. Departments responsible for health and social security and the Ministry responsible for the economy and industry;
2. National Union of Health Insurance Funds;
3. Additional health insurance organizations;
4. Distributors of optical medical devices;
5. Manufacturers of optical medical devices;
6. Insured people.
The composition and operating rules of the observatory are set by decree of ministers responsible for health and social security.
The provisions of this Decree shall enter into force under the conditions set out in the third and fourth paragraphs of Article 56 of Law No. 2013-1203 of 23 December 2013 on the financing of social security for 2014 as amended.
Derogation from provisions 2° of Article R. 871-2 of the Social Security Code The 100% limit for care delivered in 2015 and 2016.
By derogation from the provisions of the second paragraph of Article 3, the first report of the observatory referred to in the first paragraph of the same article shall be submitted by 30 June 2016.
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 November 18, 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
