Key Benefits:
Publics concerned: insured beneficiaries of the supplementary universal health coverage (CMU-c), insured beneficiaries of the assistance to the payment of supplementary health insurance (ACS) and having signed a contract among selected offers, compulsory health insurance organizations, complementary health insurance organizations, health professionals, health institutions, health centres.
Subject: Determination of the terms and conditions for the implementation of the third-party fee for CCA beneficiaries, where the health professional wishes to have a single interlocutor, and updating these terms and conditions for CMU-c beneficiaries.
Entry into force: the text comes into force on the day after its publication.
Notice: The purpose of this Order is to update the terms and conditions for the implementation of the third-party fee for the beneficiaries of the CMU-c and to determine the terms and conditions of the third-party fee allowing health professionals who wish to have a single interlocutor, when the insured person is a beneficiary of the CCA and has signed a selected supplementary health insurance contract. The text specifies, for this purpose, the procedure applicable between health professionals and health insurance organizations, on the one hand, and the procedure applicable between supplementary health insurance organizations and health insurance organizations, on the other.
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. 861-3 and L. 863-7-1;
Vu la Act No. 2003-1199 of 18 December 2003 the financing of social security for 2004, including article 33;
Vu la Act No. 2013-1203 of 23 December 2013 the financing of social security for 2014, including its article 56;
Having regard to the advice of the Board of the National Health Insurance Fund on 2 June 2015;
Considering the advice of the Central Board of Directors of the Agricultural Social Mutuality dated 11 June 2015;
Considering the referral of the National Union of Health Insurance Funds Council dated 21 May 2015,
Decrete:
Title VI of Book VIII of the Social Security Code is amended as follows:
1° It is entitled: "Additional health protection and assistance in the payment of supplementary health insurance";
2° It is composed of the following three chapters:
(a) A chapter I, entitled: “Additional Health Protection Provisions” including articles D. 861-1 to D. 861-8;
(b) Chapter II, entitled: “Financial provisions for the funding fund for the complementary protection of universal coverage of disease risk” and composed:
-a section 1, entitled "General Provisions", including Article D. 862-1;
-of section 2, entitled: "Additional Health Insurance Organizations Provisions", including sections D. 862-2 to D. 862-4; and
-a section 3, entitled: " Provisions relating to social security organizations", including articles D. 862-5 to D. 862-7;
(c) Chapter III, entitled: "Help to the payment of supplementary health insurance" including articles D. 863-1 and D. 863-2;
3° Sections D. 861-2 to D. 861-6 are replaced by the following:
"Art. D. 861-2.-To be eligible for a paid third party under section L. 861-3, the beneficiary of the care must submit to the professional or health care the health insurance card referred to in section L. 161-31. In the event that the card cannot be read or that the card is not updated, the beneficiary may present the certificate of entitlement issued by the organization serving the basic health insurance benefits. An order issued by the Minister for Social Security determines the contents of this certificate.
"The payment to the professional or health-care establishment of the acts or benefits made under the provisions referred to in Article L. 861-3 shall be guaranteed, subject to the general conditions for the care of the acts or benefits considered and provided that the health insurance card of the beneficiary of the care is not included in the list of objections referred to in Article R. 161-33-7 on the day of the issuance of these joint benefits or,
"Art. O.C. 861-3.-Where the benefits of the basic health insurance plan and the supplementary benefits are different, the third party shall be paid in accordance with the terms set out in sections D. 861-4 to D. 861-7.
"By exception, health care professionals and institutions may sign agreements with obligatory or complementary health insurance organizations that define the terms and conditions of the paid third party other than those mentioned in the preceding paragraph. When organizations serving the benefits of a basic health insurance plan are not signatories to these conventions, they are informed of their content by the signatory parties.
"Art. O.C. 861-4.-For the acts and benefits provided by health professionals and those who do not enter the scope of the annual funding of health facilities referred to in L. 174-1, the advance waiver of costs involving a single interlocutor referred to in L. 861-3 shall be carried out according to the following procedure:
« 1° The professional or health care institution shall transmit to the organization serving the basic health insurance benefits, under the conditions set out in sections R. 161-47 and R. 161-48, the documents referred to in section R. 161-40 for the recognition of care and for the opening of the right to reimbursement;
« 2° The organization serving the basic benefit of liquid health insurance the share of expenses incurred by the basic plan and by the supplementary health insurance agency respectively. It makes the payment to the professional or health care institution of all the amounts paid. It provides a statement of benefits to the organization serving the basic plan benefits and to the supplementary health insurance organization;
« 3° The exchange of information between the organizations serving the benefits of the basic health insurance plan and the supplementary health insurance organizations is carried out electronically and is in accordance with the technical specifications defined by the terms of reference of the open standard of exchange between the disease and external stakeholders, established by the national health insurance funds after consultation with the supplementary health insurance organizations;
"The amounts due to the organization serving the basic health insurance benefits by the supplementary health insurance organization are paid within five days from the date of the invoice by the compulsory health insurance.
"The payment by the supplementary health insurance organization is accompanied by the sending of an electronic proof of payment.
"The service rendered by the health insurance organization is charged to the supplementary health insurance organization under conditions fixed by order.
"Art. O.C. 861-5.-For benefits other than those referred to in section D. 861-4 issued by the health care facilities referred to in L. 174-1, the advance exemption of costs incurred on the share taken over by the supplementary health insurance organization is carried out in either of the following two terms:
« 1° The health care institution submits an application for electronic payment to its pivotal caisse, which promptly transmits it to the care provider the benefits of the basic health insurance plan. When the dematerialized shipment is impossible, the institution directly addresses the request for paper-based payment to the organization serving the benefit of the basic health insurance plan. This organization makes the payment of the amount corresponding to the health care institution on behalf of the supplementary health insurance organization and sends to the health care institution a statement of the benefits provided by the supplementary health insurance organization. The relationship between the organization serving the beneficiary of care the benefits of the basic plan and the one serving the complementary benefits is defined in accordance with Article D. 861-4(3);
« 2° The institution addresses its request for payment directly to the supplementary health insurance organization. Under his or her responsibility, he shall ensure the liquidation of the benefit, the payment to the establishment of the corresponding amount, and the sending of a statement of the insured benefits.
"Art. O.C. 861-6.-Except in the event of a duly motivated rejection and notified to the concerned by the organizations serving the benefits of a basic plan, payments to professionals or health facilities referred to in D. 861-4 and 1° of D. 861-5 shall be made within a time limit of:
« 1° Seven days from the date of the acknowledgement of receipt referred to in the sixth paragraph of Article R. 161-47, in the event of the use of an electronic care sheet;
« 2° Twenty-one days from the date of delivery by the professional or health care institution, in the event of the use of a paper-based care sheet. This period is extended by fifteen days when the paper-based care sheet has been sent to a health insurance organization different from that used to provide the basic health insurance benefit to the recipient. » ;
5° Chapter I is supplemented by the following two articles:
"Art.D. 861-7.-An order sets out the content of the benefits statements addressed to health professionals and institutions as well as the terms and conditions for the exchange of information between organizations serving the benefits of a basic health insurance plan and supplementary health insurance organizations.
"Art. O.C. 861-8.-For the benefit of the paid third party provided for in the ninth paragraph of section L. 861-3, the beneficiary must submit to the professional or health-care establishment his health insurance card referred to in section L. 161-31 and the paid third-party certificate issued by his or her organization serving the basic health insurance benefits. » ;
6° Chapter III contains the following articles:
"Art. D. 863-1.-In the context of the implementation of the paid third party, the supplementary health insurance organization shall, within 48 hours, transmit to the compulsory health insurance, each new membership, subscription, renewal or termination of a contract selected by a beneficiary of the deduction provided for in section L. 863-2. To this end, he mentions the commencement and termination dates of the contract and the type of contract entered into by the beneficiary as provided for in the second paragraph of Article R. 863-11.
"Art. D. 863-2.-To benefit from the paid third party provided for in section L. 863-7-1, the beneficiary of the care shall present to the professional his health insurance card referred to in section L. 161-31. In the event that the card cannot be read or that the card is not updated, the recipient may submit the full third party certificate issued by the organization serving the basic health insurance benefits.
"The payment to the professional of the acts or benefits made under the provisions referred to in Article L. 863-7-1 shall be guaranteed, subject to the general conditions for the care of the acts or benefits considered and provided that the health insurance card of the beneficiary of the care is not included in the list of opposition referred to in Article R. 161-33-7 on the day of the issuance of such acts or benefits or, in the cases provided for in the preceding paragraph
"When the health care professional wishes to benefit from a single interlocutor, it implements the third party paying in accordance with the terms set out in sections D. 861-4, D. 861-6 and D. 861-7. »
The Decree No. 99-1079 of 21 December 1999 relating to the application of the advance health care exemption and amending the social security code is repealed.
By derogation fromArticle D. 861-4 of the Social Security Code in its writing resulting from this Order and for acts and benefits that do not fall within the scope of the annual funding of health facilities referred to in section L. 174-1 of the same Code, the paid third party shall apply on the basis of the dates fixed by the last paragraph of I of section 33 of Act No. 2003-1199 of 18 December 2003 Social Security Funding for 2004. Before these dates, the provisions of section D. 861-5 of the same code are applicable.
When the third-party fee provided for in Article L. 863-7-1 of the same code is applied, the provisions of the second sentence of 2° of Article D. 861-4 apply, between 1 July 2015 and 31 December 2015, to the minimum levels of care for the expenses set by the decree referred to in Article L. 863-6 of the same code, in its drafting resulting from the I of Article 56-12 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 June 29, 2015.
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
