France: Healthcare: Compliance: Understanding the “100% Healthcare” reform
Effective dates: January 2019, January 2020, January 2021 and January 2023
This in-depth article is provided by Asintas’ French Partner Gerep. They will be offering regular updates on this healthcare reform as it moves forward, and any impact that it may have on corporate social insurances.
The ‘100% Healthcare’ reform was a promise made by French President Emmanuel Macron when a candidate in the 2017 presidential election. It became operative on January 1st, 2019 and is already having an impact on the daily lives of employees undergoing dental treatment or looking for hearing aids.
This reform sets out to do away with co-payment amounts for dentures, glasses and hearing aids when part of government-defined ‘100% healthcare baskets.’ Two or three device categories can be found in these baskets, as the case may be. Details are below:
- A 100% healthcare basket:
- Laying down maximum retail prices (MRPs) for ophthalmic and hearing appliances, and maximum prices for dentistry
- With revised, or non-revised base amounts for determining compulsory first pillar reimbursements [BRSS or Basis for Reimbursement by Social Security]
- One or two other baskets:
-
- A basket with charges at regulated prices
- A basket with non-regulated (freely determined) prices
- With reduced, or unchanged SS base amounts
Below is a summary of the reform at the end of the first stage on the way to full implementation in 2023. It encompasses hearing-aid appliances (January 1) and dentistry (April 1) as well as ophthalmics.
HEARING AID APPLIANCES
A new list of specific hearing-aid designations applies as of January 1, 2019.
These new designations are most welcome and have been well received especially as no updating had taken place over the last 20 years and the new list includes all currently-known devices. Some obsolete devices have been left out (such as devices with only 8 processing channels).
It is important to make a distinction between the sales price (maximum retail price = MRP) which is the maximum price a healthcare professional may charge an insured for the device and the Social Security reimbursement base amount (BRSS) which calculates the reimbursement due on the device (in audiology, 60% x BRSS).
There are two classes of devices:
- Class I devices: These make up the 100% healthcare basket. They have 12 processing channels and an amplification system outputting external sounds at 30 decibels. An insured person benefits from a 30-day trial period before purchase and the device is guaranteed for four years. Follow-up services are provided at least once a year to continuously adjust the device’s processing to changes in hearing loss.
- Class II devices: Contrary to the class I basket, the MRPs for this class are freely determinable. The base amounts used for reimbursement (by Social Security and second pillar mutual insurers) are, however, the same as in class I. There are more options (6) for class II devices compared to those in class I (at least 3).
| Until end 2018 | Since January 1 2019(1) |
From January 1 2020(1) |
From January 1 2021(1) |
|
| Maximum price (MRP) for a class I device (100% healthcare) | No set price | €1,300 maximum per device |
€1,100 maximum per device |
€950 maximum per device |
| Maximum price (MRP) for a class II device | No set price | No set price | No set price | No set price |
| Basis for Reimbursement by Social Security (BRSS) | €199.71 per device | € 300 per device | € 350 per device | € 400 per device |
| Actual Social Security reimbursement (60% x BRSS) | € 119.83 per device | € 180 per device | € 210 per device | € 240 per device |
| (1) for people over 20. |
DENTISTRY
A new designation list will apply from April 1, 2019 following an agreement signed with the dentist federations. The objective is to reorient the work of dental practitioners towards more preventive, conservative dentistry.
The agreement fully complies with the spirit of the 100% Healthcare reform as it sets out to reduce a patient’s copay to provide a response to the problem of people foregoing treatment (estimated to be 17% of the population).
The three types of dental treatment are:
- Conservative treatment (scaling, treatment of tooth decay, root canal work, etc.)
- Surgery (extractions)
- Installing fixed prosthetic devices (such as crowns, bridges, inlays, onlays and other appliances, etc.)
The first effects of the 100% Healthcare reform will begin April 1 with the revised reimbursement base amounts for some conservative and surgical procedures. The primary increases in reimbursement base amounts on April 1 and the final values as of 2023 are outlined below.
Conservative and surgical procedures
Again, it is important to distinguish between price (here, the fee) and the reimbursement base amount (BRSS). As of April 1, 2019, the BRSS of only some procedures have been revised, but not the prices charged (fees), as these are generally already regulated (except for inlays and onlays, for example, where fee overruns can occur).
| Regulated charges (i.e. BRSS) | Until end March 2019 | From April 1, 2019 | Finally in 2023 |
| Anchored restoration | € 79.53 | € 92.00 | € 100.00 |
| 2-sided restoration | € 33.74 | € 42.00 | € 50.00 |
| Decay treatment, 3-sided or more | € 40.97 | € 53.00 | € 65.50 |
| 3-sided inlay or onlay | € 40.97 | € 100.00 | € 100.00 |
| Pulp capping | Not reimbursable | € 60.00 | € 60.00 |
| Root canal work on an incisor or canine | € 33.74 | € 33.74 | € 47.00 |
| Extraction of two milk teeth | € 25.08 | € 30.00 | € 37.00 |
Dentures
Today, 1 in 6 insureds foregoes dental treatment, in particular when involving fitting dentures.
A maximum limit on crowns will apply from April 1, 2019, and this will be the first stage in pricing adjustments that will accompany those of routine procedures.
100% Healthcare for dentures will be implemented in two stages: in January 2020 for crowns and bridges (all types of material) and in January 2021 for fixed resin crowns.
Three baskets have been created along with this new designation list:
- A 100% healthcare basket
- A minimized-copay basket
- A freely-priced basket
These three baskets are devoted exclusively to prosthetic procedures. Each prosthetic procedure in the designation list appears in one of the 3 baskets.