Hospital cost reimbursement

[allanb]

There's one thing (at least!) that I don't understand about hospital

cost reimbursement in France.  A separate thread, about

hip replacement, has made me look again at the costs when I had the same

operation about two years ago.

For almost everything that

happened in the hospital, wherever the CPAM reimbursed something, it was

at 100%, and I'm not sure why.  I know that treatment for a registered

long-term affliction (an ALD) is reimbursed at 100%, and I have an ALD,

but it's connected with my heart, not an arthritic hip.  The Ameli

website seems to say that the general rate is 80% except in the case of

an ALD; does this mean that if you have an ALD you will get the 100%

rate even if it's a procedure that has nothing to do with the

affliction?  Or could it be because I was over a certain age?  (I was 69

at the time.)

Without going into all the detail, the costs that were paid 100% were:

- the hospital's daily charge, except for the forfait journalier;

- fees of the surgeon, anaesthetist, and radiologist;

- the new joint itself, which was an expensive piece of kit;

- physiotherapy while I was still in the hospital (about a week);

- all X-rays and blood tests;

- all medication.

I'm not complaining, of course, but I'd like to know because - like the

poster of the other thread - I'm trying to make a sensible decision

about whether to renew my Mutuelle policy, or perhaps to reduce the

level of cover.

[NormanH]

[quote user="allanb"] does this mean that if you have an ALD you will get the 100%

rate even if it's a procedure that has nothing to do with the

affliction?  Or could it be because I was over a certain age?  (I was 69

at the time.)

[/quote]

Normally you are only given 100% for the ailments specified on the protocol issued by the CPAM at your GP's request.

This cover lasts 5 years and then has to be re-applied for.

However it rather depends when it was done.  A few years back checks were very slack and there was a tendency to pay 100% for everything if you had an ALD even though this wasn't strictly the intention.

There was a considerable tightening up on this a year or so ago, and it unlikely that this would be the case nowadays

[Patf]

Reimbursements are so unpredictable here.

 I had 100% reimbursed for the hospital part of my hip replacement (except for the 16€per day cost of the room)

Previously husband had 100% reimbursement while still using E111 for 3 days in a clinic for operation on a broken leg.

BUT:

I went into intensive care 3 days when I had an emergency heart problem, and this was only covered 70% . Bill for 1400€ (no topup)

Husband was sent to hospital by ambulance with suspected heart problem - all reimbursed 70%, bill for 1000€.

So that was when we decided to take out a top up insurance policy.