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100% ALD


hakunamatata

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I have been granted by CPAM 100% for  my glaucoma and related eye problems, however after paying 40 euros for a specialist opthalmic appointment I have only received from CPAM 23 euros.  I find these reimbursements very difficult to understand although I have been trying to work it out for 2 years now!  My OH has 100% for his diabetes and always receives a full reimbursement.  I am shortly going for laser surgery and maybe further surgery after that so I would like to know what to expect.  Anybody have any answers?  I will of course phone the English speaking line but it would be interesting to know if anyone has had any similar experience
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100% means 100% of the basic tariff, not 100% of your costs.

The 100% cover does not cover the excess fee charged by secteur 2 health professionals, who charge more than the basic tariff.

In case of a secteur 2 ophthalmologist, €23 is the maximum reimbursement.

If you choose a secteur 1 doctor or specialist, who does not charge more than the basic CPAM tariff, you will get 100% reimbursement for anything related to your ALD.

You can find out about CPAM reimbursements here: http://www.ameli.fr/assures/soins-et-remboursements/ (in google English here)

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Who reffered you to this specialist? If it was your medecin traitent then in future I would ask the question before they arrange the appointment.

I don't know but alarm bells start to ring with me when you say laser surgery. Before you commit make sure that you'll get a full refund or you could be in for another nasty shock.

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Don't forget that they may have taken off something for costs of medicines or transport not directly related to that particular appointment.

That is to say you may owe some 'franchises' from other things and they are simply catching up on what you owe.

Fox example 50 centimes per box of tablets, or 2 euros each way for transport, or the 'La participation forfaitaire de 1 euro' per consultation

If someone has an appointment with a Doctor at some distance, who also prescribes 4 medicines the bill can look like this:

4 euros transport fees

1 euros forfaitaire

2 euros 'franchise'

that is to say you  would get back 7 euros less than you paid.

It could be even  higher if you have other things 'in the pipeline' to pay back

In some cases  there is also a payment of 18 euros, but not for ALDs I think. I just mention it for others who wonder about how things are calculated

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Interesting comments, thank you, things become clearer.  I am always fully reimbursed for my medication and have never understood why I am not asked to pay the 1 euro charge so I understand now they make it up by deducting from another payment.  I have no transport charges only monthly medication.  What I do not understand is why my OH has had heart surgery and lots of other proceedures and has never paid a penny. I have sent an email to the clinic to ask what the likely charges for my laser surgery will be so I will let you know the outcome

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As Clair said this particular specialist may charge over the odds. So your husband's Doctor who charges the 'normal' price is paid for, whereas your may be charging more (called dépassement d'horaires)

I quoted an article in another thread which showed how some of these doctors refuse people on the CMU because that only pays back the basic cost

Not all specialists charge the minimum rate, and France is rapidly developing a two tier system.

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Morning NormanH  I have just found this on the clinic web site

Les Docteurs LALLEMENT Alexandre, Valérie SERRES, Christophe and Patrick MALAN Gazagne exercise under the Sector II of the Convention. Their fees are free.

Le reimbursement by health insurance will be based on the conventional rate. If necessary, you can repay a Mutual complementary part.

There is also a list of fees.  Can I now breath a sigh of relief???
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It will really depend upon what the clinic are charging in the way of fees and what level of cover you have on your mutuelle.

To work through an example. 

Say the standard cost of treatment according to the official tariff is 1,000€.

Say the actual cost of the operation is 1,500€.

Your CPAM will cover 70% of the tariff, ie 700€, leaving a shortfall of 800€ chargeable to you or your mutuelle.

If you have 100% cover on your mutuelle, they will cover the shortfall up to 100% of the tariff, ie 300€, leaving you to pay the remaining 500€.

If you have 150% cover on your mutuelle, they will cover the shortfall up to 150% of the tariff , ie 800€, leaving you to pay nothing.

 

 

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Hi Sunday Driver, we used to converse on another Forum!  I am very confused by this system, what you are saying then is that despite the fact I have letters from CPAM agreeing to covering me with ALD they still do not cover the full 100% so my question is what is the point of ALD cover ?  I understand it in OH's case because he is diabetic but still dont grasp why all his treatment has been totally free i.e heart operations, xrays, etc etc.  Sorry to be so dim I dont normally have a problem understanding matters but this one has really got me. I cant see what benefit I am getting from CPAM's granting me the 100% ALD

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hakunamatata

You are only covered 100% for the ALD itself up to the rates published by CPAM. You are not covered for other, non-related illnesses. I'm not a doctor so on the face of it it is difficult to see what a heart operation has to do with diabetes.

There is one other possibility. Do you have an E121 and does it say incapacity on it?

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This much I understand, I am only covered for matters relating to my eye problems.  That is  all I expect, however I agree with you my OH got all his treatment free, diabetes can affect the heart so maybe that is why but for me if it only covers my eye problems I will be happy, I just dont think it is giving me a full refund at the moment and that is why I asked the question, well I will just have to wait and see (or not!!!!)._
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I'm not sure you are right SD.

This is a case of ALD, so the CPAM will pay 100% of the official tariff, not 70%.

That is the point of the status

Where the problem might lie is if the actual cost is above the official one, in which case it depends on the terms of the Mutuelle whether they cover the shortfall  (dépassement d'horaires) or not.

This is one reason to have a good Mutuelle, a question which sometimes is raised on here.

In short for the OP: the point of being classified as having an ALD is that 100% rather than 70%  of the official rate is paid for by the CPAM.

On the other hand if the specialist ( as is sometimes the case) charges above that official rate the CPAM still only pays the official one.

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Good evening NormanH  Did you see my post where the clinic says the specialist fees are free, I presume therefore that I am covered 100% and any shortfall will be made up by the Mutuelle, I have 150% cover with them.  Its a mine field this isnt it[8-)]

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[quote user="hakunamatata"]

Did you see my post where the clinic says the specialist fees are free, I presume therefore that I am covered 100%[/quote]

Is this, as in the UK, where the initial consultation is free and where an analysis of the proposed treatment is discussed and a fee suggested?

Sue

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No. The medical fees are covered too, but some specialists charge an extra fee. It's a question of how that would be paid that is being discussed, but as the OP has a good Mutuelle it is pretty clear that she is covered. In any case her specialist seems to be in the majority of those who don't charge extra.

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[quote user="NormanH"]No. The medical fees are covered too, but some specialists charge an extra fee. It's a question of how that would be paid that is being discussed, but as the OP has a good Mutuelle it is pretty clear that she is covered. In any case her specialist seems to be in the majority of those who don't charge extra.[/quote]

It was clear to me Hukunamata was using a machine translator to translate the French site info she was looking at ie she was offered 'free' as a translation for 'libre' which is not quite the same thing .

Perhaps this info will add weight to my concern:

http://www.narbonne-ophtalmologie.com/honoraires.html

Sue

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Thanks for pointing that out. I thought she had established that they were charging standard fees.

No it doesn't mean free...it means that they are free to charge what they like .

The fees are clearly stated.

For example they begin at 23 euros (the standard) for a consultation, and can go up to 60 euros.

In this case the consultation would be reinbursed at 22 euros (the standard 23-1 euro 'forfait' at 100% of the standard charge)

The rest could be met by the Mutuelle up to 150% if the standard charge.

It is important to know both exactly how much the particular specialist will charge, and what the base for the standard re-reimbursement is

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[quote user="NormanH"]Thanks for pointing that out. I thought she had established that they were charging standard fees.

No it doesn't mean free...it means that they are free to charge what they like .

[/quote]

This is one of the reasons I was worried about H's interpretation.

Sue

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In fact it also explains the original figures.

She was reimbursed 23 euros which is 100% of the CPAM tariff, so for them she received  100% .

Of she was not on an ALD she would have only got 70% of that 23 euros, say around 15.

The remaining 17 euros is for her to pay with the help of the Mutuelle if it covers more than the 100% of the  CPAM tariff.

If as stated she has a 150% cover that would be 23 x 150%..up to say 34 euros covered with the rest to be paid for.

Her husband also on "100%" cover is presumably being treated by a Doctor 'Secteur 1' who charges the CPAM tariff, and who is therefore totally covered by the ALD status

This difference between Doctors who charge extra and those who don't is why I wrote about a 'two tier' system, and why a good Mutuelle cover is important

The other thing to note on that site is that "Les

actes d'exploration (angiographie et OCT) et de laser (rétine et iris)

pratiqués à la clinique ne bénéficient pas du tiers payant. Vous devrez

régler sur place (uniquement en espèces ou par chèque).  "

In other words the part that is over 70%, plus the part possibly to be paid by the Mutuelle, have to be paid for up front by cash or cheque, and then reimbursed

On the positive side, the site gives as a tariff 'Laser maculaire 146,30 à 190 €'.

Presuming that the lower figure is the CPAM one the 190 is still within 150% so should be covered by the Mutuelle if it indeed is at 150%

Perhaps H can look and see if she has had a second reimbursement (from her Mutualle) for that first 40 euro charge.

It can be confusing in the bank statement, because the CPAM and Mutuelle repayments show up separately, with the Mutuelle one coming a bit later.

If she has had that it confirms that the Mutuelle is covering some of the extra. 

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[quote user="hakunamatata"]

Hi Sunday Driver, we used to converse on another Forum!  I am very confused by this system, what you are saying then is that despite the fact I have letters from CPAM agreeing to covering me with ALD they still do not cover the full 100% so my question is what is the point of ALD cover ?  I understand it in OH's case because he is diabetic but still dont grasp why all his treatment has been totally free i.e heart operations, xrays, etc etc.  Sorry to be so dim I dont normally have a problem understanding matters but this one has really got me. I cant see what benefit I am getting from CPAM's granting me the 100% ALD

[/quote]

Sorry about the confusion.  I was replying to your comment about having seen the fees and breathing a sigh of relief so I wanted to make sure you were aware of how the reimbursements worked for dépassements.  In doing so, I missed your original mention of it being an ALD.

Norman has kindly provided additional explanations of the process.

 

 

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  • 2 weeks later...
I am delighted to hear that.

Thank you for getting back to us with the good news.

Did he confirm that it was cash or cheque?

I usually pay by carte bleue, and as that comes out of my account on the 27th of the month I have usually been reimbursed before the money is taken!

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