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Healthcare and Social Security

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Which are the conditions to be covered by the securité sociale ?

Every salaried worker, of French nationality or a foreigner, has the right to benefit from social security in order to cover health costs incurred in case of accident or illness. When you are affiliated, you receive a number and a social security card, the carte vitale, which will enable you to be reimbursed for health costs. Your dependents (spouse or partner and children under 16 or under 20 if studying) are covered as well. Costs covered include medical and dental expenses, prescribed medicines and hospital fees.

After the affiliation there is a qualifying period (délai de carence: 60 h in the last month or 120 h over last three months) before you can get the reimbursement (prestation en nature) from the social security. For this period you have to be covered in your home country or to pay on your own.

Salary compensation (préstation en especes) is only paid once you have worked at least 200 h during the last 3 months.

How can I be covered when I am not salaried worker ?

If you are a grant holder or if you benefit from an allowance, you need to draw up a personal insurance policy or to be insured in your country of origin.

Do I need further insurance ?

Social security does not generally reimburse 100% of health costs. It may be that the outstanding fees are high. 

A mutuelle covers the own contribution (”ticket moderateur”) or even all costs (”Ticket moderateur” and “dépassement honoraire”) depending on the nature of your contract and other aspects of health care that are either poorly or not at all reimbursed like spectacles or dentures. 

How to chose a doctor ?

You have to choose a generalist as family doctor. He can prescribe you to go to the specialist, if necessary. You can’t go directly to a specialist, otherwise you might not be reimbursed by the sécurité sociale.You may consult a doctor in the private sector (office, clinic) or in the public sector (hospital, dispensary).

The fees are either set by the social security or unregulated, depending on the doctors status. Doctors are required to inform their patients by indicating their fees and their status in the waiting room.

What are the differences in price setting ?

-If a doctor is “conventionné”, the price is fixed by the social security and your reimbursement will be about 70 %. Your mutuelle (additional insurance policy) will cover the rest.Some cases are covered at 100% (specially serious illnesses, after an agreement has been made with the social security, pregnancy and illnesses caused by a professional accident)
-If a doctor is “conventionné à honoraire libres” the cost of the consultation varies.You will be reimbursed on the basis fixed by the social security for a consultation conventionné and your mutuelle will reimburse all or a part of the rest, according to your contract.
-If a doctor is “non conventionné”, the cost is set by the doctor according to his reputation (only 2% of all doctors). Social security reimburses a few euros, following a “tarif d’autorité” and your mutuelle decides how much it will reimburse. Sometimes you pay the entire cost yourself. 

How to pay ?

Doctors are paid directly by cheque or cash. Rarely you can pay by carte bleu.

You pay the full fees. To get reimbursed quickly the payment is reported from the doctor to the social security by use of the carte vitale. After reimbursement of this first part, the balance, called “ticket modérateur” (own contribution) and any fees over the recognized ceilings may be paid by your complementary health insurance.If the doctor has no possibility to register the data from the carte vitale, he will give you a ”feuille de soins”, which has to be filled in (name, address, matriculation number) and send to the social security for reimbursement. 

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What other healthcare services I might need ?

The healthcare system is very diversified and you need to look for services like X-ray, ultrasound scans, scanner, laboratory, or physiotherapy in different places. To get reimbursed you always have to get a prescription from the generalist.

When do I need a prior approval (entente préalable)?

For some medical care (i.e. physiotherapy, speech therapy) the social security has to approve the treatment prescribed and the patient has to wait for the beginning of the treatment. This demand can be made by the doctor or by the patient.

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How to find a doctor who speaks my language ?

Usually the consulates provide a list and associations like Adapt in France or AVF might help.

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What happens in the case of illness-conducted absence from work (being on a sick leave) ?

If a doctor considers that you are unfit to attend your place of work he will give you a sick leave certificate (“arrêt de travail”). This paper has to be send to your employer and to the social security within 48 h in order to inform them about the situation. Social security will reimburse you up to 80% of your salary (“indemnities journalières”), excluding the first three days of absence. The employer may cover the loss of salary. 

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How professional accidents are treated ?

In case of an accident during working hours or on the way to or from work all costs are completely and immediately covered by the social security.

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What to do in case of emergency? Which number in which case ?

- 18 fire service : In case of a serious problem, which needs rapid action and first aid
- 15 SAMU service d’aide medicale d’urgence provides medical assistance in emergencies . They advise over the phone, can send a medical team to the site and can direct you to other medical services- 17 police adirect connection with the emergency services will rapidly transfer your call
- SOS medecins: Local telephone service which can send the duty doctor for cases of fever or other illnesses
- The information, who is the duty doctor or duty chemist is available at the local police station. The duty chemist can only deal prescriptions of the duty doctor.
- 112 to contact the emergency services by mobile

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What do the ambulances ?

Ambulances should not be confused with emergency ambulances. They carry only a basic medical equipment and are a means of transport for sick people between home and hospital or between hospitals.

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What are the differences of public and private hospital ?

The hospital is a state run institution, where all standard treatment is reimbursed by the social security. The departmental head doctors often have a private practice within the hospital where they charge for their services.

The clinic is a private institution often offering specialised services and sometimes more comfortable accommodation. Treatments may only partly be reimbursed.

If you have to go to hospital, you need to take your own nightwear and toiletries.

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What do I pay when I have to go to a hospital ?

In most of the cases, if the hospital is conventionné, social security advances the bulk of the cost of the hospital stay directly, leaving your mutuelle, or you, to pay the rest (ticket modérateur). A small daily contribution (forfait hospitalier), telephone and television rest at your charge.

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What kind of service do I get in the pharmacie? And which reimbursement ?

Pharmacists are at your disposal for minor health problems that do not require a visit of a doctor. They are also responsible for checking prescriptions issued by doctors, to ensure that there are no interactions between medicines.

Opening hours are the same as shops in general.

Pharmacies deliver three types oif medicine:
-Supplied on prescription only : generally reimbursed
-Freely available: may be reimbursed , if prescribed by a doctor
-Cosmetic and other products (i.e. shampoo against louses)

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What is happening in the case of pregnancy ?

When your pregnancy is confirmed by a gynaecologist, you have to inform immediately the social security and the CAF to receive a “carnet de maternité”, which contains all information and claim forms. All costs for pregnancy and birth are fully reimbursed. A first prenatal examination is required before the fourth month of pregnancy, followed by monthly exams. Two scans will be made to verify the baby’s development.For the birth, you have the choice of a public hospital or a private clinic. If you opt for a public hospital, a midwife will manage your labour and delivery. The obstetrician will be on-hand to assist in case of complications. At a private maternity clinic your own obstetrician will be assisted by a midwife. Birth at your home place is absolutely not common, and therefore difficult to organize.

In general the rest period is 16 weeks (6 antenatal, 10 postnatal) During this period your salary is paid by the social security. 

You may be entitled to receive “allocations famiales”, a monthly family allowance payment, starting from the first month of pregnancy until the baby is three months old. Subsequent payments depend on your income.For the citizenship status of the new baby you have to contact your embassy or consulate.

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What care is given to children, what is recommended and what is obligatory ?

At birth, the baby receives its “carnet de santé”, which guides the parents in the care of the child (growth, feeding, vaccinations) Several check-ups are obligatory during the first six years. A visit one week after birth, at 9 month and at 24 month are conditional to receive family allowance.

Obligatory vaccinations are for diphtheria, tetanus and poliomyelitis (DTP) and the BCG which immunizes against tuberculosis. Other vaccinations are highly recommended (whooping cough, ROR (measles, mumps, rubella) or anti-haemophilia vaccines)

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What does the PMI center do ?

Every town has a PMI (centre de protection maternelle et infantile), where free medical care is given to children under 6 years of age.

Développement Christophe Arsonnaud - Chris informatique