What is long-term illness (ALD)?
ALD: definition
Long-term conditions are conditions involving “prolonged treatment and particularly expensive therapyentitling those who suffer from it to exemption from the co-payment”, i.e. to full coverage of their treatment costs, within the limit of the reimbursable scope (article L.322-3 of the Social Security Code).
Exempt ALD and non-exempt ALD
The law distinguishes two main types of long-term conditions: exempt and non-exempt ALD. The exempt ALD concerns a person suffering from a serious illness, evolving over more than six months and requiring expensive treatment. In this context, health costs linked to this condition are covered by Social Security. based on maximum reimbursement. We then talk aboutexemption from user fees.
Non-exempt ALD applies when no costly treatment is necessary. In this case, Health Insurance reimburses illness-related care at the usual rates. However, this system allows you to benefit from a work stoppage more than six months as well as, under certain conditions, the covering transport costs. There is no standard list and their qualification is left to the discretion of the medical profession. We can nevertheless cite glaucoma, osteoarthritis, hypothyroidism and even epilepsy.
What are the 30 diseases recognized by the Ministry of Health?
List of 30 illnesses covered 100% by Health Insurance
The Ministry of Health has established a list of 30 long-term conditions:
- disabling stroke,
- bone marrow failure and other chronic cytopenias,
- chronic arteriopathies with ischemic manifestations,
- complicated bilharziasis,
- severe heart failure, serious arrhythmia, serious valvular heart disease, serious congenital heart disease,
- chronic active liver diseases (hepatitis B or C) and cirrhosis,
- severe primary immunodeficiency requiring prolonged treatment, human immunodeficiency virus (HIV) infection,
- type 1 diabetes and type 2 diabetes,
- severe forms of neurological and muscular conditions (including myopathy), severe epilepsy,
- hemoglobinopathies, hemolysis, severe constitutional and acquired chronic,
- hemophilia and serious constitutional disorders of hemostasis,
- coronary heart disease,
- severe chronic respiratory failure,
- Alzheimer’s disease and other dementias,
- Parkinson’s disease,
- hereditary metabolic diseases requiring specialized prolonged treatment,
- cystic fibrosis,
- severe chronic nephropathy and primary nephrotic syndrome,
- paraplegia,
- vasculitis, systemic lupus erythematosus, systemic sclerosis,
- progressive rheumatoid arthritis,
- long-term psychiatric conditions including recurrent depression and bipolar disorders,
- ulcerative colitis and progressive Crohn’s disease,
- multiple sclerosis,
- progressive structural idiopathic scoliosis (the angle of which is equal to or greater than 25 degrees) until spinal maturation,
- severe spondyloarthritis,
- organ transplant results,
- active tuberculosis, leprosy,
- malignant tumor (colorectal, skin, lung, breast cancer, etc.), malignant disease of lymphatic or hematopoietic tissue.
ALD 31: so-called “non-listed” conditions
The ALD 31 list brings together so-called “non-listed” conditions concerning patients affected a serious form of an illness, or a progressive or disabling form of a serious illness, not appearing on the list of ALD 30. These illnesses require prolonged treatment with a foreseeable duration of more than six months and particularly expensive therapy. Examples: Paget’s disease, chronic or recurrent ulcers with severe functional impact. The disease must meet at least two of the following four criteria:
- upcoming hospitalization;
- repeated technical medical procedures;
- repeated biological acts;
- frequent and regular paramedical care.
The ALD 32 list
The ALD 32 list concerns patients suffering from several characterized conditions, leading to a disabling pathological state and requiring continuous care of a foreseeable duration more than six months. We then speak of “polypathologies”.
How does Health Insurance coverage work?
If the law distinguishes two main categories of ALD, it is with a view to different coverage by Health Insurance.
Exemption from user fees for exempt ALDs
In the case of an exempt ALD, there is no co-payment. The costs of care relating to these conditions are covered within the limit of 100% of the Social Security liability tariff.
To enable the costs relating to ALD to be distinguished from the patient’s other treatment costs, the doctor uses a special prescription model known as “Bi-zone” which allows the costs incurred under ALD to be separated from those relating to other pathologies not classified as ALD. This makes it easier to process reimbursements by Health Insurance.
Extended work stoppage and transport costs for non-exempt ALDs
Although long-term non-exempt conditions require a work interruption or care lasting more than six months, they do not give rise to rights to 100% coverage. Care is reimbursed at the usual rates. Health Insurance covers costs up to 65% of the Social Security reimbursement base in terms of travel costs, transport costs and accommodation costs linked to thermal treatments relating to the condition.
Non-exempt ALDs require the establishment of a protocol by the attending physician. This protocol allows the patient to extended work stoppage to receive daily allowances for three years (then to be placed on disability). It also allows the waiting period to be retained only for the first work stoppage for the same three-year period.
What are the steps to apply for ALD care?
The patient suffering from a pathology classified as a long-term condition should contact their treating physician. He is the only one authorized to trigger the implementation procedure.
Establishment of the treatment protocol by the attending physician
The treatment protocol is established by the attending physician, after possible consultation with the specialist doctors who follow the patient’s exonerating long-term illness (ALD). Its duration and renewal are left to the initiative of the attending physician. The care protocol allows you to inform the person about the actions and services necessary for the treatment of your ALD, in order to be exempt from the co-payment when they are taken into care.
The care protocol contains all the therapeutic elements planned and mentions the doctors and other health professionals (nurses, physiotherapists, etc.) who will follow the patient.
Its validation by Health Insurance
After study by its medical advisor, Health Insurance gives his agreement for the coverage under the ALD of all or part of the care and treatments linked to the pathology presented by the patient.
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