Moderator ticket: Definition and exemption

The moderator ticket corresponds to the share of health expenses left with the patient’s responsibility after reimbursement of health insurance, but before deduction of other costs of the insured. Its amount varies depending on medical and medication acts, conditions and compliance with the coordinated care pathway. Explanations!

What is the moderator ticket?

A flat -rate participation in addition to the reimbursement of social security

The moderator ticket is the share of medical costs which remain the responsibility of the insured social after reimbursement of social security. It corresponds to a percentage of health expenses which is not covered by health insurance. In France, the moderator ticket varies according to the type of care, the category of the medical procedure, and the situation of the insured.

Care concerned by the moderator ticket

The moderator ticket applies to the majority of carelike consultations in doctors, medical acts and hospitalization, but it can be reduced or deleted in certain situations, for example for care related to long -term conditions (ALD).

What do the abbreviations mean “TM” and “BR” in mutual?

The abbreviations “TM” and “BR” refer to the Moderator and at the Refund base. Mutuals support all or part of this moderator ticket. This reduces the part to pay from the insured. The reimbursement base serves as a starting point to calculate CPAM reimbursements and, possibly, of the mutual.

How does the moderator ticket work?

The functioning of the moderating ticket is based on the following principle: part of the medical costs is covered by social security, while the rest payable by the insured. This rest is the moderator ticket.

Support for the CPAM fixed participation ceiling

Social Security reimburses part of the expenses According to an agreement ratewhich is fixed for each medical act (consultation, care, surgical acts, etc.). This reimbursement is expressed as a percentage of the agreement rate. For example, for a consultation with a general practitioner, Social Security reimburses 70 % of the agreement rate.

Calculation of the moderator ticket

The moderator ticket depends on several factors, in particular of the type of care and medical acts. If the consultation rate is 25 euros, the CPAM reimburses 70 % (or 17.50 euros). The moderator ticket is then 8.50 euros (detail of the calculation: 30 % – this without counting two euros for the lump sum participation).

What is the amount of the moderator ticket?

The moderator ticket sees its amount vary depending on medical acts or medicines. It is thus a function of two criteria:

• Of responsibility (or conventional tariff) of the act. This is the rate set by Social Security and applicable by doctors practicing the conventional tariff without exceeding fees.
• Of reimbursement rate Provided for the medical procedure or the purchase of drugs. This rate varies according to the nature of the act or medication.

Examples of moderator ticket according to acts or care

Consultation with a general practitioner

Consultation with a general practitioner is a basic care in the health system. The responsibility rate for this consultation is set by Social Security, and a percentage is supported by the latter. The moderator ticket remains the responsibility of the insured or is taken care of by its complementary health.

• Liability rate: 25 euros for a general medicine consultation.
• Social Security reimbursement rate: 70 %.
• Social security reimbursement: 17.50 euros (70 % of 25 euros).
• Moderator ticket: 7.50 euros (25 – 17.50).

Consultation with a specialist

Consultations in a specialist can lead to a higher moderator ticket due to the higher rate of the consultation. However, if the consultation Respects the coordinated care pathway(passing through the attending physician), the reimbursement of social security is greater than that of a consultation without orientation.

• Liability rate: 30 euros for a consultation.
• Social security reimbursement rate: 70 % (if the care path is respected).
• Social security reimbursement: 21 euros (70 % of 30 euros).
• Moderator ticket: 9 euros (30 – 21).

Hospitalization

In the event of hospitalization, the moderator ticket is calculated on the basis of a Daily package hospital which corresponds to a lump sum per day of hospitalization. In addition to this package, medical acts, radiology examinations or surgical acts can generate an additional moderator ticket.

• Liability rate: 20 euros per day for the daily package.
• Social Security reimbursement rate: 80 % for an approved establishment.
• Social security reimbursement: 16 euros (80 % of 20 euros).
• Moderator ticket: 4 euros (20 – 16) per hospital day for an approved establishment.

Refunded drugs

The moderator for drugs depends on Drug responsibility ratewhich is often set by Social Security, and the reimbursement rate thereof. For example, for a current medication, the reimbursement rate can be 65 %.

• Drug responsibility rate: 5 euros.
• Social Security reimbursement rate: 65 %.
• Social security reimbursement: 3.25 euros (65 % of 5 euros).
• Moderator ticket: 1.75 euros (5 – 3.25).

Sessions with a psychologist

Psychotherapy sessions are not covered by social security, Except in the context of psychiatric care or after a medical prescription in specific situations. The moderator ticket can therefore correspond to the entire price, or be partially covered by complementary health depending on the contract subscribed.

• Liability rate: 50 euros for a psychotherapy session.
• Social security reimbursement rate: not systematically reimbursed.
• Social security reimbursement: 0 euro (no standard reimbursement).
• Moderator ticket: 50 euros (all of the price, unless a mutual is taken care of).

Moderator for EHPAD

The EHPAD moderator ticket concerns The accommodation ratebecause medical care, which includes acts reimbursed by Social Security, can be supported by the latter. The cost of accommodation, on the other hand, remains the responsibility of the resident.

• Liability rate: between 50 and 100 euros/day.
• Social security reimbursement rate: Social Security reimburses dependence medical care, but not accommodation.
• Social security reimbursement: no refund for accommodation.
• Moderator ticket: the share of accommodation (50-100 euros/day) remains the responsibility of the resident, except state aid or supported by a mutual.

In which case is the moderator ticket increased?

In the event of non-compliance with the care pathway

The increase occurs in case of Failure to comply with the coordinated care pathway. Thus, the moderator ticket is increased for patients who have not declared a doctor or who directly consult another doctor, general practitioner or specialist (apart from those that can be consulted freely), without going through their attending physician.

Example

Thus, the consultation of a general practitioner approved by sector 1 by a patient who has not declared a doctor will be reimbursed as follows:

• Health insurance will only reimburse 30 % of the consultation rate (instead of 70 %), or 7.50 euros.
• The amount of the moderator ticket will be 17.50 euros.
• Two euros will always be deducted, unless the lump sum participation.
• The rest for total responsibility for the patient will therefore be 19.50 euros on the 25 euros rules.

An increase not reimbursed by the mutual

Know that, even if you have a mutual insurance company, the increase in the moderator ticket for non-compliance with the care pathway will not be reimbursed. Indeed, the law prohibits the management by complementary health.

Who benefits from the exemption from the moderator ticket?

Principle of exemptions

To allow certain categories of persons to meet the expenses of care imposed by their state, the Social Security Code provides for a certain number of cases of total exemption from the moderating ticket and therefore the Support for all healthcare costs by health insurance, within the limit of the reimbursement base provided for each act.

Examples of exemptions

This is particularly the case for (the list is non -exhaustive):

• the health costs of pregnant women from the first day of the sixth month of pregnancy until twelfth day after childbirth, whether or not they are related to pregnancy;
• hospital costs as well as all the care provided in health facilities for newborns, within 30 days of birth;
• Care consecutive to an accident at work or an occupational disease;
• patient care and treatments with an ALD;
• abortion (voluntary termination of pregnancy).

In addition, the beneficiaries of the complementary solidarity health does not have to pay the moderator ticket.

Is the moderator ticket reimbursed by the mutual or complementary health?

Mutual care

The moderator ticket is an important concept within the framework of the care system, aimed at the balance of the care plan, while maintaining the participation of the insured. It can be partially or completely supported by a mutual or complementary health, depending on its table of guarantees.

A variable refund depending on the mutuals

Holders of complementary health will see the moderator ticket supported by their contract Within the limits of guarantees subscribed. Thus, for holders of a basic guarantee, the mutual will take place within the limit of 100 % of the reimbursement base. Any fee overruns will remain the responsibility of the insured.

Where to consult the amount of a moderator ticket following a treatment?

On his Ameli account

After consulting a healthcare professional, the amount of a moderator ticket is available on his Ameli account. Indeed, he is deduced from Refund statements detaileds, which also indicate the rate of the medical procedure and the amount reimbursed by social security.

On the vital card or via the mutual

Sometimes after paying for a treatment, it is possible to see the amount of the moderator ticket directly on thee Related of the vital card or on the documents transmitted by social security. The mutual can also provide a summary on the part it has taken care of, which often includes the moderator ticket.

What is the difference between the moderator ticket and the medical franchise?

The medical franchise is a lump sum participation applied to certain care or medication, regardless of the reimbursement of the CPAM. The medical franchise concerns specific care, such as drugs, paramedical acts or transport. The medical franchise cannot be taken care of by a mutual.

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