Affections de longue durée and actes lourds
People with chronic illnesses or medical conditions that require long-term treatment typically are entitled to reimbursement at 100%
An Affection de longue durée (ALD) is a chronic illness or medical condition that requires long-term and usually expensive treatment. Some 113 million people, or 20% of the population, are registered with Assurance Maladie for long-term condition or illness.
ALDs typically give a right to reimbursement at 100%, for treatment relating to them (technically speaking, the patient is exempt from the ticket modérateur). It does not necessarily mean exemption from paying dépassements, nor non-reimbursable elements such as the franchises médicales (levies taken off medicine reimbursements) or the daily forfait hospitalier fee for stays in hospital.
In 2024 a minister stated that the ALD system was under review as it was costly, however many health associations signed an open letter defending it.
ALDs include strokes causing disability, serious heart illness, HIV, diabetes, severe high blood pressure, Alzheimer’s, Parkinson’s, cancer and endometriosis.
When a patient enters the ALD system, he or she receives a letter informing them and there should be a new section in their online Ameli account giving details of their situation.
Most but not all ALDs are 100% reimbursed.
Conditions and illnesses for which medical costs are generally reimbursed at a rate of 100% are called ALDs exonérantes (exempting ALDs). The main ones are on a list called ALD 30, with a few additional conditions listed on ALD 31 and ALD 32.
Non-exempt ALDs are less common and include some medical conditions that require a leave of absence from work and/or continuous care for a foreseeable period of time, not exceeding six months. Their diagnosis is subject to the discretion of the doctor and the Cpam.
Some examples of conditions that are considered non-exempt ALDs include glaucoma, osteoarthritis, hypothyroidism, epilepsy and coeliac disease.
Fees for expensive procedures
The ticket modérateur – whereby you or your mutuelle pay a remainder of the cost of a service after the state-reimbursed percentage – is not applied for some costly procedures known as actes lourds, mainly those for which the state tariff is €120 or more, whether carried out in a GP surgery or hospital.
These are reimbursed to the full state tariff, minus a forfait (fixed payment) of €24. If several actes are carried out during one doctor visit or hospital stay, you only pay the forfait once.
Certain procedures including emergency transport, x-rays, scans and MRIs costing more than €120, are covered 100% without the forfait (note honoraires libres doctors can still make a surcharge).
Some people are exempt from the forfait – notably those on the Complémentaire santé solidaire for people on low incomes, those receiving disability pensions, pregnant women and people with Affections de longue durée.