Le Cleiss Particuliers Employeurs Indépendants Documentation Actu

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1. Scheduled treatment subject to prior authorization

Before you leave, you must apply for prior authorization of coverage for care requiring at least a one-night hospital stay or the use of highly specialized and costly medical equipment or facilities.

Treatments subject to prior authorization are as follows:

• Care requiring the use of major medical equipment: scintillation camera with or without a positron coincidence detection system, positron emission tomography, positron camera, clinical nuclear magnetic resonance imaging or spectroscopy, CT scanner, hyperbaric chamber, medical cyclotron;
• Cardiological procedures using medical imaging, via the endovascular route;
• Neuroradiology procedures via the endovascular route;
• Procedures on the crystalline lens, with or without a vitrectomy, or any other surgical ophthalmological procedure;
• Ambulatory carpal tunnel and other superficial nerve release procedures, as well as other surgical hand procedures;
• Treatment of chronic renal insufficiency through extrarenal purification;
• Cancer treatment;
• The examination of a person's genetic characteristics or identification of a person through genetic fingerprints for medical purposes;
• Clinical and biological assisted reproductive technology procedures and biological prenatal diagnostics activities.

The portable S2 certificate

The portable S2 certificate, « Entitlement to scheduled treatment », authorizes you to travel to another EU or European Economic Area (Iceland, Liechtenstein, and Norway) member state to receive medical care. It means that your care will be covered as provided by local law and according to local rates. Indeed, you will receive the same care as members of the local social security system.

If you are covered under the general scheme, you will need to apply for this document (S2 form) by post to:

CPAM DU MORBIHAN
CNSE – MÉDECIN CONSEIL
CS 80330
56018 VANNES CEDEX

For other French social security schemes, you will need to apply for this document (S2 form) from your local health insurance fund in France.

Your application must be sent along with a detailed medical certificate issued by your designated primary care physician (doctor registered in France or doctor registered in the EU/EEA/Switzerland), specifying:

- your medical condition,
- the type of care you intend to receive,
- the medical reasons for which you intend to seek care elsewhere in Europe,
- the country and the facility in which you will receive care,
- the expected beginning and end dates of your course of treatment.

You will receive notice of prior authorization or refusal of coverage from your health insurance fund within 14 days of receipt of your application. If you receive no response within this timeframe, your application has been approved.

You must apply for your authorization far enough in advance so that your local health insurance fund can process it before you leave.

However, if the patient requires urgent care which can neither be postponed nor performed in France, prior authorisation may be issued retrospectively when the patient was prevented from requesting such authorisation before his departure or could not wait for the decision of the competent institution.

Your authorization will not be granted automatically. Indeed, the following conditions apply:

• The care or treatments you plan to receive abroad must be covered by the French social security system;
• This care or treatment must be appropriate to your condition;
• This care must not be available in France, within a medically acceptable time frame, in light of your current state of health and the expected course of your illness.

If your application is approved, you will be issued with an S2 certificate you will need to show in the Member State you are visiting either to one of the local health insurance fund or directly to your healthcare provider so that your care is covered locally pursuant to local law.

If your request for prior authorization has been denied, the decision must be reasoned and include instructions on the appeals procedure.

SPECIAL CASE:

If you are not a resident of the competent State, you will need to apply for authorization of scheduled care through the institution of your place of residence, which will immediately forward your application over to your fund of membership (competent institution). In this case, authorization can be granted:

• if the care is among the treatments covered domestically by the State of residence and
• if the care cannot be provided within a reasonable timeframe from a medical standpoint with regard to your state of health and the probable course of your illness.

If you need critical emergency care and prior authorization cannot be denied (the care is covered domestically by the member State of residence and cannot be provided within a reasonable timeframe from a medical standpoint), you will be granted authorization by the health insurance fund of your place of residence on behalf of your fund of membership.

If you or your family members are residing in a State that has opted for the reimbursement of care on a lump-sum, the competent institution to issue the prior authorization will be the health insurance fund of your place of residence as that is the fund that will cover the cost of your scheduled care.

Coverage of transportation expenses:

When the medical service processes an application for prior authorization of scheduled care, it must also process any request for coverage of related transportation expenses at the same time, using the criteria set forth by French regulations (submission of an application for prior authorization valid as a medical prescription).

Transportation expenses must have been medically prescribed to the patient and are reimbursed on the basis of the least expensive itinerary and means of transportation that are compatible with the patient's state of health.

Requesting reimbursement when you return to France

• If you paid your medical expenses upfront, you can submit your paid invoices and proof of payment, along with a completed S3125c form, to your health insurance fund to request reimbursement. Your health insurance fund may require additional documents, such as medical reports or scan results.
  You have a two-year deadline to apply to your health insurance fund for reimbursement of your medical expenses.
  If your reimbursements are related to an illness, your two-year deadline begins on the date of care and expires at the end of the same calendar quarter, two years later.
  If your reimbursements are maternity-related, your two-year deadline begins on the date your pregnancy was medically confirmed.
• The fund will examine your request for reimbursement. In particular, it will check whether prior authorization was granted and whether the conditions for reimbursement provided by French law, such as the requirement for a prior agreement or a medical prescription, were met.
• Where applicable, the fund will reimburse you for your care based on Social Security rates in the country where the care was provided or, if you so request, based on French Social Security rates up to a maximum of actual expenses. A supplement can be considered if the foreign rates are lower than the French rates for the same treatment: the French health insurance fund will issue a supplementary reimbursement, up to a maximum of your upfront expenses. For example, for a procedure billed 150 euros, if you were issued a 100-euro reimbursement in the foreign country and the French social security rate is 150 euros, you may receive a 50-euro supplement from your French fund.

2. Scheduled treatment not subject to prior authorization

Coverage of other scheduled care, particularly standard ambulatory care, is not subject to prior authorization from your local French health insurance fund, but this care must be part of the benefits to which you are entitled in France. Otherwise, no reimbursement is allowed.

However, certain types of care or treatment may be subject to prior authorization from the French system:

• Dentofacial orthopedics, 
• massage-physical therapy procedures requiring prior authorization beyond a predetermined number of sessions, 
• certain laboratory tests and analyses,
• certain cholesterol-lowering drugs,
• certain medical prostheses,
• long-distance transportation (over 150 km), frequent transportation, commercial airline or boat transportation, transportation connected to the care or treatment of children and adolescents enrolled in early-intervention medical-social centers ("centres d'action médico-sociale précoce/CAMSP") and medical-psycho-pedagogical centers ("centres médico-psycho-pédagogiques/ CMPP").

Before you leave, you need to inquire whether the care or treatments you plan to receive will require prior authorization from the Health Insurance Fund in order to be covered. If so, prior authorization will be also required for coverage of scheduled care in another State.

Your designated primary care provider must fill out the request for prior authorization of coverage and give it to you. You must then complete it and send it to the medical Service of your local Health Insurance Fund in France. You must also send the prescription (original or copy) for care or procedures performed by allied health professionnals (physical therapists, speech therapists, othoptists), for travel expenses for medical purposes, for lab exams or for medical equipment along with your application.

You will receive notice of prior authorization or refusal of coverage from your Health Insurance Fund within period of 15 to 21 days of receipt of your application, depending on the nature of the care. If you receive no response within this timeframe, your application has been approved.

If you request for prior authorization has been denied, the decision must be reasoned and include instructions on the appeals procedure.

Requesting reimbursement when you return to France

• If you paid your medical expenses upfront, you can submit your paid invoices and proof of payment, along with a completed S3125c form, to your health insurance fund to request reimbursement. Your health insurance fund may require additional documents, such as medical reports or scan results.
  You have a two-year deadline to apply to your health insurance fund for reimbursement of your medical expenses.
  If your reimbursements are related to an illness, your two-year deadline begins on the date of care and expires at the end of the same calendar quarter, two years later.
  If your reimbursements are maternity-related, your two-year deadline begins on the date your pregnancy was medically confirmed.
• The fund will examine your request for reimbursement. In particular, it will check whether prior authorization was granted and whether the conditions for reimbursement provided by French law, such as the requirement for a prior agreement or a medical prescription, were met.
• Where applicable, the fund will reimburse you for your care only based on French Social Security rates up to a maximum of actual expenses.