6. French Health Insurance Card - 'Carte Vitale'
6.1. Carte Vitale
Historically, if you received medical treatment in France other than as a hospital in-patient, you were obliged to pay at the end of your treatment and later receive reimbursement from the social security system, as well as your 'top-up' insurer if you had one.
The process of recovery of charges required that patients submit a receipt for the treatment (feuille de soins) to the local health authority, the Caisse Primaire d'Assurance Maladie.
This system still remains in place with a small minority of GPs and some consultants, but the paper based process has been streamlined and automated with the issue to registered individuals of a plastic photo identity health insurance card.
The card is called the Carte Vitale.
It is embedded with a microchip and contains your unique social security insurance number, comprising 15 numbers. They correspond to your gender, year of birth, month of birth, department of birth (99 if overseas), place of birth (or country if overseas), birth registration, and security control numbers (last two numbers).
The card does not include medical information, although the government have introduced a voluntary on-line personal record system, called Mon espace santé, but formerly known as the Dossier Médical Partagé (DMP).
Everyone aged 16+ years of age is required to have one. Children under 16 years are included on the card of their parent or guardian.
You will need to update (mettre a jour) your card each year, which you can normally do in a chemist or via your doctor.
In January 2023, after local trials, the government introduced a digital version, called ‘e-carte Vitale’.
It comes in the form of a smartphone app, called l’ApCV, which can be downloaded via the government portal 'France Connect'.
It will be rolled out across the country to the end of 2025.
Once downloaded, users enter their social security number and upload a selfie, plus a photo of their ID card.
After compliance checks have been completed the plastic health card is deactivated.
The government have stated that use of the app will not be compulsory and the existing plastic card will remain in use, at least for the time being.
As with the plastic version, the e-carte-Vitale can pay GPs, hospitals and pharmacies, provided they have either NFC contactless payment system or a QR code reader.
For patients with complementary health cover (a 'mutuelle'), where the health provider uses the system of ‘tiers payant’ payments will be processed automatically, as is currently the case.
The application automatically downloads receipts for payments, up to 7 days after they are made. After this period, they become inaccessible. Once downloaded, the receipts are permanently available.
Prior to obtaining your health card you will need to pay for treatment at the point of care, for which you will be given a feuille de soins, which you send to your local health authority for (full or partial) reimbursement. You should keep a copy and only send recorded delivery, with covering letter and your social security number, if you have it.
When you receive medical treatment, the card is presented to your French doctor/chemist who places it into a card reader enabling you to later obtain direct reimbursement from the insurance fund, rather than having to submit a feuille de soins.
6.2. Tiers Payant
The carte vitale is not a payment card.
Nevertheless, for most people today use of the card enables patients to obtain direct payment of at least some of their medical costs, via the health system, a process called 'tiers payant'.
Many patients also automatically benefit from tiers payant for that part of the charge reimbursable by the State, notably:
Those who have been admitted to hospital;
Those suffering from a major or long-term illness - affection longue durée (ALD);
Beneficiaries of the Complémentaire Santé Solidaire (Sans Participation);
Those suffering from a work-related illness or disease;
Those undertaking organised screening, such as a mammography.
In other cases, doctors and consultants have the discretion to decide whether they are prepared to accept tiers payant, but it is in operation in most GP surgeries.
If you have a complementary health insurance policy many GPs also offer the tiers payant mutuelles/complémentaire, under which the insurers are notified of their charge by the social security system and the doctor is reimbursed by them. The practice is also becoming common among specialist consultants and dentists and other medical specialists.
Normally, if the information is transmitted electronically, you should receive reimbursement within a few days.
Where complete direct payment occurs the tiers payant process is called ‘intégral’; where only the State-reimbursable part of the charge is paid direct it is said to be ‘partiel’, unless that charge is fully reimbursable by the State.
The process is also in place for laboratory tests and x-rays and has been used by pharmacies for many years, where it is almost universal. Thus, if you visit a chemist armed with a prescription from your doctor that part of the charge reimbursable by the health system will be paid directly, with any balance payable direct by your insurer, subject to the terms of your policy. Only if you refused a generic medicine, in lieu of a branded medicine, would a chemist not offer it, unless your doctor had made it clear the prescribed medicine could not be substituted.
The system of tiers payant does not always mean that all charges will be covered. Some charges may remain the responsibility of the patient, such as the various 'participations forfaitaires', which will appear on your medical treatment and bank statements. If you do not have complementary health cover that part of the charge not reimbursed by the state will be payable by you at the point of delivery.
In addition, an increasing number of consultants impose charges that exceed the official tariff. These charges are called dépassements d'honoraires. The extent to which they are picked up by your complementary policy will depend on the policy terms.
The government has been seeking to make universal the system of tiers payant. However, there has been resistance to the change from the medical profession, which considers that there remain many technical barriers to the adoption of the system, such that payment for the consultation cannot be guaranteed. As a result, the government has backed off and the existing arrangements remain in place whilst a working party examines the issue in greater detail.
The system of tiers payant is only possible once you have your ‘carte vitale’.
If you also have complementary health insurance, most insurers are linked into the social system through which their share of the charge will also be reimbursed.
If no direct payment by your health insurer is in place you will need to send to your insurer the receipt for payment you receive from the health system, the - relevé de remboursement.
You should normally expect to receive reimbursement directly into your bank account within a week.
Once you have your social security number you can open an account with Ameli, the official website of the main health insurance system in France, the Caisse nationale d'assurance maladie (Cnam).
'Ameli' is the acronym for Assurance Maladie En Ligne, the on-line service of the health system. Although it is not obligatory to hold an on-line account you will find it useful to do so.
With this on-line account you can monitor the progress of your payments and reimbursements and undertake other administrative tasks. You will no longer receive paper based notifications.
From your account you can obtain an attestation des droits, which confirms your affiliation to the French health system.
The website is also being upgraded to enable you to also obtain a Covid vaccine certificate and a 'health passport' (pass sanitaire) if you have received the vaccine, although you should normally receive the former from your doctor or chemist.
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