Exemption from patient contribution

Reimbursement is calculated based on 100% of the standard tariff, applicable to insureds in the "green" category. For insureds in the "pink" or "buff" categories, where practitioners can charge higher fees, full coverage or exemption from patient contribution (E.P.C.) does not therefore mean that all medical expenses incurred will be fully reimbursed, but simply that no deduction will be applied to the fund's reimbursement tariff.

Exemption from patient contribution is applied:

  • For medical procedures (excluding dental and biology) that are codified:
    • under the General Classification for Professional Procedures (N.G.A.P.), are allocated a coefficient equal to or greater than 50,
    • under the Common Classification for Medical Procedures (C.C.A.M.), have a reimbursement rate equal to or greater than:
      • €154.70 if fees are set using the standard tariff,
      • €91.00 if the procedures are dispensed as outpatient care in French public hospitals.

When these procedures require a hospital stay, exemption from patient contribution is extended to all medical expenses incurred during that hospital stay.

  • When the care recipient is recognised with a long-term illness.
  • When the benefit itself is fully reimbursable (treatment or stays invoiced on a flat-rate basis, ambulance transport, etc.).
  • For hospital stay costs relating to a continuous hospital stay of more than 30 days.
  • For treatment dispensed to premature infants in a specialised centre or department.
  • For the hospitalisation of newborns when this occurs within thirty days of birth.
  • For the purchase or repair of prosthetic and orthopaedic devices (major appliances).
  • For certain medications or products of human origin.
  • For orthodontic treatments.
  • For health expenses for the disabled.
  • For reimbursing certain medical expenses for the mother-to-be, from the first day of the sixth month of pregnancy until the day before giving birth.
  • For reimbursing the cost of a hospital or clinic stay during the birth, within the limit of the statutory tariffs.
  • For reimbursing flu vaccines when the recipient is aged over 65.
  • For investigations needed to diagnose infertility and its subsequent treatment.