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what is third-party payment and how do I benefit from it?

This term is omnipresent when it comes to discussing the costs of health expenses: third-party payment. Omnipresent but yet not always well known. So what does this system set up to facilitate access to care consist of? Concretely, it exempts from making the advance of medical expenses reimbursed by Health Insurance during a consultation. In general, when a person consults a health professional, he settles it immediately, Upon receipt of the care sheet, the Health Insurance reimburses the costs incurred, and the complementary health insurance (if one has one) takes charges the complementary part of these health costs (according to the terms and conditions of the contract). Also, third-party payment makes it possible not to have to advance the part reimbursed by Health Insurance and therefore to be exempted from immediately paying the health professional, knowing that there are two types: total third-party payment (or full ) and partial third-party payment. In the first case, the insured has no costs to pay: he is therefore exempted from paying the healthcare professional immediately.

But beware, the latter is only reserved for categories of people who meet specific criteria as explained by Health Insurance: beneficiaries of the CMUC (Complementary Universal Health Coverage), recipients of the AME (Help State medical service), persons on “exempt” ALD (for care concerning their condition) but also pregnant women (compulsory prenatal and postnatal examinations, all care related or not to maternity, from the 6th month of pregnancy up to the 12th day after delivery and certain pregnancy-related care). In the case of partial third-party payment, the part of the costs not covered by Health Insurance, which bears the name of co-payment, must be paid to the healthcare professional. The co-payment therefore corresponds to the part of health expenses that remains payable once the Health Insurance has reimbursed its “share”. This applies to all reimbursable health costs: consultation with the doctor, medical biology analysis, radiology examination, prescribed medication, etc. The amount varies according to the services.

What is the fixed participation, paid by (almost) everyone?

For example, for a consultation with your general practitioner, it is equal to €7.5. Because on the basis of a conventional price of 25 € for the consultation, the sum of 17.50 € is covered by the health insurance (70%), which leaves an amount of 7.5 €. But it can be increased in the event of consultation of a health professional outside the course of coordinated care. For example, it is equal to €17.5 for a consultation with a general practitioner outside the coordinated care pathway (only 30% covered by health insurance, therefore up to €7.50). This is why, to be well reimbursed, it is essential to choose and declare your attending physician. Good to know: the moderating ticket is automatically deducted from the amount of reimbursements. “ If you have complementary health insurance, it can cover it according to the contract taken out “, notes the Health Insurance. Note, however, that for any consultation, medical procedure, radiological examination, biological analysis paid for by the Health Insurance, the sum of 1 euro is due to him, this is “the flat-rate contribution. »

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For example, for a consultation with your general practitioner: the consultation is reimbursed at 70% of the basic rate of €25, i.e. €17.50. It is from this amount that the flat-rate contribution is subtracted, the amount reimbursed by Health Insurance will therefore be €16.50. This device applies to people over 18 with an amount automatically deducted from each reimbursement. In the event of multiple consultations on the same day, it is capped at 4 euros per day and per healthcare professional. However, the following are exempt: children and young people under the age of 18, pregnant women from the 1st day of the sixth month of pregnancy and up to the 12th day following the date of delivery and people benefiting from Complementary health solidarity or state medical assistance. Note that the reimbursement statements can be consulted from the ameli account, section “My payments”. “ The statements provide information on all the services paid but also on any deductions such as the flat-rate contribution or the medical deductible. “, notes the organization

In addition to examinations, treatments or medical analyzes and consultations with your attending physician, third-party payment also applies to the delivery by the pharmacist of drugs reimbursed by health insurance. However, the latter may not practice it in the event of refusal to use generic drugs. To benefit from third-party payment, the process is simple, namely to present your up-to-date Vitale card. This update can be done in most pharmacies, multi-service terminals made available in Health Insurance reception points and in certain health establishments and must be carried out at least once a year. It turns out that since January 1, 2017, health professionals can also offer third-party payment on the mandatory part to all policyholders regardless of their situation, “ But this is not an obligation “, recalls the Health Insurance. Apart from cases subject to a legal obligation, practitioners are therefore free to refuse to practice third-party payment. What about teleconsultation? The third-party payment is not mandatory because it is an exception to the care pathway.

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