Coordinated or uncoordinated care pathway: how does this affect me?
To benefit from the best reimbursement rate from Health Insurance or your mutual insurance company, compliance with the care pathway is an essential criterion.
This system put in place by the Social Security guarantees you the reimbursement of your health costs, according to the rates of agreement and in compliance with the regulations in force.
The care pathway aims to encourage policyholders to behave responsibly with regard to their medical expenses. In a nutshell, it’s a set of steps to follow for “better” covered care!
How’s it going ?
The principle is simple: you first declare your attending physician to the Health Insurance. As part of a coordinated care pathway, it is “compulsory” to go through the appointed doctor before consulting any specialist.
To do this, two options are possible:
- You do it directly with your doctorfilling in the dedicated form and sending it to your health insurance fund.
- Online on presentation of your vital card to the doctor of your choice. The declaration is automatically transmitted to the health insurance fund.
What is the purpose of the coordinated care pathway?
The attending physician knows you like the back of his hand. He is in the best position to provide you with the appropriate care, and to refer you, if necessary, to other practitioners depending on your state of health.
Reimbursement rates vary according to the course of care:
- Coordinated care pathway : for a consultation with a general practitioner in sector 1, reimbursement is made according to the fixed agreement rate, i.e. 70% of your healthcare expenses.
- Uncoordinated care pathway : the reimbursement rate is revised downwards. It thus increases to 30% of the price of the consultation instead of 70%.
Take for example a consultation with a general practitioner for angina.
You have followed the coordinated care pathway = You have consulted the professional you have declared as the attending physician to Health Insurance. Your reimbursement will be 70% of the Social Security convention rate. At the general practitioner, the basis for reimbursement by Social Security is set at €25. You will therefore be reimbursed €16.50 by Health Insurance after deduction of a €1 flat-rate contribution. Your mutual will reimburse you the rest and your wallet will thank you!
You did not follow the coordinated care pathway = You did not consult the professional you declared as your health insurance doctor. Your reimbursement will be 30% of the Social Security convention rate, i.e. €6.50. The reimbursement of your mutual will also be impacted because this increase is not reimbursable by complementary health insurance. The rest will be up to you.
Exceptions to the coordinated care pathway
Although respecting the care pathway is essential to benefit from a better reimbursement rate, there are, however, a few exceptions.
In the event of an emergency, if you are far from your place of residence, or if you consult a general practitioner established for less than 5 years in private practice, you can of course leave the course of care.
The exception also applies to ophthalmological, gynecological, dental, pediatric or psychiatric consultations for 16-25 year olds.
Apart from these cases, Social Security will reduce its coverage and your health insurance may refuse any reimbursement.
And at HEYME, what does mutual insurance give?
At HEYME from €9.90/month we cover your essential needs: hospitalization, routine care, pharmacy. And if you need extended coverage, we offer 4 levels of guarantees to meet your expectations.
Regardless of the level chosen, you have unlimited access to medical teleconsultation 24 hours a day with ABI. You can consult a doctor from your smartphone and directly from your sofa!
We also provide you with an app to view your reimbursements, download your third-party payment card, send us your documents and find a doctor near you!
And the icing on the cake… an app with good deals and discounts on your favorite brands: shopping, cinema, restaurant…
👉 HEYME student mutual