Management of a long-term illness (ALD) by the Health Insurance

Verified 24 August 2023 - Legal and Administrative Information Directorate (Prime Minister)

What support for an ALD? Some are exempt: the costs related to the care are reimbursed to the maximum of the ceiling. You are exempt from user fees. Others are not exempt: you are then reimbursed at the usual social security rates. Management is therefore different and may require a care protocol. The latter is translated by a support form that opens the rights to support 100%.

Exempt

These are conditions whose seriousness and/or chronic character require prolonged treatment and a particularly costly therapeutic treatment.

Various pathologies are affected by ALD. Some are on a list.

List of ALD 30

Initially, there were 30 conditions. Today, severe high blood pressure is no longer included in this list. However, it continues to be called a list ALD 30.

These conditions include the following:

  • Disabling stroke
  • Bone marrow failure and other chronic cytopenias
  • Chronic arteriopathies with ischemic manifestations
  • Complicated bilharzia
  • Severe heart failure, serious arrhythmias, severe valvular heart disease, severe congenital heart disease
  • Active chronic liver disease (hepatitis B or C) and cirrhosis
  • Severe primary immunodeficiency disorder requiring prolonged treatment, human immunodeficiency virus (HIV) infection
  • Type 1 diabetes and type 2 diabetes in adults or children
  • Severe forms of neurological and muscle disorders (including myopathy), severe epilepsy
  • Severe hemoglobinopathies, haemolysis, chronic constitutional and acquired hemoglobinopathies
  • Serious hemophilia and constitutional disorders of haemostasis
  • Coronary artery disease: myocardial infarction
  • Severe chronic respiratory failure (e.g. severe asthma)
  • Alzheimer's disease and other dementias
  • Parkinson's disease
  • Hereditary metabolic disorders requiring specialized prolonged treatment
  • Cystic fibrosis
  • Severe chronic kidney disease and primary nephrotic syndrome (kidney failure)
  • Paraplegia
  • Vasculitis, systemic lupus erythematosus, systemic sclerosis
  • Progressive rheumatoid arthritis
  • Long-term psychiatric disorders (e.g. recurrent depression, bipolar disorder)
  • Active ulcerative colitis and Crohn’s disease
  • Multiple sclerosis
  • Progressive structural idiopathic scoliosis
  • Spondyloarthritis severe
  • Organ transplant suites
  • Active tuberculosis, leprosy
  • Malignant neoplasm (cancer), malignant disorder of lymphatic or haematopoietic tissue (e.g. lymphoma)
‘Off-list’ ALD (ALD 31)

In addition to these conditions ALD 30 those referred to as "off-list" (ALD 31, with reference to theALD 30).

They are therefore not on the list of ALD 30.

An ALD 31 must be cumulatively the following 2 conditions:

  • You have either a severe illness or a progressive or disabling illness, or you have several illnesses that lead to a disabling medical condition
  • Treatment that is expected to last longer than 6 months and is particularly expensive is needed.

Examples: Paget's disease, chronic or recurrent ulcers with severe functional impact, endometriosis.

Polypathologies (ALD 32)

The term polypathologies is used when you have more than one characterized condition, leading to a disabling condition and requiring continuous care for a foreseeable duration of more than 6 months and particularly costly (ALD 32).

Example :

A 90-year-old person with polyarthrosis with gait disturbance, urinary incontinence and essential tremor.

ALD 30

The costs related to the care of the ALD are reimbursed to the maximum of the reimbursement ceiling by the Sickness Insurance. We are talking about the exemption of user fee.

Your treating doctor will make a request for you to 100% regarding the care and treatment related to your ALD.

You benefit from the paying third party; you do not advance the costs of care and treatment in relation to your ALD.

Care and treatment are provided at 100% on the basis of the Social Security tariff. For this purpose, a specific pattern of prescription, called bizone ordinance, has been created. The ordinance has two distinct areas:

  • An upper part reserved for treatments related to ALD, taken care of at 100%
  • A lower part reserved for care not related to ALD, reimbursed at the usual Social Security rates.

FYI  

Certain expenses remain at your expense, such as overpayment of fees, the flat-rate contribution of 1 €, the medical deductible or the hospital package.

Your complementary can take charge of the hospital fee and the excess of fees.

The exemption is granted for an initial period varying according to the condition.

She's renewable for an equivalent period or for 10 years.

At the end of the period granted by your care protocol, if your illness still requires acute care, your doctor will apply for a new ALD. This renewal is possible as long as your health justifies it, without any limit of age or number of renewals.

FYI  

The transport costs for treatment or examination related to ALD patients with one of the disabilities requiring sanitary transport (lying down position, need oxygen or surveillance...) are taken care on medical prescription.

ALD 31

The costs related to the care of the ALD are reimbursed to the maximum of the reimbursement ceiling by the Sickness Insurance. We are talking about the exemption of user fee.

Your treating doctor will make a request for you to 100% regarding the care and treatment related to your ALD.

You benefit from the third party paying .; you do not advance the costs of care and treatment related to your ALD.

Care and treatment are provided at 100% on the basis of the social security tariff. For this purpose, a specific pattern of prescription, called bizone ordinance, has been created. The ordinance has two distinct areas:

  • An upper part reserved for treatments related to ALD, taken care of at 100%
  • A lower part reserved for care not related to ALD, reimbursed at the usual Social Security rates.

FYI  

Certain expenses remain at your expense, such as overpayment of fees, the flat-rate contribution of 1 €, the medical deductible or the hospital package. Your complementary can take charge of the hospital fee and the excess of fees.

The duration of the necessary procedures and benefits is proposed by the doctor, examined and validated by the medical service of the Sickness Insurance.

At the end of the period granted by your care protocol, if your illness still requires acute care, your doctor will make a request for renewal of ALD. This renewal is possible as long as your health justifies it, without any limit of age or number of renewals.

ALD 32

We are talking about a combination of several conditions resulting in a disabling medical condition requiring treatment for a foreseeable period of more than 6 months and particularly costly

There's no no user fees, i.e. to remain dependent once the health insurance has reimbursed its share.

The protocol of care is a form established by your treating doctor, in consultation with the other doctors who follow your ALD.

The protocol has a fixed duration.

It provides support for 100% (on the basis of the Social Security tariff), with the agreement of the medical practitioner of the Health Insurance.

It consists of 3 parts:

  • 1 is stored by your treating doctor
  • 1 is for the medical officer of the Health Insurance
  • 1 is for you. You must sign it and present it to each doctor you see to benefit from the treatment of 100% for care related to your illness.

Please note

In some cases, such as when the diagnosis is made during hospitalization or in an emergency situation, a doctor other than your treating doctor can establish this care protocol and make this request.

The protocol provides the following information:

  • Care, laboratory tests and treatments needed to manage and monitor your disease
  • Supported care and treatment at 100% and those who are reimbursed at the usual Social Security rates. Some care and treatments may not be covered, for example, proprietary medicines that are not on the list of reimbursable medicines
  • Specialists in “direct access”, without going through the attending physician.

Care by the sickness insurance bodies of the acts and benefits of minor and major beneficiaries infected with the human immunodeficiency virus or the hepatitis C virus shall be protected by secrecy.

Health Insurance will therefore not mention these treatments in the statements sent to the parents or legal representative, whether it is the paper count or the Ameli account.

FYI  

As part of the care pathway for patients with ALD, any physician involved in the management can prescribe physical activity appropriate to the pathology, physical abilities and medical risk. But it won't be covered by Health Insurance.

Non-exempting

These are conditions that require a break in work or ongoing care of a predictable duration longer than 6 months.

They do not qualify for the user fee.

All your care provided under the ALD is therefore reimbursed at the usual Social Security rates.

This "non-exempt" ALD allows you to benefit from:

  • A work stoppage of more than 6 months
  • And the support of your transport in connection with ALD.

If you are away from work due to long illness, you can receive daily allowances beyond 6e months, if your medical condition warrants it. You need the approval of the medical officer of the health insurance.

Please note

The duration of an uninterrupted work stoppage may not exceed 3 years. Beyond that, you will have to return to work (with or without accommodation) or be placed on disability (with pension depending on the rate of incapacity for work).

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