The following are details of Affections Longue Durée (ALDs) as presently defined by the French Government. ALDs are medical conditions for which 100% re-imbursement is available through the French State Healthcare scheme.
In addition, the Government's statement of 14th December 2007 indicated that anyone who developed a medical condition for which Private Health cover was not available, since moving to France, may be able to affiliate to CMU. Details of how this is to operate have not yet been released.
It has been pointed out to us that the list of exempted medical conditions in France differs from those in the UK. It is therefore possible that an illness quqlifying for free prescriptions in the UK may incur a charge in France.
Translation kindly produced by ‘Nickel’, A ‘Living France’ forum member.
Resulting in a serious prolonged neurological disorder.
* However, in less serious cases following prolonged ‘re-education’, the exemption may be withdrawn, but it may still be possible to claim exemption if there is another underlying ALD cause, e.g. Diabetes.
Bone Marrow Aplasia
* Acquired aplasias when treated can regress, and then exemption will no longer be granted.
* Others due, for example to cancer, will be included under ALD "Tumeurs malignes" and will be exempt.
Chronic progressive Peripheral Artery Disease (including coronary artery disease), with clinical evidence of ischaemia.
Ischaemia is ‘the absolute or relative loss of blood supply to a tissue’.
* As this is a common disease process there are several categories, but to claim any exemption, it would be necessary to show clinical evidence of ischaemia.
Bilharziasis - Schistosomiasis Parasitic disease caused by a flatworm.
* The primary infection is now readily treated and is excluded from exemption - only the complications allow any exemption, but this is unlikely to be of concern in this instance.
Congenital Heart Disease, Severe Cardiac Insufficiency or Heart Failure, Severe Heart Valve defects.
* ‘Hole in the heart’ all ventricular defects are exempt.
* Some mild atrial defects, either surgically corrected or not, as long as no residual problems exist, are NOT exempt.
* Mild Pulmonary stenoses are NOT exempt.
It seems in general if the defect causes symptoms it will be exempt.
All patients having surgical treatment of their heart valves are exempt, including any treatment for prophylaxis against infection, and any anticoagulant therapy.
Chronic Active Liver Disease and Cirrhosis.
Chronic active liver disease - serious disorder that may progress to Cirrhosis.
Causes - excessive alcohol intake, infection with Viruses - Hepatitis B / Hepatitis C, certain metabolic disorders (e.g. Wilson's disease).
Biliary cirrhosis. Genetic disorders.
‘Chronic’ refers to a duration of 6 months of persistent, abnormal biological findings.
Cirrhosis - Replacement of liver tissue by scar tissue, leading to progressive loss of liver function (generally irreversible).
Those conditions likely to cause ‘portal hypertension’ (raised blood pressure in the liver veins) and/or liver failure and requiring long term treatment are exempt!
* There are pages and pages on liver diseases - but the chronic ones including cirrhosis all seem to be exempt.
Primary Immunodeficiency disorders requiring prolonged treatment, and Infection with Human Immuno-Deficiency Virus (HIV).
There is a vast range of very well documented disorders, from severe to mild, requiring a wide range of treatment from stem cell transplant to antibiotics.
* Much progress has been made in the treatment of these disorders - exemption may be given, renewable at 2 yearly intervals depending on progress.
* Some ‘minor’ disorders do not seem to attract any exemption.
May of course lead to Acquired Immunodeficiency Syndrome - AIDS, if one or more - from a list of 20 or so specific pathologies is also present.
Insulin Dependent Diabetes Type 1 - Non Insulin Dependent Diabetes Type 2.
They are now simply referred to as Type 1 and Type 2 diabetes (also in France).
Type 1 Diabetes - usually diagnosed in childhood and adolescence, occurs because the pancreas is producing too little or no insulin.
Accounts for approx 10% of diabetes.
Type 2 Diabetes - usually diagnosed after the age of 40 (although seen now in younger age groups), and more common in overweight people. Insulin may still be produced, but the cells become resistant to its effect. Accounts for approx 90% of diabetes.
The initial treatment for Type 2 is to follow a diet (weight loss), and exercise as this can stabilize sugar levels, exemption may not therefore be granted during this early stage of the disease.
Type 1 and established Type 2 both have exemption, and due to the large range of other conditions that may arise secondary to the diabetes (eyes / blood vessels / neurological problems / increased incidence of infections etc), these treatments may also be exempt.
Some other conditions may lead to diabetes (Secondary Diabetes) e.g. pancreatic disease / Endocrine disorders / Steroid medication, etc.
This will also gain exemption.
Severe neuromuscular disorders (including myopathies).
A somewhat disparate group.
* A very large group of disorders, with symptoms ranging from mild to severe, exemption is given accordingly.
Homozygotic Haemoglobinopathies.
Range of genetically inherited disorders of Haemoglobin.
Thalassaemia and Sickle Cell Anaemia.
The pattern of inheritance determines the severity of the condition - If one normal ‘gene’ and one defective ‘gene’ are inherited, the result can be benign - if two defective "genes" are inherited (homozygotic), then the disease will be severe and gain exemption.
Haemophilia -Genetically inherited disorder of blood coagulation.
Several types depending on which of the factors necessary for clotting are affected.
Sex-linked so females carry the disease, and males are affected. Some spontaneous haemophilias can occur.
Also included are some other diseases of clotting mechanism, e.g. Von Willebrands disease.
* These are all exempt.
Severe (arterial) Hypertension.
There are strict clinical guidelines for the measurement of blood pressure in order to claim exemption.
There have to be 2 out of 3 conditions present.
* Exemption can be renewed over the course of the disease.
Myocardial infarction (Heart Attack) dating less than 6 months).
Exemption if clinical diagnosis is supported by confirmation of tissue necrosis (death) by means of ECH / Echocardiography and enzyme analysis.
Exemption is for 6 months from date of infarct, and may be renewed once.
Due to the possible effects after a heart attack, exemption may be granted because other ALD’s come in to play, e.g. coronary insufficiency and ischaemia, heart failure, etc.
Severe Chronic Respiratory Disease.
Many disease processes can result in chronic respiratory disease (diseases of the airways and structures of the lung).
Apart from any severe clinical picture there are strict criteria which are to be met to gain exemption. These include analysis of the oxygen carrying capacity of the blood. Results of Pulmonary (Lung) Functions Test - spirometry.
* e.g. Asthma - Must show; 1) Permanent clinical evidence of dyspnoea (difficulty in breathing), 2) Persistent evidence of obstruction even under treatment, and 3) requiring prolonged daily medication (bronchodilators).
Severe but short-lived episode, e.g. following trauma/operations, are not included, nor are some chronic broncho-pulmonary infections, unless they fall into the above criteria.
Leprosy or Hansen's Disease.
Chronic Infectious disease caused by a bacterium. Two forms - Paucibacillary and Multibacillary.
Enormous progress has been made in the elimination of Leprosy thanks to multi drug therapy. Exempt.
Parkinson's Disease.
A degenerative disorder of the central nervous system comprising: Tremor - Rigidity - Akinesia (slow/absence of movement), and Postural Instability ‘TRAP’. Diagnosis based on medical history and neurological examination.
1-2% of people over 65.
In mild cases there may be only minor motor disruptions, whilst in others there may be severe disability.
No cure but effective anti Parkinson's medication, plus many other regimes (yoga, tai chi, Alexander lessons, speech therapy etc).
Exemption is granted according to the severity of the condition - in mild cases, well controlled on anti Parkinson medication they may be no exemption.
In rapidly developing Parkinson's with incapacity, requiring increasing medication and support, exemption will be granted.
Hereditary metabolic diseases requiring long term specialist treatment.
This group concerns ‘monogenic’ inherited diseases - i.e where there is only one defective gene, for the disease to be apparent it is usually transmitted as an autosomal recessive (each parent transmits a defective gene).
This is a large group of rare disorders all relating to disorders of metabolism. e.g. Metabolism of proteins, lipids, haemoglobin, metals, hormones, etc.
Exempt, but subject to frequent reviews to assess progress.
Cystic Fibrosis or Mucoviscoidosis.
It is an autosomal, recessive, inherited disease of the mucus and sweat glands, causing progressive disability. Can be diagnosed prior to birth or by a sweat test or genetic testing. Affects pancreas, gastrointestinal tract, liver, lungs. Mucus is thick and sticky, allowing recurrent breathing problems and chest infections. Progresses to eventual lung failure. Treatments have improved with life expectancy now in the 30s.
Once diagnosis is confirmed exemption is granted, (diagnosis may not be made in milder cases until adolescence).
Chronic Renal (Kidney) Disease - Primary Nephrotic syndrome.
A progressive loss of renal function. Usual underlying causes are Diabetes - Hypertension - Glomerulonephritis.
They are considered severe based on various clinical/biological examinations e.g. permanent hypertension problems with metabolism.
Therapy consists of treating the primary cause - (if possible) and/or treating the secondary effects in an attempt to slow down the progress, which in turn may lead to kidney failure requiring dialysis or transplant.
* Chronic renal disease is exempt.
Treatment consists of supportive measures and immunosuppressives (steroids).
Prognosis - can be mild and with long remissions, or lead to renal failure.
* May be exempt depending on severity.
Paraplegia. Impairment in nerve function of lower body- loss of ability to move/feel both legs and lower trunk.
Multiple causes - Lesions of the peripheral nerves - Spinal cord (the level of injury is important). Brain lesions and congenital disorders.
Commonest cause is due to trauma.
* Whatever the cause, exemption is granted when the condition is ‘disabling’.
Some situations are reversible in which case the exemption will be removed, others of course may lead to a progressive and permanent disability, requiring prolonged care and support.
Periarteritis Nodosa, Systemic Lupus Erythematosus, Progressive Systemic Scleroderma.
Auto-immune Chronic Inflammatory Connective Tissue Diseases.
* If limited just to skin lesions it may not be exempt
Treatment is symptomatic and huge advances have been made in the understanding of this disease.
* Discoid lupus which is mainly confined to skin and Drug Induced Lupus (many drugs can produce symptoms of lupus) are not exempt.
* Localised scleroderma - usually (but not always) confined to the skin - rarely develops into the systemic scleroderma and may not be exempt.
Rheumatoid Arthritis - Chronic inflammatory auto-immune disease affecting many of the joints in the body.
Painful condition causing destruction of the joints and loss of mobility with increasing disability. Slow onset usually affecting small joints of hands and feet and may progress to larger joints. The inflammatory changes can affect other organs - liver, lungs, heart etc.
Diagnosis is made from a list of 7 criteria of which 4 are necessary to confirm.
Some have mild symptoms but for the majority of sufferers the disease steadily progresses to substantial functional disability.
A number of advances are being made in drug treatments along with the importance of rest and physical activity.
There are many other chronic arthritic diseases, e.g. Psoriatic Arthritis which also have exemption and others still such as Crohn's disease which are listed separately.
Psychosis, Severe personality disorders, Mental Retardation (this term is no longer used in UK/US and Learning Difficulties, Severe mental impairment - Intellectual and Developmental Disabilities are current terminologies).
A huge range of disorders, not easily classified, with crossing-over between ‘psychiatric’ and ‘neurological’ causes.
Includes - Schizophrenia, Bipolar disorder, Unipolar disorder (severe clinical depression) Delerium.
Initial exemption of 6 months as condition assessed with renewal though some acute psychoses will not be covered.
And also, the dementias occurring in older age group no matter what the cause, e.g. Alzheimer's, Pick's disease, senile dementia.
Exemption depends on severity, many minor or transitory problems will not be exempt. Alcohol and drug dependency can produce a number of neurological - psychological problems - psychosis - dementia - personality disorder - depression etc.
* This somewhat oversimplifies a very large and varied group of disorders.
Ulcerative Colitis and Crohn's Disease.
* Although both conditions do carry an increased incidence of bowel cancer - these patients tend to have more frequent investigations than the general population and it is likely that their cancer will be diagnosed and treated early.
Mutiple Sclerosis. A chronic inflammatory disease of the Central Nervous System whereby the fatty sheaths around the nerve are destroyed resulting in loss of transmission of the "nerve / electrical" impulses.
Usually occurs with ‘attacks’ of loss of sensation (most common) or muscle weakness, maybe speech problems or eye signs. This may be transitory so a diagnosis may not be made. May be months, or even years before the next attack. Gradually becomes more progressive with less remissions.
During attacks neurological symptoms may be severe requiring hospitalisation.
Exemption for 6 months following any attack, and each new attack gaining a similar exemption, but as the disease progresses to possibly cause severe disability, exemption will be granted.
Progressive Scoliosis (where the angle is equal or more than 25°) up to spinal maturity.
Permanent lateral deviation of the spine with rotation of the vertebral bodies.
Cause uncertain but may run in families, usually diagnosed in middle childhood though some scolioses are apparent at birth due to Spina Bifida, Cerebral Palsy etc.
Tends to progress, the 25° angle is an indication of severity. Basis of treatment is to obtain by the end of growth a spine as straight and balanced as possible, by use of plasters corsets surgery.
Exemption for scolioses of 25° and above, and for infantile scolioses of a smaller angle requiring orthopaedic treatment.
Ankylosing Spondylitis. Chronic degenerative inflammatory disease of Spine. Onset insidious - repeated back ache in young age group.
Diagnosis by clinical, radiology and some specific blood tests.
May be mild but tends to progress and bones of the spinal column fuse together (ankylosis) causing severe handicap. It is a systemic disease so other organs - eyes, heart, and kidneys may be affected. May be secondary to other disease processes e.g. Reiter disease / Crohn's / Ulcerative Colitis.
Treatment - No cure - anti-inflammatory - immuno-suppressive medication - Physical therapy (swimming, yoga, tai-chi, etc) and surgery.
*Exemption, as are some of the primary causes, e.g. Crohn's.
Organ transplants – Post operative care.
Organ transplants include kidney, heart, liver, pancreas, lung, intestines and by extension bone marrow.
All exempt because of continuing follow-ups, including immuno-suppressive medication, assessment of transplant and monitoring of any complications (rejection, infection, etc).
Corneal transplants are not exempt unless systemic immuno-suppressive medication required - when exemption is for 1 year and is renewable.
Active Tuberculosis. A common and serious infectious disease, caused by a Mycobacterium. Usually affects lungs but can involve other organs.
Although a common infection throughout the world most people who are infected have a ‘latent’ asymptomatic form. This may however progress to active disease (10%) and this is a serious condition requiring long-term medication (up to a year) of 2 or more drugs.
Diagnosis is by isolating the organism or microscopic study of the lesions, however, treatment may begin on clinical diagnosis before confirmed diagnosis.
Seen more often now in people with a compromised immunology (due to immuno-suppressive medication or disease, e.g. AIDS), and due to widespread travel to regions where Tuberculosis is common.
Treatment effective so exemption is granted, but reviewed on 6 month/yearly basis - when ‘cured’ subsequent radiological follow-up may not be exempt.
Malignant cancer and cancer of the lymph or blood system.
Malignant cancer occurs when certain cells start to grow and invade the surrounding tissues and may spread to other parts of the body.
An enormous number of different cancers can occur depending on the originating cell type.
Diagnosis is made on clinical, radiological imaging, and definitive diagnosis on histological examination of a biopsy.
Advances are continually being made in the understanding of causes and treatment of cancers, (too many to warrant inclusion here) which may involve surgery, chemotherapy, radiotherapy.
Exemption depends on the specific cancer, staging, prognosis, treatment etc.
Exemption may also be granted for:
ALD 31: A serious disease not in the above categories where continuous care is anticipated to last for a minimum of 6 months - examples stated are - Macular degeneration (commonest cause of blindness in people over 50), Xeroderma Pigmentosum.
Other specific deseases include:
*Haute Autorité Santé at present, has only issued guidelines for Turners syndrome. I assume the remainder will follow in due course.
ALD 32: Where several diseases may be present, again where continuous care is anticipated to last for a minimum of 6 months, an example given is of an elderly, blind person who suffers a hip fracture, a so-called Polypathology.