CNAMTS's presentation

CNAMTS (National Health Insurance Fund for Salaried Workers)

Created in 1945, the general health insurance scheme – of which the CNAMTS (Caisse nationale d’assurance maladie des travailleurs salariés) is the national fund – is governed by three basic principles: equal access to health care, high-quality care and solidarity. Today it provides health coverage for 50 million people and devotes an annual €120 billion to payment of sickness, maternity and industrial industry benefits.

France’s main insurer

A compulsory scheme, national health insurance is the branch of the social security system providing sickness, maternity, industrial injury, disability and death benefits, for salaried employees and their dependants. It is France’s main social insurer, providing coverage for nearly 85% of the population (about 50 million people) and 80% of all sickness benefit payments.

The health insurance fund reimburses health care costs and provides cash benefits to compensate for the loss of income in certain kinds of situations (illness, maternity, industrial injury). Annual payments are of the order of €120 billion. More than half (52%) concern hospitalisation costs in public or private hospitals and nursing homes. The second expenditure item is drugs, with upwards of 2 billion items reimbursed each year, representing a total cost of €16 billion.

Recipients include 7 million people suffering from a long-term illness (cardio-vascular disease, diabetes, cancer, etc.) who are entitled to 100% coverage of all related expenses. 4.3 million people on low incomes also qualify for full coverage, paid for by the general health insurance scheme or other organisations under the “complementary universal medical coverage” (CMUC) scheme.

An annual €1 billion in reimbursements
France’s health insurance system processes about half a million claims for reimbursement each year, a figure which has grown by about 5.5% annually since 1999. Over 74% of these claims are transmitted electronically by hospitals and health professionals using the “carte Vitale” (medical insurance smartcard) or other electronic transfer system.

Thanks to computer technology (the health branch of the Régime général is one of the biggest users of computer resources), reimbursements for carte Vitale transmissions are made within just one week.

Nearly two thirds of patients are exempted from part of the upfront payment (under the tiers payant system). For about 60% of those, the reimbursement process is simplified, with the insurance fund forwarding the record of reimbursement directly to their complementary health insurance provider (mutuelle, private insurance company, etc.).

A decentralised organisational structure
In statutory terms, the CNAMTS is a public administrative body operating under the supervision of the Ministry of Health and Solidarity and the Ministry of Economy and Finances. Its role is to set strategic direction for the health branch of the social security system and to control and coordinate a decentralised network of funds comprising:

• 128 local health insurance funds (CPAM) in mainland France,
• 4 general social security funds (CGSS) in the overseas departments,
• 16 regional health insurance funds (CRAM),
• 22 regional health insurance unions (URCAM),
• 3 health insurance fund management unions (UGECAM).

The organisation also has 5,500 advisory centres throughout the French territory, receiving about 40 million people each year. This drop-in service is completed by 76 services platforms, capable of responding to 94% of the two million or so calls received each month.

The health insurance system employs 107,000 staff, including 2,800 computer specialists, 2,500 practitioner-advisors (doctors, dentists, pharmacists), 620 staff providing an interface with health professionals and 276 consulting engineers on industrial injury issues.

Risk managers

Apart from administering reimbursements, as the leading player of the health care system the CNAMTS develops risk management policies with the aim of improving public health, enhancing the quality and efficiency of the health care system, and controlling health expenditure by maintaining a balance with the public resources allocated.

To that end they pursue a policy of negotiated agreements with more than 250,000 health professionals, identify and promote prevention and information initiatives, are involved in the process of ensuring coverage through collective bargaining agreements and contribute to the organisation of healthcare provision as a whole.