The long-term illness (ALD) system today covers almost all the most costly chronic conditions in France. The 100% coverage of the convention rate by Social Security does not only apply to the famous list known as “ALD 30”: other situations grant the same rights, while some reimbursements will evolve starting in October 2026. Understanding these distinctions allows for anticipating what remains the patient’s financial responsibility.
Exempt ALD and non-exempt ALD: what the reimbursement rate changes concretely
Most articles focus on the list of 30 conditions. They overlook a distinction that directly affects the amount reimbursed: not all ALDs eliminate the co-payment.
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| Type of ALD | Exemption from co-payment | Reimbursement rate for related care | Examples of situations |
|---|---|---|---|
| ALD 30 (list) | Yes | 100% of the convention rate | Diabetes, multiple sclerosis, cancer |
| ALD 31 (out of list) | Yes | 100% of the convention rate | Serious illness not listed, progressive or disabling form |
| ALD 32 (multiple pathologies) | Yes | 100% of the convention rate | Multiple conditions leading to a disabling state |
| Non-exempt ALD | No | Standard rates (70%, 60%…) | Complicated fracture with a stoppage exceeding 6 months |
A patient with a non-exempt ALD benefits from facilitated administrative follow-up, but their care remains reimbursed at standard rates. The financial difference over a year of treatment can be significant, especially for repeated procedures such as physiotherapy sessions or imaging exams.
To consult the list of serious illnesses and their treatments, it is important to remember that this list is just one of the three components of the exempting system. ALD 31 covers serious conditions not included in the official list, provided that the treating physician justifies a prolonged and costly treatment. ALD 32 is aimed at patients with multiple conditions, none of which, taken alone, would appear on the list.
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Reform of October 2026: low SMR medications and end of 100% reimbursement
Starting from October 1, 2026, low medical service rendered (SMR) medications (reimbursed at 15% for standard insured individuals) will no longer be covered at 100% for patients with ALD. This measure affects the three exempt categories: ALD 30, ALD 31, and ALD 32.
Until now, a patient with ALD had all their prescribed medications within their care protocol fully reimbursed. After the reform, medications with a 15% SMR will remain reimbursed at 15%, regardless of the patient’s ALD status, unless there is a regulatory exception.
This change has direct consequences on the remaining out-of-pocket expenses. For certain chronic conditions requiring multiple combined treatments, some of the prescribed medications may fall under this low SMR category. The role of supplementary health insurance then becomes crucial to cover the gap.
What does not change after October 2026
- Consultations, medical acts, and exams related to ALD remain covered at 100% of the convention rate, including hospitalizations
- Medications with moderate or major SMR (reimbursed at 30% or 65% under normal circumstances) continue to be fully covered within the care protocol
- Medical devices listed among reimbursable products (prostheses, equipment) retain their 100% coverage if mentioned in the protocol
ALD care protocol: the exact scope of 100% reimbursement
Full reimbursement does not cover all care for a patient with ALD. Only acts and treatments directly related to the exempting condition benefit from the 100% rate. A consultation with a dermatologist for a skin issue unrelated to a patient with ALD 30 diabetes will be reimbursed at the standard rate.
The care protocol, drafted by the treating physician and validated by the medical service of Health Insurance, delineates this scope. This document lists the acts, health professionals, and treatments covered. Anything outside the protocol falls under common law.
Costs that remain the patient’s responsibility despite ALD
The “100%” refers to the convention rate of Social Security, not the actual billed price. Excess fees are not covered by ALD. A specialist in sector 2 may charge above the applicable rate, and this difference remains entirely the responsibility of the patient or their supplementary health insurance.
The fixed contribution of one euro per consultation and the medical deductibles on medications and health transport also apply to patients with ALD. These amounts are capped annually, but they accumulate for patients with frequent consultations.
ALD and health insurance: why supplementary coverage remains necessary
The ALD system significantly reduces out-of-pocket expenses but does not eliminate them. Excess fees, medical deductibles, and, starting in October 2026, certain low SMR medications generate recurring costs.
For patients with conditions requiring follow-up by multiple specialists in sector 2, the annual accumulation of excess fees can amount to several hundred euros. A health insurance plan tailored to chronic illnesses can help cover these gaps, particularly through specific packages for excess fees and non-reimbursed medical devices.
The choice of supplementary health insurance should be reassessed at the time of entering ALD. The useful guarantees before diagnosis (optical, dental) may not necessarily be the most important after. The “fees” and “pharmacy” categories become priorities to limit the actual out-of-pocket expenses over a year of care.
The 100% coverage under ALD remains a major safety net of the French healthcare system. The reform of October 2026 regarding low SMR medications serves as a reminder that this safety net has limits, and that the care protocol remains the central document to know precisely what is covered.