Question 8746 — people with disabilities

Summary

The budget of medico-social establishments for disabled people is determined to cover all of their operating expenses, including consultations and interventions by health professionals who contribute to the achievement of their missions. According to the regulations in force, the costs linked to additional care delivered by independent health professionals after prior agreement from the control service medical are only reimbursed, in addition to the budget of these structures, under certain conditions: when this care does not fall within the missions of the establishment; or when the service cannot provide them sufficiently completely or regularly due to their intensity or technicality. Additional care meeting these criteria is reimbursed by compulsory health insurance under legal conditions. common. Apart from these cases, the interventions of liberal professionals must be provided by the establishment from its budget. This regulation, which applies to all medico-social establishments for disabled people including early medico-social action centers (CAMSP), makes it possible to avoid double financing by health insurance, via the ESMS allocation and via fee-for-service pricing in the city. However, These rules for financing complementary care are today unevenly applied in the field, and there are clearly differences in interpretation and implementation between primary health insurance funds, which can lead to disruptions in coverage. The fluidity of the journeys of disabled people constituting a priority issue, work has been undertaken to clarify the modalities for taking into account responsible for this additional care and allow harmonization of the practices of primary health insurance funds (CPAM).  Circular DGCS/3B/2017/148 of May 2, 2017 relating to the transformation of the support offer for people with disabilities as part of the “a supported response for all” approach asks regional health agencies, in conjunction with the CPAMs and the establishments concerned, to objectify the complementary care situations. Furthermore, a mission from the general inspectorate of social affairs is underway in order to carry out an inventory of the activity of the CAMSPs, as well as the medical-psycho-pedagogical centers (CMPP), and to study the questions relating to compliance with the recommendations of good professional practices in these networks as well as the brakes and levers that constitute their modes of operation. current funding. This various work will make it possible to move forward in resolving issues related to the management of complementary care in social and medico-social establishments, and in particular in CAMSPs and CMPPs.

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