Information Reimbursement from the State Medical Benefits Office

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Contact details

Service des Prestations Médicales de l'État

19, Avenue des Castelans
Stade Louis II - Entrée C
BP 679
98014 MONACO CEDEX

State Medical Benefits Office :
(+377) 98 98 81 39

Fax : (+377) 98 98 41 67

Opening Hours : Public opening: from 9.30am to 5.00pm from Monday to Friday - By phone: from 8.30am to 5.00pm from Monday to Friday

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Service des Prestations Médicales de l'État

19, Avenue des Castelans
Stade Louis II - Entrée C
BP 679
98014 MONACO CEDEX

Opening Hours : Public opening: from 9.30am to 5.00pm from Monday to Friday - By phone: from 8.30am to 5.00pm from Monday to Friday

Phone : (+377) 98 98 81 39

Fax : (+377) 98 98 41 67

Send us an email
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Beneficiaries

The State Medical Benefits Office (SPME) will cover your health costs if you are:

  • Active civil servants and other Government and Commune officials 
  • Retired civil servants and other Government and Commune officials, resident in Monaco
  • Monegasque students over 21 years 
  • Officials in receipt of compensation for involuntary loss of employment 
  • Recipients of the Fund covering work-related accidents 
  • Doctor or Heads of Service appointed by Sovereign Ordinance, and administrative employees at Princess Grace Hospital Centre
  • Retired French civil servants resident in Monaco

You will be considered an insured person covered by the SPME.

Under your registration number, SPME coverage can also be extended to your spouse and children (or your spouse’s children), as dependents, subject to verification of the following conditions:

Spouse:

  • Spouse must not work and/or must not qualify for medical benefits provided by another Monegasque or foreign scheme
  • Spouse must be ordinarily resident within the insured person’s household
  • You must submit the following together with your request to cover your spouse:
         - A photocopy of your marriage certificate 
         - A certificate attesting to the fact that you no longer retain rights under your previous insurance coverage

 

Children:

  • The insured person must be the head of the household with respect to the children whom he or she has responsibility for 
  • Children must:
         - If aged over 16, be in school or attending secondary or higher education 
         - Be under 21 (or 28 in the case of those pursuing studies at an educational institution in the Principality)
         - Be ordinarily resident in the insured person’s household. Where children are not resident in the insured person’s household, this must be due to educational or health reasons, or as a result of a court decision
  • Please remember to attach the following supporting documents:
         - A photocopy of your family record booklet 
         - Certificate of attendance at an educational institution (in the case of a child)
         - In the event of a divorce or separation, a photocopy of the non-reconciliation order or ruling setting out custody arrangements

 

Reimbursement

To obtain reimbursement of your healthcare costs, the treatment form and, where applicable, prescription must be sent to the SPME, either electronically (using the Electronic Treatment Forms (FSE) procedure) or in hard copy.

Please consider using the FSE procedure. All you need to do is present your SPME card to your practitioner. You no longer need to send your treatment forms to the SPME. The FSE is completed directly by your doctor, in secure electronic format, and then sent immediately to the SPME for processing and reimbursement.

See the Press Release.

Out of hospital care

Procedures carried out by doctors, midwives and biologists

Definition:

TThis refers to procedures carried out in private practices or at mutual health centres.

It includes the following services:

  • Consultations
  • Home visits
  • All diagnosis and treatment procedures:
            - Technical medical procedures (code: ATM) 
            - Imaging or x-ray procedures (code: ADI or ADE) 
            - Surgical procedures (code: ADC) 
            - Biological procedures (code: BMO or B)

Imaging and biological procedures require a prescription.

Conditions:

The treatment form completed by the practitioner must be sent to the SPME, accompanied by the relevant prescription where required.

Common treatment forms are now used by all social security schemes in Monaco (SPME, CCSS, CAMTI) and are distributed to contracted practitioners.

Please consider using the FSE procedure. All you need to do is present your SPME card to your practitioner. You no longer need to send your treatment forms to the SPME. The FSE is completed directly by your doctor, in secure electronic format, and then sent immediately to the SPME for processing and reimbursement.

See the Press Release .

Please note

Prescriptions are valid for six months.

Prior consent of Medical Advisor:

In accordance with current legislation, some procedures are subject to prior consent being granted by the SPME Medical Advisor. Your practitioner must submit a request for prior consent when required and wait to receive this consent before the procedures are carried out.

In all cases, prior consent from the Medical Advisor is valid for six months.

Dental care

Definition

This refers to procedures carried out in private practices or at mutual health centres.

It includes the following services:

  • Treatments:
       - Procedures listed under code D (for dental surgeons: dental procedures and treatments 
       - Procedures listed under code Z (for dental surgeons): radiography 
       - Procedures listed under code CCD (for dental surgeons): consultations 
       - Procedures listed under code K or KC (for oral medicine specialists): extractions, surgery 
       - Procedures listed under code CS (for oral medicine specialists): consultations

 

  • Dentures:
       - Procedures listed under code DPRL (fixed denture): bridge, crown (metallic, veneer, ceramic), pivot tooth, implant 
       - Procedures listed under code DPRL (removable denture): resin plate, metal frame, skeletal
       - Denture listed under code DIMP (fixed denture): dental prosthesis by implant procedure. Only implant prostheses are reimbursable; the costs incurred for fitting implants are not. Ensure that you request a detailed quote for all the work that will be billed to you (implants and implant prostheses).

 

  • Dentofacial orthopaedics or orthodontics:
       - Procedures listed under code CS: consultation 
       - Procedures listed under code DORS: dentofacial orthopaedic treatment 
       - Procedures listed under code Z: X-rays

Conditions

The treatment form completed by the practitioner must be sent to the SPME.

Common treatment forms are now used by all social security schemes in Monaco (SPME, CCSS, CAMTI) and are distributed to contracted practitioners.

Prior consent from the Dental Advisor

In accordance with current legislation, some procedures are subject to prior consent being granted by the SPME Dental Advisor. Your practitioner must submit a request for prior consent when required and wait to receive this consent before the procedures are carried out.

It is mandatory in the following cases:

  • Preparation or fitting of any prosthetic 
  • Any orthodontic treatment 
  • Any special treatment or multiple extraction (more than eight teeth)

 

In all cases, prior consent from the Dental Advisor is valid for six months.

Procedures carried out by paramedics

Definition

This refers to procedures carried out by the following health professionals, either in private practice or as an employee of another practitioner:

  • Midwives, when related to nursing care (code: AMI or AIS)
  • Speech therapists (code: AMO) 
  • Orthoptists (code: AMY)
  • Physiotherapists (code: AMS or AMK)
  • Pedicurists (code: POD)
  • Nurses (code: AMI or AIS)

 

All of these procedures require a prescription issued by a doctor.

Conditions

The treatment form completed by the practitioner carrying out the procedure must be sent to the SPME, together with the prescription and/or the request for prior consent showing the SPME Medical Advisor’s decision.

Common treatment forms are now used by all social security schemes in Monaco (SPME, CCSS, CAMTI) and are distributed to contracted practitioners.

Please note

Prescriptions are valid for six months.

Prior consent of Medical Advisor

Procedures carried out by nurses and allied health professionals may be reimbursed provided that, in the case of certain procedures, including functional rehabilitation, nursing care, speech therapy and orthoptics…, the SPME, on the advice of its Medical Advisor, has agreed in advance to cover them.

All requests for prior consent should be sent to the SPME Medical Advisor.

Requests should include the original prescription issued by the doctor specifying the nature of the procedures, where they are to be carried out and the number of sessions to be completed (the last of these is not mandatory in the case of functional rehabilitation).

Requests should specify the following information:

  • Full name and SPME registration number of the insured person
  • Full name of the person receiving treatment 
  • Details of the health professional who will be carrying out the procedure
  • Nature and code of procedures to be carried out and date of request

 

Treatment may not be provided until the SPME Medical Advisor has agreed to cover it, except in cases of medical emergency.

In all cases, prior consent from the Medical Advisor is valid for six months.

Hospital care

Inpatient care

Hospital admissions in Monaco and the Alpes-Maritimes department

Stays in public hospitals in Monaco and the Alpes-Maritimes, and in the Monaco Cardiothoracic Centre (CCT)

This covers the following public hospitals:

  • Monaco Princess Grace Hospital Centre (CHPG)  
  • Hospitals and university hospitals in the Alpes-Maritimes department

 

Stays can be in the public sector or in private practice.

Public basis

If you are admitted to Princess Grace Hospital Centre on a public basis, to a French public hospital or to the Monaco Cardiothoracic Centre, you will not have to pay the full cost of your stay upfront, since you can make use of the "third-party payment system".

You must present to the hospital your registration card or a certificate confirming your entitlement.

The hospital sends a request for payment to the SPME Medical Advisor. Once approved by the Medical Advisor, the SPME will pay its share of the costs directly to the hospital.

You will then be responsible for paying the hospital for the following costs as appropriate:

  • Where 80% of costs are covered, the remaining 20% known as the ticket modérateur (patient’s contribution) 
  • Any supplement for a private or twin room payable in certain public hospitals if you requested a specific type of accommodation for reasons of personal convenience

 

Private practice

At Princess Grace Hospital Centre you may request to be admitted under the private practice of one or more hospital practitioners.

This option is selected by signing the "patient choice form" on which the names of the various practitioners chosen by the patient must be indicated.

In such cases, the costs of the hospital stay will be covered by the SPME under the same conditions as if the patient had been admitted to hospital on a public basis.

The various practitioners treating the patient on a private basis will, however, invoice their own fees in addition. These will be reimbursed on the same basis as out of hospital care.

You are therefore likely to be required to bear the cost of fees over and above the amount which will be reimbursed by the SPME.

It is up to you whether you choose to be treated by a practitioner working on a private basis.

Where several practitioners are involved in your care, and you wish to be treated by one on a private basis, you are not obliged to opt for private practice in the case of the other practitioners.

Stays in private clinics in Monaco and the Alpes-Maritimes:

Private clinics are:

  • The Monaco Institute of Sports Medicine and Surgery (IM2S)
  • Private clinics in the Alpes-Maritimes department

 

If you are admitted to a private clinic (excluding at Princess Grace Hospital Centre), you will, in principle, need to pay upfront the costs of your stay and the fees charged by the practitioners treating you.

Each clinic is free to determine whether or not it will operate the third-party payment system.

In the case of full third-party payment: the SPME will pay the costs of the hospital stay (in accordance with current legislation and on the same basis as hospitalisation in the public sector) and practitioners’ fees (on the same basis as for out of hospital care).

Please note:

If you pay the full cost of your stay and practitioners’ fees: ensure that the clinic provides you with form S3404. This is the only document which is accepted for SPME reimbursement of the costs.

Depending on the fees invoiced by the practitioner(s) and the rules for reimbursement, the costs of a hospital stay and fees in private clinics can be significantly higher than the amount reimbursed.

When being admitted in hospital, make sure you are aware of the full financial consequences of your choice. Ask for a quote for this purpose.

Prior consent of Medical Advisor

Some procedures are subject to prior consent being granted by the SPME Medical Advisor.

In accordance with current legislation, your practitioner must submit a request for prior consent when required.

Hospitalisation in France outside the Alpes Maritimes department

If you choose a hospital outside Monaco or the Alpes Maritimes department for reasons of personal convenience, the costs of a hospital stay will be paid (public sector) or reimbursed (private sector) up to the limit of the daily rate at Princess Grace Hospital Centre or, failing that, at Nice University Hospital. 

Outpatient care and care without accommodation

Definition

This includes:

  • Outpatient care: consultations, minor surgery, medical imaging and biological analysis conducted on an outpatient basis at public and private hospitals
  • Ambulatory care or care without accommodation: a limited number of surgical and diagnostic procedures specified on a list and carried out with or without anaesthetic, requiring some observation or recovery time but not full accommodation (length of hospital stay is less than 24 hours) 
  • Admission to hospital for a day during which medical procedures, check-ups, and treatments not requiring a longer hospital stay are carried out (length of hospital stay is less than 24 hours) 
  • Treatment provided by accident and emergency departments in hospitals and not requiring a hospital stay of more than 24 hours 
  • Home hospital care: a hospital service which provides an alternative to full hospitalisation. Home hospital care provides a way of managing patients requiring ongoing care and medical observation 
  • Home care: a service which allows elderly people who need nursing and personal care to remain in their homes

Conditions 

Outpatient care provided in the public hospital sector uses the third-party payment system, i.e. patients do not have to pay the full medical costs upfront and are responsible only for the ticket modérateur (patient contribution), where 80% of costs are covered.

Pharmacy (Remember to always attach your medical prescription to the treatment form issued by the pharmacist)

Medicines

Definition

This refers to all products issued by pharmacies: medicines, personal hygiene products, nutrition and dietary products and disinfection products.

Conditions

To be eligible for reimbursement, medicines must:

  • Be prescribed by a practitioner in accordance with the stipulated therapeutic indications 
  • Be included on the list of reimbursable medicines

 

The treatment form completed by the pharmacist must be sent to the SPME with:

  • For a one-off prescription: by the original medical prescription 
  • For a repeat prescription:
       - For each renewal: by a photocopy of the original prescription including a note about any previous renewals 
       - For the final renewal: by the original prescription noting all previous renewals

 

The original prescription must also be presented to the pharmacist each time the prescription is issued.

In order to avoid a lower reimbursement rate, consider asking your pharmacist whether a generic medicine is available. If it is, the pharmacist can substitute the generic option for the prescribed medicine, unless the doctor has specified on the prescription that he or she does not approve such a substitution.

Common treatment forms are now used by all social security schemes in Monaco (SPME, CCSS, CAMTI) and are distributed to contracted practitioners.

Prior consent of Medical Advisor

In accordance with current legislation, medicines not on the approved list are subject to prior consent from the SPME Medical Advisor. Your practitioner must submit a request for prior consent.

Please note

Prescriptions are valid for six months.

Unless you are going abroad, you must limit your purchases to the quantity required for one month’s treatment.

Even if they have been prescribed, not all products are eligible for reimbursement. 

Consumables, products and equipment included on the List of Reimbursable Products and Services (LPP)

Definition

This applies particularly to:

  • Medical devices used in treatments and daily living aids
  • Items for dressings
  • Orthotics and external prostheses
  • Implantable medical devices
  • Vehicles for those with physical disabilities

Conditions

The following is required for reimbursement:

  • The original medical prescription 
  • The item must be listed on the LPP
  • The relevant section of the invoice issued by the supplier (pharmacist or orthotist) must be attached

 

The treatment form completed by the pharmacist must be sent to the SPME.

Common treatment forms are now used by all social security schemes in Monaco (SPME, CCSS, CAMTI) and are distributed to contracted practitioners.

Prior consent of the Medical Advisor

Certain products on the List of Reimbursable Products and Services (LPP) are only reimbursable if prior consent has been obtained from the SPME Medical Advisor. It is important to seek advice from the supplier.

Please note

Prescriptions are valid for six months.

Vision (Remember to always attach your medical prescription to the order form)

Glasses

With a view to improving the reimbursement conditions for corrective glasses, a standard rate has been agreed with the various opticians in the Principality and neighbouring municipalities.

Contracted opticians agree to:

  • Apply a standard rate when selling standard quality lenses to the public
  • Issue a quote showing the standard-rate sale price and the amount of additional charges (both reimbursable and non-reimbursable) as well as the reimbursement rate for each order

 

Make sure that you request this quote when ordering your glasses so that you are aware of the cost before the service is provided. 

Regardless of the age of the beneficiary, lenses supplied by a non-contracted optician will be reimbursed at five times the reimbursement rate applied in France.

Conditions

The order form drawn up by the optician (with the quote and invoice sections completed), together with the prescription, must be sent to the SPME.

Download the order form (French only) Download file Bon de commande de lunettes (369-0006_01-2017) Bon de commande de lunettes (369-0006_01-2017)

Should you break or lose your glasses within six months of purchase, you may replace them directly and send the SPME the new order form issued by the optician (with the quote and invoice sections completed), together with the replacement of glasses form.

Download the replacement of glasses form (French only) Download file Demande de remboursement de remplacement de lunettes perdues ou cassées moins de six mois après l'achat (369-0001_01-2017) Demande de remboursement de remplacement de lunettes perdues ou cassées moins de six mois après l'achat (369-0001_01-2017)

Please note

Prescriptions are valid for six months.

Contact lenses

Conditions

Contact lenses are reimbursable subject to certain medical conditions which your ophthalmologist will be able to explain to you.

A maximum annual allowance is available for the purchase of contact lenses.

The order form drawn up by the optician (with the quote and invoice sections completed), together with the prescription, must be sent to the SPME.

Download the order form (French only) Download file Bon de commande de lentilles (369-0007_01-2017) Bon de commande de lentilles (369-0007_01-2017)

Please note

Prescriptions are valid for six months.

Reimbursement rate

Reimbursement is usually calculated on the basis of 80% of the applicable cost; the remaining 20% is to be paid by the insured person. This is the portion commonly known as the "ticket modérateur" (patient contribution).

However, 100% of costs will be reimbursed for the following insured persons:

  • Insured persons who are:
       - Current civil servants and other Government and Commune officials 
       - Retired permanent civil servants of the State or Commune who are resident in Monaco 
       - Officials of the State or Commune with cumulative service of two years’ full-time employment within the public sector 
  •  Insured persons or dependents who are exempt from the patient contribution

 

The 100% reimbursement rate is applied to these insured persons in the following cases:

  • For medical procedures (excluding dental and biological procedures) which, coded according to the Classification Commune des Actes Médicaux (CCAM, Common Classification of Medical Procedures), have a reimbursement rate equal to or greater than:
       - €140.14, where fees are fixed according to the standard rate 
       - €91.00, where procedures are carried out in outpatient departments of French public hospitals 
    Where such procedures require a hospital stay, exemption from the patient contribution is extended to cover all medical costs incurred during the hospital stay

 

  • Ambulance transport

 

  • Daily charges

 

  • Medicines not on the approved list

 

  • Large prosthetics and medical aids

 

  • Costs of stay for a continuous period of hospitalisation lasting more than thirty days 

 

  • Care provided for premature babies in a specialist department or hospital 

 

  • Hospitalisation of new-born babies within thirty days following birth 

 

  • Purchase or repair of prosthetics or orthopaedic aids (large) 

 

  • Certain medicines or products of human origin 

 

  • Orthodontic treatments 

 

  • Health expenses incurred by people with disabilities 

 

  • Health expenses related to an accident at work or occupational disease 

 

  • Reimbursement of certain medical costs for pregnant women, from the first day of the sixth month of pregnancy until the day before birth 

 

  • Reimbursement of the costs of staying in a hospital or clinic during childbirth, within the limits of statutory rates 

 

  • Reimbursement for flu vaccines where the beneficiary is aged over 65 

 

  • Examinations required to diagnose and treat infertility
Last update: 23/10/2017

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