The ALD 30 system is based on a regulatory list of exempting conditions, but its practical application varies by primary health insurance funds, care protocols, and updates from the High Authority of Health. Here, we detail the technical points that most public guides overlook.
Territorial Disparities in ALD Admission
For the same pathology listed under ALD 30, the decision to grant ALD status is not uniform from one department to another. Several recent reports document significant discrepancies between primary health insurance funds, particularly regarding type 2 diabetes and heart failure.
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These disparities are explained by local interpretations of severity criteria and the role of the medical advisor, who assesses the compliance of the care protocol submitted by the attending physician. The same patient may be admitted to ALD in one department and denied in another, even though the pathology and treatment are the same.
This observation raises the question of doctrinal harmonization. The CNAM now publishes an annual barometer on ALD beneficiaries, but admission criteria remain dependent on the local medical service practices. For professionals assisting patients with their procedures, we recommend consulting the health information on Your Health Assistant to have a clear reference before drafting the protocol.
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List of 30 Exempting Conditions: The Official Reference
The term “ALD 30” is historical. Severe hypertension has been removed from the list, but the name persists in common usage. Here are the conditions that qualify for exemption from the co-payment:
- Disabling stroke
- Bone marrow failures and other chronic cytopenias
- Chronic arterial diseases with ischemic manifestations
- Complicated schistosomiasis
- Severe heart failure, severe rhythm disorders, severe valvular heart diseases, severe congenital heart diseases
- Active chronic liver diseases (hepatitis B or C) and cirrhosis
- Severe primary immunodeficiency requiring prolonged treatment, HIV infection
- Type 1 and type 2 diabetes
- Severe forms of neurological and muscular conditions (including myopathy), severe epilepsy
- Hemoglobinopathies, severe constitutional and acquired chronic hemolyses
- Hemophilias and severe constitutional hemostasis disorders
- Coronary artery disease
- Severe chronic respiratory failure
- Alzheimer’s disease and other dementias
- Parkinson’s disease
- Hereditary metabolic diseases requiring specialized prolonged treatment
- Cystic fibrosis
- Severe chronic nephropathy and primary nephrotic syndrome
- Paraplegia
- Vasculitis, systemic lupus erythematosus, systemic scleroderma
- Evolving rheumatoid arthritis
- Long-term psychiatric conditions
- Progressive ulcerative colitis and Crohn’s disease
- Multiple sclerosis
- Progressive structural idiopathic scoliosis
- Severe spondyloarthritis
- Post-organ transplantation outcomes
- Active tuberculosis, leprosy
- Malignant tumor, malignant condition of lymphatic or hematopoietic tissue
This reference does not cover “off-list” ALDs (ALD 31) or disabling multi-pathologies (ALD 32), which fall under a distinct exemption mechanism.
ALD Care Protocol: What the Attending Physician Actually Commits To
The care protocol is the central document of the system. Written by the attending physician, it details the pathology, the acts and services covered at 100%, as well as the expected duration of treatment. Only the care listed in the protocol benefits from the exemption from the co-payment.
The medical advisor of the primary health insurance fund has a timeframe to validate or refuse the protocol. If there is no response beyond this timeframe, the agreement is deemed granted. We observe that the refusal rate varies by pathology: long-term psychiatric conditions and certain forms of type 2 diabetes are scrutinized more closely than malignant tumors, for which admission is almost systematic.
The protocol also commits the patient. Any care provided outside the coordinated pathway (such as consulting a specialist without going through the attending physician) remains subject to the co-payment, even if the pathology is listed under ALD 30.
Updating ALD Protocols by the HAS
The High Authority of Health recommended in 2023 to revisit certain ALD protocols, particularly for breast cancer and type 2 diabetes. The goal is to adapt the duration of exemption to therapeutic advances. Better-controlled forms may lead to a quicker exit from the system.
This evolution modifies the timing of care. A patient in complete remission from breast cancer, whose protocol anticipated a duration of five years, may not have their ALD renewed if the medical advisor deems that the severity criteria are no longer met. The decision is based on the analysis of the medical file at the time of renewal.
Another trend documented by the CNAM: the share of ALDs related to psychiatric conditions and dementias is increasing, while certain classic cardiovascular pathologies tend to stabilize among those under 65. This epidemiological shift redistributes the volumes of protocols processed by primary health insurance funds.
Exemption from ALD Co-Payment: The Concrete Limits
100% coverage does not mean zero out-of-pocket expenses. The exemption applies to the reimbursement base of Social Security, not to excess fees. Three items are systematically excluded from the system:
- Excess fees from practitioners in sector 2
- Flat-rate participation and medical deductibles (on medications, paramedical acts, health transports)
- Daily hospital fee in case of hospitalization
A complementary health insurance remains necessary to cover these residual items, even in ALD. The system alleviates the financial burden on heavy acts and prolonged treatments, but does not eliminate it entirely.
The distinction between “related” and “unrelated” care concerning ALD constitutes another frequent point of friction. A diabetic patient in ALD who consults for an ENT condition unrelated to their diabetes will be reimbursed at the usual rate, with the application of the co-payment. The care protocol precisely delineates the scope of the exemption.