In France, the long-term illness (ALD) system allows several million patients to benefit from 100% coverage by Health Insurance for care related to their condition. The official list, often referred to as “ALD 30,” includes chronic diseases that require prolonged and costly treatment. Since 2026, regulatory changes have reshaped the actual contours of this coverage, with direct consequences on reimbursements.
What the 2026 reform changes for ALD patients
Most articles available online present the ALD system as a total exemption from the co-payment. The reality is more nuanced since the implementation of the 2026 reform.
From now on, only care strictly related to the recognized condition remains covered at 100%. Prescriptions that do not directly relate to the ALD condition revert to common reimbursement rates: 65%, 30%, or even 15% depending on the medical service provided by the medication or procedure.
For a diabetic patient consulting a dermatologist for a skin issue unrelated to their diabetes, the consultation will be reimbursed at the usual rate, not at 100%. This distinction between “related” and “unrelated” care already existed in the texts, but its application has become stricter. It affects approximately 14 million ALD patients across the country.
A second aspect of this reform comes into effect on October 1, 2026: 171 medications with low medical service will be delisted, including for ALD patients. In practice, treatments that were previously covered at 100% under a recognized condition may fall outside the reimbursement scope if their therapeutic effectiveness is deemed insufficient.
To consult the list of covered diseases and the details of associated examinations and treatments, one must refer to the regulatory texts updated by Health Insurance, as the exact content of the care protocol depends on each condition.
Exempting ALD: which conditions are on the official list
The so-called “ALD 30” list actually now includes only 29 conditions since the removal of severe hypertension. However, the historical name is still used by the administration and healthcare professionals.
The covered conditions fall into several major categories:
- Cardiovascular diseases: disabling stroke, severe heart failure, coronary disease, chronic arterial diseases with ischemic manifestations
- Metabolic and endocrine diseases: type 1 and type 2 diabetes, cystic fibrosis, hereditary metabolic diseases
- Cancers: malignant tumor, malignant condition of lymphatic or hematopoietic tissue
- Neurological and muscular diseases: severe forms of epilepsy, multiple sclerosis, paraplegia, Parkinson’s disease, Alzheimer’s disease
- Inflammatory and autoimmune diseases: rheumatoid arthritis, ulcerative colitis, Crohn’s disease, severe spondyloarthritis
- Chronic infections: HIV infection, chronic active hepatitis B or C
- Psychiatric diseases: psychosis, severe personality disorders, bipolar disorder
- Organ failures: severe chronic respiratory failure, chronic kidney failure, post-organ transplant
In addition to this list, two other categories of ALD exist. “Off-list” ALDs cover serious conditions not listed in the official list but whose treatment lasts more than six months. ALDs for “disabling comorbidities” concern patients with multiple conditions that, taken individually, do not appear on the list, but whose combination results in a disabling state.
Care protocol and the role of the primary care physician in ALD recognition
Admission to ALD is not automatic. It is the primary care physician who establishes the care protocol, a document that specifies the treatments and medical acts covered at 100% under the recognized condition. This protocol is then sent to the medical advisor of Health Insurance for validation.
The care protocol precisely delineates the scope of reimbursements. Any medical act that falls outside this framework is reimbursed at the normal rate. This mechanism makes the 2026 reform particularly sensitive: complex prescriptions, common among patients with comorbidities, may now contain both lines covered at 100% and others at 65% or less.
The duration of recognition in ALD varies depending on the condition. Some are granted for a limited duration (typically two to five years) with the possibility of renewal. Others, such as irreversible conditions, benefit from unlimited recognition.
Actual out-of-pocket expenses in ALD: what the supplementary health insurance still covers
Even with 100% coverage, the out-of-pocket expenses are not zero for an ALD patient. The fixed contribution of one euro per consultation, the medical deductibles on medications and health transport, as well as the daily hospital fee are not covered by the exemption from the co-payment.
Additional fees charged by doctors in sectors 2 or 3 are also the patient’s responsibility. A specialist consulted under an ALD can perfectly charge an additional fee that Health Insurance will not cover, even if the act is included in the care protocol.
A complementary health insurance remains necessary to absorb these residual costs. “Responsible” contracts generally cover the daily hospital fee without duration limitation and part of the additional fees, but the levels of coverage vary significantly from one organization to another.
With the planned delisting of 171 medications with low medical service starting in October 2026, some ALD patients will need to check if their supplementary insurance covers these treatments or if the cost will fully fall into their personal budget. Complementary health contracts do not cover all delisted medications, and carefully reading the general conditions has become a less theoretical exercise than before.
