Health Insurance refunds, how does it work?

Health Care & Carte Vitale
1

The reimbursements are worked out as a percentage.


We did a study about the mutuelle system and learned quite a lot and the first thing we noted was that there actually was no such thing as a general 300% or 400% apart from specific fields you can choose from like dental or eye care. (Providing of course you have rights to the French social security system and hold a carte vitale and there are many ways to get hold of one)


First of all you need to know what this percentage represents; the invoiced amount is irrelevant as far as the French health system is concerned. 100% to the French health system means the price 'it' believes is fair.


So let us say that;
- you are quoted for a crown at dentist, the dentist will invoice you 280 €
- the Social security fair price is107.50€ (this is known as the 100% or ‘barème ’).



Very rarely does the social security give you 100% but they assign a percentage that they pay, in this case it is 70% of the ‘barème ’
Therefore on this occasion they would refund; 75.25€ (ref ameli.fr)


So say you have the work done;


Case 1; with no Mutuelle
-----------------------------------
Invoice Total 280.00€
Health System 75.25€ (70% leaving 30% of the ‘barème’ not refunded)
Mutuelle - none

Left to pay by you 204.25€



Case 2; with Mutuelle at 100% (of the bareme)
-------------------------------------------------------------------
Invoice Total 280.00€
Health System 75.25€ (70% leaving 30% of the barème not refunded)
Mutuelle 32.25€ (they pay the remaining 30% to make it up to 100%)
Left to pay by you 172.50€



Case 3; with Mutuelle at 150% (of the bareme)
-------------------------------------------------------------------
Invoice Total 280.00€
Health System 75.25€ (70% leaving 30% of the barème not refunded)
Mutuelle 86.00€ (they pay the remaining 30% to make it up to 100% and add another 50% of the 107.50€)


Left to pay by you 118.75€



Case 4; with Mutuelle at 200% (of the bareme)
-------------------------------------------------------------------
Invoice Total 280.00€
Health System 75.25€ (70% leaving 30% of the barème not refunded)
Mutuelle 139.75€ (they make it up to 100% and add (100% of the) 107.50€)


Left to pay by you 65.00€



Case 5; with Mutuelle at 300% (of the bareme)
-------------------------------------------------------------------
Invoice Total 280.00€
Health System 75.25€ (70% leaving 30% of the barème not refunded)
Mutuelle 204.75€ (they make it up to 100% and add 200% of the 107.50€)


Left to pay by you 0.00€



Some important points
--------------------------------


We might mention that some mutuelles will give you 10% if you own your own business and are recognised as travailleur non salarié.
Another point is that 'Medecine douce' such as physio if not prescribed first by your doctor, may not be covered, so go to the docs first.
Note:
1. that the Mutuelle only ever refunds with a maximum of your invoice total


2. There maybe a maximum per annum per person


3. Sometimes it is worked out in euros not percentage


4. Very rarely do you get a 300% in everything on the policy, you may have 300% on doctors fees and 100% on dental, not advised! The mutuelles make the difference between the service and the product, meaning you could get 300% for the service and only 100% for the product) and wonder why not all the invoice is paid by your complementary health insurance.


5. You may the 100%of the invoiced amount back from the state security system IF you are a long term sufferer for a particular ailment.This 100% will be applicable for treatment to that particular ailment and not the other treatment for both services and products including call-outs. Just ask your doctor about the 100%.


Different mutuelles have different policies, this can become more and more complex so always seek advice,


2

Thank you for letting me know, the accountant (who is about to be 'let go') has never even mentioned it.

3

Oh, did I meantion there may be some tax benefits if you are TNS? Check out the Loi Madeleine web site (http://www.loimadelin.com/loi-madelin/souscrire-contrat-madelin) or ask your mutuelle if you qualify and the amounts to claim back and that includes your life partner. You may even calculate (if you know the figures) the amount by yourself; http://www.loimadelin.com/calcul-disponible-fiscal-madelin

4

Hi Tracy

this percentage depends on the mutuelle in question and here is an example (and I am NOT promoting this mutuelle, I don't know it at all) but it is an example.

http://www.viaxis-assurances.fr/mutuelle-tns states that;

  • April : You benefit from a reduction of 15% compared to the standard system

  • Covea risks : - 20 % for company creations for up to 2 years

  • Swisslife : You benefit from a reduction of 15% compared to the standard system

some make it a reduction for certain people (businesses) and for a length of time but you really need to find out from your insurer. Perhaps they have already applied this reduction for you!

5

For the Travailleur non-salarie what is the 10% bit? Very interested as I was salarie initially but now TNS.

6

Well laid out John, thank you for that as is a common question on here. Dental and optical work is reimbursed very poorly by the SECU.

Do you think we should add this to the Useful links Terry?

7

Tracy, where do you think my article went to?

8

Another point that I don’t think was mentioned above is, check whether or not the health provider you are considering using is “conventionné” or not. This applies to dentists particularly but others too. If they are “conventionné” it means they charge the state-recommended fee for the treatment. So in theory if you could only ever use those providers, you would never need more than 100% mutuelle cover. The catch is that it’s not always possible, sometimes you have to use non-conventionné providers. But worth knowing I think.