Settle down with a cup of tea…this is complicated if you are new to the system.
If you have a treatment that costs 100€, which is something CPAM pay 75% of you’d think you would get 75€ back from CPAM. But no! As their ‘base de remboursement’ could be much lower, say 50€ for that specific treatment. So you will only get 75% of 50€, ie 37.50€.
But no matter, my mutuelle will pay the rest surely? But no! If the level of cover you have taken out with your mutuelle is only 150% for that type of treatment, they will only pay up to 150% of the base de remboursement of 50€, so will only pay up to 75€.
So in this example CPAM pay 37.50€, and the mutuelle will pay another 37.50€ to bring you up to 75€, and you will have to pay the remaining 25€.
Clear as mud??
So the first thing to look at is what level of cover you have taken out with your mutuelle. You should have a small card, like a credit card, and on the back will be a table with incomprehensible acronyms, and percentages underneath.
So as an example the acronym OPT, which is optical costs, could be set at 150%, and HOSP, which is hospital at 300%. So you can see exactly what you are covered for. It is quite possible that your cardiologist is secteur 2, so allowed to charge much more than the CPAM base de remboursement. In which case unless you have a high level of cover from your mutuelle you won’t get that much back. And if you booked an urgent appointment “privée”, then it will cost you more too even if they are secteur 1.
Here is a link to the Ameli pages which shows the percentages CPAM pay for the different acts, and then the costs of each act