Complementary health insurance in France: what it is and how it works – The Connexion
Everyone resident in France is entitled to be in the French healthcare system – but almost everyone also has a separate ‘top-up’ policy, to cover parts of the costs not covered by the state.
Known as assurance maladie complémentaire (complementary health insurance) this refers to the various schemes designed to complement France’s assurance maladie obligatoire compulsory insurance cover.
As a general rule the state only covers a limited percentage of medical costs, as a proportion of an official state tariff for a given medical act, called the tarif de convention. For example, the state covers 70% of the €25 charged for a standard visit to a GP.
What is more, certain medical professionals are allowed to charge more than the tarif de convention, and amounts above and beyond it, called dépassements, are also not subject to any reimbursement from the state.
As a result, so as not to have unpleasant surprises, most people have a top-up, also known as a mutuelle, that covers most or all the remaining amounts.
In 2020, 96% of the population of mainland France had top-up cover according to France’s public finance auditor the Cour des comptes.
Read more: An overview of the French healthcare system in 2021
How do top-ups work?
Top-ups comes in three forms:
Mutuelle policies originating from the Code de la Mutualité, which shaped the way in which they operate. Mutuelles are non-profit organisations which specialise in top-up healthcare. The term is however often used informally as a catch-all for the whole range of top-up insurance options.
Institutions de prévoyance (provident funds), which are non-profit-making organisations controlled by the Code de la Sécurité sociale and generally responsible for collective workplace insurance schemes.
Insurance companies controlled by the Code des assurances, which are private companies and normally offer other services as well.
If you are working, your top-up policy will generally be taken out and paid for in part by your employer and provided as part of a group contract to all staff members.
Group policies were initially only offered by institutions de prévoyance, but since they became obligatory for employers under the French ANI law in 2016, mutuelles and standard insurance firms now provide them as well.
However, individuals can also take out their own policy for themselves and potentially including their immediate family as well.
This is the option which self-employed people, farmers, small business owners, pensioners etc. would normally need to take in order to top up their mandatory health insurance.
While businesses are obliged to provide their employees with complementary health insurance, individuals who do not benefit from this are not required to take out their own policy; they can just pay their own expenses directly instead.
Equally, employees who are not satisfied with the guarantees offered by their work-associated policy can also take out additional cover, leaving them with three different forms of health insurance.
People on low-incomes may benefit from free or subsidised top-up cover under a scheme called complémentaire santé solidaire.
How do you get reimbursed?
Some complementary insurance policies are likely to cover all costs which exceed your basic state insurance, while others offer more limited cover. A given policy is likely to offer more generous cover for certain areas as opposed to others, hence the usefulness of shopping around to make sure you find the one best-tailored to your needs.
When you see a doctor or other healthcare professional, you should present your carte Vitale health card.
In the case of some doctors, who practise what is called le tiers payant, this means there is nothing to pay upfront for the part covered by the state, and with some doctors’ set-ups, nothing to pay at all if your mutuelle covers the full cost.
If they do not offer le tiers payant, you need to pay upfront but you will receive reimbursements automatically into your bank if you present your carte Vitale. The mutuelle’s payments will also be automatic, if you have set up a link between your state health insurance body and mutuelle.
Around 90% of GPs and two-thirds of consultants will accept cartes Vitales, but if they do not you will need to pay for the treatment at the point of care and then send in paper feuilles de soins documents from the doctor to your state health insurance body so that it and your top-up insurer can reimburse you.
If your top-up insurance provider is not linked up with your state health body then you will have to pass on your relevé de remboursement documents, showing state reimbursement received, to the top-up insurer.
If you do not have a top-up policy or it does not fully cover your treatment, then you may be left with out of pocket costs for of le ticket modérateur – the part of the tarif de convention not covered by the state – and any dépassements charged.
For example, if you see a GP who charges at the set state rate, the part that is not covered by the state is 30% of €25 = €7.50, plus a set €1 deduction, so €8.50 to pay.
Some people, including pregnant women and people with certain chronic health conditions, have no ticket modérateur to pay and will have 100% of their appointment costs covered by their mandatory insurance, though dépassements may still apply.
Related articles
Is there a time limit for using feuille de soins for health repayment?
New online health space: What it changes for residents in France
Digital carte Vitale: Where, how and when is this used in France?
