What is mandatory health coverage?
Compulsory health coverage in France is provided by Social Security. If you are affiliated to the general scheme, you will be partially reimbursed for your health expenses, such as medical consultations, the purchase of medication or laboratory analyses. This reimbursement is based on a conventional rate set by the Health Insurance, generally covering 70% of the costs incurred. However, the remaining out-of-pocket expenses, known as the “co-payment”, may vary depending on the type of care, compliance with the coordinated care pathway, and medical procedures.
Some situations, such as hospitalizations or hearing aids, can result in significant costs. To reduce this out-of-pocket expense, subscribing to a complementary health insurance becomes a valuable asset.
What is the purpose of a complementary health insurance?
Complementary health insurance supplements the reimbursements made by Social Security. It covers all or part of the remaining out-of-pocket expenses, known as “out-of-pocket expenses”, after the intervention of the Health Insurance. The role of the complementary health insurance is therefore to Reduce your healthcare expenses by covering medical procedures that are not or partially reimbursed by Social Security.
For example, if you consult a specialist for 60 euros, the Health Insurance will reimburse 70% of the conventional rate, i.e. about 42 euros. The complementary health insurance can then cover the remaining 18 euros, depending on the level of coverage taken out. Complementary health insurance policies can be taken out with a mutual insurance company, an insurance company or a provident institution.
Examples of refunds:
- For a consultation at 60 euros, Social Security reimburses 42 euros, leaving a balance of 18 euros. A complementary health insurance with a 100% guarantee will cover these 18 euros.
- For a consultation with a practitioner on a fee-free basis, Social Security reimburses 16.10 euros on a basis of 23 euros. If the cost of the consultation is 60 euros, a 200% complementary health insurance could cover up to 46 euros, thus reducing your out-of-pocket expenses.
Is complementary health insurance mandatory?
It is important to distinguish between individual health insurance and group health insurance. Individual health insurance is not mandatory but is strongly recommended, especially in the face of rising healthcare costs, optical costs or consultations with specialists with free fees.
Anyone, whether they are an employee, student, retired or unemployed, can benefit from complementary health insurance on an individual basis. This type of contract covers costs not covered by Social Security, including certain services such as osteopathy. In case of low resources, you can also benefit from the Complementary health insurance (CSS), which covers healthcare costs within the limits of Social Security tariffs.
Since 2016, companies have been required to offer collective health coverage to their employees. This scheme is financed at least 50% by the employer, offering protection that is often more advantageous than an individual mutual insurance company. From 2024, this obligation will be extended to public administrations, making it compulsory for civil servants to subscribe to complementary health insurance.
What are the advantages of a complementary health insurance?
Subscribing to a complementary health insurance has several advantages, adapted to your personal or professional situation:
- Refund supplement: Supplementary coverage covers the remaining health costs after the intervention of the Social Security. Group contracts are generally more protective and less expensive than individual contracts.
- Coverage of specific care: A complementary health insurance covers expenses not reimbursed by the Health Insurance, such as excess fees, dental prostheses, optical costs, or alternative medicine.
- Third-party payment: Thanks to the third-party payment card, you do not need to advance the costs for your medical consultations, your purchases in pharmacies, or your examinations in radiology centers.
- Assistance and prevention services: Some complementary health insurance companies offer additional services such as assistance withmicile, childcare in the event of hospitalization, or health prevention workshops.
Namely: Since January 2021, the “100% Santé” scheme has allowed all French people to benefit from audiological, optical and dental care without out-of-pocket expenses. These benefits are fully covered by the Health Insurance and your complementary health insurance.
What are the benefits covered by a complementary health insurance?
The guarantees offered by a complementary health insurance vary depending on the contract taken out. One Complementary basic health insurance generally covers the co-payment for simple medical procedures, without exceeding fees. On the other hand, a Intermediate coverage offers better care, in particular for:
- Medical consultations and care, even in the event of excess fees.
- Prescription medications.
- Classic hospitalization costs.
- Mid-range dental care and prostheses.
- Mid-range optical care.
For optimal protection, you can opt for a Higher Reimbursement Category. This option offers better coverage for fee overruns and specialized care, such as hearing aids, orthodontics for adults, or alternative medicine.
Namely: The responsible health insurance contract encourages policyholders to follow a coordinated care pathway. This type of contract offers tax advantages, such as a tax reduction on the contributions of the insured and the employer.
Mutual health insurance: are there any specialized complementary health insurances?
Complementary health insurance can be adapted to specific needs or to particular age groups. Like what Senior health insurance is designed for people aged 60 and over, better covering the costs related to hospitalizations, accidents, and alternative medicine, often necessary to relieve age-related pain.
Other mutual insurance companies specialize in specific areas, such as The optical mutual insurance company, which focuses on expensive eye care, or Dental mutual insurance, which provides coverage for advanced surgeries and dental care. There are also adult orthodontic mutual insurance companies, which cover treatments not reimbursed by Social Security, such as orthodontic care for adults.
What are the levels of care?
The levels of coverage by your complementary health insurance depend on the contract you have taken out. Generally, warranties are expressed in Refund rate. For example, a rate of 200% means that you will be reimbursed up to twice the conventional Social Security rate, up to the limit of the costs incurred.
For certain items of expenditure, your complementary health insurance may provide for a Pick-up package, expressed in euros. For example, a flat rate of 250 euros per year for optical care.
How much does a health insurance cost?
The cost of a mutual health insurance varies depending on the level of coverage chosen, your income, your age, and your professional status. It is essential to compare the different offers available to find the one that best suits your needs and budget.
What are the terms of reimbursement?
The reimbursement of health expenses by your complementary health insurance depends on several factors:
- Third-party payment: If the health professional accepts the third-party payment system and your mutual insurance company is linked to the Health Insurance by teletransmission, you do not need to advance the costs. The Health Insurance and your complementary insurance reimburse the health professional directly.
- Classic refund: If the third-party payment is not accepted, you must pay for the consultation and then be reimbursed within 5 days by the Health Insurance, followed by your complementary insurance within 48 hours to 4 days.
Good to know: To be reimbursed quickly, choose a mutual insurance company linked to the Noémie (Open Standard for Exchanges between the Disease and External Stakeholders) remote transmission system.
Focus on complementary group health insurance
Since 1 January 2016, all companies have been required to offer a Complementary group health insurance to their salaires, whatever their seniority. This contract is negotiated by the employer and contributions are often deducted directly from salary. The employer pays at least 50% of the contribution, which often makes this option more advantageous than a supplemental insurance taken out individually.
However, it is important to check the guarantees offered by your company mutual insurance company, as they can sometimes be insufficient or poorly adapted to your needs.
Mutual and complementary health insurance: what is the difference?
From a legal point of view, a distinction is made between The mutual insurance company, which is a contract offered by a non-profit mutual society, Complementary health insurance, which is a contract issued by an insurance company. In practice, for policyholders, there is no significant difference between the two, as they offer the same guarantees.
What is a supplemental health insurance and what is it for?
The supplemental insurance is an additional insurance contract that comes in addition to the reimbursements of your main mutual insurance company. It covers the costs that remain to be paid after the intervention of Social Security and your complementary health insurance.
Did you know? You can take out a supplementary health insurance with the insurer of your choice, regardless of who manages your complementary health insurance.
How to modulate your health contract to save money?
It is possible to reduce the cost of your mutual health insurance by modulating the guarantees of your contract according to your real needs. For example, if you don’t need certain specific coverage, you can opt for a contract that offers basic guarantees, which will reduce the amount of your contributions.
Practical tip: Compare health insurance offers regularly to adjust your coverage to your current needs and save money.
Complementary health insurance is an essential tool to protect you against unexpected medical expenses. Whether it is individual or collective, taken out personally or through your employer, it is essential to understand the guarantees and levels of coverage to choose the mutual insurance company that will best meet your needs. Remember to consider your personal and professional circumstances to maximize the benefits of your health coverage.
