Which reimbursements for which care?

Which reimbursements for which care?

Health Insurance provides a base cover of health expenses; it can be completed by complementary health. In addition, third-party payment systems make it possible not to advance costs related to health expenses, on all or part of these expenses.

Who manages Health insurance ?

Health insurance is:

  • The « Caisses primaires d’assurance maladie (Cpam) » (Health care insurance fund) for the people coming under the general social insurance scheme.
  • The « Caisses de Mutualité sociale agricole (MSA) » (Agricultural social mutual fund)
  • As well as certain specific employees’ schemes.

The “third-party payment”? Within the framework of the third-party payment, you do not have to advance money for your expenses reimbursed by Health insurance; you are only paying the costs not covered by the latter, in this case the copayment (partial third-party payment).
In some cases (beneficiaries of the “Complémentaire santé solidaire – CSS”), the third-party payment can be full (or total): you then have no costs to lend, you do not pay the copayment.
The third-party payment is a right for all the patients fully covered by Health insurance (according to long term illness (“Affection de longue durée, ALD”) or for pregnant women).

What is the basic coverage?

Health insurance reimburses all or parts of your health expenses. Within the scope of the coordinated approved health care pathway and based on the Social security cost, the usual refund rates are of:

  • 80% for the hospitalisation expenses
  • 70% for medical consultations and radiological examinations.
  • From 65% to 30% for medicines. Some medicines known as irreplaceable and particularly pricey are 100% reimbursed.
  • 60% for medical devices (except for ocular and facial prosthesis, prosthesis for your body and vehicle for physically disabled (VHP) which are fully covered).
  • 60% for nursing care, physiotherapy acts, biological analyses.quel remboursement avec la Sécurité sociale

Is the rest at my expense?

The copayment is the health expenses part that remains your responsibility after the Health insurance reimbursement. Its rate fluctuates depending on the procedures and medicines, your situation, and whether or not the coordinated approved health care pathway is respected.

For acts exceeding a certain price, the copayment which remains at your expense is replaced by a 24€ flat-rate contribution.

If you have an additional healthcare cover, it can cover all or part of your copayment if the agreement you sign up to provides for it. Check with it.

From now on, employees can benefit from an additional cover financed partially by their employer, and the self-employed workers can choose one that covers part of the rest of their expenses: dental and optic care, excess fees.

Is a 100% coverage by Health insurance possible?

A 100% coverage is possible only in a certain situations and in particular for persons with long-term illness (“personnes en affection de longue durée (ALD)”), that is to say with a disease whose severity and / or chronic nature requires particularly expensive treatment and therapy. The ALD give the right to a full coverage (on the basis of the Social security cost) for related care (on request made by your general practitioner to the health insurance medical service). The excesses and flat-rate contributions remain applicable. Other cares are still covered at the usual Health insurance rate.

Did you know? In the event of a stay longer than 24 hours in a public or private hospital (including discharge day), you must pay a flat rate: it represents the patient’s financial contribution to the accommodation and maintenance costs incurred by his hospitalisation.

What are the cases of copayment’s augmentation?

If you are not in the coordinated approved health care pathway, which means you did not declare your general practitioner or if you directly see another doctor (apart from specialist doctors with authorized direct access), the Health insurance will increase your copayment. You will be less reimbursed.

Nevertheless, if you benefit from the “Complémentaire santé solidaire (CSS)” , if you are pregnant (for compulsory examinations and from the first day of the 6th month of pregnancy for all reimbursable care) or if you are the victim of an occupational accident, the copayment’s increases are covered by the CSS, maternity insurance or occupational accident and disease insurance.

It should be noted that:
The health professional additopnal fees are never covered by Health insurance.
Thereby, find out before choosing your general practitioner: unlike sector 1 doctors, who apply the rates set by agreement with the Health insurance (so-called Social security rates), the doctor in sector 2 freely sets his prices. He can therefore practice overcharging, which are not reimbursed by Health insurance but can be covered by a complementary health insurance, an insurance company, or a provident institution (The rates charged by doctors can be viewed in the health directory).