Who distributes health supplements?
Whether you have health insurance or mutual health insurance, both contracts have the same objective: to reimburse part or all of the health costs that are not covered by Health Insurance during your consultations with a doctor or following medical treatment. Various studies by public bodies estimate that 93% of French people are covered by complementary health insurance.
The difference between mutual insurance and health insurance lies mainly in the statutes of the organization with which you have taken out your complementary health insurance. Although the two types of organism have relatively identical functions in practice.
A mutual health contract is distributed by a mutual. Governed by the Code de la Mutualité, mutual insurance companies have solidarity and mutual aid as their main values. The risk of illness and the reimbursement of medical care are shared between the members of the mutual. A request to join a mutual insurance company cannot be refused for health reasons, unlike an insurance company, which may require a medical questionnaire.
Unlike insurance companies, a mutual is not supposed to make any profit, because it has no shareholder to remunerate. Any surpluses realized each year are used in the following years to meet new needs, develop new guarantees and new services, or in anticipation of difficult times. In addition, the operation of a health mutual is based on equality: the representatives are elected on the principle of one vote per member. An insurance company is for its part a profit-making organization, subject to the Insurance Code.
Health insurance, mutual health insurance: who reimburses what?
The Health Insurance is the organization that takes care of the first level of reimbursement for a patient’s care. Each employee, depending on his status or profession, must be affiliated to one of the compulsory schemes, which generally covers 70% of the healthcare costs of patients and their dependents. For example, there are the following mandatory schemes: Social Security for employees, RSI for self-employed workers, Student Social Security, etc.
A complementary, whether it is a contract taken out with a mutual or an insurance company, will take care of the reimbursement of sums not covered by compulsory health insurance. The subscription to complementary health insurance is optional and is subject to the payment of a monthly contribution. This contribution depends on the guarantees and levels of reimbursement chosen by the insured.
The price of the contract varies according to many criteria such as the age of the insured, his department of residence, the number of people attached to the contract, and mainly the guarantees chosen. When signing your contract, you must pay particular attention to the guarantees provided for consultations with the doctor (general practitioner and specialist), the purchase of drugs in pharmacies, treatments operated at the dentist, optical care and other equipment such as hearing aids.
Refunds: convention rate (TC), co-payment (TM), reimbursement basis (BR)
Social Security has defined for each medical act a Convention Tariff, which will determine the amount that will be reimbursed for each of your medical treatments. Here are some examples of convention rates:
Treatment of a cavity on one side at the dentist: 16.87 euros;
A visit to a general practitioner in sector 1: 23 euros;
A spectacle lens: from 2.29 euros for a person over 18;
A dental crown: 107.50 euros, the fees charged by dentists being free;
A reimbursement percentage will be applied to this convention rate, which will allow the calculation of the amount which will be reimbursed to you directly by Social Security. In the most general cases, the reimbursement rate applied is 70%. For drugs, the reimbursement rate will depend on the color of the labels (65% for white stickers, 30% for orange stickers, etc.)
The moderating ticket (TM) designates the difference between the convention rate and the amount reimbursed by Social Security. It will determine the amount remaining at your expense or at the expense of your complementary health insurance, if you are the holder.
The simplest is probably to take an example. In the case of a visit to a sector 1 doctor:
The convention rate is set at €23
The reimbursement rate set by the Sécu is 70%, i.e. €16.10, from which €1 of medical deductible should be withdrawn
The co-payment is therefore €6.90
The rest to be paid by the patient therefore reaches 7.90€, addition of the co-payment and the deductible euro
Depending on the guarantees taken out, your mutual will cover all or part of the co-payment.
How to read the guarantees offered in a mutual quote?
The health insurance quotes present their different guarantees in the form of a percentage representing a share of the convention rate (% TC).
A “100% mutual” (the simplest form of mutual) will therefore reimburse you 100% of the convention rate. In the case of the most frequent medical procedures such as a visit to your general practitioner, it will simply cost you €1 per medical procedure.
However, many health professionals practice excess fees, thus sometimes greatly exceeding the convention rate defined by Social Security.
Similarly, the convention rates applied by the Social Security in the optical (glasses, lenses) or dental (crown, inlay-core, dental appliance, orthodontics) fields are sometimes ridiculously low compared to the rates charged by dentists or opticians. .
It is therefore not uncommon to see mutual or health insurance offering reimbursements of 500% or 600% of the Convention Tariff. For such contracts, what is the amount reimbursed by your complementary health insurance?
How about comparing mutuals to choose the one that suits you best?
The example of a visit to a doctor practicing excess fees
You consult a doctor of your choice, who practices fee overruns, billing the consultation at the rate of 35 euros. You have also taken out 150% mutual insurance.
The convention rate for a consultation with a general practitioner (sector 1) is €23
With a reimbursement rate of 70%, the mandatory reimbursement therefore reaches €16.10
Your mutual 150% in consultation reimburses a maximum of €34.50 (1.5 x €23)
Your mutual 150% therefore reimburses €34.50 – €16.10 = €18.40
The amount remaining at your expense is therefore €1.50 (€35 – €16.10 – €18.40 + €1)
