To supplement the benefits of compulsory health insurance schemes, insurers offer complementary health insurance contracts. What are the costs generally covered by these contracts? What are its limits? What services are offered by insurers?
• Reimbursement of treatment costs
• Responsible supplementary insurance contracts
• Other reimbursements
• Most insurers offer their policyholders access to networks of health professionals.
• The third party payment
• The services offered by complementary health insurance
Reimbursement of treatment costs
Health care costs are partially covered by compulsory health insurance schemes. The additional insurance intervenes to supplement these reimbursements, to a greater or lesser extent, depending on the guarantees subscribed (within the limit of the costs actually incurred).
Responsible supplementary insurance contracts
Today, almost all contracts are responsible in the sense that they must respect several obligations and prohibitions of reimbursement set by the State.
Specifically, responsible complementary insurance contracts must at least guarantee:
• Full coverage after social security intervention for certain care and equipment belonging to the “ 100% health ” baskets in the optics, dental or hearing aid sectors, within the limit of capped prices;
• The user fee (i.e. the portion remaining payable by the insured after reimbursement of compulsory health insurance) for all acts and services reimbursed by social security, except those related to thermal cures, homeopathic medicines and drugs reimbursed at 15% or 30% by health insurance;
• The daily hospital fee billed by health establishments, without time limit;
• The costs of dental prostheses and orthodontic care up to a minimum of 125% of their reimbursement base (Social Security portion included);
• In optics, a minimum flat rate, per period of 2 years, for the acquisition of optical equipment (lenses + frames). For minors under the age of 16 or in the event of vision changes, this period is reduced to one year. This flat rate is fixed at 100 € minimum for simple corrections, 150 $ minimum for mixed corrections (that is to say simple and complex) and 200 $ minimum for complex corrections. In all cases, the amount of support allocated to the frame will be a maximum of 100 $.
For policyholders with a near vision deficit and a distance vision deficit, and who cannot or do not wish to wear progressive or multifocal lenses, the policy guarantees may cover the cost of two devices, each correcting one of these two deficits. The rules for coverage by responsible contracts are applicable to each piece of equipment considered individually (floor, ceiling, and renewal period).
If the additional insurance contract taken out offers coverage for excess fees, coverage for overruns made by physicians who have not signed up to one of the controlled pricing practices (OPTAM or OPTAM CO) is then capped.
To know Doctors can subscribe to a moderated pricing practice system: OPTAM (controlled pricing practice option) and OPTAM-CO (controlled pricing practice option, surgery and obstetrics).
To find out whether or not a doctor has joined the OPTAM or the OPTAM-CO, you can consult the site
Responsible contracts do not support:
• Flat-rate participation ($ 1 per consultation) and medical deductibles payable by the insured;
• An increase in the insured’s participation for non-designation of a treating doctor or consultation of another doctor without a prescription from the treating doctor (insured person known as “outside the treatment path”);
• Excess fees when the insured consults a specialist to whom the law does not allow direct access without going through his attending physician (i.e. a specialist other than a gynecologist, ophthalmologist, psychiatrist or neuropsychiatrist – patient between 16 and 25 years old, stemmatologist).
Finally, under these responsible contracts, the complementary organizations must communicate to policyholders each year the amount and composition of the management and acquisition costs of the contracts.
Other reimbursements
Complementary insurance contracts can go beyond the minimum guarantees defined by the responsible contract, for example by providing for the medicare supplement leads of:
• The daily hospital fee billed by medico-social establishments;
• Supplement for a private room;
• Lenses, refractive surgery;
• Costs of dental prostheses and dent facial orthopedics (ODF) beyond the user fee, and implants;
• Orthopedic and prosthesis costs, over and above the user fee;
• Preventive acts (such as vaccines), alternative medicine, not covered by the compulsory regime;
• A package for thermal cures Some insurers offer other services such as:
• A maternity premium or a birth package;
• A funeral package.
Most insurers offer their policyholders access to networks of health professionals.
Set up mainly in the field of optics, dentistry and hearing aids, these networks make it possible to benefit from negotiated prices and commitments in terms of quality and services rendered. By deciding to go to a professional who is a member of a network, an insured may, depending on the characteristics of his contract, see his “out-of-pocket” (that is to say the part of the expenses which remains at his charge) completely disappear. After reimbursement of compulsory health insurance).
The third party payment
All patients who have taken out a responsible contract can be offered third-party payment by their healthcare professional up to the co-payment for the minimum guarantees defined by the responsible contract.
Agreements signed between insurers and certain health professionals (pharmacists, medical analysis laboratories, radiologists, medical auxiliaries, opticians, etc.) make it possible to exempt policyholders from the advance of all or part of their expenses after reimbursement. By the compulsory regime.
In practice, it is sufficient for the insured to present to the healthcare professional a third-party payment certificate issued by the insurance company.
Supplementary solidarity health contracts
Since November 1, 2020, the Solidarity Health Complementary, a new system to help access additional health protection, has replaced the CMU-C and ACS systems.
Policyholders affected by this system benefit from full reimbursement of the co-payment, full coverage for glasses, hearing aids and dental prostheses within the framework of 100% health, exemption from certain costs and full third-party payment. .
Note: If you choose a complementary organization rather than compulsory health insurance as the manager of your contract, you will be able to access additional optional guarantees.
The services offered by complementary health insurance
Insurance companies increasingly offer their policyholders information and support services in various forms:
• Information (practical, price and qualitative) to orientate oneself in the health system;
• health advice and telephone support platforms;
• Personalized services (coaching, psychological support, quote analysis, etc.);
• Information leaflets, Internet spaces dedicated to prevention, meetings and conferences, etc.
Assistance services may also be offered in supplementary health insurance contracts:
• Housekeeper, nurse;
• Child care;
• Tutoring ;
• Animal care;
• Repatriation.
