The majority of medical services are covered by health insurance, then by the mutual insurance company which completes the reimbursement. How to calculate the rate of coverage by his mutual?
Health insurance sets for each act or product it covers a reimbursement basis (BR)which corresponds to its reference rate, a reimbursement rate that it applies to this reference tariff and which determines the amount of his refund. Reimbursement by health insurance may therefore be lower than the basis for reimbursement. The difference between the basis of reimbursement and what the health insurance reimburses is called the co-payment. Complementary health insurance can reimburse: the co-payment and any overruns, compared to the reference rate. Reimbursement of complementary health insurance will depend on the guarantees of each contract. The guarantees of a complementary health insurance can be expressed either as a percentage of the reimbursement base (BR), or in euros. How to calculate the reimbursement rate of his mutual?
What are the base prices?
Social Security reimburses part of the health costs based on a reference rate called “reimbursement base”. The non-reimbursed part, called co-payment, remains the responsibility of the insured. It is this part, or rather a part of this part, that mutuals or health insurances reimburse.
Reimbursements of supplementary health insurance are variable according to the proposed formulas. They can for example range from 100% of the reimbursement bases, a formula corresponding to the basic contracts, up to 200%, or even 300% of these same reimbursement bases, or sometimes even at actual costs for some. 100%, 200%, 300%, this means that your complementary health insurance covers up to 100%, 200% or 300% of the Social Security Reimbursement Base (BR) amount. It remains to be checked whether the guarantees include or exclude the reimbursement of the Compulsory Health Insurance (AMO): if the guarantee is expressed “reimbursement of the AMO included”, this means that the guarantee displayed includes the reimbursement of the AMO ; if the guarantee is expressed “reimbursement of the AMO excluded”, this means that the guarantee expressed does not include the reimbursement of the AMO and reflects the strict reimbursement of the complementary health insurance.
► For a person over 18 respecting the course of care and consulting a specialist doctor who charges free fees (sector 2) and whose consultation costs €55, Social Security will refund 70% of €23its base rate (BR) for a specialist consultation, i.e. €16.10 (- 1 euro which corresponds to the non-reimbursed flat-rate contribution which remains the responsibility of the insured), i.e. in total: €15.10.
If this person has complementary health insurance that reimburses 100% of the basic social security rate (with the assumption of reimbursement from compulsory health insurance included), this means that their complementary health insurance will reimburse them €6.90 for co-payments, i.e. 30% of the social security reimbursement base (i.e. 30% x €23 = €6.90). The amount that remains payable by the patient is then €33, ie €55 – €15.10 (amount reimbursed by social security) – €6.90 (amount reimbursed by complementary health insurance).
200% means that the complementary reimburses up to 2 times the Social Security reimbursement base minus the reimbursement of compulsory health insurance within the limit of the expense incurred (always with the assumption of reimbursement of health insurance included). In this case, the complementary will cover: 30% x €23 for co-payments and 100% x €23 for overruns, i.e. €29.90 (€6.9 + €23). The amount remaining payable by the insured will then be €10: €55 – €15.10 (sum reimbursed by social security) – €29.90 (amount reimbursed by the complementary).
300% means that the complementary reimburses up to 3 times the Social Security reimbursement base minus the reimbursement of the Compulsory Health Insurance within the limit of the expense incurred (always with the assumption of a reimbursement of the Compulsory Health Insurance included). In this case, the complementary will cover: 30% x €23 for co-payments and 200% x €23 for excess fees, i.e. a maximum of €52.90 (6.90€ + 46€). In this example, the insured will therefore be fully reimbursed. He will only have to pay €1 for the flat-rate contribution, which remains the responsibility of the insured.
What are the mutuals that reimburse the best?
To choose the right health supplement, contact the health supplements on the market (of which there are many!) and compare their offers. To do this, it is important:
► of properly assess your needs (depending on your age, the composition of your household, your specific optical/audio/dental needs, for example),
► ofstudy in detail the guarantees offered with regard to the tariff (examples: in the event of hospitalization, is the private room reimbursed by complementary health insurance? For what amount and for what duration?
► of look at the services offered that can make the difference (illustrations: care networks, third-party payment partners, medical teleconsultation services, assistance and home help services, preventive actions, etc.).
► of ask the chosen organization to explain what he will pay you if you consult a doctor free of charge whose consultations amount to 40, 60 or 80 euros. Then do simulations that will allow you to better understand the differences.
“Faced with the inherent complexity of the reimbursement system, we have a collective challenge to improve information for policyholders on the functioning of reimbursements and the relationship between compulsory health insurance and complementary health insurance, in particular in the context of the 100% Health reform. With regard more specifically to the legibility of contract guarantees, complementary health insurance are committed to providing their policyholders with common examples reimbursement expressed in euros for the most frequent acts (such as consultation with a general practitioner/specialist, purchase of optical equipment). This will contribute to make it more readable, and therefore more comparable, complementary health guarantees. UNOCAM and the three families of complementary health insurance made a strong commitment to this on February 14, 2019 as part of a market agreement.“explains Maurice Ronat, President of the National Union of Complementary Health Insurance Organizations (UNOCAM).
Thanks to UNOCAM – Maurice Ronat, Delphine Benda – for their validation.