Guide to French Health System
4. 'Mutuelles' and 'Top Up' Health Insurance in France
- Limits of State Health System
- How Much do you Pay?
- Does a Top-Up Policy Make Sense?
- Obtaining Voluntary Health Insurance
- Terminating Your Top-Up Policy
4.1. Limits of State Health System
Whilst there may be a universal system of health cover in France, as a general rule the State only picks up a percentage of your medical costs.
In France, a multi-layered insurance-based system exists, in which the statutory system provides basic cover, supplemented by a system of secondary private insurance.
The percentage level of reimbursement by the statutory system varies, depending on the type of treatment received and from whom.
The social security system will normally pay for 70% of GP fees and between 30% and 65% of prescribed medicines, using the official regulated base figure for reimbursement.
Over and above the basic 70% reimbursement level, the fees charged by many consultants is higher than the statutory rates for treatment. These additional charges are called dépassements d'honoraires.
Hospital charges are generally reimbursed at the rate of 80%.There are also certain hospital services and facilities not covered by the State system, depending on the hospital, eg private room, television.
Finally, the levels of reimbursement for dental, optical and auditive treatment is also well below the actual charges, although in recent years there has been a significant improvement reimbursement arrangements, provided you have 'top-up' insurance policy.
In addition, in cases of specific major illnesses, or for someone on a low income covered by the Complémentaire Santé Solidaire (CSS), the system will generally reimburse 100% of the costs.
Beyond these general statements the level and scope of reimbursement depends on the type of treatment, the type of illness, your circumstances, and the cause of the illness. More information about actual reimbursement levels is provided in other pages in this guide.
However, the main point here is that if you want to be fully insured and have most of your costs reimbursed, then you will need to take out voluntary health insurance cover, or ‘top-up’ health cover, as it is sometimes called.
This applies even if your health cover is provided through an S1 health certificate of entitlement, as the S1 only grants entitlement to the same level of reimbursement as French nationals.
Similarly, if you run a business in France you will need to consider taking out 'top-up' cover. Salaried workers are generally covered by collective policies, but not in all cases.
The secondary insurance system is called l'assurance complémentaire santé.
In English the policies are variously described as 'complementary' health insurance, 'voluntary' health insurance and 'top-up' health insurance.
The additional cover does not allow you to 'jump the queue' for treatment – it merely reimburses that part of the cost not paid for by the social security system.
Voluntary insurance cover will pay most, but not all, of the residual costs of medical care, so you will still be left with a small amount to pay yourself. The amount will depend on the terms of your policy, your circumstances, and the nature of your treatment.
Thus, for example, voluntary insurers are specifically forbidden by the government to provide insurance cover for the €1 surcharge that now applies to all medical consultations, and there are restrictions on cover for those who do not proceed via their family doctor for medical treatment.
You will also find that most policies exclude insurance of illness or accident arising from certain 'dangerous' sports, with potential limits on alcohol or drug related illnesses or accidents. Most also limit cover for dental and ophthalmic treatment.
If your doctor or consultant charges more than the official rates (as many are allowed to do) you will also find many policies do not pick up this extra charge, or only pick up a proportion of it, up to a maximum amount.
So, you need to determine the level of cover you seek and pay the appropriate premium.
Apart from the issue of the level of reimbursement, you are likely to find that most 'top-up' contracts do not offer immediate cover. The period of delay (called a délais de carence) may be only three months, but on some contracts, it is as long as a year.
Other contracts provide for a reduced level of cover during the preliminary period.
The policies are not the same, so you need to read the policy to be clear about what is and what is not covered.
Next: How Much do You Pay?
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