Reimbursement of your costs in the French health system is becoming increasingly complex and less generous. How does it all stack up?
Regular readers of the Newsletter will be aware that in the much vaunted French health system you do not normally get full reimbursement of your costs.
This is because, unlike in the UK 'capitation' system, where the payment model to doctors is based on the number of patients, in France it is a fee based system that is used.
With two notable exceptions (serious illness and low income), not all of the medical fees and costs are covered by the social security system.
The amount for which you are responsible depends on the type of treatment being received, and from whom.
How are Costs Calculated?
The starting point for the calculation of these costs is the official tariff for each medical act, called the ‘base de remboursement’.
Against this official tariff a percentage level of reimbursement (taux de remboursement) is applied.
Each type of medical act has a different tariff, and sometimes a different level of reimbursement.
In the vast majority of cases this percentage level of reimbursement is around 70% of the official tariff.
However, patients are required to make a personal contribution, called a franchise or forfait.
The level of this contribution varies by type of medical act, but for routine visits to your doctor it is €1, while medical acts costing in excess of €91 will cost you €18 directly. There is also a daily forfait for staying in hospital of €18.30.
When all this has been played out, the amount that is left for you to pay is called the ticket moderateur, a bizarre term that not even the French properly understand.
In practice, however, there is often far more for you to pay.
That is because, for certain types of medical treatment, the tariff used by the government does not reflect the actual fee charged.
The difference between the official tariff and the actual charge is called a ‘dépassement’.
So, although you may well get 70% reimbursement, it may be against a lower base figure than you are actually being charged.
The worst examples of the gap between the official tariffs and the actual charges occur with the dental and optical professions, but they are becoming increasingly widespread in all kinds of medical treatment, including prescription medicines, where the levels of reimbursement are being reduced on a regular basis.
The level of these ‘dépassements’ can vary widely, although for medical treatment with your family doctor the official, and currently modest, tariff generally applies.
Nevertheless, the government are currently undertaking a review of the fees payable to local GPs (to combat a hemorrhaging of new entrants) and it is possible that fees for certain kinds of treatment could rise in the future.
As the level of reimbursement from the health system rarely reflects your actual costs, most people take out a voluntary health insurance policy, called a complémentaire santé.
Depending on the level of cover in the policy this insurance policy will cover most, but not all of the charges you will incur.
Of course, the insurance policy itself has a cost, so some people prefer to take their chances and do not take out a policy.
Nevertheless, with the evident determination of the present government to privatise as much as possible of health service costs, it is inevitable that these insurance polices will be increasingly important in the future.
The following diagram shows schematically how these different costs and reimbursements hang together.
In this example, for an x-ray, the total level of reimbursement through the complementary health insurance is 150% of the basic social security tariff, including the basic tariff itself.
What it shows is that this insurance takes care of some of the additional costs incurred through dépassements, although not all of them.
In the first row are the actual charges you pay, made up of the official tariff and the supplementary charges shown in row 2, while row 3 shows how these charges are recovered.
Actual Charge: €70
Official Tariff: €38.57
Supplementary Charge: €31.43
Health System: 70%/€38.57 - €1 = €26.00
'Forfait' Directly Payable: €1
Complementary Health Insurance:
Balance Directly Payable: €12.14
The level of reimbursement through your voluntary health insurance is not always at 150%; it all depends on the level of cover you want, and that you are prepared to pay for.
The following diagram shows the distribution of costs and reimbursements for fitting a crown to a tooth.
In this case, the level of reimbursement of dental treatment in the complementary health policy is set at €250 over and above the statutory level of reimbursement.
Note that for dental treatment there is no forfait that operates, although, for anything other than routine treatment, the dépassements are generally far higher.
Actual Charge: €500
Official Tariff: €107.50
Supplementary Charge: €392.50
Health System: 70%/€107.50 = €75.25
Complementary Health Insurance:
Balance Directly Payable: €174.75
The above figures are only an example of the supplementary charges that you may encounter. Depending on where you go they could be lower or higher.