Healthcare: What refund will I get?

Healthcare: What refund will I get?

The breakdown of reimbursements between the state social security and your top-up medical insurance can be complicated

EVEN if you receive “100%” reimbursements - for example for treatment of certain serious illnesses - you will not necessarily get all the money you paid out back again.

Almost all doctors are secteur 1 or secteur 2. On seeing a secteur 1 doctor, a patient with no special conditions or circumstances will be entitled to have a set percentage of a standard state fee for a medical service reimbursed.

The standard fee is called the tarif de convention. For example, to see your GP would cost €22 and you would be reimbursed 70% (watch out - if you do not have your own GP - médecin traitant - or you see another doctor without passing via him or her, you get a lesser percentage: this is called going hors parcours de soins - “outside the care route”).

The part left for you or your private insurance is known as the ticket modérateur.

People on “100%,” on the other hand, are covered for the full tarif de convention.

If a doctor you see is secteur 2 (also called honoraries libres) this means they can charge more than the tarif de convention. In this case, even if you get a “100%” reimbursement it will not cover this surplus. A private top-up (mutuelle) may cover some or all of it - a 100% one will cover 100% of the tarif de convention - none of the surplus - but some are 200% etc.)

A tiny minority of doctors and specialists are secteur 3 - you get about €1 of refund and have to pay for the rest.

Most people also have some deductions on refunds called the €1 participation forfaitaire and franchises médicales - a kind of tax on medicines and some medical acts, paid by everyone except the “free” categories we have outlined (eg. people on the CMUC).

How it works

Here is a general example of the breakdown of reimbursements (reimboursement) between state and top-up (mutuelle) if you visit a doctor working under the sector 2 regime with a €50 tariff.

The sécurité sociale reimburse you at 70% of €22 (the base tariff of the sécurité sociale) which is €15.40.
A further €1 is taken off (la participation forfaitaire) and is non reimbursable leaving the state to pay you €14.40.

100% indicates that a mutuelle will reimburse up to 100% of the base tariff, meaning up to €22. So the mutuelle covers: 100% of the base tariff, that is €22 minus the €14.40 already covered by the sécurité sociale and the €1 fixed cost.
Thus it pays €6.60. So the amount you pay is €50 - €14.40 - €6.60 = €29

200% indicates that a mutuelle will reimburse up to 2x the base tariff, meaning up to €44 (2 x €22). So the mutuelle covers: €44 - €14.40 = €28.60. So the amount you pay is €50 - €14.40 - €28.60 = €7

300% indicates that the mutuelle will reimburse up to 3x the base tariff, meaning up to €66 (3 x €22 euros). So the mutuelle covers:
€66 - €14.40 = €51.60. So the amount you pay is just the €1 forfait. Note: You never get given more than you paid

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