French 'top-up' health insurance explained

No ‘top-up’ health cover can be costly if you are unlucky. Fortunately, a new law will make it easier from next month to change policies

5 November 2020
By Connexion journalist

Residents in France who do not have “top-up” health insurance can face hospital bills of thousands – as some discovered this year after intensive care stays for Covid-19.

This is an extreme case. An estimated 96% of people do have such cover as it is generally thought to be worth the extra monthly cost it usually involves to avoid unpleasant surprises such as this.

It means taking out a private policy with an insurance company or a “friendly society”, or, if you have a low income, applying for the state’s complémentaire santé solidaire (CSS) scheme.

Top-up policies (assurance maladie complémentaire) are often called mutuelles, though technically this term only refers to those provided by the not for profit friendly societies.

As with any insurance, you will be out of pocket if you never have health problems.

However, if the time comes that you do, it can be valuable, whether for regular doctor visits and diagnostic tests or for a hospital stay.

Cover for buying glasses is also often generous.

When taking out a policy, you need to consult a list of what it offers for different kinds of medical expense. One piece of good news is that, from December 1, you may cancel one at any time, with no penalty, eg. if you find an alternative that suits you better. However, you must have held the policy for at least one year.

Healthcare in France isn't completely 'free'

The reason for top-up insurance is that French state healthcare is not completely “free”.

With a few exceptions, such as care for certain designated long term conditions, you are automatically reimbursed by the state for only part of the cost, eg. 70% of the fee for visiting a GP (the remaining 30% is called le ticket modérateur).

Importantly, this percentage rate is applied only to a set state tariff for a given service (eg. €25 for a GP visit) and many doctors are permitted to charge more. This is meant to be done with moderation, but with some specialists, these dépassements d’honoraires can mean their fee is double the basic amount.

A good top-up policy comes into play here, as it may reimburse up to 200% for consultations, meaning it covers you for your out-of-pocket costs up to a bill of twice the state fee.

All policies have a certain level of hospital cover

Féreuze Aziza, an adviser at France Assos Santé, a body representing patients, said they had heard of people with no top-up facing bills of up to €8,000 for stays related to Covid.

Hospital fees include several elements: first, a daily €20 charge towards accommodation. It is not state-reimbursed but most mutuelles cover it. Then there are frais d’hospitalisation – a bill for services of the hospital’s medical staff and costs of medicine and equipment.

This is where things can get complicated, as they vary by hospital and department and can mount up to as much as €3,000 a day in intensive care.

These are state-reimbursed at 80%, although certain specific procedures with a tariff of at least €120 individually are only charged to the patient at €24.

Ms Aziza said that many of the items totted up under “hospitalisation fees” do not come under this latter category, so this is where the problem arises for those with no top-up.

There can also be extra fees for comforts, such as a private room or TV.

She said dépassements d’honoraires are not usually the issue in hospital, apart from where a hospital doctor is performing an operation on a private basis – and he or she should specify if this is the case.

Ms Aziza said patients treated for coronavirus should have the right to a free private room.

She added that France Assos Santé asked the government in March to cover all medical fees related to coronavirus but this was not approved.

However, she said the government has now asked hospitals not to claim bills incurred by someone who is treated for Covid-19 who does not have top-up cover. In this case, the cost to the hospital will instead be covered by a fund called the Caisse d’Amortissement de la Dette Sociale, she said.

One insurer, Mutuelle Just, estimates that the average cost of a policy for an individual is €40 per month, and €110 for a family of four. Since 2016, employers are obliged to pay at least 50% of the cost of a top-up policy for their employees. Costs are state-regulated and they rise by age, but are not inflated for pre-existing conditions and have no exclusions.

Low income top-up insurance

For those on the lowest incomes, there is the CSS.

This came into effect last year and replaced previous schemes CMU-C and ACS. It provides free complementary health insurance for any individual with no more than €9,032/year coming in (or €13,547 for families of two, €16,257 for three, €18,966 for four, then an extra €3,613 per additional person).

Households with slightly higher incomes (up to €12,193; €18,289; €21,947, €25,604) also benefit but pay a monthly fee whose amount adds up per person, based on age: from €8 for those aged 29 or less to €30 for those aged 70 or more. People on CSS cannot by law be charged dépassements, and their care is all covered 100%.

The government estimates that around 1.5million people in France are eligible but do not have it. France Assos Santé says this is because it is not widely known about and applying can be complicated.

You can apply in your personal account at ameli.com under Mes démarches or by sending or dropping in a form to your Cpam. 

RSA income support recipients do not have to show their financial resources.

You have to say if you want your normal state health insurance body (eg. Cpam) to be responsible for your CSS or a mutuelle.

Like our main image? Created for The Connexion by artist Perry Taylor, you can see more of his work at Perry Taylor Art.

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