Doctor sectors affect your reimbursements

The médecin traitant, usually a généraliste (general practitioner) who is your own personal doctor, is a key concept in France. 

This doctor should be your first port of call for most forms of non-urgent care and, in many cases, if you see a specialist without their referral, your state reimbursement will be lower. If you do do this it is called going hors parcours de soins (out of the ‘health pathway’). However, there are some exceptions to this (see below).

Another important concept to understand is doctor sectors. Most doctors are conventionné secteur 1 or conventionné secteur 2 (also called honoraires libres: unfixed fees). 

Conventionné means they have an agreement with the social security authority. 

Doctors in sector 1 can only charge the set tarif de convention for consultations, for example €30 for a GP visit. The exception to this is if you agree to a higher fee because of special circumstances such as the doctor seeing you outside of their normal hours. 

There are also a few ‘special’ kinds of consultation that can however also cost more – these are: 

€47.50-€67.70 (depending on specialism and sector) for ‘more complex’ consultations for serious illnesses such as multiple sclerosis and Parkinson’s Disease €60-€81.70 for ‘very complex’ consultations such as for cancer. 

Your reimbursement for seeing these doctors is calculated by taking the base de remboursement (reimbursement base amount), which is in this case the tarif de convention, and multiplying it by the relevant reimbursement rate (usually 70%).

Doctors in sector 2 are allowed to charge above the tarifs de convention, with the extra part of the fee being called dépassements. However, your base de remboursement is still the same as, or in some cases even lower than, the tarif de convention. 

The ‘base amount’ is the same as the tarif de convention if the sector 2 doctor signed an ‘Optam’ contract, promising to charge only ‘moderate’ dépassements. If not, the base, and therefore the state reimbursement, will be a little lower than usual, with more left to be picked up by you or a top-up insurance.

Doctors in sector 3 (hors convention or non-conventionnés) have not signed an agreement with social security and you are reimbursed about €1. They are not common, but have become somewhat more so in recent years due to some doctors being dissatisfied with the state rates. 

Specialists are often sector 2 and you may have no choice but to use one if there are no sector 1s in your area for the specialism you require. You can find information about local doctors’ fees at the Ameli website.

There are certain less well-known categories of doctor, including sector 1 with DP (droit permanent à dépassement), which means they can charge extra despite technically being sector 1. Patient reimbursements are the same as for sector 2. 

You should also note that there are some different tariffs for children compared to adults Remember also, that when you go to other doctors without referral from a médecin traitant you will in many cases receive lower reimbursement, with the difference not compensated by a mutuelle unless, for example, you are away from home, you are seeing your doctor’s replacement when he or she is away, or for a few specific kinds of specialist. The latter, who you can consult en accès direct (without referral) include: gynaecologists, ophthalmologists, psychiatrists (if you are aged 16-25) and stomatologists.

Examples of ‘100%’ and ‘200%’ mutuelles 

Basic mutuelle coverage and sector 1 doctors 

A basic mutuelle may cover 100% of the tarif de convention, so it will pay back the remainder of your €30 consultation fee, minus the €2 participation forfaitaire, when you visit a sector 1 doctor. In this case, most of the cost is reimbursed and your personal expense is very limited.

Reimbursement for sector 2 doctors 

This full coverage does not usually apply when you visit a sector 2 doctor, who often charges above the tarif de convention. For example, if a sector 2 doctor with an Optam contract charges €40, Cpam still reimburses 70% of €30, which is €21, minus the €2 tax. This means €19 is paid to you by Cpam.

Role of different mutuelle levels 

With a 100% mutuelle, reimbursement is limited to 100% of the €30 base, usually minus the €2 tax. In this case, the mutuelle pays €9, and you must personally cover the €2 tax plus the extra amount over €30, which is €12. With a 200% mutuelle, reimbursement can reach twice the tarif de convention, that is €60, so in this situation you are fully reimbursed except for the €2 tax.

Limits of high-percentage mutuelle plans 

A mutuelle offering more than 200% brings no extra benefit in this example, because you cannot be reimbursed more than the amount you paid. For instance, a 300% mutuelle allows reimbursement up to €90 (3 × €30), which can be useful mainly when consulting specialists who charge very high fees.