Reimbursing eye care in France

Buyer beware 

As with dental crowns and bridges, glasses are concerned by the 100% Santé scheme. Opticians are required to bring eye-care products and services that benefit from this coverage to the attention of customers. 

Under the scheme, opticians must offer ‘basket A’ (100% Santé) products to all customers; however, anti-fraud body DGCCRF found that, following the start of the scheme, nearly 60% of sellers were failing to inform customers of the ‘100% Santé’ option or failed to display eligible frames in their stores or sought to downplay the quality of basket A products to dissuade customers.

This came as consumer associations noted price rises for products not covered by the scheme, referred to as ‘basket B’, linked to coverage decrease on these by social security and private insurance companies. When shopping for glasses, it is therefore advisable to prompt opticians to tell you about 100% Santé and show ‘basket A’ products in addition to others.

Your optician must give you standard estimate

Any devis (quote) from your optician must provide a detailed list of prices for optical aids you wish to buy, including any add-on features and characteristics that come with the equipment. 

This also includes the initial fitting session required for safely using contact lenses. A follow-up check may sometimes be offered to verify if contact lenses cause an adverse reaction to your eyes.

100% Santé scheme does not cover contact lenses. 

Glasses lenses fall into two categories. Basket A lenses are fully reimbursable if you have a responsible mutuelle, as they fall within the 100% Santé scheme. You should not incur any out-of-pocket expense for these. 

Basket B lenses come under the ‘freely-set price’ category.  Reimbursement rates for products falling within this second category are generally low; depending on your policy, your mutuelle may reimburse a portion of ‘basket B’ products, but this is not guaranteed. As a result of the scheme, many mutuelles significantly reduced their levels of coverage for ‘basket B’. 

To avoid major differences in quality and performance, technical requirements and specifications for ‘basket A’ and ‘basket B’ lenses are largely similar.

Lens manufacturers are required to obtain a certificate from the Health Ministry in order to market their products, and for this, they must show that for each type of ‘basket B’ lens they plan to sell, they also offer a ‘basket A’ identical correction lens.

To keep their certification, manufacturers have to maintain a steady supply of basket A lenses. Differences may involve various categories of lenses with different standards of resistance and thinness, as well as optional coatings, such as anti-scratch and anti-UV treatments. However, it is possible to buy ‘basket A’ lenses with anti-reflective and anti-refraction treatments.

Specifications of frames

Technical specifications and requirements for frames from both ‘basket’ classes are identical. ‘Basket B’ products, however, include luxury brand names, which are typically not reimbursed. 

More expensive private insurance policies may reimburse in part the cost of luxury frames; you will need to check this with your insurer. The new regulation allows the combination of lenses from one class with a frame from the other. However, the combination of lenses from two different classes is not allowed. 

Fully reimbursable frames with no out-of-pocket expense under ‘basket A’ should be charged at less than or equal to €30. Beneficiaries of the complémentaire santé solidaire (CSS) are required to limit their choice to ‘basket A’ products. If they choose to buy a product from ‘basket B,’ they will lose any advantages of the CSS for this purchase.

Reimbursement 

The 100% Santé health reform provides full coverage for glasses but not contact lenses. Opticians must provide a reasonable selection of glasses lenses which are fully reimbursable through a combination of public and private insurance. 

The 100% Santé scheme specifies the five types of vision disorders for which doctors and opticians may prescribe corrective lenses and which will be reimbursed by the Assurance Maladie: 

• astigmatism
• hyperopia
• myopia
• presbyopia
• amblyopia. 

Opticians are typically required to put on display a choice of at least 35 different frames for adults that are compatible with the scheme.

For children, there must be a choice of at least 20 frames. If some of the frames differ only in colour, the range must include a minimum of 17 different frame models for adults and 10 for children.

To buy a fully reimbursable pair of glasses, you need a valid prescription. The scheme provides that a share of your reimbursement is covered by assurance maladie and the remainder by your top-up health insurance. 

To benefit, you therefore must have a top-up policy. People should usually not buy a new pair for at least two years, with exceptions including renewal in one year if the glasses have become damaged and do not work well, or if there are new medical conditions and you have a prescription. 

If you have no top-up policy, assurance maladie will still provide a small reimbursement for glasses but only at 60% of certain, very low, ‘base’ rates, leaving you out of pocket for most of the cost. You may, however, still choose products from ‘basket A’ ranges, which benefit from price caps, both for frames and lenses.

Contact lenses 

Assurance maladie only reimburses part of the cost of contact lenses if they are medically prescribed, in the case of:

• irregular astigmatism
• severe myopia (8 dioptres or more)
• accommodative esotropia
• anisometropia (more than 3 dioptres) and not suitable for glasses
• keratoconus. 

Assurance maladie reimburses 60% of the costs within a fixed annual amount of up to €39.48 a year per eye, i.e., up to €23.69 per eye. This means you need good mutuelle coverage to recoup much of the costs for these.

Surgery

Assurance maladie does not provide reimbursement for laser eye surgery to correct vision problems. Some mutuelles offer reimbursement at varying levels. If you need cataract surgery, the cost varies depending on the procedure and establishment.