Reimbursement system and top-up insurance

The reimbursement system

The healthcare system is reimbursement-based, meaning that, in many cases, the patient pays the cost of a visit or treatment then reclaims a set percentage afterwards.

Reimbursements are usually done using a carte Vitale.

This card is issued to everyone in the French health system. It sends details to your state healthcare body and you are reimbursed with a bank transfer, usually within days.

If you have top-up insurance and have notified its details to your CPAM, then this will make an automatic pay-out too.

Note however that buying medicines from pharmacies does not usually require up-front payment. You present your carte vitale (and a card from the top-up if you have one) and the pharmacist reclaims the cost on your behalf. This system is called the tiers payant and is common in pharmacies and state hospitals, but may not be universal for every type of healthcare service in France.

People with long-term illnesses for which they have 100% state reimbursement (affections de longue durée: eg. diabetes, severe high blood pressure, Parkinsons, cancer and Alzheimers) benefit from it for care related to the illness. Maternity care is also reimbursed 100% (some postnatal care and pediatric care for the child are also covered).

Each medical act or treatment, including dental and optical, has a basic set value, called the tarif de convention. Reimbursements are based on a percentage of this eg. 70% for doctor and dentist consultations, 80% for hospitals and a variable amount for medicines. For a primary care physician visit you are reimbursed 70% of a fixed €30, which, after deduction of a €2 health tax gives €19.

If a patient chooses to use a ‘sector 2’ doctor who charges above the basic rate any state reimbursement is still based on the tarif de convention (or sometimes less) – this is where a good top-up can help.

In dentistry, consultations and check-ups are reimbursed at 60%, as are basic treatments such as fillings and extractions.

While you are generally free to choose which doctors and hospitals to use, you are advised to register with a personal primary care physician, known as your médecin traitant or médecin généraliste, and use them as a first port of call for problems unless there is a good reason not to (eg. if you are away from home). If you do not do so – for example you go straight to a specialist – reimbursement is lower.

Doctors often practice alone although medical centres with several doctors and sometimes other professionals such as nurses, on one site, are becoming more common.

Out of hours there is a duty primary care physician (médecin de garde) for each area for emergencies (you can call 116 117). There is also SOS Médecins for home visits (tel: 3624), available 24 hours a day across most of France. Check your area is covered.

If tests or X-rays are required they are done at laboratories or in hospitals on referral.

You organize these yourself and take the results to your doctor.

You will also be expected to keep X-rays between visits. The work of nurses (infirmiers) and physiotherapists (kinés) is reimbursed at 60%.

Certain more costly procedures called actes lourds, whether done in a surgery or hospital, are 100% reimbursed, although in some cases minus a set €24 fee.

Top-up insurance

Many people take out top-up insurance (assurance complémentaire) to reimburse the difference between the cost of treatment and what is reimbursed by social security.

People often call all top-up insurance a mutuelle, though strictly-speaking this only applies to ones run by non profit-making ‘friendly societies’.

Though it is not obligatory for everyone to have such insurance (the exception being employees in the private sector, where it is a legal requirement for companies to pay for 50% of the cost), around 95% of the population do. It is highly recommended as the non-reimbursed part may be costly, especially if you need regular care or a hospital stay.

Policies can be inexpensive, though costs rise with age and depending on how extensive the cover is (but not depending on health conditions).

The level of top-up (and what is covered) varies. Policies often refer to percentages of cover.

In this case, 100% reimbursement means reimbursement up to the tarif de convention; 150%, 200% etc means costs of going to sector 2 doctors will also be covered more fully (or completely), which is useful as some charge well above the standard fee. However, you are not reimbursed more than what you paid.

Top-up policies may be obtained from various sources, including big French and international insurance firms, various smaller friendly societies and firms specialized in helping English-speaking expats.

If you are married, have a partner and / or children, know that dependents (personnes à charge) can often be included in your policy. Also worth knowing is that some communes in France offer a group policy known as a mutuelle communale, often less costly due to a negotiated group rate.

100% Santé

100% Santé is a government scheme designed to ensure that certain essential healthcare items can be obtained with no out-of-pocket cost for patients who are covered by the public health system and have a mutuelle.

It focuses on a limited number of everyday health needs that were historically expensive and poorly reimbursed: optical care – glasses and frames, dental care – certain crowns, bridges and dentures, and hearing care – hearing aids and related equipment.

For each category, the state has defined a basket of approved products that meet quality standards while remaining affordable.

If a patient chooses an item from this 100% Santé basket, and has a ‘responsible’ mutuelle policy (most come under this heading), the combined reimbursements from Sécurité sociale and the mutuelle should cover the full cost, leaving nothing to pay.

Importantly, patients are not obliged to use the 100% Santé options, however reimbursements can be limited if they do not.

For Americans used to high out-of-pocket costs for glasses, dental work or hearing aids, 100% Santé can be a welcome surprise.

Pharmacies

Pharmacies are widely available and identified by a green cross. Pharmacists can give advice on minor health problems - and are even trained to identify whether a wild mushroom is edible.

Supermarkets are not allowed to sell medicines, even common painkillers and other non-prescription medicines (though this has been debated). Stores called parapharmacies (or equivalent grocery store sections) may stock non-medical items like diet products, personal hygiene products, vitamins and bandages.

The amount of state reimbursement for a medi­cine can vary, depending on how vital and effective it is deemed to be. Non-prescription medicines can now be bought at online pharmacies. A list of approved ones can be found at ordre.pharmacien.fr.

Some pharmacies open outside normal hours on a rota system - see www.3237.fr or call 3237 (€0.35/min).