What costs are not covered by inpatient mutuelle?
Costs for other appointments and medical needs can quickly add up
Patients with a long-term illness get ‘100%’ cover
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Reader question: I only have an in-patient mutuelle. Will I be faced with high expenses for normal appointments?
An inpatient mutuelle (top-up insurance) will almost certainly cover the most costly procedures you may face.
While these are more expensive than outpatient appointments and primary care and medicines, these can add up depending on how often you need medical care.
French state health insurance (Assurance Maladie) only covers a portion of medical out-patient costs, for example 70% of the standard rate for a GP appointment.
The non-state-reimbursed part of the standard rate (known as the ticket modérateur) must be paid out of pocket, as must any additional amounts (dépassements d’honoraires) charged on top of the standard rate by certain doctors, known as sector 2 or 3 (the latter are rare).
If you must attend frequent out-patient appointments for a persistent issue, or need to see several specialists – who are often sector 2 – you may soon be spending hundreds of euros in additional fees.
Professionals in sector 1 charge based on rates set by the state and therefore benefit from maximum possible reimbursement (up to the state cap for the appointment type), but outside of these, total costs and reimbursement rates vary considerably.
Other healthcare costs that are only partially reimbursed by Assurance Maladie include X-rays, prescription medicines, laboratory analysis and vaccines with the ticket modérateur set at varying rates.
Items such as glasses, dental prostheses and hearing aids are not fully state-funded, whereas most mutuelles now make it possible to have good-quality provision ‘free’ with a combination of the state refund and the mutuelle.
Outside of these fees, there are also elements that are refunded by neither Assurance Maladie nor mutuelles.
These include the participation forfaitaire, a top-up levy of €2 on most consultations or ‘medical acts’, as well as franchises on medicines, transport, and care from nurses or physiotherapists. These have daily and annual caps.
However, note that patients with a recognised long-term illness (affection de longue durée) receive ‘100%’ cover for medical expenses through Assurance Maladie (only related to that specific illness) regardless of their mutuelle status. However, this is only 100% of the basic rate, so does not include dépassements.
This only applies to specific recognised illnesses, and your ALD status must be applied for via your GP and confirmed by your healthcare caisse.
For example, if you have to frequently see specialists because of a bad knee, appointments will not come under long-term illness coverage, but appointments related to a Parkinson’s diagnosis or cancer treatment will.
