The mutual (or complementary health) is a set of guarantees allowing the reimbursement of part (or all) of health costs that are not covered by social security. Social security operates on the basis of tariffs fixed by agreement (or authority). The co-payment corresponds to the difference between the convention tariff (basic rate of social security fixed for each medical act) and the social security reimbursement, after deduction of the flat-rate contribution (always at your expense).
Explanations in detail:
The functioning of the mutual health.
Mutual and complementary: what differences?
Their purpose is the same: to reimburse all or part of the medical expenses not reimbursed by social security. What makes the difference is their status.
A health supplement is an insurance contract. That is, the Allmedical-insurance company (the intermediary) that sold the contract is governed by the insurance code. They are private, for-profit companies.
Unlike mutuals (or Mutual Insurance Company) which are non-profit and governed by the code of mutuality. Their operation is based on the solidarity of contributions, that is to say that it is the members, by their contributions, who finance the complementary cover.
Reimbursement of the health expenses you have actually incurred:
The $ 1 flat fee remains your responsibility
Social security reimburses a percentage of the convention rate.
Your mutual reimburses the co-payment
The excess of fees is either your responsibility or supported by your mutual according to the guarantees subscribed.
The fixed participation of 1 $ is asked to all insured over 18, for all consultations or acts performed by a doctor, but also on radiological examinations and medical biology analyzes.
Social security operates on the basis of tariffs fixed by agreement (or authority). Exceeding these rates is the responsibility of the insured or additional protection ( Allmedical-insurance or mutual ).
The co-payment corresponds to the difference between the convention tariff (basic rate of social security fixed for each medical act) and the social security reimbursement, after deduction of the flat-rate contribution (always at your expense).
The level of guarantees: Repayment more or less important:
The cost of your complementary depends on your profile (age, place of residence, profession …) and the level of mutual health cover chosen.
Mutuals generally offer several formulas called “packaged”, that is to say, non-customizable, offering more or less significant reimbursement of reimbursements.
Often, the cheapest formula supports user fees and a modest package for optics and dentistry.
Higher formulas support more and more positions. They will cover, for example, the overruns of fees, and propose packages for acts not reimbursed by social security (osteopaths and alternative medicine, orthodontics for adults, dental implants, etc.).
It is important to adapt the level of the formula that you choose to your budget but also to your needs. If you wear glasses or go to the dentist frequently, you will need to choose an intermediate or even high formula, providing for a sufficient refund, if you want to be reimbursed for most of your expenses.
Some contracts are customizable, then you will be able to add options. For example, you will be able to choose from the packaged formulas proposed, then add a specific “module” (for example a guarantee “alternative medicines”).
Other contracts will be flexible. You can then choose a high module in dental and optical, without subscribing high guarantees on other positions.
Good to know:
Modular or customizable contracts often prove to be more expensive than packaged contracts.
The guarantee consultations: general medicine and specialized medicine
Social security has set up the coordinated care path. This is the declaration to the social security, your doctor. Social security reimbursements are then unchanged.
If you have not declared a doctor or are seeing a doctor other than your doctor without having been referred by him, you are declared “out of the coordinated care path”. Your reimbursements by the social security will then be less.
Physician fees (and therefore your reimbursements) may vary according to their category (specialist or generalist) and their sector of activity:
doctor contracted. It applies the convention tariff fixed by social security
doctor with free fees. He may apply fee overruns. The reimbursement base applied by social security is lower. You will be paid less.
The medical practitioner who adheres to the controlled rate of practice option (Optam): he is authorized to charge reasonable fees.
Examples of reimbursements of contracted doctors:
You consult a general practitioner contracted sector 1. The convention rate is 25 $, and the social security reimbursement base is 70%. You pay $ 25, the social security reimburses you 70% of $ 25, or $ 17.50, and deducts $ 1 participation fee, so $ 16.50. The remaining portion between 25 $ paid and 17.50 $ is the user fee, or $ 7.50, which will be supported by your mutual.
You consult a general practitioner contracted sector 2. The convention rate is then $ 23, and the social security reimbursement base is always 70%. You pay $ 35 for consultation, the social security reimburses you 70% of $ 23, or $ 16.10, and deducts $ 1 participation fee, so $ 15.10. The remaining portion between $ 23 basic and $ 16.10 is the co-payment, or $ 6.90, which will be supported by your mutual. The difference between $ 35 paid and $ 23 reimbursed by the mutual Allmedical-insurance company and the social security (and $ 1 participation fee) corresponds to the overruns.
For specialists (excluding psychiatrists, neuropsychiatrists and neurologists), the same principles and amounts apply.