Calculating Healthcare Reimbursement: Choosing the Best Coverage – BTS Assurance

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Summary

The mutual reimbursement calculation is a crucial step to understand how your healthcare expenses are covered. By analyzing guarantees and mastering the basis of reimbursement, you can optimize your reimbursements and minimize your out-of-pocket costs. This article explains the steps to calculate your reimbursements and choose the best supplemental health insurance.

The Foundations of Reimbursement Calculation

What is the Base of Reimbursement (BRSS)?

The Social Security Reimbursement Base (BRSS) corresponds to the reference tariff set by Health Insurance for each medical procedure. This tariff serves as the basis for calculating reimbursements by the Social Security and, additionally, by your health mutual. It is important to note that BRSS does not always reflect the actual cost of medical procedures, which can lead to a remaining charge for the patient.

In 2025, the consultation fee for a general practitioner has been set at 30 €, an increase compared to previous years to better reflect healthcare cost trends. This tariff constitutes the BRSS for this type of care. This means all reimbursements are calculated from this amount.

Example of BRSS: Detailed Calculation

Here are some practical examples to illustrate how BRSS and related reimbursements work:

Calculating Reimbursement for a General Consultation in 2025

Let’s consider a concrete example of a consultation with a general practitioner:

1. Actual consultation fee: 30 €
2. BRSS: 30 €
3. Social Security coverage:
   30×70%=21 
4. Co-payment (remaining covered by mutual):
   30−21=9 €

If your mutual insurance offers 100 % BRSS reimbursement, it will fully cover the co-payment, meaning you will have no remaining charge. However, if surplus fees are applied (common with sector 2 specialists), the mutual must have a reimbursement rate above 100 % to cover these costs.

Impact of Surplus Fees

In some cases, doctors apply surplus fees, especially outside the coordinated care pathway or for practitioners in sector 2. These surcharges are not covered by social security and require a mutual offering coverage above 100 % BRSS. For example:

• If a general practitioner bills a consultation at 50 € (instead of the 30 € set by BRSS), your mutual will need to reimburse an additional part to cover this excess.

Calculation in this case:

• Social Security reimbursement: 30×70%=21 
• Mutual reimbursement at 150 % BRSS: 30×150%=45 €
• Total reimbursed: 21 €+(45 €−21 €)=45 €
• Remaining insured charge: 50 €−45 €=5 €

Why is Understanding BRSS Essential?

Knowing BRSS and its application is essential to:

1. Choose an appropriate mutual based on your needs (e.g., frequent surplus fees).
2. Understand your reimbursements and anticipate remaining costs.
3. Optimize your healthcare spending, especially for costly procedures like dental care or consultations outside sector 1.

How Does Reimbursement Rate Work?

The health mutual supplements the reimbursement provided by Social Security, according to a percentage specified in your contract (100 %, 150 %, 200 %, or more). This percentage applies not to the actual cost of the medical act but only to the Social Security Reimbursement Base (BRSS).

Calculation Method

Each reimbursement is divided into two steps:

1. Social Security Reimbursement:

   • Social Security covers a percentage of the BRSS, usually 70 % for medical consultations.
   • A flat participation fee of 1 € is deducted.

2. Mutual Supplement:

   • The mutual covers all or part of the co-payment (the remaining amount after social security reimbursement).
   • If your mutual offers 150 % BRSS, it also covers a part of potential surplus fees, up to 1.5 times the BRSS.

Practical Example

Here’s an example for a consultation billed at 50 €, with a BRSS of 30 € and a mutual at 150 % BRSS:

1. Step 1: Social Security Reimbursement

   • 30×70%=21 €
   • Flat participation fee: 21−1=20 €
   • Social Security reimburses 20 €.

2. Step 2: Mutual Reimbursement

   • Maximum amount reimbursed by mutual:
     30×150%=45 €
   • Part covered by mutual:
     45−20=25 €45 – 20 = 25 ,€

3. Step 3: Remaining charge

   • Total reimbursed by SS + Mutual:
     20 €+25 €=45 €
   • Remaining insured charge:
     50−45=5 €

Comparison of Reimbursement Rates

Why is Understanding Reimbursement Rates Important?

1. Assess your needs: If you see doctors with surplus fees, a mutual with 150 % BRSS or more is highly recommended.
2. Anticipate your costs: Understanding how your reimbursement is calculated helps you avoid unpleasant surprises.
3. Optimize your coverage: Choose a contract that covers your frequent expenses (dental care, out-of-sector consultations, etc.).

Different Reimbursement Modes

1. Percentage Reimbursement

Percentage-based reimbursement is the most common. It is based on the Social Security Reimbursement Base (BRSS). Depending on your mutual’s coverage rate (100 %, 150 %, 200 %, etc.), this method allows reimbursement of all or part of the co-payment and, in some cases, surplus fees.

Comparison of Coverage Rates

Example:
For a 50 € consultation with a BRSS of 30 €:

• 100 % BRSS: Total reimbursement = 30 €, remaining charge = 20 €.
• 150 % BRSS: Total reimbursement = 45 €, remaining charge = 5 €.
• 200 % BRSS: Total reimbursement = 60 €, remaining charge = 0 €.

2. Flat Rate Reimbursement

Some mutuals prefer to use fixed flat rates, especially for specific expenses like glasses, alternative medicines, or equipment not reimbursed by Social Security. These flat rates simplify calculations and allow the insured to know exactly what they will receive.

Example: Reimbursement of Optical Equipment

In this example, the reimbursement is capped at 350 € for a pair of glasses, leaving a remaining charge of 50 € for the insured.

3. Reimbursement at Actual Costs

High-end mutuals offer reimbursement at actual costs, meaning all incurred expenses are reimbursed in full after deducting the part covered by social security. This mode is particularly suitable for covering significant surplus fees or costly treatments.

Example: Consultation with Surplus Fees

For a consultation billed at 80 € with a BRSS of 30 €:

• Social Security reimbursement: 30×70%=21 €
• Mutual reimbursement at actual costs: 80−21=59 €
• No remaining charge.

How to Choose the Right Reimbursement Method?

1. Percentage reimbursement: Ideal for routine consultations with few or no surplus fees.
2. Flat rate reimbursement: Suitable for specific expenses like optical or alternative therapies.
3. Reimbursement at actual costs: Perfect for insured persons with high or frequent medical expenses.

Comparison of Guarantees and Examples

Example 1: Consultation with a Sector 2 Specialist

In this example, a consultation with a specialist billed at 50 € is analyzed, with a BRSS of 30 €, Social Security reimbursement at 70%, and mutual at 150 % BRSS.

Detailed Calculation:

1. Social Security reimbursement:
   30×70%=21€
2. Mutual reimbursement:
   30×150%=45 €
   45−21=24 €
3. Remaining insured charge:
   50−45=5 €

Example 2: Dental Prosthesis (Ceramic Crown)

Here, a ceramic crown costing 300 € is analyzed. The BRSS is set at 120 €, with a social security reimbursement of 60%, and mutual at 200 % BRSS.

Detailed Calculation:

1. Social Security reimbursement:
   120×60%=72 €
2. Mutual reimbursement:
   120×200%=240 €
   240−72=168 €
3. Remaining insured charge:
   300−240=60 €

Comparison of Examples

Analysis and Advice

• Routine consultations: A mutual with a 150 % BRSS rate is often sufficient to cover most surplus fees.
• Costly treatments (dental, optical): Coverage at 200 % BRSS or higher is recommended to reduce out-of-pocket costs, especially for significant surcharges.
• Optimization: Adapt your choice of mutual to your specific needs (frequent consultations, dental care, hospitalizations) to maximize reimbursements while controlling your budget.

Table of Top Mutuals

• Ameli.fr – Official Health Insurance Website:
  https://www.ameli.fr

  • Detailed information on BRSS, reimbursements, and the coordinated care pathway.

• UFC Que Choisir – Independent mutual comparison:
  https://www.quechoisir.org

  • In-depth analyses and feedback on the best health mutuals.

• Santé Magazine – Guides on mutual selection:
  https://www.santemagazine.fr

  • Practical advice and news on mutual contracts.

• Mutuelles.fr – Online comparison:
  https://www.mutuelles.fr

  • Comparison of offers and reimbursement calculators.

Mutual for Expatriates: Essential Coverage Abroad

For expatriates, signing up for a suitable health mutual is essential to benefit from optimal coverage during stays abroad. Unlike French social security, which limits reimbursements to care provided in France or specific cases (like the European Union), an expatriate mutual offers extensive guarantees, tailored to local medical care in the country of residence.

These mutuals generally cover:

• Medical consultations and hospitalizations, even in countries where healthcare costs are high (e.g., United States, Switzerland).
• Repatriation expenses, in case of emergency requiring return to France for treatment.
• Routine and preventive care, including alternative medicines and vaccinations.
• A multi-currency coverage to avoid exchange rate losses.

Among specialized providers, CFE (Caisse des Français de l’Étranger) or insurers like April International and Allianz Care offer tailored plans to meet expatriates’ needs. These mutuals also allow options based on the duration of expatriation (short-term, long-term, or permanent).

Conclusion

Mastering the mutual reimbursement calculation is essential to evaluate your guarantees and select the most suitable coverage. Analyze your health needs, compare contracts, and ensure you choose a mutual that truly meets your expectations.

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