Complementary health insurance: three essential figures on the remaining costs

Out-of-pocket health expenses remain a central issue in the debate on healthcare access in France. Despite a protective social security system, insured individuals face uncovered expenses, which can pose a significant financial burden. A recent study by Malakoff Humanis, a key player in social protection, offers new insights by cross-referencing its data with that of Health Insurance. It highlights three key figures related to the crucial role of supplementary health insurance in reducing these out-of-pocket costs. These data underscore the tangible impact of mutuals such as Harmonie Mutuelle or SwissLife, as well as companies like MMA or Groupama, in alleviating the costs borne by patients.

The analysis is based on a dual observation. On the one hand, without supplementary health insurance, French people’s remaining charge would reach nearly half of the total cost of outpatient care, while with coverage from complementary health organizations (Ocam), this rate decreases significantly. On the other hand, patients with long-term illnesses (ALD) continue to bear a substantial share of expenses, despite the “100%” coverage promised by compulsory insurance. This study thus reveals a frequently unknown reality, highlighting the primary role of mutuals such as Matmut, Mgen, or LCL Santé in healthcare coverage.

Alongside these findings, the issue of transparency in the reimbursement system remains a concern. Voices such as Deputy Jean-Carles Grelier’s call for clarifying the division between Social Security and supplementary insurers, to better communicate the supportive role of insurers in funding healthcare. This question raises a major challenge for public authorities, which lack transparent information, and for insured individuals who are often overwhelmed by sometimes complex bills.

The predominant role of supplementary health insurance in reducing out-of-pocket costs in outpatient care

Financially, Malakoff Humanis’s study on outpatient care highlights one key figure: the remaining charge after Social Security reimbursement averages 47% of the total cost of care. However, this figure drops sharply to 14% when coverage from supplementary health insurance is included. This illustrates the essential role played by mutuals and health insurers in maintaining household financial balance.

The remaining charge includes the portion of costs not reimbursed by Social Security or by supplementary insurers, such as excess fees, medical deductibles, or certain unrecognized procedures. Among the most prominent mutuals in this landscape are Harmonie Mutuelle, MMA, and SwissLife, actors who actively work to lighten this financial burden. For example, a consultation with a specialist costing 30 euros, with a 50-euro excess fee, will be reimbursed by Social Security about 16.50 euros. The remaining charge would initially be significant, but the mutual could step in to cover part, or all, of the remaining costs.

The categories of expenses involved and their coverage

• 🩺 Outpatient consultations and medical procedures: partially reimbursed by Social Security, with a variable remaining charge depending on excess fees.
• 💊 Medications: some drugs outside the reimbursement list generate a higher remaining charge.
• 🏥 Hospital care: deductibles and additional charges not covered by Health Insurance.
• 👓 Optical and dental prostheses: historically significant expense sectors with concentrated remaining charges.

Type of expense 🏥	Remaining charge without supplementary insurance 💶	Remaining charge with supplementary insurance 💳	Reduction in remaining charge 🔽
Outpatient consultations	47 %	14 %	33 points
Medications	25 %	10 %	15 points
Optics	60 %	20 %	40 points
Dentistry care	55 %	25 %	30 points

Despite these advances, questions about reimbursement delays and administrative complexity remain. Organizations like Mgen or LCL Santé are implementing digital solutions to facilitate reimbursement management and improve transparency, while comparison platforms like AcommeAssure encourage insured individuals to choose offers tailored to their needs, which could further reduce remaining charges.

Remaining charges in chronic diseases: an still-heavy burden for ALD patients

Patients with long-term illnesses (ALD) theoretically benefit from 100% coverage by Health Insurance. However, Malakoff Humanis’s study reveals a different reality. These insured individuals bear an average annual remaining charge of 1,055 € on a total average expense of 6,948 €. This amount amounts to about 15% of the actual costs, twice the rate observed for patients without ALD.

This disparity results from several factors. The co-payment, though theoretically eliminated in ALD, does not include excess fees that remain the patient’s responsibility. Additionally, auxiliary costs such as medical transport, non-reimbursed care, or hospital accommodation generate extra costs. This phenomenon highlights a structural flaw in implementing full coverage.

The main expense categories remaining at the ALD patients’ expense

• 🚑 Excess medical fees: a critical issue for costly conditions.
• 🚌 Non-covered medical transports.
• 🏨 Hospital room accommodation.
• 💉 Paramedical care outside of standard tariffs.
• 🛡️ Supplementary insurance: essential in reducing this remaining charge.

Type of expense in ALD 🔬	Annual average expense (€) 💰	Remaining charge after Sécu (€) 💳	Share of remaining charge (%) 📊
Total expenses	6,948	1,055	15 %
Excess fees	1,200	900	75 %
Sanitary transport	500	300	60 %
Hospital accommodation	800	500	62.5 %

The support of supplementary health insurers such as Matmut or Groupama appears crucial here. These actors cover a significant part of the remaining costs, limiting the risk of care abandonment for these vulnerable patients. Highlighting this economic reality invites a reassessment of existing systems and a strengthening of cooperation between the mandatory regime and supplementary insurers for better ALD coverage.

Average reduction of remaining costs to 11% thanks to supplementary health insurance

An additional key figure from the analysis shows that, on an average annual expenditure of 1,408 € in outpatient and hospital care, the remaining charge after reimbursements from Social Security and supplementary insurers drops to about 11%. This rate indicates a significant decrease from the initial post-Security rate, demonstrating the fundamental role played by mutuals such as Harmonie Mutuelle, Mgen, or SwissLife.

Here, supplementary health insurance acts as a true safety net for insured individuals, enabling continued access to care without excessive out-of-pocket costs, even in the face of unforeseen or high expenses. This assistance is especially important for ALD patients, who see their remaining charge reduced to about 4.5% thanks to the intervention of supplementary organizations, with an average final amount of 315 €.

Specific advantages of responsible supplementary health insurers

• 🔐 Guarantees regulated by law ensuring compliance with care packages without remaining charges.
• ⚖️ Coverage of fees related to excess charges in certain plans.
• 📈 Improvement in prevention and medical follow-up promoted by integrated offerings.
• 💡 Funding of additional services such as telemedicine and health coaching.
• 💰 Adjustment of contributions based on personal situation for better coverage.

Type of insured 👥	Average expense (€) 🔢	Remaining charge after Sécu and supplementary (€) 💳	Share of remaining charge (%) 🎯
Patient without ALD	1,408	154	11 %
Patient with ALD and supplementary insurance	6,948	315	4.5 %

According to experts, having a competitive mutual insurance, such as AcommeAssure or LCL Santé, can be a strategic move to control these amounts. The positive impact of mutual retention on the reimbursement capacity of supplementary insurers is also a factor to monitor in upcoming contract developments.

Hospital coverage: 90% of uncovered costs are covered by supplementary insurers

The financial burden associated with hospitalization remains one of the main sources of remaining costs. The study published by Malakoff Humanis emphasizes that supplementary health insurers cover about 90% of expenses not covered by Health Insurance in hospitals. This coverage includes:

• 🛏️ Hospital excess fees.
• 🚪 Costs for private or single rooms.
• ⚙️ Certain technical procedures not covered by Social Security.
• 🏥 Additional hospitalization-related costs.

Such involvement from organizations like Matmut, SwissLife, or even Groupama provides significant financial support, which is essential in face of rising hospital costs. This comprehensive hospital coverage helps prevent care abandonment and preserves the budget of insured individuals facing serious conditions requiring intensive treatment.

Type of hospital expenses 🏥	Part not reimbursed by Sécu (%) 🔎	Coverage by supplementary insurers (%) 💪	Final remaining charge (%) 📉
Excess fees	80 %	90 %	8 %
Private room	70 %	90 %	10 %
Technical procedures	50 %	90 %	5 %

However, it should be noted that this coverage depends closely on the type of contract subscribed. More comprehensive options with insurers like MMA or LCL Santé guarantee increased coverage, while some basic contracts leave a higher residual charge.

Transparency and clarity: the main challenge of the healthcare reimbursement system in 2025

The reimbursement system in France relies on a dual mechanism combining the mandatory scheme and supplementary organizations. However, the division of responsibility between these two actors often remains unclear for insured individuals, despite its crucial importance. This issue was recently highlighted by Jean-Carles Grelier, Deputy of the Democratic and Independent group, during the presentation of Malakoff Humanis’s study results.

Patients often experience difficulties in understanding their bills, reimbursement delays, and the precise nature of covered or non-covered services, which often leads to negative perceptions. This opacity also generates misunderstandings about the role of supplementary health insurers. While mutuals like Harmonie Mutuelle or Mgen shoulder a significant part of the costs, their involvement is insufficiently recognized. A determined effort appears necessary to restore better visibility of the care pathway and the economic impact of each actor.

• 🔍 Clarification of reimbursement procedures between Health Insurance and supplementary insurers.
• 📝 Simplification of explanatory documents sent to insured individuals.
• 📊 Improvements in digital tools for real-time monitoring of reimbursements.
• 🤝 Strengthening dialogue between institutions and supplementary health insurers.

Main readability issues 🧐	Impacts on the insured ⚠️	Proposed solutions 💡
Complex and unclear invoices	Misunderstanding of payable amounts	Simplified and transparent documents
Long reimbursement delays	Financial tensions	Accelerated processes via digitization
Misunderstanding of the role of supplementary insurers	Trust disruption	Awareness campaigns

Initiatives such as those promoted by MMA or AcommeAssure to digitalize access to information are already underway, promoting an improved user experience and better understanding of healthcare funding.

Towards an expanded analysis of cross-sector health data

The unprecedented cross-referencing of data from Malakoff Humanis with that of the National Health Data System (SNDS) opens new prospects for improving the management of the French health system. This innovative approach allows for a better understanding of real insured needs and refines reimbursement and prevention policies.

Among the potential avenues are:

• 🛡️ Strengthening targeted prevention actions to reduce care expenses.
• 🔄 Optimizing care coordination between professionals and facilities.
• 🚨 Enhancing efforts against benefit fraud and abusive reimbursements.
• 📈 More detailed analysis of care consumption behaviors.
• 📊 Improving transparency for more efficient system management.

Possible application areas 🔧	Expected benefits 🏆	Challenges to address 🚧
Prevention	Cost reduction and enhancement of public health	Precise identification of at-risk populations
Care coordination	Better quality and continuity of care	Integration of diverse actors within the system
Fraud fight	Significant savings for the system	Data security

This innovative approach, supported notably by groups such as SwissLife or Matmut, could fundamentally transform health governance in France, with a target set for 2030 to better control expenses and achieve fairer coverage.

The mutual health organizations, an essential actor in controlling out-of-pocket costs in 2025

The Malakoff Humanis study reaffirms an undeniable truth: without the presence of supplementary health insurers, out-of-pocket costs for patients would be considerably higher, hampering access to care for a large part of the population. Mutual organizations such as Harmonie Mutuelle, Matmut, or Mgen constitute a vital pillar of the French social model.

For insured individuals, it is highly recommended to:

• 🔎 Compare offers from various insurers like MMA, SwissLife, or Groupama.
• 📅 Take advantage of mid-term cancellation options to subscribe to a more effective mutual plan.
• 💰 Seek a contract suited to personal needs to avoid unnecessary expenses.
• 🛡️ Check guarantees related to excess fees and dental or optical care.
• ⚖️ Maintain a balance between monthly contributions and optimal coverage.

Key advice for insured 🎯	Goal 🏆	Expected outcome ✅
Regularly changing mutual insurance	Optimize quality/price ratio	savings up to €300 per year
Using comparison platforms	Find an offer suited to needs	Reduction of remaining costs
Verifying specific guarantees	Secure coverage of healthcare costs	Less financial surprises

The weight of mutual retention, that is, the portion of contributions directly allocated to coverage, is an indicator to monitor for assessing an organization’s reimbursement capacity. In 2025, supplementary health insurers remain a crucial pillar to ensure access to care without financial obstacles.

To deepen these topics:

• The importance of supplementary health insurers according to Malakoff Humanis
• Causes of increased out-of-pocket costs
• Detailed analysis by Malakoff Humanis
• Additional reports on mutual and radiology coverage
• Three key figures on remaining charges

FAQ about remaining charges and supplementary health insurance

• ❓ What is the remaining charge in health?
  The remaining charge is the portion of healthcare expenses that the insured must pay after reimbursements from Social Security and their supplementary health insurance.
• ❓ Why are supplementary health insurances essential?
  They significantly reduce the remaining charge, especially by covering excess fees, deductibles, and certain services not covered by Health Insurance.
• ❓ How to choose your health mutual?
  You should assess your personal and family needs, compare the guarantees offered by insurers like LCL Santé, MMA, or SwissLife, and take advantage of mid-term cancellation options to switch if necessary.
• ❓ Are ALD patients well protected?
  Theoretical coverage is at 100%, but data show they still bear a significant remaining charge, highlighting the importance of an effective mutual insurance.
• ❓ What are the prospects for improving system transparency?
  The cross-referencing of SNDS data with that of supplementary insurers makes for better clarity and more effective reimbursement management.

Source: www.magnolia.fr