In summary
| 📖 Section | Description |
|---|---|
| 🏛 How Social Security Works | Explains that the system is based on national solidarity where contributions fund health benefits. |
| 🩺 Reimbursable Health Benefits | Details the different benefits covered by Social Security, including consultations, medications, and hospitalizations. |
| 🚑 Medical Consultations | Consultations are partially reimbursed based on the coordinated care pathway and the type of doctor consulted. |
| 💊 Medications | Classifies medications into various categories with reimbursement rates ranging from 15% to 100% depending on their medical importance. |
| 🏥 Hospitalizations | Hospitalization costs are covered up to 80%, with exceptions for costly treatments under certain conditions. |
| 🚖 Other Reimbursable Benefits | Includes medical transport costs, thermal cures, as well as glasses and dental care with their specific reimbursement rules. |
| 📑 Administrative Procedures | Outlines the steps to obtain reimbursement, including the use of the claim form and the Vitale card. Also explains the importance of online management via Ameli. |
| 🆘 Exceptions and Supplementary Health Insurance | Discusses benefits not fully covered by Social Security and the crucial role of supplementary insurance in minimizing remaining expenses. |
Social Security in France plays a vital role in protecting health and well-being of citizens. Understanding its reimbursement mechanisms is essential to navigate the healthcare system effectively. This article provides an overview of the basics of Social Security reimbursement.
How Social Security Works
The system of Social Security is based on national solidarity, where workers’ contributions finance healthcare benefits for everyone. Each insured receives reimbursements based on their health expenses.
Reimbursable Health Benefits
Social Security covers a wide range of benefits, including medical consultations, medications, and hospitalizations. The rates of reimbursement vary depending on the benefits.
Medical Consultations
Consultations with a general practitioner or specialist are partially reimbursed. The reimbursement rate depends on adherence to the coordinated care pathway. If you see a general practitioner, the base fee is €26.50, and Social Security reimburses 70% of this amount, which is €18.55, minus a €1 flat participation fee. Consultations with specialists may have different rates, but reimbursements are similar, always based on the base reimbursement set by Social Security. By following the coordinated care pathway through your referring physician, you obtain the best reimbursement rate.
Medications
Medications are classified into different categories based on their medicinal utility, with reimbursement rates varying from 15% to 100%. Medications with a white label are reimbursed at 65%, those with a blue label at 30%, and those with an orange label at 15%. Irreplaceable and particularly costly medications may be reimbursed at 100%. To qualify for reimbursement, medications must be prescribed by a doctor and listed on the list of reimbursable products by Social Security. This classification helps prioritize the reimbursement of the most essential medications for public health.
Hospitalizations
Hospitalization costs are also covered, including care and surgical interventions. The reimbursement rate can reach up to 80%, with possible additional expenses. For example, for a hospital stay in a public hospital or a contracted clinic, Social Security reimburses 80% of the stay costs. The remaining 20%, called ticket moderateur, may be covered by supplementary health insurance. For stays longer than 24 hours, a daily hospital fee is also payable. Costs related to specific surgical procedures may vary, and some very expensive acts may be fully or partially covered, depending on agreements with the Health Insurance.
Other Reimbursable Benefits
Transport Costs
Medical transport costs are reimbursed at 65%, except for certain cases like long-term illness (ALD), which can be reimbursed at 100%. Transport services include ambulance rides, contracted taxis, or light medical vehicles necessary for medical reasons.
Thermal Cures
Thermal cures are reimbursed at 65% for treatment costs, and at 100% for transport and accommodation expenses under certain conditions. The cures must be prescribed by a doctor and performed in an approved establishment to qualify for reimbursement.
Glasses and Contact Lenses
Optical equipment, such as glasses and contact lenses, have very low reimbursement rates. For example, glasses (frame and lenses) are reimbursed at 60% of the Social Security base, which is often well below the actual price paid. A supplementary health insurance may be necessary to obtain better coverage.
Dental Care
Dental treatments, such as consultations, orthodontic treatments, and prostheses, are partially reimbursed. Reimbursement rates vary depending on the type of care. For example, a scaling is reimbursed at 70% of the €28.92 base, approx. €20.24. Dental prostheses, such as crowns, are reimbursed at 70% of a €120 base, which is €84.
Reimbursement and Base of Social Security Benefits Table
| Type of Benefit | Base of Reimbursement (BRSS) | Social Security Reimbursement Rate | Amount Reimbursed by Social Security |
|---|---|---|---|
| General practitioner consultation sector 1 | €26.50 | 70% | €18.55 |
| Specialist consultation sector 1 | €30.00 | 70% | €21.00 |
| Specialist consultation sector 2 | €23.00 | 70% | €16.10 |
| Glasses (frame) | €2.84 | 60% | €1.70 |
| Single lenses | €6.25 | 60% | €3.75 |
| Complex lenses | €24.54 | 60% | €14.72 |
| Dental crown | €120.00 | 70% | €84.00 |
| Scaling | €28.92 | 70% | €20.24 |
| Orthodontic treatment (per semester) | €193.50 | 100% | €193.50 |
| Medications with white label | Variable (e.g., €10.00) | 65% | €6.50 |
| Medications with blue label | Variable (e.g., €10.00) | 30% | €3.00 |
| Medications with orange label | Variable (e.g., €10.00) | 15% | €1.50 |
| Hospitalization costs (per day) | €20.00 | 80% | €16.00 |
| Transport costs | Variable | 65% | Variable |
| Thermal cure (treatment) | Variable | 65% | Variable |
| Hearing aid (class 1) | €400.00 | 60% | €240.00 |
| Orthopedic insoles (size > 37) | €28.86 | 60% | €17.30 |
Administrative Procedures
To obtain reimbursement, it is necessary to provide a claim form or a Vitale card. The procedures can be carried out online via the Health Insurance website. Here is a guide to help you understand the various steps and documents needed to facilitate your reimbursements.
Claim Form
The claim form is a document you receive from your doctor or a healthcare professional after a consultation or treatment. It contains all the information needed for reimbursement. To ensure your form is accepted, it must be completed and signed by the healthcare professional. Then, you should send it to your health insurance fund.
Vitale Card
The Vitale card is an essential tool to streamline your administrative procedures. It contains all your administrative information necessary for reimbursement of your care. By presenting your Vitale card at each consultation, you avoid sending the claim form. The data are transmitted directly to the Health Insurance for faster reimbursement.
Online Procedures
Procedures can be easily completed online via the Health Insurance website. By logging into your Ameli account, you can track your reimbursements, download documents, and ask questions. Here are some online services available:
- Reimbursement Tracking: You can consult your recent reimbursements and the history of your care.
- Document Downloads: You can download your health rights certificates, doctor declarations, etc.
- Questions and Answers: An FAQ service is available to answer your common questions.
Prior Agreement (Pre-authorization)
For certain care or treatments, prior approval from the Health Insurance is required. This means the insurance must give its agreement before the care is performed. The doctor fills out a prior agreement form and sends it to the fund. The fund will make a decision within a few weeks. This process is essential for costly or specific procedures, such as certain surgeries or specialized treatments.
Third-Party Payment
The third-party payment system allows you not to pay upfront for medical expenses during consultations or pharmacy purchases. This system is mainly accessible to certain categories of people, such as beneficiaries of the CMU-C, those with long-term illness (ALD), etc. The healthcare professional is directly reimbursed by the Health Insurance and your supplementary health insurance.
European Health Insurance Card (EHIC)
For medical care in Europe, the European Health Insurance Card allows you to benefit from coverage of your medical expenses according to the legislation in force in the country of stay. This card is free and valid for one year. It is important to request it in advance from your health insurance fund to be covered during your trips in Europe.
Prescription
A prescription is often required to get reimbursement for certain medications and care. Your doctor provides it after consultation. For some costly medications or specific treatments, the prescription must be presented in pharmacy for reimbursement to be processed. Make sure your prescription is complete and legible to avoid delays.
Exceptions and Supplementary Health Insurance
Some benefits are not fully reimbursed by Social Security. Subscribing to a supplementary insurance can cover the remaining expenses. These additional insurances play a crucial role in covering healthcare costs.
Benefits Not Fully Reimbursed
Many healthcare benefits are not entirely reimbursed by Social Security. For example, consultations with specialist doctors, complex dental care, and optical equipment can incur significant costs. Social Security applies a fixed reimbursement rate, often lower than the actual cost. Surplus fees charged by sector 2 or 3 doctors, as well as certain medications and specific treatments, are only partially covered.
The Role of Supplementary Health Insurance
Supplementary insurances help bridge the gap between Social Security reimbursements and the actual costs. They can cover all or part of the remaining expenses, depending on the level of coverage chosen. These insurances are especially useful for covering surplus fees, costly dental care, glasses, and contact lenses. By subscribing to supplementary insurance, insured individuals can obtain better reimbursement and reduce their out-of-pocket expenses.
Types of Supplementary Insurances
There are several types of supplementary insurances tailored to different needs:
- Mutuelles: Non-profit organizations offering supplementary health contracts. They operate on solidarity principles and do not require medical screening for membership.
- Insurance companies: Offer contracts with various coverage options, often adjustable to individual needs.
- Pre-Insurance Institutions: Often linked to businesses, providing group contracts for employees with typically advantageous guarantees.
Choosing Your Supplementary Insurance
To select an appropriate supplementary insurance, compare the different offers available on the market. Criteria to consider include:
- Coverage level: Ensure the insurance covers the most common health expenses for yourself and your family.
- Cost: Compare fees and assess whether the benefits justify the price.
- Waiting periods: Some insurances impose waiting periods before certain benefits can be used.
- Additional services: Some policies offer extras such as third-party payment, partner care networks, or preventive advice.
Examples of Reimbursements
Here are some common expenses and their reimbursements with and without supplementary insurance:
Consultation with a Specialist
- Actual cost: €50
- Reimbursement by Social Security: 70% of €26.50 = €18.55
- Out-of-pocket without insurance: €32.50
- Out-of-pocket with insurance: €0 (if insurance reimburses 100% of remaining costs)
Dental Care
- Cost of a dental crown: €500
- Reimbursement by Social Security: 70% of €120 = €84
- Out-of-pocket without insurance: €416
- Out-of-pocket with insurance: €0 to €200 (depending on coverage level)
Optical Equipment
- Cost of glasses (frame + lenses): €300
- Reimbursement by Social Security: 60% of €2.84 (frame) + 60% of €8.29 (lenses) = €6.68
- Out-of-pocket without insurance: €293.32
- Out-of-pocket with insurance: €0 to €100 (depending on coverage level)
Summary Tables of Reimbursement Rates
General Health Insurance
| Type of Benefit | Reimbursement Rate |
|---|---|
| Doctor and healthcare professional fees | 70% |
| Laboratory analyses and tests | 60% |
| Medications with white label | 65% |
| Medications with blue label | 30% |
| Medications with orange label | 15% |
| Optical, device, and prosthesis costs | Variable |
| Hospitalization | 80% |
| Transport costs | 65% |
| Thermal cure | 65% |
Old-Age Solidarity Fund (FSV) or Assistance for Elderly People (Aspa)
| Type of Benefit | Reimbursement Rate |
|---|---|
| Doctor and healthcare professional fees | 100% |
| Laboratory analyses and tests | 100% |
| Medications with white label | 100% |
| Medications with blue label | 100% |
| Medications with orange label | 100% |
| Optical, device, and prosthesis costs | 100% |
| Hospitalization | 100% |
| Transport costs | 100% |
| Thermal cure | 100% |
Alsace-Moselle Local Scheme
Reimbursement rates for the Alsace-Moselle local scheme are specific and can be checked on the site regime-local.fr, in the Reimbursements section.
Mines’ Health Insurance
| Type of Benefit | Reimbursement Rate |
|---|---|
| Doctor and healthcare professional fees | 100% |
| Laboratory analyses and tests | 100% |
| Medications | 100% |
| Other medical expenses | 100% |
| Hospitalization | 100% |
| Transport costs | 100% |
| Thermal cure | 100% |
For complete information on the reimbursement rates of Mines’ Health Insurance, please consult the notice provided by the insurance.
Conclusion
Understanding the basics of Social Security reimbursement is essential to optimize your healthcare expenses and fully benefit from the system. By following the proper procedures and knowing the reimbursement rates, you can better manage your medical costs.
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