Understand Mandatory Health Insurance (AMO) and Supplemental Health Insurance (AMC)

In Summary

📖 Section	Description
🛡️ Mandatory Health Insurance – AMO	Mandatory Health Insurance (AMO) provides basic coverage for each individual residing and working in France, offering universal access to essential healthcare, regardless of financial situation.
🏥 Functioning of the AMO	Funded by social contributions and public taxes, the AMO covers consultations, hospitalizations, and medications. It aims to reduce healthcare costs through national solidarity.
💳 Benefits Covered by the AMO	The main benefits include medical consultations, hospitalizations, and medications, with reimbursement rates depending on the medical service provided.
💰 Reducing Healthcare Expenses	The AMO decreases out-of-pocket costs for insured persons, enabling fairer access to care. Low-income individuals may benefit from specific schemes such as CMU-C or ACS.
📋 Management and Control Mechanisms	Managed by CPAMs, the AMO ensures regulatory compliance and proper fund allocation through controls and efficient reimbursement management via the Vitale card.
🌍 Universal and Solidarity Access	The AMO guarantees that all residents benefit from protection, pooling risks and costs to improve equity in access to healthcare.
🏥 Additional Mandatory Health Insurance – AMC	The AMC complements AMO reimbursements, covering costs not included by the latter.
🤝 Types of AMC Organisms	Includes mutuals, provident institutions, and insurance companies, each offering contracts tailored to different insured needs.
📑 Forms of AMC	Group contracts, subscribed by companies or associations, are mandatory for employees and partially financed by employers. Individual contracts, taken out by individuals, provide personalized coverage.
🚫 Obligation to Subscribe to the AMC	The AMC is not mandatory for everyone but is strongly recommended for more comprehensive health coverage. Employees must join group contracts, while non-salaried individuals have the freedom to choose individual contracts.
🏥 Why Subscribe to a Supplementary Health Insurance?	Subscribing to an AMC allows for third-party payment and covers expenses not reimbursed by the AMO, improving access to care and reducing out-of-pocket costs. It also offers additional benefits such as coverage of alternative medicine, dental, and optical care.
❓ Conclusion	AMO and AMC are essential for ensuring adequate health protection in France, enabling effective management of healthcare expenses and ensuring fair access to medical services.

Mandatory Health Insurance (AMO) is a social protection system that provides each individual with a basic coverage for health. In France, anyone residing and working must register with a mandatory health insurance scheme.

Functioning of Mandatory Health Insurance

Mandatory Health Insurance (AMO) is a key pillar of the social protection system in France, aimed at guaranteeing each person basic coverage for healthcare. Here is a detailed explanation of its operation.

Funding of the AMO

The AMO is primarily financed by social contributions from workers and employers. These contributions represent a portion of employees’ gross income and are paid to social security funds. Additionally, a share of public taxes, including the Generalized Social Contribution (CSG) and the Contribution for the Repayment of Social Debts (CRDS), also contributes to funding the AMO. This mixed system of financing ensures national solidarity, allowing for an equitable distribution of costs across different population groups.

Benefits Covered by the AMO

The AMO covers part of medical expenses, alleviating the financial burden on insured individuals. The main covered benefits include:

1. Medical Consultations: The AMO covers a portion of the costs for consultations with general practitioners and specialists. The reimbursement rate is usually 70% of the base rate established by Social Security.
2. Hospitalizations: Hospitalization costs are also partly covered by the AMO. This includes medical care, surgical procedures, and hospital stay fees. Reimbursements can reach 80% of the incurred costs, with the remaining being called co-payment.
3. Medications: The AMO reimburses part of the cost of medications prescribed by a doctor. Reimbursement rates vary depending on the medical service rendered (SMR) of the medication, ranging from 15% for low-SMR drugs to 100% for essential medicines.

Reducing Insured People’s Healthcare Costs

By covering part of the medical costs, the AMO helps lower healthcare expenses for insured persons. This partial reimbursement system ensures that healthcare remains accessible to everyone, regardless of income. In fact, low-income individuals often benefit from specific schemes such as the Universal Medical Coverage (CMU-C) or the Aid for Paying Health Insurance (ACS), which cover the co-payment and provide additional coverage.

Management and Control Mechanisms

The management of the AMO is handled by primary health insurance funds (CPAM), responsible for collecting contributions and reimbursing healthcare expenses. They ensure compliance with regulations and monitor expenditures to prevent misuse and fraud. The electronic transmission of health claim forms via the Vitale card enables faster and more efficient reimbursement management, reducing processing delays and simplifying procedures for insured individuals.

Universal and Solidarity Access

The AMO guarantees universal access to healthcare, ensuring that everyone residing and working in France can benefit from basic social protection. This principle of national solidarity allows for risk pooling and cost distribution among all insured persons, contributing to better equity in healthcare access.

The Objectives of Mandatory Health Insurance

Mandatory Health Insurance (AMO) is designed to provide at least minimal medical coverage to all residents, regardless of their financial situation. Its objectives are multiple and aim to guarantee a fair and accessible healthcare system.

Guarantee of Universal Medical Coverage

The primary goal of the AMO is to ensure medical coverage for every individual living in France. This universal coverage guarantees that all people, whether employed, self-employed, or unemployed, can benefit from health protection. By establishing mandatory coverage, the AMO fights against inequalities in access to healthcare services.

Access to Essential Care

The AMO allows each insured person to access essential care. This includes medical consultations, hospitalizations, and medications. By covering part of the medical expenses, the AMO reduces the out-of-pocket costs for patients, making healthcare more affordable.

Reduction of Social Health Inequalities

By covering part of healthcare costs, the AMO plays a crucial role in reducing social health inequalities. Low-income individuals, often more vulnerable, can access the same health services as wealthier individuals. Specific schemes such as the Universal Disease Coverage (PUMA) and the Additional Universal Medical Coverage (CMU-C) are in place for unemployed or low-resource individuals.

Contributing to Social Protection

The AMO significantly contributes to social protection in France. It ensures financial security against unforeseen health expenses. By pooling risks, the AMO allows costs to be shared fairly among insured persons, strengthening national solidarity.

Prevention and Health Promotion

The AMO also encourages prevention and health promotion initiatives. Covering services like vaccinations and screenings, it contributes to disease prevention and long-term cost reduction for the healthcare system.

Economic Support

By guaranteeing health coverage, the AMO helps individuals stay healthy, positively impacting productivity and economic participation. An accessible and efficient healthcare system is vital for a stable and prosperous economy.

Flexibility and Evolution

The AMO is designed to adapt to demographic changes and evolving health needs of the population. It continuously evolves to meet new health challenges and ensure adequate coverage for all.

Functioning of the Complementary Health Insurance (AMC)

Complementary Health Insurance (AMC) is a crucial scheme that complements AMO reimbursements. It plays a vital role in covering costs not reimbursed by mandatory insurance, providing wider and more complete coverage for insured persons.

Composition of the AMC

The AMC includes all mutuals, provident institutions, and insurance companies. These organizations offer complementary health contracts that cover part or all of the medical expenses not reimbursed by the AMO.

Mandatory and Flexible Nature of the AMC

Aside from employees, who must join a group contract set up by their employer, subscribing to an AMC is not mandatory. However, it is strongly recommended to take out supplementary health insurance for more extensive coverage of care costs. Comparison tools such as lesfurets can help choose the best option based on individual needs and budgets.

Reimbursement and Coverage

The AMC allows coverage of costs not reimbursed by the AMO, including excess fees, dental care, optical expenses, and some alternative medicines. Reimbursements are based on the coverages specified in the contract. Policyholders can benefit from third-party payment, meaning they do not need to pay upfront; the healthcare provider is directly reimbursed by the complementary insurer.

The Types of Organisms Providing Complementary Health Insurance (AMC)

Complementary Health Insurance (AMC) is offered by three main types of organizations. Each is regulated by a specific legislative framework and offers tailored health supplementary plans to meet various insured needs.

Mutuals

Mutual organizations are non-profit entities governed by the Code of Mutuality. They operate on principles of solidarity and risk pooling. Members pay contributions that are later used to reimburse health expenses of members.

• Mutuals operate without profit objectives and reinvest surpluses for member benefit.
• They offer a wide range of contracts tailored to different needs, often including preventive services and well-being.
• Mutuals are democratically governed, with each member having a vote rights on key decisions.

Provident Institutions

Provident institutions are governed by the Social Security Code and are tasked with offering previsional benefits and supplementary health plans. They are typically created by social partners through collective agreements and sectoral accords.

• They provide group contracts mainly for employees of companies covered by collective agreements.
• Provident institutions ensure additional social protection, covering not only healthcare costs but also prevision guarantees like disability and death.
• Their management is joint, involving representatives of employers and employees.

Insurance Companies

Insurance companies, governed by the Insurance Code, can be commercial entities or mutual-based organizations. They offer a broad range of insurance products, including supplementary health.

• Insurance companies are flexible and can offer customized contracts, tailored to individual insureds’ needs.
• They often provide additional services such as assistance services, wellness programs, and expanded coverage options.
• These companies can offer individual contracts and group contracts, the former often taken out by self-employed workers and retirees, and the latter by companies for their employees.

Forms of Complementary Health Insurance (AMC)

Complementary Health Insurance (AMC) can take two main forms: group contracts and individual contracts. Each form addresses specific needs and offers advantages suited to different insured situations.

Group Contracts

Group contracts are subscribed by associations or companies to cover a group of beneficiaries. These contracts are particularly advantageous for private sector employees.

• Association or company: Group contracts are negotiated and subscribed by professional associations, unions, or companies. They allow risk pooling and often benefit from more favorable rates.
• Law ANI: Since the implementation of the ANI law (Interprofessional National Agreement) in 2016, all companies are required to offer a health complementary plan to their employees. This contract must include a minimum benefits package and be financed at least 50% by the employer.
• Advantages for employees: Employees benefit from more favorable conditions through group negotiation, often including extended guarantees at competitive rates. These contracts cover not only employees but also, in some cases, their dependents (spouses and children).

Individual Contracts

Individual contracts are directly taken out by the insured for themselves and their dependents. These contracts are especially suitable for self-employed workers (TNS), retirees, and unemployed individuals.

• Autonomy in choosing: Insured persons can choose their supplementary health plan based on their specific needs and budget. They have the freedom to compare different offers and select the one with the best guarantees.
• Covers dependents: Individual contracts can include coverage for dependents of the insured, such as spouses and children, providing comprehensive family protection.
• Suitable for non-salaried persons: These contracts are especially popular among self-employed workers, merchants, craftsmen, and liberal professionals, who do not benefit from company group plans. Retirees, often more vulnerable to health risks, also opt for tailored individual contracts.

Mandatory Subscription to AMC

Mandatory Group Contracts for Employees

For private sector employees, subscribing to a group supplementary health plan has been mandatory since the ANI law (Interprofessional National Agreement) enacted in 2016.

• Employer participation: Companies must offer a health supplementary plan to their employees, financed at least 50% by the employer. This contract must include a minimum benefits package covering essential healthcare expenses.
• Benefits for employees: This obligation ensures all employees benefit from additional social protection, reducing their out-of-pocket costs for healthcare.

Voluntary Subscription for Other Categories

For individuals who are not employees, such as self-employed persons, retirees, and <strong/unemployed, subscribing to an AMC is voluntary.

• Strong recommendation: It is highly recommended to take out a supplementary health plan to benefit from broader coverage of care costs. This helps cover medical expenses not reimbursed by the AMO, such as exceeding fees, dental care, and optical expenses.
• Access to quality care: Without AMC, individuals may face significant expenses in case of illness or accident. A supplementary health plan ensures better accessibility to care and promotes prevention of health risks.

Exemptions and Flexibility

Certain categories of employees can be exempt from the obligation to join the collective health plan of their company.

• Exceptions: For example, fixed-term contract employees (CDD) of less than three months, part-time employees whose contribution exceeds 10% of their salary, or those already covered by an individual health plan, may request a exemption.
• Flexibility: Employers must offer some flexibility and inform employees of the exemption conditions and available options to subscribe to an individual supplementary plan if needed.

Mutual Comparison Tools

For non-salaried individuals, online mutual comparison tools, such as lesfurets, are valuable tools for choosing a tailored health supplementary plan. They enable comparisons based on coverage, rates, and specific needs.

• Informed choice: Using a comparison tool helps make an informed choice and find the health supplementary plan offering the best value for money.
• Cost optimization: It also helps optimize costs by avoiding excessive premiums for unnecessary coverage.

Why Subscribe to a Supplementary Health Plan?

Coverage of Expenses Not Reimbursed by the AMO

Subscribing to a Complementary Health Insurance (AMC) allows covering care expenses not reimbursed by Mandatory Health Insurance (AMO). This includes significant costs that, without supplementary coverage, remain the responsibility of the insured.

• Exceeding fees: Some doctors charge fees higher than the reimbursement bases set by the AMO. An AMC can cover these excess charges, thereby reducing the remaining bill for the patient.
• Dental and optical care: The costs of dental care and optics can be very high. The AMC provides additional reimbursements for dental prostheses, glasses, and contact lenses, which are often poorly reimbursed by the AMO.
• Alternative medicines: Consultations of complementary medicine (osteopathy, acupuncture, etc.) are generally not covered by the AMO. A supplementary health insurance can include these services within its guarantees.

Advantages of Third-Party Payment

The third-party payment system allows not having to pay upfront for care costs. With AMC, the patient benefits from third-party payment, simplifying access to care.

• Simplification of procedures: By presenting their supplementary health card, the patient does not need to pay initial costs. The healthcare professional is directly reimbursed by the insurance company and the supplement.
• Facilitated access to care: This system is especially useful for significant or recurring expenses, such as costly medications or specialized consultations.

Full Coverage of Healthcare Expenses

An AMC offers a more comprehensive coverage of healthcare expenses, providing financial security and peace of mind.

• Reduction of out-of-pocket costs: By covering costs not reimbursed by the AMO, the AMC significantly reduces the remaining bill, allowing insured persons to access quality care without financial worries.
• Additional benefits: AMC plans can include additional services, such as packages for thermal cures, non-mandatory vaccines, or hearing aids.

Adaptation to Specific Needs

Supplementary health plans offer great flexibility and can be tailored to the specific needs of each insured.

• Customized contracts: Insured persons can choose guarantees based on their specific needs, whether young, retired, self-employed, or large families.
• Comparison tools: Using insurance comparison tools helps find a health supplementary plan with the best value for money, with guarantees suited to individual needs.

Prevention and Well-being

Some AMC plans offer prevention and well-being services that are not covered by the AMO.

• Prevention programs: Disease prevention programs, medical monitoring, and vaccinations are often included.
• Well-being services: Services such as gentle gymnastics, nutrition workshops, or dietetic consultations can be offered, contributing to better overall health.

How to Get Reimbursed by the AMC?

The holder of an AMC can be reimbursed based on the coverages specified in their contract. Using third-party payment simplifies reimbursements by directly crediting the healthcare professional via the Vitale card.

Inequalities and Management of the AMC

Unequal Coverage

The two-tier health insurance system, with AMO and AMC, may lead to coverage inequalities. About 4% of the French population does not have a supplementary health plan, with coverage varying by age and status.

High Management Costs

The management costs of health supplementary plans are high, partly due to competition and marketing expenses. In 2018, administrative fees for supplementary plans exceeded those of Social Security, accounting for 20% of total contributions.

Rising Contributions

Contributions for complementary health plans are steadily increasing, but this is accompanied by an increase in benefits. In 2019, management fees represented a significant part of contributions, contributing to price hikes.

Socioeconomic Inequalities

Individual contracts are often more expensive than group plans, creating disparities for retirees and low-income individuals who need more healthcare.

Conclusion

AMO and AMC are two essential pillars of the health system in France, ensuring adequate social protection and helping to reduce medical expenses. Understanding their functioning allows better management of healthcare costs and guarantees optimal coverage.

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