Calculation of Insurance Refund : Choosing the Best Coverage – BTS Insurance

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In Summary

The mutual insurance reimbursement calculation is a crucial step to understand how your healthcare expenses are covered. By analyzing coverage options and understanding the basis of reimbursements, you can optimize your reimbursements and minimize your out-of-pocket costs. This article outlines the steps to calculate your reimbursements and select the best supplementary health insurance.

Foundations of Reimbursement Calculation

What is the Base of Reimbursement (BRSS)?

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

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

Example of BRSS: Detailed Calculation

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

Calculating Reimbursement for a General Consultation in 2025

Let’s consider a specific case of a general practitioner consultation:

1. Actual consultation fee: 30 €
2. BRSS: 30 €
3. Social Security coverage:
   30×70%=21 
4. Remaining charge (covered by mutual insurance):
   30−21=9 €

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

Impact of Excess Fees

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

• If a general practitioner charges 50 € (instead of the fixed 30 € BRSS), your mutual insurer 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 charge insured: 50 €−45 €=5 €

Why is it Essential to Understand BRSS?

Knowing BRSS and how it is applied is essential to:

1. Choose a suitable mutual insurance based on your needs (e.g., frequent excess fees).
2. Understand your reimbursements and anticipate remaining costs.
3. Optimize your healthcare expenses, especially for costly procedures like dental care or out-of-sector consultations.

How Does the Reimbursement Rate Work?

The supplementary health insurance complements 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).

How the Calculation Works

Each reimbursement is divided into two steps:

1. Social Security reimbursement:

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

2. Additional coverage by mutual insurance:

   • The mutual insurer covers all or part of the ticket modérateur (the remaining amount after Social Security reimbursement).
   • If your mutual is at 150% BRSS, it also covers a part of potential excess fees, up to 1.5 times the BRSS.

Practical Example

Here is an example for a consultation billed at 50 €, with a BRSS of 30 € and mutual insurance 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 the mutual:
     30×150%=45 €
   • Part covered by mutual:
     45−20=25 €

3. Step 3: Remaining charge

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

Comparison of Reimbursement Rates

Why Understand Reimbursement Rates?

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

Different Reimbursement Modes

1. Percentage Reimbursement

The percentage reimbursement is the most common mode. 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 ticket modérateur and, in some cases, excess fees.

Coverage Rate Comparison

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 mutual insurers prefer to use fixed flat rates, especially for specific expenses, such as glasses, alternative medicine, or non-reimbursed equipment 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, reimbursement is capped at 350 € for a pair of glasses, leaving a remaining charge of 50 € to the insured.

3. Reimbursement of Actual Costs

High-end mutual insurers offer reimbursement based on actual costs, meaning all incurred expenses are fully reimbursed after deduction of the part covered by social security. This mode is particularly suitable for covering significant excess fees or expensive treatments.

Example: Consultation with Excess Fees

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

• Social Security reimbursement: 30×70%=21 €30 times 70 % = 21 ,€
• Mutual refund based on actual costs: 80−21=59 €
• Remaining charge insured: None.

How to Choose the Right Reimbursement Mode?

1. Percentage reimbursement: Ideal for routine consultations with little or no excess fees.
2. Flat-rate reimbursement: Suitable for specific expenses such as optics or alternative medicine.
3. Reimbursement based on actual costs: Perfect for insured individuals with high or frequent medical expenses.

Coverage Comparison 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 insurance at 150% BRSS.

Detailed Calculation:

1. SS Reimbursement:
   30×70%=21€
2. Mutual Reimbursement:
   30×150%=45 €
   45−21=24 €
3. Remaining charge insured:
   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 insurance at 200% BRSS.

Detailed Calculation:

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

Comparison of Examples

Analysis and Recommendations

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

Best Mutual Insurance Table

• 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 insurer comparisons:
  https://www.quechoisir.org

  • In-depth analysis and user feedback on the best health mutual insurers.

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

  • Practical advice and news on mutual insurance contracts.

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

  • Comparison of offers and reimbursement simulators.

Mutual Insurance for Expatriates: Essential Coverage Abroad

For expatriates, subscribing to an appropriate health mutual insurance is essential to benefit from optimal coverage during stays abroad. Unlike French social security, which limits reimbursements to care provided in France or in specific cases (such as within the European Union), an expatriate mutual offers extended guarantees, tailored to local medical treatments in the resident country.

These mutuals typically cover:

• Medical consultations and hospitalizations, even in countries where health costs are high (e.g., United States, Switzerland).
• Repatriation services, in case of emergencies requiring return to France for treatment.
• Routine and preventive care, including alternative medicines and vaccinations.
• Multicurrency coverage to avoid losses due to exchange rates.

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

Conclusion

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

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