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 various 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 seen. |
| 💊 Medications | Classifies medications into different 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 transportation costs, thermal cures, as well as glasses and dental care with their specific reimbursement rules. |
| 📑 Administrative Procedures | Outlines the steps to obtain reimbursement, notably using the health form and the Vitale card. Also explains the importance of online management via Ameli. |
| 🆘 Exceptions and Additional Health Insurance | Addresses benefits not fully covered by Social Security and the essential role of supplementary insurance to minimize remaining costs. |
Social Security in France plays a crucial role in protecting citizens’ health and well-being. Understanding its reimbursement mechanisms is essential for navigating the healthcare system effectively. This article provides an overview of the basics of Social Security reimbursement.
How Social Security Operates
The system of Social Security relies on national solidarity, where contributions from workers finance health benefits for everyone. Each insured benefits from reimbursements based on their health expenses.
Reimbursable Health Benefits
Social Security covers a broad range of benefits, including medical consultations, medications, and hospitalizations. The reimbursement rates vary depending on the benefits.
Medical Consultations
Consultations with a general practitioner or specialist are partially reimbursed. The reimbursement rate depends on adhering to the coordinated care pathway. If you see a general practitioner, the basic fee is €26.50, and Social Security reimburses 70% of this amount, which is €18.55, minus €1 for the flat participation fee. Consultations with specialists may have different fees, but the reimbursement rates are similar, always based on the refundable base set by Social Security. If you follow the coordinated care pathway through your primary care physician, you get the best reimbursement rate.
Medications
Medications are classified into different categories according to their medical utility, with reimbursement rates varying from 15% to 100%. Medications with a white sticker are reimbursed at 65%, those with a blue sticker at 30%, and those with an orange sticker at 15%. Irreplaceable, especially costly medications, may be reimbursed at 100%. To benefit from 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 medications deemed most essential for public health.
Hospitalizations
Hospitalization costs are also reimbursed, including care and surgical procedures. The reimbursement rate can go up to 80%, with additional expenses possible. For example, for hospitalization in a public hospital or a contracted clinic, Social Security reimburses 80% of the stay costs. The remaining 20%, called ticket modérateur, can be covered by supplementary health insurance. For stays exceeding 24 hours, a daily hospital fee is also payable. Expenses related to specific surgical interventions may vary, with some very costly procedures being fully or partially covered, depending on agreements with the health insurance.
Other Reimbursable Benefits
Transportation Costs
Medical transportation costs are reimbursed at 65%, except for certain cases such as long-term conditions (ALD), which can be reimbursed at 100%. The transportation involved includes ambulance trips, contracted taxis, or light medical vehicles, necessary for medical reasons.
Thermal Cure
Thermal cures are reimbursed at 65% for treatment costs, and at 100% for transport and accommodation fees under certain conditions. Cures must be prescribed by a doctor and performed in an approved facility to qualify for reimbursement.
Glasses and Contact Lenses
Optical equipment, such as glasses and contact lenses, have very low reimbursement rates. For example, glasses (frames and lenses) are reimbursed at 60% of the reimbursable base by Social Security, which is often well below the actual price paid. Additional supplementary health insurance might be needed to obtain a better coverage.
Dental Care
Dental treatments, like consultations, orthodontics, and prostheses, are partially reimbursed. Reimbursement rates vary by type of care. For example, a dental scaling is reimbursed at 70% of the €28.92 base, approximately €20.24. Dental prostheses, such as crowns, are reimbursed at 70% of €120, which equals €84.
Table of Benefits and Reimbursement Base of Social Security
| Type of Benefit | Reimbursement Base (BRSS) | Social Security Reimbursement Rate | Amount Reimbursed by Social Security |
|---|---|---|---|
| General practitioner consultation in sector 1 | €26.50 | 70% | €18.55 |
| Specialist consultation in sector 1 | €30.00 | 70% | €21.00 |
| Specialist consultation in sector 2 | €23.00 | 70% | €16.10 |
| Glasses (frame) | €2.84 | 60% | €1.70 |
| Eyeglass lenses (simple) | €6.25 | 60% | €3.75 |
| Eyeglass lenses (complex) | €24.54 | 60% | €14.72 |
| Dental crown | €120.00 | 70% | €84.00 |
| Scaler | €28.92 | 70% | €20.24 |
| Orthodontic treatment (per semester) | €193.50 | 100% | €193.50 |
| Medications with white sticker | Variable (e.g., €10.00) | 65% | €6.50 |
| Medications with blue sticker | Variable (e.g., €10.00) | 30% | €3.00 |
| Medications with orange sticker | Variable (e.g., €10.00) | 15% | €1.50 |
| Hospitalization costs (per day) | €20.00 | 80% | €16.00 |
| Transportation 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 a reimbursement, you must provide a health form or a Vitale card. The procedures can be done online via the Health Insurance website. Here is a guide to help you understand the various steps and documents needed to facilitate your reimbursements.
Health Form
The health form is a document you receive from your doctor or healthcare professional after a consultation or treatment. It contains all the necessary information for reimbursement. To be accepted, your form 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 simplify your administrative procedures. It contains all your administrative information required for reimbursement of your care. Presenting your Vitale card at each consultation avoids sending the health form. The data are transmitted directly to the Health Insurance for faster reimbursement.
Online Procedures
The procedures can be easily performed 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 view your recent reimbursements and the history of your care.
- Document Downloads: You can download your proof of rights, doctor declarations, etc.
- Questions and Answers: An FAQ service is available to answer your common questions.
Prior Agreement (Consent)
For certain care or treatments, prior approval from the Health Insurance is required. This means the Insurance must give approval before the care is carried out. The doctor fills out a prior agreement form and sends it to the fund, which will make a decision in a few weeks. This process is essential for costly or specific procedures such as certain surgical operations or specialized treatments.
Third-Party Payment
The third-party payment system allows you not to pay in advance during consultations or pharmacy purchases. This system is mainly available to certain categories of people, such as beneficiaries of CMU-C, those with long-term conditions (ALD), etc. The healthcare professional is directly compensated 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 coverage of your care according to the legislation of 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 European travel.
Prescription
A prescription is often required to get reimbursement for certain medications and care. Your doctor issues it after a consultation. For some costly medications or specific treatments, the prescription must be presented at the pharmacy for reimbursement to be applied. Ensure your prescription is complete and legible to avoid delays in reimbursement.
Exceptions and Additional Health Insurance
Some benefits are not fully reimbursed by Social Security. Subscribing to supplementary health insurance can cover the remaining costs. These supplementary insurances play a crucial role in covering health expenses.
Benefits Not Fully Reimbursed
Many health benefits are not completely reimbursed by Social Security. For example, consultations with specialist doctors, complex dental care, and optical equipment can incur significant costs for patients. Social Security applies a fixed reimbursement rate, often below the actual cost of care. Overcharges by sector 2 or 3 doctors, and certain medications and specific treatments, are only partially covered.
The Role of Supplementary Health Insurance
Supplementary health insurances help bridge the gap between Social Security’s reimbursement and the actual costs of care. They can cover all or part of the remaining expenses, depending on the coverage level chosen. These insurances are particularly useful for covering overcharges, expensive dental care, glasses, and contact lenses. By subscribing to supplementary health insurance, insured individuals can get better reimbursement and thus lower their out-of-pocket expenses.
Types of Supplementary Health Insurances
Several types of supplementary insurances exist, tailored to different insured needs:
- Mutuals: Mutuals are non-profit organizations offering supplementary health contracts. They operate on solidarity principles and do not require medical screening for membership.
- Insurance Companies: These offer contracts with various coverage plans, often customizable according to individual needs.
- Prevention Institutions: Often linked to companies, offering group contracts for employees, with often more advantageous guarantees.
Choosing Your Supplementary Health Insurance
To select a suitable supplementary health insurance, it is important to compare different offers on the market. Criteria to consider include:
- The level of coverage: Ensure that the supplementary insurance covers the most common health expenses for you and your family.
- The cost: Compare the prices of different plans and evaluate whether the coverage justifies the cost.
- The waiting periods: Some insurers impose waiting periods before certain benefits can be used.
- Additional services: Some supplementary insurances offer extra services such as third-party payment, partner care networks, or preventive advice.
Examples of Reimbursements
Here are some common expenses and how they are reimbursed with or without supplementary health insurance:
Consultation with a Specialist
- Actual cost: €50
- Social Security reimbursement: 70% of €26.50 = €18.55
- Out-of-pocket without insurance: €32.50
- Out-of-pocket with insurance: €0 (if the insurance covers 100% of remaining costs)
Dental Care
- Cost of a dental crown: €500
- Social Security reimbursement: 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
- Social Security reimbursement: 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 |
|---|---|
| Fees for doctors and medical auxiliaries | 70% |
| Laboratory analyses and tests | 60% |
| Medications with white sticker | 65% |
| Medications with blue sticker | 30% |
| Medications with orange sticker | 15% |
| Optical costs, aids, prostheses | Variable |
| Hospitalization | 80% |
| Transport costs | 65% |
| Thermal cures | 65% |
Old-Age Solidarity Fund (FSV) or Income Support for the Elderly (Aspa)
| Type of Benefit | Reimbursement Rate |
|---|---|
| Fees for doctors and medical auxiliaries | 100% |
| Laboratory analyses and tests | 100% |
| Medications with white sticker | 100% |
| Medications with blue sticker | 100% |
| Medications with orange sticker | 100% |
| Optical costs, aids, prostheses | 100% |
| Hospitalization | 100% |
| Transport costs | 100% |
| Thermal cures | 100% |
Local Régime of Alsace-Moselle
The reimbursement rates for the Alsace-Moselle local regime are specific and can be consulted on the website regime-local.fr, under the Reimbursements section.
Mining Social Security
| Type of Benefit | Reimbursement Rate |
|---|---|
| Fees for doctors and medical auxiliaries | 100% |
| Laboratory analyses and tests | 100% |
| Medications | 100% |
| Other medical expenses | 100% |
| Hospitalization | 100% |
| Transport costs | 100% |
| Thermal cures | 100% |
For complete information on the reimbursement rates of Mining Social Security, please refer to the notice provided by the Mining Social Security.
Conclusion
Understanding the basics of Social Security reimbursement is essential to optimize your health expenses and benefit fully from the system. By following the appropriate procedures and knowing the reimbursement rates, you can better manage your medical costs.
Further Information
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