Supplementary health insurance: three essential figures on the remaining out-of-pocket costs

Out-of-pocket costs in health care remain a central issue in the debate on access to care in France. Despite a protective Social Security system, insured individuals face uncovered expenses, representing a sometimes heavy financial burden. A recent study by Malakoff Humanis, a key player in social protection, provides unprecedented insight by cross-referencing its data with that of the Health Insurance. It highlights three key figures relating to the crucial role of supplementary health insurances in reducing this remaining charge. These data underscore the tangible impact of mutual companies like Harmonie Mutuelle or SwissLife, as well as companies such as MMA or Groupama, in alleviating the costs borne by patients.

The analysis is based on a double observation. On one hand, without supplementary health insurance, the remaining charge for the French would reach nearly half of the total cost of primary care, while with coverage from Ocam (Complementary health insurance organizations), this rate decreases significantly. On the other hand, patients with long-term conditions (ALD) continue to bear a substantial share of expenses, despite the “100% coverage” promised by the mandatory scheme. This study thus reveals a often overlooked reality, highlighting the essential role of mutual companies like Matmut, Mgen, or LCL Santé in health coverage.

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

The leading role of supplementary health insurances in reducing out-of-pocket costs in primary care

Financially, Malakoff Humanis’s study on primary care highlights a first key figure: the remaining charge after reimbursement by Social Security averages 47% of the total care costs. However, this figure drops sharply to 14% when coverage by supplementary health insurances is included. This demonstrates the crucial role played by mutual companies and health insurance plans in maintaining household financial stability.

The remaining charge includes the portion of costs not reimbursed by Social Security or supplementary insurers, including excess fees, medical deductibles, or certain unrecognized procedures. Among the most prominent mutual companies in this landscape are Harmonie Mutuelle, MMA, and SwissLife, which actively intervene to lighten this financial burden. For example, a consultation with a specialist with a conventioned fee of 30 euros, if it involves an excess fee of 50 euros, will see Social Security reimburse approximately 16.50 euros. The initial remaining charge would thus be significant, but the mutual insurer can step in to cover part, or all, of the remaining costs.

The categories of expenses involved and their coverage

• 🩺 Consultations and medical acts: partially reimbursed by Social Security, with a variable remaining charge depending on excess fees.
• 💊 Medications: certain off-list medications generate a higher remaining charge.
• 🏥 Hospital care: deductibles and additional charges not covered by Health Insurance.
• 👓 Optics and dental prostheses: historically significant sources of expenditure with concentrated remaining charges.

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

Despite these advances, questions about reimbursement delays and administrative complexity remain. Organizations such as 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, potentially further reducing out-of-pocket costs.

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

Patients with long-term conditions (ALD) theoretically benefit from 100% coverage by Health Insurance. However, Malakoff Humanis’s study highlights 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 corresponds to about 15% of the actual costs, which is twice the rate observed for patients without ALD.

This disparity is explained by several factors. The copayment, although theoretically eliminated in ALD, does not include excess fees, which remain the patient’s responsibility. Additionally, ancillary costs such as medical transport, non-reimbursed care, or hospitalization expenses generate additional costs. This highlights a structural flaw in the implementation of full coverage.

The main expense items remaining for ALD patients

• 🚑 Excess medical fees: a crucial issue for high-cost pathologies.
• 🚌 Non-fully covered medical transports.
• 🏨 Hospital room charges.
• 💉 Paramedical treatments not covered by standard tariffs.
• 🛡️ Supplementary insurance: essential role in reducing this remaining charge.

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

The support from supplementary health insurers such as Matmut or Groupama appears crucial here. These actors cover a significant portion of the remaining costs, limiting the risk of care abandonment among these vulnerable patients. Highlighting this economic reality calls for a review of existing systems and increased cooperation between the mandatory scheme and supplementary insurers for better ALD coverage.

The average reduction of remaining charges to 11% thanks to supplementary health insurances

An other key figure from the analysis reveals that, on an average annual expense of 1,408 € in primary and hospital care, the remaining charge after reimbursement by Social Security and supplementary insurers drops to about 11%. This rate represents a significant decrease compared to the initial post-Security figure, demonstrating the fundamental role played by mutual companies like Harmonie Mutuelle, Mgen, or SwissLife.

Supplementary health insurance acts here as a true safety net for insured individuals, allowing 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 supplementary organizations, with an average final amount of 315 €.

The specific advantages of responsible supplementary health insurances

• 🔐 Guarantees regulated by law ensuring care baskets are provided without remaining charges.
• ⚖️ Coverage of fees related to excess charges in certain contracts.
• 📈 Improvement of prevention and medical follow-up supported by integrated offers.
• 💡 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 insurance (€) 💳	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 company, such as AcommeAssure or LCL Santé, can prove strategic for controlling these amounts. The positive impact of the mutual retention on the repayment capacity of supplementary insurers is also a factor to monitor in the evolution of future policies.

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

The financial burden associated with hospitalization remains one of the main sources of remaining charges. The study published by Malakoff Humanis emphasizes that supplementary health insurances intervene up to 90% of the costs not covered by the Health Insurance at the hospital. This coverage includes, in particular:

• 🛏️ Excess hospital fees.
• 🚪 Charges for private or single rooms.
• ⚙️ Certain technical acts not covered by Social Security.
• 🏥 Ancillary costs related to hospitalization.

Such involvement by organizations like Matmut, SwissLife, or even Groupama translates into substantial financial support, essential in the face of rising hospital costs. This comprehensive hospital coverage helps prevent care abandonment and preserves the budgets of insured individuals facing serious pathologies requiring intensive treatment.

Type of hospital expenses 🏨	Unreimbursed part by Sécu (%) 🔎	Coverage by supplementary insurers (%) 💪	Final remaining charge (%) 📉
Excess fees	80 %	90 %	8 %
Private room	70 %	90 %	10 %
Technical acts	50 %	90 %	5 %

However, it’s important to note that this coverage heavily depends on the type of insurance contract chosen. More comprehensive options offered by insurers like MMA or LCL Santé guarantee increased coverage, whereas some basic contracts may leave a larger remaining charge.

Transparency and clarity: the major challenge of the health reimbursement system in 2025

The reimbursement system in France is based on a dual mechanism involving the mandatory scheme and supplementary organizations. However, the distribution of coverage between these two actors often remains confusing for insured individuals, despite its critical importance. This aspect was recently highlighted by Jean-Carles Grelier, deputy of the Democrats and Independents group, during the presentation of the Malakoff Humanis study results.

Patients’ difficulties in understanding their bills, reimbursement delays, and the precise nature of what is covered or not often lead to negative perceptions. This opacity also generates misunderstandings about the role of supplementary health insurers. While mutual companies like Harmonie Mutuelle or Mgen shoulder a significant portion of the costs, their involvement is insufficiently recognized. A decisive action 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.
• 📊 Improvement of digital tools for real-time reimbursement tracking.
• 🤝 Strengthening dialogue between institutions and supplementary health insurers.

Major readability issues 🧐	Consequences for the insured ⚠️	Proposed solutions 💡
Complex and unclear bills	Disagreement over payment amounts	Simplified and clear documents
Long reimbursement delays	Financial tensions	Accelerated process via digitalization
Misunderstanding of the role of supplementary insurers	Trust disruption	Awareness campaigns

Initiatives such as those promoted by MMA or AcommeAssure to digitize access to information are already underway, promoting an improved user experience and a better understanding of care financing.

Towards an expanded analysis of cross-sector health data

The unprecedented cross-referencing of Malakoff Humanis data with that of the National Health Data System (SNDS) opens new perspectives to improve the management of the French health system. This innovative method allows for a better understanding of insured individuals’ real needs and to refine reimbursement and prevention policies.

Among the proposed avenues are:

• 🛡️ Enhancement of targeted prevention actions to reduce care costs.
• 🔄 Optimization of care coordination between professionals and establishments.
• 🚨 Increased fight against fraud in benefits and abusive reimbursements.
• 📈 More detailed analysis of care consumption behaviors.
• 📊 Improved transparency for more efficient system management.

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

This innovative approach, encouraged notably by groups like SwissLife or Matmut, could permanently transform health governance in France, aiming to better control expenses and ensure fairer coverage by 2030.

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

The Malakoff Humanis study reaffirms an undeniable truth: without the presence of supplementary health insurers, the remaining charge for patients would be significantly higher, jeopardizing access to care for a large part of the population. Mutual companies such as Harmonie Mutuelle, Matmut, or Mgen constitute a fundamental pillar of the French social model.

For insured individuals, it is highly recommended to:

• 🔎 Compare offers from various insurers such as MMA, SwissLife, or Groupama.
• 📅 Take advantage of mid-year cancellation to subscribe to a more effective mutual company.
• 💰 Seek a contract tailored to personal needs to avoid unnecessary expenses.
• 🛡️ Check guarantees regarding excess fees and dental or optical care.
• ⚖️ Maintain a balance between monthly premiums and optimal coverage.

Key advice for insured 🎯	Objective 🏆	Expected result ✅
Regularly change mutual insurance	Optimize quality/price ratio	Save up to 300 € per year
Use comparison platforms	Find a suitable offer	Reduce out-of-pocket costs
Check specific guarantees	Ensure coverage of care	Fewer financial surprises

The weight of the mutual retention, meaning the share of contributions directly dedicated to benefit coverage, is an indicator to monitor when assessing an organization’s repayment capacity. In 2025, supplementary health insurances remain a crucial pillar to ensure access to care without financial obstacles.

To explore these topics further:

• The importance of supplementary health insurances according to Malakoff Humanis
• Causes of increasing out-of-pocket costs
Detailed analysis by Malakoff Humanis
• Additional files on mutual insurance and radiology
• Three key figures on remaining charges

FAQ about remaining charges and supplementary health insurances

• ❓ What is the remaining charge in health care?
  The remaining charge is the portion of health expenses the insured must pay after Social Security and their supplementary health insurance reimbursements.
• ❓ Why are supplementary health insurances essential?
  They significantly reduce the remaining charge, notably by covering excess fees, deductibles, and certain services not covered by Health Insurance.
• ❓ How to choose your health mutual?
  It involves assessing personal and family needs, comparing guarantees offered by organizations like LCL Santé, MMA, or SwissLife, and taking advantage of mid-year cancellation to switch if necessary.
• ❓ Are ALD patients well protected?
  Theoretically, coverage is 100%, but data shows they still bear a significant remaining charge, which highlights the importance of a high-performance mutual.
• ❓ What are the prospects for improving system transparency?
  The cross-referencing of SNDS data with supplementary health sources allows for better readability and more effective management of reimbursements.

Source: www.magnolia.fr