Understanding Mandatory Health Insurance (AMO) and Complementary Health Insurance (AMC)

In Summary

📖 Section	Description
🛡️ Mandatory Health Insurance – OM	Mandatory Health Insurance (OM) provides a basic coverage for every individual residing and working in France, offering universal access to essential healthcare services, regardless of financial situation.
🏥 How OM Works	Funded by social contributions and public taxes, OM covers consultations, hospitalizations, and medications. It aims to reduce healthcare costs through national solidarity.
💳 Benefits Covered by OM	The main benefits include medical consultations, hospital stays, and medications, with reimbursement rates depending on the medical service provided.
💰 Reducing Healthcare Costs	OM reduces out-of-pocket expenses for insured individuals, enabling more equitable access to care. Low-income individuals may benefit from specific schemes such as CMU-C or ACS.
📋 Management and Control Mechanisms	Managed by CPAMs, OM ensures regulatory compliance and proper fund allocation through controls and efficient reimbursement management via the Vitale card.
🌍 Universal and Solidary Access	OM guarantees that every resident benefits from protection, pooling risks and costs to improve fairness in access to healthcare.
🏥 Additional Health Insurance – AMC	AMC complements OM reimbursements, covering expenses not paid by OM.
🤝 Types of AMC Organisms	Includes mutual insurance companies, 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, purchased by individuals, provide personalized coverage.
🚫 Mandatory Subscription to AMC	While not obligatory for all, AMC is highly recommended for more comprehensive health coverage. Employees must join group contracts, whereas self-employed individuals have the freedom to choose individual contracts.
🏥 Why Subscribe to Supplementary Health Insurance?	Subscribing to AMC allows access to direct payment (tiers payant) and covers expenses not reimbursed by OM, improving care access and reducing out-of-pocket costs. It also offers additional benefits such as coverage of alternative medicines, dental, and optical care.
❓ Conclusion	OM and AMC are essential to ensure adequate health protection in France, allowing efficient management of healthcare expenses and guaranteeing equitable access to medical care.

Mandatory Health Insurance (OM) is a social protection system that provides each individual with a basic health coverage. In France, everyone residing and working must enroll in a mandatory health plan.

How Mandatory Health Insurance Works

Mandatory Health Insurance (OM) is a key pillar of France’s social protection system, aiming to guarantee a basic health coverage for everyone. Here is a detailed explanation of its operation.

Funding of OM

OM is mainly financed by social contributions from workers and employers. These contributions represent a portion of employees’ gross wages and are paid to social security agencies. Additionally, a share of public taxes, such as the Generalized Social Contribution (CSG) and the Contribution for Social Debt Repayment (CRDS), also funds OM. This mixed financing system ensures national solidarity, allowing equitable cost distribution across different population groups.

Benefits Covered by OM

OM covers part of medical expenses, easing the financial burden for insurees. The main covered benefits include:

1. Medical Consultations: OM covers a portion of the costs for consultations with general practitioners and specialists. The reimbursement rate is generally 70% of the base tariff set by social security.
2. Hospitalizations: Hospital stay costs are also partially covered by OM, including medical care, surgical procedures, and hospital fees. Reimbursements can reach 80% of the expenses, with the remaining called ticket modérateur.
3. Medications: OM reimburses part of the cost of medications prescribed by a doctor. Reimbursement rates vary based on the medical service rendered (SMR), ranging from 15% for low-medical-value medicines to 100% for essential medicines.

Reducing Insureds’ Healthcare Expenses

By covering part of medical costs, OM helps lower the out-of-pocket expenses of insured individuals. This partial reimbursement system ensures healthcare remains accessible to all, regardless of income. Low-income individuals often benefit from specific schemes such as the Universal Complementary Health Coverage (CMU-C) or Help with Payment for Complementary Health (ACS), which cover the ticket modérateur and provide additional coverage.

Management and Control Mechanisms

Management of OM is carried out by primary health insurance funds (CPAM), responsible for collecting contributions and reimbursing healthcare expenses. They enforce regulations and monitor spending to prevent abuse and fraud. Electronic transmission of billing forms via the Vitale card enables faster, more efficient reimbursements, reducing processing delays and simplifying procedures for insured persons.

Universal and Solidary Access

OM ensures universal access to healthcare, guaranteeing that every person residing and working in France benefits from basic social protection. This principle of national solidarity allows for risk pooling and cost-sharing among all insured, fostering better equity in healthcare access.

Objectives of Mandatory Health Insurance

Mandatory Health Insurance (OM) is designed to provide a minimal medical coverage to all residents, regardless of their financial situation. Its aims are multiple, striving to establish a fair and accessible healthcare system for everyone.

Guarantee Universal Medical Coverage

The primary goal of OM is to ensure medical coverage for every individual residing in France. This universal coverage guarantees that all people—whether employed, self-employed, or unemployed—have access to health protection. By imposing mandatory coverage, OM fights against inequalities in access to healthcare.

Access to Essential Care

OM allows each insured person to access essential care. This includes medical consultations, hospitalizations, and medications. By covering part of medical expenses, OM reduces the remaining charge for patients, making healthcare more affordable.

Reducing Social Health Inequalities

By covering some healthcare costs, OM plays a vital role in reducing social health inequalities. Low-income individuals, often more vulnerable, can benefit from the same health services as wealthier persons. Specific schemes like Universal Disease Coverage (PUMA) and Universal Complementary Health Coverage (CMU-C) are in place for the unemployed or low-resource individuals.

Contribution to Social Protection

OM significantly contributes to social protection in France. It provides financial security against unforeseen health expenses. By pooling risks, OM facilitates equitable distribution of costs among all insured, reinforcing national solidarity.

Prevention and Health Promotion

OM also promotes preventive measures and health education. Covering services such as vaccinations and screenings, it aids in disease prevention and long-term cost reduction for the healthcare system.

Support for the Economy

By ensuring access to health coverage, OM helps individuals stay in good health, positively impacting productivity and economic participation. An accessible, efficient healthcare system is crucial for a stable and prosperous economy.

Adaptability and Evolution

OM is designed to adapt to demographic changes and evolving health needs of the population. It continuously evolves to address new health challenges and provide adequate coverage for all.

How Complementary Health Insurance (AMC) Works

Complementary Health Insurance (AMC) is an essential system that supplements the reimbursements of OM (Mandatory Health Insurance). It plays a vital role by covering expenses not paid by OM, offering broader and more comprehensive coverage to insured individuals.

Composition of AMC

AMC includes all mutual insurance companies, provident institutions, and insurance companies. These organizations offer complementary health contracts that cover some or all of medical expenses not reimbursed by OM.

Obligation and Flexibility of AMC

Besides for employees, who must join a group contract set up by their employer, subscribing to AMC is not mandatory. However, it is strongly recommended to have a complementary health plan for extended coverage of care costs. Insurance comparison tools like lesfurets can assist in selecting the best option according to individual needs and budgets.

Reimbursement and Coverage

AMC allows covering expenses not reimbursed by OM, including excess fees, dental care, optical expenses, and some alternative medicines. Reimbursements depend on the guarantees specified in the contract. Beneficiaries benefit from tiers payant, meaning they do not need to pay upfront; healthcare providers are directly reimbursed by the supplementary insurer.

Types of Organisms Providing Complementary Health Insurance (AMC)

Complementary Health Insurance (AMC) is offered by three main types of organizations. Each is regulated by specific legislation and provides tailored health coverage solutions.

Mutual Insurance Companies

Mutuals are non-profit organizations governed by the Code of Mutuality. They are based on principles of solidarity and risk sharing. Members pay contributions that are used to reimburse health expenses.

• Mutuals operate without profit motive and reinvest surpluses for members’ benefit.
• They offer a wide range of contracts suited to various insured profiles, often including preventive services and welfare.
• Governed democratically, each member has a vote rights on key decisions.

Provident Institutions

Provident institutions are regulated by the Code of Social Security and aim to provide prevention benefits and additional health coverage. They are usually created by social partners within collective agreements and sectoral agreements.

• They provide group contracts mainly for employees covered by collective agreements.
• They offer social protection covering not only healthcare but also disability and death.
• Their management is parity-based, involving employer and employee representatives.

Insurance Companies

Insurance companies, governed by the Code of Insurance, can be commercial entities or mutual societies. They provide a broad range of insurance products, including complementary health.

• Insurance companies are flexible and can offer customized contracts adapted to individual needs.
• They often provide additional services such as assistance, wellness programs, and extended coverage options.
• These companies can offer individual and group contracts, with the former often subscribed by freelancers 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 is designed to meet specific needs and provide benefits suited to different insured situations.

Group Contracts

Group contracts are subscribed by associations or companies to cover a group of beneficiaries. These are especially 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 typically benefit from lower rates.
• Law ANI: Since the implementation of the ANI Law (Interprofessional National Agreement) in 2016, all companies are required to offer a health insurance plan to their employees. This contract must include a basic care package and be funded at least 50% by the employer.
• Benefits for employees: Employees benefit from more favorable conditions through group negotiations, often with extended coverage at competitive prices. These contracts cover not only employees but also, in some cases, their dependents (spouses and children).

Individual Contracts

Individual contracts are directly subscribed by the insured for themselves and their dependents. They are especially suitable for self-employed workers (TNS), retirees, and unemployed persons.

• Autonomy in choice: Insured persons can select their health policy based on their specific needs and budget. They are free to compare different offers and choose the best coverage.
• Covers dependents: Individual contracts can include coverage for dependents, such as spouses and children, ensuring full family protection.
• Suitable for non-salaried workers: These contracts are particularly popular among independent workers, merchants, artisans, and liberal professions, who do not benefit from company group plans. Retirees, often more vulnerable, 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 is mandatory since the ANI law (Interprofessional National Agreement) enacted in 2016.

• Employer participation: Companies must offer a health insurance plan for their employees, financed at a minimum of 50% by the employer. This contract must include a basic care package covering essential health 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 non-salaried individuals, such as self-employed workers, retirees, and unemployed, subscribing to AMC is voluntary.

• Strong recommendation: It is highly recommended to subscribe to supplementary health to benefit from broader coverage of care costs. This helps cover expenses not reimbursed by OM, such as excess fees, dental care, and optical expenses.
• Access to quality care: Without AMC, individuals could face significant expenses in case of illness or accident. Supplementary health offers better accessibility and contributes to disease prevention.

Exemptions and Flexibility

Some categories of employees may be exempt from the obligation to join their company’s collective health plan.

• Exceptions: For example, employees on short-term contracts (CDD) less than three months, part-time employees whose contribution exceeds 10% of their salary, or those already covered by an individual health insurance plan can request a dispensation.
• Flexibility: Employers must offer flexibility and inform employees about dispensation conditions and options to subscribe to a personal plan if needed.

Mutual Insurance Comparators

For non-salaried persons, online mutual insurance comparators, such as lesfurets, are valuable tools for choosing an appropriate complementary health product. They enable comparison based on coverage, prices, and individual needs.

• Informed choice: Using a comparator helps making an informed decision and finding the best value-for-money supplementary plan.
• Cost optimization: It also helps optimize costs by avoiding overpayment for unnecessary coverage.

Why Subscribe to Supplementary Health?

Coverage of Costs Not Reimbursed by OM

Subscribing to a Complementary Health Insurance (AMC) allows covering care expenses not reimbursed by Mandatory Health Insurance (OM). This includes significant costs that, without supplementary coverage, would be paid out-of-pocket by the insured.

• Excess fees: Some doctors charge fees above the reimbursement base established by OM. AMC can cover these excess fees, reducing the remaining charge for the patient.
• Dental and optical care: Dental and optical costs can be very high. AMC offers additional reimbursements for dental prostheses, glasses, and contact lenses, which are often poorly reimbursed by OM.
• Alternative medicines: Consultations for alternative medicines (osteopathy, acupuncture, etc.) are generally not covered by OM. Supplementary coverage can include these services.

Advantages of the Tiers Payant

The tiers payant system allows patients not to pay upfront for care. With AMC, patients benefit from tiers payant, simplifying access to healthcare.

• Simplification of procedures: By showing their supplementary health card, patients do not need to pay immediately. Healthcare professionals are directly reimbursed by the insurance and supplementary insurer.
• Facilitated access to care: This system is especially useful for expensive or recurrent expenses, such as costly medications or specialist consultations.

Full Coverage of Healthcare Expenses

An AMC provides a more comprehensive coverage of healthcare costs, offering financial security and peace of mind.

• Reduction of remaining charge: By covering expenses not reimbursed by OM, AMC greatly reduces out-of-pocket costs, allowing access to quality care without financial worries.
• Additional benefits: AMC plans can include extras 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 individual needs.

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

Prevention and Well-being

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

• Prevention programs: Disease prevention, medical follow-up, and vaccination programs are often included.
• Well-being services: Activities like gentle gymnastics, nutrition workshops, or dietary consultations may be offered, contributing to overall health improvement.

How to Get Reimbursed by AMC?

The AMC beneficiary can be reimbursed based on the guarantees specified in their contract. The use of tiers payant facilitates reimbursement management by directly crediting the health professional via the Vitale card.

Inequalities and AMC Management

Unequal Coverage

The two-tier health insurance system, with OM and AMC, can lead to coverage inequalities. About 4% of the French population lack supplementary health, resulting in heterogeneous coverage depending on age and status.

Costly Double Management

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

Rising Contributions

Contributions for supplementary health plans are regularly increasing, often alongside a rise in benefits. In 2019, management costs represented a significant part of contributions, fueling price hikes.

Socio-economic Inequalities

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

Conclusion

OM and AMC are two essential pillars of the health system in France, ensuring adequate social protection and reducing medical expenses for citizens. Understanding how they operate allows for better management of healthcare costs and guarantees optimal coverage.

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