Mutual health insurance is an insurance contract that intervenes in addition to the assumption of your health costs by the health insurance or to cover the care not supported by the latter. Different organizations offer complementary health contracts: insurance companies, mutuals, and provident institutions.
The common objective of these organizations is therefore to strengthen your health cover by reimbursing all or part of your health expenses not covered by the basic guarantees of the compulsory scheme.
THE DIFFERENT TYPES OF MUTUALS
Subscription to individual health insurance is not compulsory but strongly recommended. On the other hand, if you are an employee, your employer must offer you complementary collective health insurance, also called company mutual insurance.
Group health coverage
Since January 1, 2016, all employers in the private sector have been required to offer supplementary health coverage to their employees. The children and the spouse can be attached to this mutual. Some employees are exempt from it (workers working from home, short-term fixed-term contracts, etc.), others can refuse it under certain conditions. The company mutual insurance contract must be covered at least 50% by the employer and provide for a certain base of guarantees:
- Reimbursement of the full co-payment for acts and services reimbursed by health insurance
- The entire daily hospital fee
- dental costs
- Fixed optical costs (per period of 2 years for adults and 1 year for children) up to a minimum of 100 euros for simple lenses and a frame, or up to 150 euros for complex lenses and a frame.
Individual complementary health insurance
While employees automatically benefit from company mutual insurance, other people must however take out an individual mutual insurance contract. These include:
- Students
- Retired seniors
- Unpaid workers
- Unemployed
Employees in breach of a contract automatically benefit from their company’s mutual insurance for a maximum period of 12 months, except in the event of serious misconduct.
Since January 1, 2020, all French people with individual complementary health insurance can benefit from 100% coverage of certain dental, optical, and audiology care.
To guarantee equitable access to often very expensive care, so-called “responsible” mutual insurance contracts must meet a certain number of obligations set by the public authorities. Today, almost all individual supplementary health insurance meets these requirements, allowing you to benefit from 100% health care offers.
THE ADVANTAGES OF THE MUTUAL FOR THE INSURED
Health insurance does not cover all health costs. The role of a complementary mutual insurance company is therefore to supplement the reimbursements of medical care and goods which may or may not be covered by social security.
The rest is to be borne by the patient
The remainder payable by the patient is the sum that the patient must pay and which is not reimbursed by social security. This includes the fixed participation, the co-payment, and any overruns of fees or medical expenses. A good mutual fund makes it possible to fill or considerably reduce this remaining charge in the context of certain health expenditure items by reimbursing all or part of the co-payment and possibly part of the excess fees.
Reimbursement of dental expenses
Dental costs are part of the health expenses where the rest to be paid is the most important. Indeed, having a crown, an implant, or having dental surgery is very expensive. This is also the case for orthodontic costs. For example, the average rest charge for a dental crown is estimated at 460 euros. Thanks to a mutual insurance company that covers part of the moderating ticket, this considerably reduces its costs. For dental costs, you must send your mutual insurance company the dentist’s estimate to make a prior request for coverage.
Reimbursement of optical expenses
The other most important item of expenditure in terms of health is that of optics. The price of lenses and frames can skyrocket, especially when it comes to complex lenses. Contact lenses are also very poorly reimbursed by social security. Having mutual insurance offers two advantages. Firstly, it considerably reduces the remainder to be paid. Secondly, the companies generally offer policyholders a network of partner stores that offer glasses at a lower cost and they receive reimbursement directly to avoid you having to pay upfront costs.
Reimbursement of audio prosthesis costs
Hearing aids are 100% covered for health pack offers ie class 1 hearing aids (selling price limit of 800 euros). This is an offer exempt from the remaining charges. All other Class 2 devices that are freely priced will be partially reimbursed.
Other costs covered by the health insurance fund
Mutuals also guarantee excellent reimbursement in the context of hospitalization, equipment, or the supply of medical equipment. This is also the case for health stays such as spa treatments, for example.
Coverage of costs not reimbursed by health insurance
The other advantage of having complementary health insurance is being able to benefit from a reimbursement package for certain treatments that are not reimbursed by health insurance. This is the case, for example, with alternative medicine such as sophrology, acupuncture, or osteopathy. Certain health purchases may also appear in the list of expenses partially or reimbursed by the health insurance fund, such as means of contraception or even pharmaceutical substitutes for quitting smoking. You will be reimbursed for daily living aids in the event of an accident, hospitalization, or immobilization.
A multitude of services
A good mutual must listen to its policyholders. It is for this reason that it offers information in its agencies or by telephone with one of our advisors. Today, mutuals offer more services through their platforms. This is what we have chosen to do also through our website. You will be able to create a customer area, modify your personal information, follow the exchanges of your contribution, and consult and download documents (reimbursement sheets, certificates, etc.). You will also find a lot of information on our offers and news in the field of health and insurance. We adapt our offers to all types of profiles: young professionals, families, companies, seniors… and offer a split payment of contributions free of charge. Thanks to our reusable bonus system from one year to the next, you will be able to enjoy real continuity in your benefits.
HOW DO OBTAIN OPTIMAL CARE?
To be properly reimbursed for your care, it is not enough to have taken out additional insurance. It is also necessary to respect the course of coordinated care.
The principle of reimbursement
Health expenditure includes the basis for reimbursement by health insurance, the flat-rate contribution to be borne by the patient, the moderating ticket which constitutes the rest of the health expenses not covered by the compulsory scheme, and finally, the possible overruns of fees for non-contracted practitioners. What the mutual pays for is the co-payment and possibly part of the overruns.
Respect for the care pathway
The coordinated care pathway was set up in July 2005. It requires all insured persons over the age of 16 to choose a referring doctor who ensures their medical follow-up and possibly directs them to specialists. Any consultation made outside of this course will result in a reduction in the reimbursement rate of the compulsory scheme. Of course, there are exceptions when consulting a doctor in an emergency, on vacation, or in certain structures. Some specialists such as dentists, gynecologists, ophthalmologists, psychiatrists, or stomatologists can be consulted directly without having to go through their doctor.
Before, it was sometimes necessary to wait for reimbursement from health insurance to send proof to your mutual insurance company. Today, thanks to the NOÉMIE link, the reimbursement process has become much faster since it is the health insurance that directly transmits the patient’s information to the mutual insurance companies. No more formalities are necessary, and treatment reimbursements have become automatic.
