Top Up Health Insurance (Mutuelle)

Find out about options for private healthcare and top-up cover for the state health system in France…

State health insurance (CPAM) repays only a percentage of medical costs and modern dental and optical treatments are often very much higher than the Tarif de Convention (or “approved treatment cost”) currently in force.

Private health insurance (santé complémentaire or mutuelle) is available from any medical insurer. Rates vary depending on the degree of cover required and status of the applicant. A person with a top-up insurance card has the treatment recorded and the appropriate balance reimbursed by their mutuelle.

How does a Mutuelle Work?

Visits to a doctor, hospital treatments and laboratory exams for example are reimbursed by the social security up to a certain amount of the Tarif de convention. For most treatments there is also a contribution forfaitaire, which is generally €1. The remaining amount, known as the ticket modérateur is paid by the patient, who in turn is reimbursed by the mutuelle up to a certain amount.

Policy prices vary and generally provide an option for a reimbursement of 100 to 400 percent of the Tarif de Convention, depending on the treatment. This means that the amount charged for medical services over the official limit is reimbursed up to a certain percentage. It is important to clarify exactly what is covered when subscribing to a complementary health insurance, reimbursements and the way it is calculated varies from one company to another.

There are various complementary health insurance schemes, each providing for different needs. It is possible to choose a mutuelle with a higher rate of reimbursement for different needs orthodontics and optical treatment for example), or coverage for hospitalisation only.

Most mutuelles pay a forfait for optical treatment, for example, up to €200 per year for lenses and frames. Provisions for dental care and orthodontics varies greatly and should be checked carefully when taking out a mutuelle.

Hospitalisation

Hospital fees are paid up to 80 percent by the CPAM, whether at a hospital or a private clinic. Patients must pay the remaining 20 percent (ticket modérateur) when they leave the hospital, except in specific circumstance, for example patients with a chronic condition or on a low income. Maternity, accidents at work resulting in a hospitalisation, and babies hospitalised in the first month following the birth are also covered at a rate of 100 percent by state health insurance.

Additional hospital costs are generally covered by a mutuelle. After 30 days of hospitalisation, the CPAM reimburses 100 percent of hospital fees.

The ticket modérateur can become very expensive after a few days in hospital, and a mutuelle is advisable to cover at the very least, all costs related to hospitalisation. Most mutuelles also pay up to a certain amount per day (forfait) for private rooms.

Private health cover

Swisslife provides health insurance to foreign residents.

Cancelling Top-Up insurance

A contract cannot be cancelled “midstream”. There are therefore two cancellation options:

• At least three months before the policy renewal date, notice of cancellation must be given by registered letter.

• Alternatively, the insured has up to 20 days after receipt of the renewal notice in which to cancel by registered letter with recorded delivery (Lettre Recommandée AR). It is the stamp on the envelope which is the final proof of the correct notice period.

The envelope should be kept as it protects the consumer – the insurance continues until registered cancellation is received.

• The insurance company is obliged to send a letter 15 days before the renewal date.

If they fail to do so, the insured can cancel the contract at any time, once the renewal date is passed, by Lettre Recommandée AR.

A policy is automatically ended by the death of the insured.