Care Covered By Health Insurance – Full Information
While some health expenses are partially reimbursed by health insurance, others are not covered at all.
Hence the interest of taking out a complementary health contract. Consultations, examinations, equipment, specific care.
Which items are covered by mutual health insurance?
In general, your complementary health contract will complete the reimbursement of Social Security, and provide for coverage of at least 100% of the convention rate (BRSS).
More covering contracts provide for reimbursement of up to 400% or even more of the security tariff and thus cover excess fees.
However, some treatments are not covered by the health insurance scheme at all; in these specific cases, a complementary health contract is your only chance of reducing your out-of-pocket costs and avoiding financial complications.
The most frequent health items are hospitalization, routine care, optics, dental, hearing and well-being. Let’s see in detail at what level your mutual intervenes on the first two positions.
Hospitalization: what costs to expect?
During hospitalization, you are billed for a hospital package, as well as hospitalization costs. The hospital package, which corresponds to participation in maintenance and accommodation costs, is not covered by the SS.
Accommodation costs and the fees of anesthesiologists and surgeons are covered at 80% by your health insurance plan.
1. The daily package
Since 2018, its amount has been set at €20 per day in a hospital or clinic and €15 in a psychiatric service. It does not give rise to any reimbursement by Social Security.
Complementary health organizations almost systematically include reimbursement in their formula. This is also an obligation for so-called responsible contracts.
2. Hospitalization costs
Hospitalization costs concern all costs related to the care given to patients: medical procedures, drugs, medical devices, but also the operating costs of the establishment, including the remuneration of nursing staff.
They are reimbursed up to 80% by health insurance.
In certain specific cases, SS coverage is 100%, for example when hospitalization takes place in the context of pregnancy from the 6th month, or even for beneficiaries of CMU-C.
In most cases, the patient therefore bears 20% of the expenses related to his hospitalization, which can represent a heavy financial burden, especially if the stay lasts several days. Again, your complementary health organization will relieve your expenses by reimbursing the co-payment.
3. Fee overruns
In private establishments, excess fees for specialists, surgeons and anesthesiologists are common.
Even at the hospital, nearly 50% of doctors are in sector 2 and therefore authorized to practice fee overruns when they practice in the liberal framework.
Fee overruns are also linked to the geographical location, Parisian doctors are the most expensive. Cataract surgery or the installation of a hip prosthesis can therefore leave you with a significant burden, which must be anticipated before the operation.
Your complementary health contract, if it provides for reimbursement beyond 100% of the BRSS, will supplement the additional cost linked to these overruns.
4. Comfort costs
Do you prefer to rest in a single room after hospitalization? The single room is also not reimbursed by Social Security. It will be billed to you if you explicitly request it.
Note that the average cost of a private room is €60 in public hospitals, and can reach double that in a private establishment.
Not negligible in the event of a stay of several nights.
If the private room is an important criterion for you, plan in your complementary health contract to cover it.
Mutual provide a flat rate per day that can cover all or part of this expense.
Some contracts also provide for reimbursement of television and press costs and costs for accompanying persons (bed and meals).
As you will have understood, hospitalization is very expensive. The 5% of French people who are not covered by a complementary health contract are exposed to a significant financial risk, because even if their health is excellent, an accident can occur and require substantial hospital care.
In this sense, some mutual offer contracts limited solely to hospitalization costs.
Routine care: significant costs to anticipate
You never go to the doctor, suffer from any pathology or follow any treatment? You can probably do without your supplementary health insurance on the routine care item. Conversely, as soon as your needs become more frequent, the assumption of the moderating ticket or any overruns of fees by your mutual insurance becomes essential.
Routine care includes medical fees during a consultation with your GP or specialist. If it comes under sector 1, no bad surprise, the practitioner agrees not to exceed the social security rate.
Social security covers 70% of the consultation, the remaining 30% is your responsibility or that of your complementary health insurance.
In sector 2, this is no longer the case, since the doctor practices free fees.
Laboratory examinations, analyzes and biology procedures are 60% covered by the SS. The same goes for paramedical fees (nurses, physiotherapists, speech therapists, etc.) which can all the more incur fee overruns.
Ditto for acts of medical imaging (x-rays, scanners, ultrasound, etc.), covered at 70% by the SS, and which may exceed the social security rate.
Finally, medical equipment, such as a prosthesis or orthopedic insoles, are partially reimbursed by Social Security and supplemented by your complementary health insurance.
In total, the intervention of your mutual may prove to be high and save you from unforeseen expenses. Do not neglect the impact of routine daily care.
The support request procedure
The coverage of your mutual insurance company varies according to the care, the doctor consulted, the types of medical procedures performed the medications.
Support for optical, dental and audio stations