Health Insurance in France: What you need to know about a Mutuelle

On account of a no-bargain Brexit, certain gatherings of British individuals should demonstrate that they have full health insurance. With the administration’s new residency site now ready for action, we investigate what precisely a French mutuelle includes.

What are mutuelles?

France’s mutuelles are non-profit organisations which have been in operation in the country for at least 150 years.

Their main purpose is to ensure social welfare but not just through additional health cover, also in terms of pensions, disability benefits and other forms of cover.

Mutuelles abide by the code de mutualité, which distinguishes them from health insurance companies in that members don’t have to pay premiums for pre-existing conditions and have a greater say in decision-making as part of this type of co-op or partnership.

While mutuelles are paid for by individuals they are not private health insurance and don’t come up with preferential treatment or access to private clinics.

How does a mutuelle actually work?

If you go to the doctor or hospital in France or have an x-ray or some other kind of test, you’ll normally pay up front.

You are then refunded a percentage of the cost via the carte vitale system, usually within a week, either by the French government if you are working or your home government if you are a pensioner (under the S1 scheme for British people).

In general terms the state covers around 70 per cent of the total, although for some serious conditions the percentage of state health cover is higher or even complete.

What a mutuelle does is cover, either partly or completely, the deficit or the part of the cost not covered by the state.

Essentially, a mutuelle is top-up health cover and one of the easiest ways of getting 100 percent health cover, although how much cover you get will depend on which mutuelle you have and how much you were charged (read on).

Recent figures for the French insurers’ group Mutualité française showed that the average resident in France will have to pay out €235 a year in medical costs not covered by the state – unless they have a mutuelle. And of course for the elderly or people with long term health conditions the figure can be a lot higher.

Not every mutuelle is the same

Depending on the policy chosen, mutuelles can cover most or all of the remaining costs not reimbursed by the state, as well as some selected medical services and the cost of medicines at the pharmacy.

In general terms basic mutuelles will take you up to 100 per cent cover but often the next step up, a standard cover offering around 150-175, or 200 percent, won’t cost a lot more and could tie you over for a lot of expensive extras such as dental and optical treatments.

Things are made more complicated by the fact that doctors in France can charge more than the base rates set by the state (tarif de convention).

This is known as dépassements d’honoraires and are added on by many specialist doctors. For example while most GPs will charge the base rate for appointment of €25 some will charge €40.

If you have a mutuelle that reimburses at 100 per cent that will only cover the €25 tariff de convention. To cover all of the €40 you’ll need a mutuelle that reimburses at 200 per cent. And the same applies to all medical treatment. Note that more expensive mutuelles will reimburse to 400 percent. More info here.

The mutuelles and complémentaite santé market is fairly flexible in this regard so it’s worth having a search online for the policy that best suits your needs and budget.

And make sure you look carefully at the rate of reimbursement.

There are plenty if not too many to choose from, so also ask French friends or your local doctor for recommendations to get a better idea and more honest opinion.

Your company might foot the bill

Since 2016 private companies in France have to provide employees with a private health insurance policy known as a mutuelle collective.

By law they have to cover a minimum 50 percent of the mutuelle’s cost and companies also tend to offer workers extended medical cover for their family members as a perk.

Employees are in fact expected to join the scheme unless they have a valid reason for not doing so.

However, if you work in the public sector, you’re job seeker, student, self-employed or a pensioner, this law doesn’t apply to you and you’ll have to opt for a mutuelle individuelle, which tend to offer less cover.

So what’s the cost?

Mutuelles are more affordable than private health cover in the UK, hence why most people in France have one.

However unlike in Britain, it doesn’t guarantee faster treatment at the hospital or get you access to private doctors and clinics either. It just assists financing the personal contribution element of France’s healthcare.

According to 2016 results by France’s Personal Insurance Price Index (IPAP), average yearly mutuelle costs range from €350 to more than €1,200.

Data from French insurance comparison site lecomparateurassurance.com found that for over 60s average annual expenditure is €2,500, roughly €212 a month.

For families where the parents are around 35 and their two children are between the ages of 7 and 3, a family bundle costs around € 90 a month, or €1083 per year.

For a 25-year-old worker on the other hand monthly mutuelle spending is around €26.

Another consideration worth noting is that different regions of France have higher and lower mutuelles prices, although this generally affects the rate by around 10 per cent.

Read the small print

The mutuelles and complémantaire santé market is a competitive one so as mentioned earlier it’s best to ignore the sale pitches and cut to the real deal.

Make sure you read carefully through what your prospective mutuelle offers, in particular the small print of your contract, as this is often convoluted but still very telling.

Watch out for what calculation they use to actually reimburse you.

Keep an eye out for the cancellation clauses too as they can be quite specific and require notice to be given several months in advance.

If you’re not a mutuelle member already, you should probably become one

Unless you’ve got private health insurance or plenty of money stashed away which you’re willing to burn in case of a medical emergency, you’d be better off paying for a mutuelle or top-up health cover in France.

Keep in mind that healthcare isn’t completely free in France (as in the case of the NHS in the UK), so fees can run into the thousands of euros if you have to go to hospital.

It’s a case of being better safe than sorry…or in debt.

Health care in France – Wiki

The French health care system is one of universal health care largely financed by government national health insurance. In its 2000 assessment of world health care systems, the World Health Organization found that France provided the “close to best overall health care” in the world. In 2011, France spent 11.6% of GDP on health care, or US$4,086 per capita, a figure much higher than the average spent by countries in Europe but less than in the US. Approximately 77% of health expenditures are covered by government funded agencies.

Most general physicians are in private practice but draw their income from the public insurance funds. These funds, unlike their German counterparts, have never gained self-management responsibility. Instead, the government has taken responsibility for the financial and operational management of health insurance (by setting premium levels related to income and determining the prices of goods and services refunded).

The French government generally refunds patients 70% of most health care costs, and 100% in case of costly or long-term ailments. Supplemental coverage may be bought from private insurers, most of them nonprofit, mutual insurers. Until 2000, coverage was restricted to those who contributed to social security (generally, workers or retirees), excluding some poor segments of the population; the government of Lionel Jospin put into place universal health coverage and extended the coverage to all those legally resident in France.

Only about 3.7% of hospital treatment costs are reimbursed through private insurance, but a much higher share of the cost of spectacles and prostheses (21.9%), drugs (18.6%) and dental care (35.9%) (figures from the year 2000). There are public hospitals, non-profit independent hospitals (which are linked to the public system), as well as private for-profit hospitals.

Health care system

The entire population must pay compulsory health insurance. The insurers are non-profit agencies that annually participate in negotiations with the state regarding the overall funding of health care in France. There are three main funds, the largest of which covers 84% of the population and the other two a further 12%.

A premium is deducted from all employees’ pay automatically. The 2001 Social Security Funding Act, set the rates for health insurance covering the statutory health care plan at 5.25% on earned income, capital and winnings from gambling and at 3.95% on benefits (pensions and allowances).

After paying the doctor’s or dentist’s fee, a proportion is reimbursed. This is around 75 to 80%, but can be as much as 100% (if you have a long duration medical problem such as a cancer). The balance is effectively a co-payment paid by the patient but it can also be recovered if the patient pays a regular premium to a voluntary health insurance scheme (more than 99% of the population as every worker is entitled, per law, to access to a company subsidized plan). Most of them are managed by non-for-profit groups.

Under recent rules (the coordinated consultation procedure, in French: “parcours de soins coordonné”), general practitioners (“médecin généraliste” or “docteur”) are expected to act as “gate keepers” who refer patients to a specialist or a hospital when necessary.

However the system offers free choice of the reference doctor, which is not restricted to only general practitioner and may still be a specialist or a doctor in a public or private hospital. The goal is to limit the number of consultations for the same illness. The incentive is financial in that expenses are reimbursed at much lower rates for patients who go directly to another doctor (except for dentists, ophthalmologists, gynaecologists and psychiatrists); vital emergencies are still exempt from requiring the advice from the reference doctor, which will be informed later.

As costs are borne by the patient and then reimbursed (most of the time on the spot as all doctors and drugstores can read the “Carte Vitale”, a smart card with all information on the patient and the co-insurance company), patients have freedom of choice of where to receive health care services.

Around 62% of hospital beds in France are provided by public hospitals, around 14% by private non-profit organizations, and 24% by for-profit companies.

Minister of Health and Solidarity is a cabinet position in the government of France. The healthcare portfolio oversees the public services and the health insurance part of Social Security. As ministerial departments are not fixed and depend on the Prime Minister’s choice, the Minister sometimes has other portfolios among Work, Pensions, Family, the Elderly, Handicapped people and Women’s Rights. In that case, they are assisted by junior Ministers who focus on specific parts of the portfolio.

The system is managed by the Caisse Nationale de l’Assurance Maladie.

Health insurance

Because the model of finance in the French health care system is based on a social insurance model, contributions to the program are based on income. Prior to reform of the system in 1998, contributions were 12.8% of gross earnings levied on the employer and 6.8% levied directly on the employee.

The 1998 reforms extended the system so that the more wealthy with capital income (and not just those with income from employment) also had to contribute; since then the 6.8% figure has dropped to 0.75% of earned income. In its place a wider levy based on total income has been introduced, gambling taxes are now redirected towards health care and recipients of social benefits also must contribute.

Because the insurance is compulsory, the system is effectively financed by general taxation rather than traditional insurance (as typified by auto or home insurance, where risk levels determine premiums).

The founders of the French social security system were largely inspired by the Beveridge Report in the United Kingdom and aimed to create a single system guaranteeing uniform rights for all. However, there was much opposition from certain socio-professional groups who already benefited from the previous insurance coverage that had more favourable terms. These people were allowed to keep their own systems. Today, 95% of the population is covered by 3 main schemes, one for commerce and industry workers and their families, another for agricultural workers, and lastly the national insurance fund for self-employed non-agricultural workers.

All working people are required to pay a portion of their income into a health insurance fund, which mutualizes the risk of illness and which reimburses medical expenses at varying rates. Children and spouses of insured individuals are eligible for benefits, as well. Each fund is free to manage its own budget and reimburse medical expenses at the rate it saw fit.

The government has two responsibilities in this system:

The first is a government responsibility that fixes the rate at which medical expenses should be negotiated and it does this in two ways. The Ministry of Health directly negotiates prices of medicine with the manufacturers, based on the average price of sale observed in neighbouring countries. A board of doctors and experts decides if the medicine provides a valuable enough medical benefit to be reimbursed (note that most medicine is reimbursed, including homeopathy).

In parallel, the government fixes the reimbursement rate for medical services. Doctors choose to be in Sector 1 and adhere to the negotiated fees, to Sector 2 and be allowed to charge higher fees within reason (“tact and mesure”) or Sector 3 and have no fee limits (a very small percentage of physicians, and their patients have reduced reimbursements). The social security system will only reimburse at the pre-set rate. These tariffs are set annually through negotiation with doctors’ representative organisations.

The second government responsibility is oversight of health-insurance funds, to ensure that they are correctly managing the sums they receive, and to ensure oversight of the public hospital network.

Today, this system is more or less intact. All citizens and legal foreign residents of France are covered by one of these mandatory programs, which continue to be funded by worker participation. However, since 1945, a number of major changes have been introduced. Firstly, the different health care funds (there are five: General, Independent, Agricultural, Student, Public Servants) now all reimburse at the same rate.

Secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and who are not students, meaning the very rich or the very poor). This regime, unlike the worker-financed ones, is financed via general taxation and reimburses at a higher rate than the profession-based system for those who cannot afford to make up the difference.

Finally, to counter the rise in health care costs, the government has installed two plans (in 2004 and 2006), which require most people to declare a referring doctor in order to be fully reimbursed for specialist visits, and which installed a mandatory co-payment of €1 (about US$1.35) for a doctor visit (limited to 50 € annually), 0.50 € (about US$0.77) for each prescribed medicine (also limited to 50 € annually) and a fee of €16–18 ($20–25) per day for hospital stays (considered to be the “hotel” part of the hospital stay; that is, an amount people would pay anyway for food, etc.) and for expensive procedures.

Such declaration is not required for children below 16 years old (because they already benefit from another protection program), for foreigners without residence in France (who will get benefits depending on existing international agreements between their own national health care program and the French Social Security), or those benefiting from a health care system of French overseas territories, and for those people that benefit from the minimum medical assistance.

An important element of the French insurance system is solidarity: the more ill a person becomes, the less they pay. This means that for people with serious or chronic illnesses (with vital risks, such as cancers, AIDS, or severe mental illness, where the person becomes very dependent of his medical assistance and protection) the insurance system reimburses them 100% of expenses and waives their co-payment charges.

Overcoming roadblocks to insurance, risk finance, and development

Finally, for fees that the mandatory system does not cover, there is a large range of private complementary insurance plans available. The market for these programs is very competitive. Such insurance is often subsidised by the employer, which means that premiums are usually modest. 85% of French people benefit from complementary private health insurance.

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