Over 95% of the French have a supplemental health insurance called mutuelle santé or mutuelle. After I explain some basic concepts, I will give you four good reasons why you should subscribe to a mutuelle. You will also learn which medical expenses are covered.
- What’s Assurance Maladie Complémentaire?
- What is a complémentaire santé?
- Who sells mutuelles santé?
- What is a French mutuelle?
- Mutuelles for private sector employees
- 4 good reasons to get a mutuelle
- What does a mutuelle santé cover?
- Responsible contract
- Solidary contract
- What’s 100% Santé?
- Beneficiaries on a mutuelle
- How much does a mutuelle cost?
- Is there an age limit for a French mutuelle?
- Waiting period
- Carte de tiers-payant
- Complémentaire santé solidaire for low income
- Right of withdrawal
- Cancel a French mutuelle
- What’s a surcomplémentaire santé?
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What’s Assurance Maladie Complémentaire?
Assurance Maladie Obligatoire (AMO) is the French mandatory health insurance whereas Assurance Maladie Complémentaire (AMC) is an optional supplemental insurance. Start with French Healthcare System if you do not know how Assurance Maladie works.
What is a complémentaire santé?
The insurance contract you enter into is called a complémentaire santé but most French use the term mutuelle instead. A complémentaire santé is also referred to as mutuelle santé or contrat de mutuelle.
complémentaire santé = mutuelle santé = mutuelle = contrat de mutuelle
Who sells mutuelles in France?
One can purchase a mutuelle santé from:
- Insurance companies
What’s a French mutuelle?
A mutuelle is one specific kind of complémentaire santé that is provided by a non-profit organization called Mutuelle. Mutuelle organizations follow code de la mutualité (group of laws specific to Mutuelles). Mutuelles are based on the principle of solidarity.
Concretely, it means that everybody has the same access to medical care regardless of their age, health conditions or wealth.
This is the reason why a Mutuelle does not select who can enroll, no health question asked.
The difference between insurance companies and Mutuelle organizations can sometimes be fuzzy. Use this organization checker from La mutualité française to verify that an organization is indeed a real Mutuelle.
Mutuelle for private sector employees
Since 2016, mutuelle santé is mandatory for private sector employees. By law, private employers in France have to provide a complémentaire santé d’entreprise (group complémentaire santé) to their employees. The employer pays at least half of the premiums. An employee can refuse the mutuelle santé provided by the employer in the following situations:
- employee already covered by a mutuelle: from a spouse’s complémentaire or an individual mutuelle or beneficiary of Complémentaire Santé Solidaire (C2S)
- part-time work
- employee on Contrat à Durée Déterminée (temporary work contract)
To refuse the company’s complémentaire, write a letter to your employer to justify your dispense d’adhésion (enrollment exemption).
After you leave the company, you can sometimes keep the company’s complémentaire santé for a while. The conditions to benefit from a group mutuelle after the end of a work contract are listed on the French government website.
4 good reasons to get a mutuelle santé
Complémentaire santé is not mandatory, unless you work for a private company. After going through the trouble of registering into the mandatory French healthcare system, you might wonder why you should get a supplemental health insurance.
Indeed, if you follow parcours de soins and you exclusively visit physicians in secteur 1, your out-of-pocket expenses are very reasonable.
For instance, a visit to your primary doctor only costs €8.50 after Assurance Maladie reimbursements.
Even so, consider these four very good reasons to get a mutuelle santé.
1. Physicians outside secteur 1
Assurance Maladie does not reimburse any dépassements d’honoraires (amount above official fee). A mutuelle santé reimburses some of the costs for physicians in secteur 2 or 3 (non conventionnés). This is particularly helpful if you live in a region of France where finding a médecin conventionné in secteur 1 is challenging. Read Health Care in France if you are not familiar with the different sectors for doctors. Check your doctor’s secteur and fees on Ameli’s annuaire (physician phonebook)
2. Treatments poorly reimbursed
Dental prosthesis, hearing or optic aids are very poorly reimbursed by Assurance Maladie. When it’s time for your teen to get braces, you might want to get a mutuelle santé that has excellent coverage for orthodontic treatments.
As an example, the total cost for my son’s braces for one semester is €970. Assurance Maladie reimburses only €193.50 of the amount. The whole treatment lasting six semesters, this leaves me with €3,882.50 out-of-pocket without a mutuelle. Read How I find the best mutuelle for orthodontist to better cover my expenses.
3. 100% Santé
Most mutuelles santé give you access to 100% Santé programs. This is really important since Assurance Maladie does not reimburse much of optic and dental costs.
4. Hospital stay
Assurance Maladie reimburses 80% of official fees for hospital stay. Most complémentaires cover the remaining 20% as well as forfait hospitalier (€20/day). Depending on your insurance level, a private room and extra amenities like tv might be partially or totally reimbursed.
What does a mutuelle santé cover?
Reste à charge (out of pocket) is the difference between what the patient pays and what is reimbursed by Assurance Maladie. Your mutuelle santé reimburses parts or sometimes the entire amount of :
- Reste à charge (out-of-pocket) on medical costs already partly reimbursed by Assurance Maladie: ticket modérateur (out of pocket) and forfait journalier in hospitals.
- Dépassements d’honoraires (amount above official fee) on medical costs already covered by Assurance Maladie.
- Some medical expenses not covered by Assurance Maladie (osteopaths or psychologists for example).
Have you heard?
In some parts of France, access to a general practitioner is very limited. These areas, called désert médicaux (medical deserts) are mainly located in the centre and North-West region of France. There are also some déserts médicaux in some municipalities near Paris.
Contrat responsable (Responsible contract)
Most mutuelles are deemed contrats responsables (responsible contracts). With a contrat responsable, a patient is better reimbursed when he follows parcours de soins coordonnés. A great advantage of a contrat responsable is that it gives you access to 100% Santé.
Contrats responsables are highly regulated and they follow stricts reimbursement rules set by the French government. Reimbursements cover at least:
- treatments that qualify for 100% Santé
- ticket modérateur (out-of-pocket)
- forfait journalier hospitalier (hospital daily flat fee)
- at least 125% of base de remboursement (reference rate) for dental prosthesis and orthodontic treatments
- between €100 and €200 for prescription glasses, every two years
Contrat solidaire (Solidary contract)
A mutuelle santé is a contrat solidaire (solidary contract) when premiums are not calculated based on the health of the insured. There is no requirement to fill out a health questionnaire to subscribe to a contrat solidaire.
Today, most mutuelles santé are both responsible and solidary.
What is 100% Santé?
100% Santé reduces the out-of-pocket expenses to zero on some dental prosthesis, hearing and optical aids.
Who can benefit from 100% Santé?
Any complémentaire santé that is responsable (responsible) gives you access to 100% Santé.
100% Santé dentaire (Dental)
100% Santé Dentaire applies to crowns, bridges and dentures. Before starting dental work, a dentist has to give you a written quote. The quote shows different options and one of them is 100% Santé, which means that you do not have to pay anything. Check the list of dental prosthesis that qualify for 100% Santé dentaire on Ameli’s website.
If your dental prosthesis does not qualify for 100% Santé, send the quote to your insurer to know how much you will be reimbursed.
100% Santé optical and auditive
100% Santé also applies to prescription glasses (lenses and frames) and auditive aids. Your optician and your hearing care professional must give you a quote with items that qualify for 100% Santé.
Beneficiaries on a mutuelle santé
One or several family members can be on the same complémentaire santé. Some organizations let you add children at no extra cost. You cannot have a child on his/her own mutuelle without a parent.
Depending on the family members needs, it can be sometimes cheaper to subscribe to multiple complémentaires santé and split the family between them.
If your teen needs braces for instance, it could be advantageous to subscribe one parent and one child to a complémentaire santé that covers orthodontics treatment very well and keep the rest of the family on a plan with a lower level of coverage (at a lower price).
How much does a mutuelle cost?
The cost for a mutuelle santé varies based on:
- your location
- the options you choose (dental, optics…)
- your age
- your family situation (how many family members will be on the contract)
Is there an age limit for a French mutuelle?
There is no age limit when you pick a Mutuelle organization. Some banks and insurance companies have restrictions on the age of the insured. There are nonetheless many offers for complémentaires santé for seniors on the marketplace.
Délai de carence (Waiting period)
Délai de carence is a period of time at the beginning of your contract when the insurer does not cover some medical costs. This is clearly indicated in your contract. This delay can last from only a few days up to twelve months. Some insurers do not apply any waiting period.
Did you know?
Mutuelle comes from the noun mutualité. Mutualité is a solidarity system between members of a group, based on mutual help.
Carte de tiers-payant (Third party card)
Most mutuelles provide tiers-payant at the pharmacy or the lab. This allows you to pay only the portion of the bill not covered by Assurance Maladie and your mutuelle. Hand out your mutuelle card to the pharmacist to benefit from tiers-payant.
How to get reimbursed?
Your complémentaire santé is linked to your Ameli account. When you hand out your carte Vitale at the doctor’s office or pharmacy, Assurance Maladie receives the information and notifies your complémentaire santé. Your reimbursement is automatically deposit into your bank account within a week.
If you don’t have your carte Vitale with you, the doctor or pharmacist gives you a feuille de soins that you mail to your local CPAM. Assurance Maladie then notifies your mutuelle.
Complémentaire Santé Solidaire (C2S)
Complémentaire Santé Solidaire (CSS or C2S) is an aid from the French government for people affiliated with Assurance Maladie with resources under a specific threshold. The threshold varies based on your location and the number of family members. If you qualify, C2S is either free or less than €1 per day and per person. With C2S, you do not have to pay for any of your medical costs (doctor, dentist, pharmacy, hospital…).
You can also fill out the demande de Complémentaire santé solidaire form and mail it to your local CPAM.
Délai de rétractation (Right of withdrawal)
When you subscribe to a mutuelle santé over the phone or on the internet, you have fourteen days to change your mind. To withdraw from your mutuelle santé, send a lettre recommandée avec accusé de réception (registered mail with signature confirmation) along with your policy number and the date of your subscription.
Cancel a French mutuelle
After 1 year of contract
You can cancel your French mutuelle at any time after the first year. Notify your mutuelle by email, regular mail, phone or through your user account. When you switch to a different mutuelle, your new insurer takes care of cancelling your former mutuelle. The cancellation takes place one month after the insurer receives the notification.
Before the end of the first year
You can cancel your mutuelle santé before the end of the first year in case of a changing event:
- you start a job with a mandatory group mutuelle santé
- family change: mariage, divorce, death of your spouse
- you move
- work change: retirement, new job.
Send your cancellation notice within three months of the event by lettre recommandée avec accusé de réception (registered mail with signature confirmation).
What is a surcomplémentaire santé?
A surcomplémentaire santé is an extra health insurance on top of your mutuelle santé. It can be useful if your mutuelle santé does not reimburse enough of your medical expenses. Most of the time though, a mutuelle santé is sufficient.
You now know why you should subscribe to a mutuelle santé. When you are ready to shop for a mutuelle, read How to Find the Best Mutuelle.