Pas Trusted News – 7 points to consider when choosing top-up health insurance in France

Anyone who pays into the French social security system and/or lives full-time in France can have their basic medical care paid, at least in part, by the state. 

However, some treatments may still carry an extra cost. We consider the options for top-up health insurance to cover this.

What does the state usually pay?

The part paid by the state varies depending on the type of care. For example it is 70% of the full cost for a visit to your GP.

As an example, a visit to the GP costs €25. The social security system reimburses 70% of this, which is €16.50 (after a €1 ‘franchise’ deduction). So, €8.50 remains payable by the patient from their own pocket or by their mutuelle ‘top-up’ policy.

In some cases today the state-funded part is paid through the tiers payant, or third-party payment scheme. In this case the costs are paid directly by the state health cover system, Assurance Maladie, to the healthcare provider, without the patient having to pay first and then be reimbursed.

What is top-up health insurance?

Technically-speaking, top-ups can be either a mutuelle or a complementaire santé. A mutuelle is provided by a non-profit organisation and is a scheme run for its members, while a complementaire is a policy from a commercial insurance company. However, the term mutuelle is widely used for such policies, even when not technically correct.

Most people have top-up insurance to cover the remainder of healthcare costs after deducting the amount paid by social security. Top-up insurance can also pay for extra costs, such as more comfortable hospital rooms, some more complex and costly forms of dental work (eg. orthodontics) or more high-end glasses and corrective lenses.

Many people have a top-up through their work (employers are obliged to offer this). Others pay out of their own pocket for an individual policy.

Only around 5% of people in France do not have extra coverage. However, during the Covid crisis, there were reports that up to 12% of older people did not have one, potentially exposing them to high hospital costs.

People who cannot afford top-up cover may be eligible for the complémentaire santé solidaire (CSS), which is intended to help low-income people. This replaced previous schemes called  ACS and CMU-C,

Read more: Explainer: the CSS, France’s free or low cost top-up health insurance 

Note that these policies are usually described as having cover at a certain percentage for various types of healthcare. For example,‘100%’ cover for doctor visits does not necessarily mean everything is paid for, it refers to you being topped up to 100% of the basic state tariff for the service in question, called the tarif de convention.

The state tariff for a GP visit, for example, is €25. However, if your doctor charges €35 (see point 2, below), 100% cover will only top you up to €25, whereas 150% would cover up to €37.50, ensuring there is nothing left to pay.

If you are among those who do not have a top-up, or if you want to find a new one, 60 Millions de consommateurs, the magazine of the official national consumer institute, has published advice to help you find the best policy. We have summarised the most useful points.

1. All ‘responsible’ policies will cover certain basics

Whether the plan is from a mutuelle or not, the most important aspect is the content of the policy.

In most cases, the contracts are state-regulated according to ‘responsible policy’ rules, and for example, provide access to the 100% Santé scheme (with no out-of-pocket costs for a range of good quality, but not top-of-the-range, dental, audio and eye-care equipment). This also applies to the chance to use the tiers payant system and a top up to at least certain minimum reimbursement levels depending on treatment.

In some cases, however, the reimbursements are capped so as to encourage people to respect the usual ‘health pathway’ (such as obtaining GP referral to visit specialists).

So, arguably, even a basic-level plan is likely to be better than no plan at all.

Having said that, policies are not all the same and the levels and types of cover provided vary to suit different risk profiles. For example, some insurers are experts at covering retirees, while some are best-known for covering people who work within a particular sector, such as building and civil engineering, or SNCF etc, or the self-employed.

2. Think about your specific needs

Try to choose the level of cover best-suited to your needs. For example, what treatment do you use, how many consultations do you anticipate you will need, and what are their fees?

Some specialists charge more than the standard rate in a practice known as dépassement d’honoraires. The social security system does not pay more to allow for this but some top-ups do. You can check if a doctor charges dépassements at l’annuaire de l’Assurance maladie (note that if they are listed as being in ‘sector 1’, this is not the case).

If you have glasses, a hearing aid, or dental prostheses, as mentioned above, a ‘100% Santé’ scheme (which aims for ‘zero out-of-pocket expenses’) is now in place for such devices. However, you must be signed up to an eligible top-up to qualify.

However this does include certain caps.

So, for example, if you have a strong prescription, and want the thinnest most expensive lenses, or you want, designer frames or the latest generation bifocal lenses, you might want to look at a policy that has optical cover above and beyond the basics, otherwise you will have to pay for the difference yourself.

Also, if you want to use ‘alternative’ medicine treatments that are not covered by the social security you may want to find a top-up that includes refunds for médecine douce.

If you have children, a ‘family contract’ may offer a fixed price inclusive of them on the same plan, but check the details as in some cases children are only included ‘free’ from the second or third child.

You should also consider the specifics of your children’s health needs (for example, dentistry, physical therapy, glasses etc).

Some policies are aimed at couples together, but tend to be best value when you both have similar needs.

3. Consider local offers

The cost of treatment and the rate of health problems can often vary from region to region in France, so it is worth considering smaller local mutuelles rather than big names. However, this may be less appropriate if you are likely to move in the future or travel a lot.

Note also that more than 2,000 local communes take part in the Ma Commune, Ma Santé scheme, which enables unemployed people, senior citizens, and the self-employed to take out a contract at a good-value price, equivalent to a group contract. Check with your mairie, or see the information helpline at the link.

4. Plan ahead

When signing up for a policy, think how your needs could change in the future, such as pregnancy, or hospitalisation for the elderly.

You can now legally cancel or alter your policy at any time, but only after you have had the contract for a year.

Some contracts also have waiting periods before you can use them, to avoid people signing up just to cover expenses they already know about (for example, upcoming dental or eye treatments, or hospitalisation). Make sure you are aware of this before signing up.

5. Do your homework

Top-up insurers have obligations to provide clear information so it is possible to compare their policies, and it is wise to spend some time understanding the policy and checking that it is right for you.

Online comparison tools, forums and reviews can help you understand further what each policy covers, what people think and how they compare in coverage and price.

Try to learn all you can: how quickly the insurer settles claims, its standards of service and dispute resolution, if it provides any assistance with telemedicine (healthcare at a distance, using technology), partner networks, and the forms of support available (for example, funeral assistance, or domestic help).

However, comparison sites may not display all of your available options, such as local insurers, or those that specialise in a particular profession.

On the other hand, some comparison sites only compare local offers, such as for the Lyon region, so it is important to use ones that are relevant to your needs.

When using comparison sites remember to opt out of marketing or you risk being bombarded by marketing emails and calls.

Look out for special clauses, exclusions, and restrictions, and always read the small print!

6. Speak to a broker

If you are struggling, or have particularly specific needs, it may make sense to speak with an independent insurance broker.

A good broker should help you to find a good-value policy that works for you (rather than for them), although many will of course take commission for their services.

Brokers should be transparent about any conflicts of interest, commissions, or any partners they have.

7. Look for financial help

If you are struggling financially, you may, notably, be eligible for complémentaire santé solidaire, which is a free or subsidised top-up provided by the state.

You can check to see if you are eligible via the Assurance Maladie’s simulateur de droits.

Other help towards paying for a top-up may include versements santé schemes that some companies offer to people on temporary or part-time contracts, meanwhile some regions offer student aids called Pass mutuelle.

It is also worth asking your mairie about possible aids (in larger areas there will be a section called centre communal d’action sociale), as well as, for pensioners, your pension fund.

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