My husband and I spent the past 10 months resolving our older daughter’s hearing issues. The process was educative and, while I try to avoid learning the hard way, I am grateful for the insights I picked up about the French health care system, which follow. Bonne lecture, et bonne santé!
Sécurité Sociale (aka “Sécu”) – the French national healthcare system
Anyone residing in France for more than 3 months is eligible for some public healthcare coverage: taxpayers and their dependents (via Caisse Primaire d’Assurance Maladie, or CPAM), legal aliens (via Couverture Maladie Universelle, or CMU), even illegal aliens (via l’Aide Médicale de l’Etat, or AME).
- If you have questions, call the Anglophone hotline.
Sécurité Sociale does not automatically cover 100% of all medical costs. This was news even to my French husband. Sécu sets an approved treatment cost for all types of care – visits, procedures, medications – and covers a percentage of that cost, ranging from 15% to 100%. But many doctors can charge more than the approved cost, which means the patient pays the balance of the approved cost PLUS the difference between the approved and actual cost.
For example, if the approved cost for visits is 23€ but my generalist charges 45€ per visit, here’s the math:
45€ (what my generalist charges)
– 16.10€ (Sécu reimbursement, 70% of the 23€ standard rate)
+ 1€ (fixed admin fee for each reimbursement – waived for children under 18, women in or beyond the sixth month of pregnancy, any services rendered in the first 12 days after a birth, and for anyone covered under CMU or AME)
= 29.90€ (my cost)
Doctor’s fees in any given neighborhood often correlate with the average income in that neighborhood. Highly reputed doctors, and those with special skills (such as fluency in English), frequently command higher fees.
Patients with chronic health problems can receive 100% reimbursement (at the approved rate, of course) for related costs.
Most dental work, apart from check-ups, is not covered by Sécu.
Reimbursements are direct deposited into your bank account.
La Mutuelle Santé – supplementary private health insurance
Because there can be significant coverage gaps with Sécu, some families, such as those who wish to see doctors in private hospitals or practices (like the American Hospital of Paris), pay into private insurance groups. And some companies pay for employees to participate in these mutuelles. The mutuelle might reimburse 100% to 400% of the approved costs set by Sécu as well as some of the dental, vision, or alternative medicine costs not covered by Sécu at all. (Ask your doctor to provide you with a receipt for your mutuelle for any costs not covered by Sécu.)
You can also link your mutuelle to your Sécu account so that a reimbursement processed through Sécu is then transmitted to the mutuelle for any supplemental reimbursement.
La Carte Vitale – the medical claims facilitator
Green and credit card-sized, the Carte Vitale simplifies the reimbursement process. A chip on the card contains just the administrative information required for Sécu to deposit your reimbursement into the bank account you’ve linked to the system. Adults and children 16+ can request a Carte Vitale and, if you have one, bring it with you for any doctor or pharmacy visits.
I’ve noticed that I almost always pay doctors and specialists – even when I present my Carte Vitale – but I don’t pay pharmacies or labs. Some doctors do not have the machine that reads the Carte Vitale and electronically transmits a claim for you. Those doctors will need to give you a feuille de soins so you can be reimbursed (see “Feuilles de Soins” below).
To note: Non-working spouses and children under 16 are covered by the account of a working spouse/parent. Because I am an adult, I have my own Carte Vitale but I don’t have my own account so my card doesn’t list our children. When I take them to the doctor or get their prescriptions filled, I need to bring my husband’s Carte Vitale with me.
Feuilles de Soins – the standard medical claims forms
Those who are eligible for coverage but who don’t have (or forget to present) a Carte Vitale should request a feuille de soins for any medical costs incurred. This form must be completed, sealed in an envelope, and submitted to your nearest CPAM branch for processing.
If your doctor does not process the Carte Vitale, s/he must give you a feuille de soins you can submit for reimbursement.
Les Médecins – the doctors
There are three classifications for doctors, each with different fee and reimbursement structures:
- les médecins conventionnés Secteur 1, honoraires sans dépassement: These doctors are contracted to honor the fees fixed by Sécu. Generally, these doctors’ fees do not surpass the approved treatment cost. Exceptions exist for house visits or visits outside of designated office hours. In case of exceptions, Sécu will reimburse the approved treatment cost (less the 1€ admin fee) and the patient covers the rest.
- les médecins conventionnés Secteur 2, honoraires libres: Sector 2 doctors are at liberty to set their own fees “with tact and moderation”, staying mindful of the fees fixed by Sécu. In return, Sécu will reimburse the approved treatment cost (less the 1€ admin fee) and the patient covers the rest.
- les médecins non-conventionnés These doctors operate outside the agreement set between Sécu and normed doctors. Sécu reimbursements for médecins non-conventionnés are dramatically lower and, in some cases, non-existent.
French doctors here are notorious for their poor penmanship. Sometimes not even other medical professionals can decipher the writing. Our pharmacist confirms this. Be sure to verify the contents of each prescription with your doctor before you leave.