Frais de Santé query

[stan]

Along with myself, my wife went to the doctors for a consultation recently. This is the first time, with the exception of registration purposes that my wife has visited her "medecin traitant". We both have a top up mutuelle.

When the statement of healthcare costs arrived from the mutuelle, I noticed that my 23€ fee was refuned 100%, whereas my wife`s 23€ fee was only refunded at 70%, meaning only 16€10c was refunded.

Next to the 100% refund of mine was highlighted " PAS DE COMPLEMENT SOINS REMBOURSES 100% PAR L.A. SS", whereas my wife had highlighted next to her 70% refund "PRESTATION DEJA REGLEE"

I have emailed in my best French, my mutuelle (Euroassurance) for them to explain this, or to point out a possible error, but they have not bother replying, hence my post here, hoping that someone will know what this means exactly in relation to these healthcare fees.

[NormanH]

Sounds as if you are on 100% cover for some reason, and that your wife's top up bit has already been paid out.

Have you checked on your bank statement to see if her payment has gone in?

In any case there should be 1€ retained out of the 23€ as a 'forfait' that is to say a charge you don't get back for each of you.

[nomoss]

stan:

Is that statement from your Mutuelle, or from l'Assurance Maladie (via the CPAM for your area)?

 

NormanH:

[quote user="NormanH"]Sounds as if you are on 100% cover for some reason, and that your wife's top up bit has already been paid out.
Have you checked on your bank statement to see if her payment has gone in?
In any case there should be 1€ retained out of the 23€ as a 'forfait' that is to say a charge you don't get back for each of you.
[/quote]

I think a lot of people probably believe that.

Actually, CPAM sneakily deducts the 1€ "forfait" from the 70% they "remburse".

That is, they "repay" 16€10 of the 23€ you paid to the doctor, then deduct 1€ from this "repayment", leaving you with a refund of only 15€10.

If, as it seems one is supposed to believe, you were paying 1€ of the doctor's charge directly, as a "forfait",  that would leave 22€ as the "base" for the 70% refund, and you would be refunded 15€40.

So you are in fact participating, not in paying the doctor, but in reimbursing yourself [:D]

Edit: Add response to stan, previously omitted.

 

[NormanH]

Yes you are  absolutely right on the detailed working of the system, but what I was trying to say is that most people don't get back the full 23€ unless you are

• Pour les consultations des enfants de moins de 18 ans ;
• À partir du 1^er jour du 6^e mois de grossesse, si vous êtes enceinte, et ce jusqu'au 12^e jour après la date de votre accouchement.
• Si vous êtes bénéficiaire de la CMU complémentaire ou de l'aide médicale de l'État (AME).

so I was surprised to see stan say he got back the full 23€

[nomoss]

[quote user="NormanH"]Yes you are  absolutely right on the detailed working of the system, but what I was trying to say is that most people don't get back the full 23€ unless you are

• Pour les consultations des enfants de moins de 18 ans ;

• À partir du 1^er jour du 6^e mois de grossesse, si vous êtes enceinte, et ce jusqu'au 12^e jour après la date de votre accouchement.

• Si vous êtes bénéficiaire de la CMU complémentaire ou de l'aide médicale de l'État (AME).

so I was surprised to see stan say he got back the full 23€

[/quote]

 

I assumed this was because of his incapacity, mentioned previously, http://services.completefrance.com/forums/completefrance/cs/forums/2767038/ShowPost.aspx , and that the statement he quoted seemed more like a CPAM than a mutuelle account.

 

[NormanH]

Perhaps it's because he has an S1. Does that exonerate people? That is one area I don't know about.

Other wise

La participation forfaitaire s'applique quel que soit le médecin

consulté, que vous respectiez ou non le parcours de soins coordonnés. Ce

qui veut dire que vous êtes concerné même si :

• Vous souffrez d'une affection de longue durée (ALD).
• Vous êtes en arrêt de travail pour maladie.
• Vous percevez une rente d'incapacité permanente suite à une maladie professionnelle ou à un accident du travail.
• Vous êtes titulaire d'une pension d'invalidité, vous êtes retraité, etc. ;

[stan]

Thanks NormanH..I checked the bank statement and the difference from the mutuelle had been refunded. The mutuelle had sent an old statement in error. Sorry, my fault...mid life moment! We are both covered 100% with the top up (minus the 1€ forfait).

[NormanH]

Glad it is settled [:)]