Health payments query

[Gardengirl]

Hi everybody, here's a question for a friend. She's in the healthcare system, a permanent resident, retied, who pays her taxes etc in France and England. We don't know the answers to her questions, as we are resident in England, and not here above the time limit. But we always have a receipt from doctors/hospitals etc and claim from EHIC or our travel insurance, whichever is correct at the time.

She pays the doctor the 24€ for her visit, sometines gets a receipt, sometimes not, has been for x-rays and had to pay 10€ for each. She hasn't had any money returned to her.

Can you please help with the following info:

1. What is the standard procedure to enable her to reclaim from her top-up health care cover?

2. Does it start with the doctor/dentist and or hospital to initiate the payment?

3. Does she take the paperwork to CPAM or to her top-up provider?

Any other help on this you can think of would be very helpful as she may not know what the right questions.

[mint]

I think,, GG, the first thing to ask her is whether her mutuelle operates the "tiers payant" system.

If it does then all repayments should be automatic into her bank account.  The CPAM also pays directly into her bank account.  Has she registered her bank account with her mutuelle and the CPAM?

 

[EuroTrash]

1. A doctor will always provide the paperwork if you ask.

2. It would be surprising if 10€ was the full cost of X-rays. Normally they cost more like 100€. Presumably the remainder of the cost (the part CPAM meets) was charged to CPAM via her her carte vitale, and the remaining 10€ can be claimed from her mutuelle if it's covered, X-rays usually are I think.

[Patf]

I don't know about a receipt, but if you pay the doctor * he/she should give you a form called feuille de soins, printed in brown on white. This you send off to cpam, having filled in your details including carte vitale number. Include a rib giving bank account details.

* some doctors have a machine which registers your CV and you don't have to pay.

[NormanH]

1) Has she declared her choice of médecin traitant to the CPAM?. If not her repayments will be much reduced.

http://www.ameli.fr/assures/soins-et-remboursements/comment-etre-rembourse/le-parcours-de-soins-coordonnes/choisir-et-declarer-votre-medecin-traitant.php

2)She should not need a receipt or a EHIC card. She should give the Doctor or Xray centre her carte vitale and that covers the part refunded by the state. She may have to advance the 23€ to the Doctor but she should get about 15€ back in her bank account if she has done as 1) above. This is 70% of the cost minus 1€ forfait

3) The part refunded by the top-up is paid automatically. When the CPAM gets the notifcation that the carte vitale has been used it sends a message to  the top-up insurance who in turn refund  their part to your bank account

[Gardian]

Just one thing to add ............... but I can't remember how it gets initiated!!!??

Its how CPAM knows whether you've got a mutuelle and if so, who it is.  I don't think that it was down to me to tell CPAM, so I reckon that the mutuelle takes that responsibility on - after all, you give them your SocSec Number when you 'sign up'. As Norman says, it then all happens automatically.

With our local pharmacie, I give them a copy of our mutuelle renewal (they periodically ask me for the latest version) and they log it into their computer - then all medication is handed over FOC. CPAM pays its 'share' and passes the remaining charge on to the mutuelle.  

[NormanH]

Yes the Mutuelle gets in contact with the CPAM who then put into action 'télétransmission'[:)]

[Gardian]

That's a relief Norman! Glad that I guessed right!

[Gardengirl]

Thanks for all the replies everyone - I'll pass them on to my friend, who was delighted at the thought of people on the forum helping to sort out her problem.

[idun]

gardengirl, as she is a french resident, she really does not have a problem that she could not have ressolved herself very simply, ie talk to the CPAM and her mutuelle. These  really are very simple  everyday things in France, really they are,  nothing complicated.

So what is going to happen IF she has a real problem?

[Gardengirl]

Idun, she has a lot of French and English friends who help her out. Her French has come on by leaps and bounds since she retired and came to live full-time in France, but she readily admits she still has big gaps. She attends a weekly French class in town, and isn't backward in coming forward to seek help when needed. She didn't know about this site, which I think is a marvel!

A further question since I saw her this morning - has anyone decided not to take out a top-up and put an amount of money away (maybe 100€) per month into an account for the time when the top-up or money is needed? We discussed how someone in very good health can suddenly have a serious illness which could cost a fortune in France. We put forward how my dear SIL and I were found to have cancer(s) and my husband had a heart attack, despite having a healthy life-style and a Mediterannean diet, so she's aware that her good health so far might not continue forever. It would be interesting to know if anyone has taken the decision to do without top-up healthcare - I must say that I wouldn't go that route myself if we became French residents, but I'm very risk-averse!

[NormanH]

I believe some people on here do this, and there may be an actuarial argument in favour; It is partly a question of what you expect from the Mutuelle.

At the moment really serious illness and accidents are covered at 100% for the treatment anyway, so that takes away part of that feeling of 'but what if.....' and you may calculate that the 30% which you have to pay of other things will add up to less that you will save by not paying an assurance although I am sure that S0d's law says I would break a leg the day I cancelled mine and hadn't yet saved anything up.

On the other hand my Mutuelle covers me for things that would not be paid for and are important to me, such as the additional costs of a single room in Hospital

You can see these here: http://www.swisslife-direct.fr/Mediatheque/Media/5853%2520C%2520012013%2520Depliant%2520Ma%2520Formule%2520Seniors.pdf

There is also the 'moral' argument that this insurance is a mutualisation or sharing out of  of costs. That is why the French word is Mutuelle not something which indicates a top up

http://www.vie-publique.fr/decouverte-institutions/finances-publiques/protection-sociale/financement/pourquoi-cotise-t-on-mutuelles-sante.html

A more pragmatic argument is that the  trend is towards the State reimbursing less and less leaving more and more to be picked up by the individual or the Mutuelle, and the fact that more and more specialists are charging 'dépassement des horaires' which isn't covered either at 100%  For those you may need 300% or 400%

[mint]

Also, GG, I don't know how old your friend is but there are many mutuelles out there who will not accept people over the age of 70.  This was discussed quite extensively on a previous thread.

If you are already with a mutuelle by then, you are not likely to be "kicked out".  As you know my OH is in his 83rd year.  We have had a mutuelle since we arrived here when he was a mere 76!

Fortunately for us, they keep on renewing our policy, that is, as long as we can pay, I expect![:)]

[Gardian]

[quote user="gardengirl "]A further question since I saw her this morning - has anyone decided not to take out a top-up and put an amount of money away (maybe 100€) per month into an account for the time when the top-up or money is needed? [/quote]

GG ............

We're certainly in the 'mutuelle camp'.

Everybody's circumstances are different of course, but as you know Mrs G has had a couple of short hospital stays in recent years. Any tests that are carried out are chargeable and (believe me!) they tested for every possibility in order to diagnose her problems. My recollection is that if we hadn't had mutuelle cover, we would have had a bill for c €700 on each occasion. If you then factor in the c €30 / mth that I would have to pay for my routine medication, you arrive at (very roughly) half of what we've paid out coming back in benefits.

But ................ it wouldn't have taken much for it to have been the other way round. Due to my exemplary personal habits, [blink] I continue to be a model of fitness. You never know what's round the next corner though.

Its insurance - not much more to be said. 

[Chancer]

My experience is the opposite, I have no mutuelle, enjoy superb health but did have a bad couple of years of accidents requiring several hospitalisations and operations.

In the good years I pay next to nothing, €6.60 towards a visit to the medecin, 30% towards any precribed medications but apart from eyedrops I dont have any, even with a full health check every january, blood and urine tests etc and twice a year consultations at the eye hospital (again €6.60 aat my charge) I pay out far less a year than I would for one monthly mutuelle payment.

What about the bad years then, all the hospitalisations, the operations, the ambulances? Well they were all 100% prise en charge, even planned things like a coloscopy and overnight visit, the propertion that I had to pay for the ambulances to that visit was less than to go 4km into town and back yet the same company took me 60kms and picked me up the next day, all the ambulances from calling SAMU were 100% prise en charge. Out patients appointments and post op prescribed meds were not insignificant but only because initially they were every few days at €6.60 per consultation.

I did have to pay the €18 forfait journalier but you can deduct from that what I would have spent on food and heating, not sure if mutuelles refund that anyway.

I am lucky in that being in a deprived area nobody, but nobody would dare to charge more than the convention.

TBH you hear lots of second hand horror stories of what hospitalisation would have cost, and the mutuelles love to dissipate them but I really do believe in 99% of the horror cases they dont pay out anything and neither would the patient have had too, excepting those who had no cover at all, not even an EHIC, I think in that case they want a credit card up front and it gets hit, I have heard of one instance of this, again second hand so it may not even have been true but wishfull thinking.

I think what really puts me off mutuelles and pretty much all insurance in France other than the obligatory motor insurance is how everyone around here tries their utmost to claim more than they pay in premiums, to rip the proverbial out of it, the mutuelles have to make a profit and its the healthy ones like me that would be paying for it.

 

[idun]

I had ten days in hospital in France and it cost thousands of euros in total, no surgery, in fact apart from bloods and urine samples little else was done to me other than prodding and poking, or simply just discussing me at the end of my  bed. The mutualist picked up a several thousand euro bill and I was glad that we didn't have to pay.

Our mutuelle also picked up most of the excess charges that a couple of surgeons wanted for operations.

It is a choice and I was always glad that we had a mutuelle.

[NormanH]

What about the bad years then, all the hospitalisations, the operations,

the ambulances? Well they were all 100% prise en charge, even planned

things like a coloscopy and overnight visit

As we have previously discussed somebody made a mistake on this, since a coloscopy for example is not reimbursed at 100% unless it is a follow up to something like bowel cancer which has previously been granted that cover.

I certainly don't doubt that this was your experience, but I don't think it is the model to base a decision on.

http://vosdroits.service-public.fr/particuliers/F164.xhtml   shows who can benefit from 100%

http://vosdroits.service-public.fr/particuliers/F165.xhtml explains the parts you have to pay for

http://vosdroits.service-public.fr/particuliers/F200.xhtml shows the costs of a going into Hospital

[Hereford]

An alternative to full "top up" can be just hospital cover especially if "older" as it is much much cheaper. My parents have this and it has worked well.  No worries whatever the reason for hospitalisation. Daily food/drink charge covered and any other test or procedure that is done in the hospital. 

One company wanted a medical certificate first to give this sort of cover but the one they chose did not. They were 78 and 79 when the cover started.

[EuroTrash]

I'm sure I've read that mutuelles are by law not allowed to take your medical history into account, just like the state scheme isn't. The premiums are based on age and sex and often on occupation and maybe where you live, but they can't ask questions about your medical history. Again - "mutuelle", as opposed to private company out to make a profit.

[Hereford]

We thought that too Eurotrash but one Company (not I think a "mutuelle") did ask, but only for hospital cover, so we crossed them off the list when looking for cover for my parents.

[Gardengirl]

Thanks for the additional comments, which I'll pass on to my friend - who's experiencing British weather today!

[mint]

[quote user="EuroTrash"]I'm sure I've read that mutuelles are by law not allowed to take your medical history into account, just like the state scheme isn't. The premiums are based on age and sex and often on occupation and maybe where you live, but they can't ask questions about your medical history. Again - "mutuelle", as opposed to private company out to make a profit.[/quote]

In my experience, ET, you can't separate mutuelles as good and private companies as bad.

Where we used to live, all the Brits we knew seemed to have been with Mutuelle de Poitiers.  I daresay there was someone in there who could speak English (it was the same how they all had the same doctor, the one who could speak English).

Well that mutuelle wouldn't accept anyone over the age of 70 so that left OH out.

Our first year we were with Exclusive Health because they spoke English and we couldn't speak French and didn't understand the health system.  The very next year, I found our present mutuelle (a private company) and have been with them ever since.

It's like private clinics versus state hospitals:  it's not always the case that the private clinic will charge more.

[Patf]

SW17 - I've sent you a pm.

[EuroTrash]

"In my experience, ET, you can't separate mutuelles as good and private companies as bad."

No I'm not making a value judgement at all - it's just that I thought the government had laid down a specific framework that mutuelles had to operate to, and I thought the solidarity thing about charging everyone the same was part of that framework.

TBH I don't necessarily see it as being 'good' that a mutuelle is compelled to charge the same premium to a person who has always looked after their health and is likely to cost the mutuelle very little, as to a person who smokes, never exercises and leads an unhealthy lifestyle and is likely to cost the mutuelle a fortune. I just thought that was how it is.

However I'm clearly confused because you say your present mutuelle is a private company, and I thought that mutuelles were by definition not for profit.I know that private companies do also offer top up insurance but I don't think that makes them mutuelles, and they don't have to operate under the same framework.

[mint]

ET, what I mean is, everybody does call their top-up insurance provider their "mutuelle", don't there?

Some are mutuelles as we might understand the word and some are private companies.  And, yes, I do think that they all have to operate within a legal framework.

As someone has already pointed out, they base their premiums on gender and age.  However, to my surprise, when I hit 60, I thoght they'd put me in the next age bracket and jack up the premiums but, no they didn't.

The next one will be when I hit 65 and I'll see then if there is a big hike.

However, I don't think that you can distinguish amongst people who look after themselves and those that don't because on that basis, once we start discriminating against smokers, say, then the obese, then perhaps homosexuals, then.....well, you do see, don't you, where would you end and who would set the criteria as to the categories of people who would pay a normal premium and who would pay an extra-over one?[:)]