Mutuelle percentages

[powerdesal]

A request for an explanation:-

I understand that top-up medical insurance cost is based on percentages , ie 100%, 200% , 300%

but what are they ''percentages'' of ?

I know that the State pays (say) 70% of a cost and the balance is either down to the individual or is paid by the 'top-up' insurance but I have no idea what the 'percentages' refer to, can anyone explain please.

[Pommier]

The state sets a 'tarif' for each procedure (eg €23 to visit the GP) and doctors who are 'conventioné' charge that price, so if you only see doctors and consultants who are conventioné you only need 100% top up because your insurance will pay the shortfall on what the state has paid (less the odd charges of €1 or so). If you go to a doctor who isn't conventioné, a 100% top up will still only pay up to the amount the state has set, so if you visit a GP charging €40 you'll only be reimbursed €23 (less the €1 that's never reimbursed). If in this case you'd got a 200% top up you'd be reimbursed the full cost (but again less the €1)

Hope that makes sense! 

[AnOther]

In simple terms 100% relates to the official government health service tariffs but if you are referred to a specialist or private establishment they can charge more hence the option to go for more than 100%

It's not just the 30% of that either, the state will only ever cover 70% of the official tariff so if that were say €100 but a specialist charged €200 the state reimbursement would still only be €70 so you would need a 200% mutuelle to fully cover that.

EDIT: Pommier beat me to it whilst typing.

[NormanH]

As previously explained there is an official tariff for each act/medicine/apparatus    etc.

This may have little to do with the actual price charged, so the idea of 100% is a bit misleading.

There are 2 secteurs of Doctors. In secteur1 they are known as conventionné and they charge the official tariff, but can charge extra in certain circumstances

In secteur 2 they are free to charge what they like, so this can be several times the official price

In both cases the Social Security will only pay 100% of its tariff.

When  Mutualle says it will pay 300% it is talking about the same thing.

So if a particular specialist asks 200€ for something that has a tariff of 100€  you are reimbursed at 70€ by the Sécu, and the Mutuelle will pay up to 300€, in this case paying out 130€ to make up the difference (these are only rough figuresand don't take into account the 1€ compulsory charge below)

The official French site for this is

http://www.ameli.fr/assures/soins-et-remboursements/combien-serez-vous-rembourse/index.php

The biggest problem comes with things like glasses, dental work such as bridges or apparatus, and hearing aids.

The tariff for these is so low that even a 300% Mutuelle will not cover the cost

A recent thread on here

http://services.completefrance.com/forums/completefrance/cs/forums/2820718/ShowPost.aspx

In any case there are a number of charges that are never reimbursed

50 centimes per box of medicines and each acte (blood test etc)

1€ a consultation

2€ transport

http://www.ameli.fr/assures/soins-et-remboursements/ce-qui-est-a-votre-charge/index.php

There is a daily charge in hospital of 18€ 'bed and board', but that is usually paid by the Mutuelle at least for a certain time

[powerdesal]

I think I understand now:-

100% Mutuelle will pay up to 100% of the tariff, 200% pays 2 x the tariff and 300% pays up to 3 x the tariff, the State paying 70% of the tariff in each case.

However, what happens in the case of a private, single person room if requested in a hospital. Is there a tariff for that?

[powerdesal]

I have just read the thread that Norman linked to and it's much clearer now.

I understand that the need for 100% or 300% can be dictated, to a large extent, by the area of residence. I am in Normandy, is there anyone living in this area who can advise from experience what percentage cover is the ''accepted norm'' in this area.

Also, any suggestions of which companies would be best.

[Pommier]

When we lived in Normandy we both had some health problems, but our 100% insurance was enough in each case. You an always ask if a person is 'conventioné secteur 1' before confirming an appointment.

We're with Myriade, but also had a good quote off ViaSanté.

[AnOther]

I don't think there is any such animal as the 'best' mutuelle, they all have their strengths and weaknesses.

Some offer more in the dental area for instance so if that is something you think you may need treatment for at some time them choose accordingly, it's not simple I'm afraid.

Everybody will have their own recommendations but think of them as you would say a recommendation for an ISP, what has proved ideal for one will have been a never to be repeated nightmare for someone else.

There are comparison sites just like for car or property insurance but a word of caution: once they have your email address you will find that they will all literally bombard you with offers forever so use a disposable one if you can.

In the end I went through my friendly local insurance broker (a fellow classic car nut so not just out for my money !) and I'm happy with what I've settled on and the price I'm paying - and I have someone to talk to in English if needs be.

Happy hunting.

[idun]

As NH said, dental and optical and hearing are all quite different and percentages are not always the best.

Still increasing cover for these three, to a rate which would cover you properly may end with your monthly payments being excessive and it could be worth your while just putting some money aside each month to pay for these things when you need them.

 

 

[NormanH]

In the case of a single room there is no tariff set by the sécurité sociale, since they don't pay for that, except in case of real medical need when it is the staff who decide.

Most mutuelles will pay from 30€ upwards, and for a set period, but some pay 'frais réels' (the actual cost)  so if this is important to you look at the fine print.

Some will also not pay this in convalescent homes.

If you don't mind taking a risk sometimes you get one because there  are no doubles available in in that case you don't have to pay the supplement

I chose a Mutuelle which is modular, so I have a higher level of hospital cover (level 5) but the dental and opticians module I have just a basic cover, since they bump up the price a lot and in any case give you little back even at 300%, since the basic tariffs are so mean

There is a thread about this here (particularly towards the end)

http://services.completefrance.com/forums/completefrance/cs/forums/2837772/ShowPost.aspx