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22 Octobre 2008
A « médecin conventionné » has signed an agreement with the « caisses de sécurité sociale ». Thanks to this agreement, he cannot choose his consultation fees, in this case we talk about « tarifs encadrés ».
On the other hand, a « médecin non conventionné » can choose his fees. We say this doctor « pratique des honoraires libres ».
What consequences ?
This difference is very important for you, as you will pay these doctors.
When the « sécurité sociale » (also called « régime obligatoire ») reimburses your medical fees, it uses different « taux ». A « taux » is a peurcentage. If you take a closer look at one of the « relevés de remboursements » you've received, you'll see that it indicates the sum paid to the doctor and the sum reimbursed (the peurcentage is also indicated). And you'll understand that « sécurité sociale » does not reimburse 100% percent.
Your complementary insurance should reimburse what remains from the total sum so you can get fully reimbursed. The peurcentage not reimbursed by the « sécurité sociale » is called « le ticket modérateur ».
So each time people talk about « une hausse du ticket modérateur » it only means that the sécurité sociale will reimburse less and leave a bigger part to your complementary insurance.
BUT, be very careful. If the « sécurité sociale » and your complementary insurance reimburse « 100% », it doesn't mean that it's « 100% of the amount paid » BUT « 100% de la base de remboursement ».
What does it mean ?
It means that « sécurité sociale » set an agreement (« convention ») with most of the doctors in which it is specified that a consultation fee should be 22 euros and no more for a « généraliste ».
The « sécurité sociale » will reimburse you 70 % of 21 euros and your complementary insurance will reimburse the remaining sum.
So, with a 100% « taux de remboursement » or « base de remboursement » you will get 21 euros back.
Why 21 euros as « base de remboursement » instead of 22 ?
But if you go to a doctor « généraliste non conventionné » and pay 40 euros, the « sécurité sociale » will reimburse you on the basis of 21 euros...
And if your complementary insurance refuses to reimburse these « dépassements d'honoraires » you will never get fully reimbursed.
So now you can better understand a few things about complementary insurances in France.
If you take a closer look at your complementary insurance police, you might see astonishing things like a reimbursement up to « 400% »!!!
In fact, most of the time it's only for glasses or dentist costs because it can be so expensive and « sécurité sociale » reimburses so badly that you need a 400% reimbursement at least if you want to be fully reimbursed.
« frais réels » what is it ?
Some complementary insurances offer a reimbursement based on « frais réels » instead of peurcentages. This means that they do not reimburse you according to the « base de remboursement » set by the « sécurité sociale » but according to how much you really had to pay.
So, if you don't have a very good « mutuelle » complementary insurance, check if your doctor is « conventionné » and that he/she doesn't « pratique les honoraires libres ».
You can ask the question when you take your appointment, it's the law, a doctor must tell you what his/her fees will be.
What's the difference between « ticket modérateur » and « dépassement d'honoraires » ?
Back to the healthcare system article