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Monday, May 29, 2023

How does health insurance reimbursement work?

In order for the reimbursement of the health insurance costs to correspond to their actual expenses (taking into account the user fee), without the funds having to reimburse without control of the fees, there are national agreements between the health insurance organizations on the one hand, and doctors and medical auxiliaries.

Depending on the doctor’s sector of activity, the reimbursement may be different:

  • The doctor in sector 1 fully adheres to the agreement and respects the rates negotiated with the health insurance. As part of the coordinated care pathway, the reimbursement rate is 70% of the conventional rate. The doctor in sector 2 freely sets his fees. The amount exceeding the conventional rate is not refunded. The approved doctor adhering to the option of controlled pricing (Optam) practices moderate overruns. The reimbursement base is identical to that of sector 1, and the rate of 70% within the framework of the coordinated care path.

There is also a possibility for doctors to practice excess fees when they receive a patient who has not been referred to them by the attending physician or who is outside the course of care.


Medicines are dispensed on medical prescriptions. To be covered, they must appear on the list of drugs reimbursable to social security. For certain specialties, reimbursement is made on the basis of a fixed price determined from the price of the cheapest generic drugs.

The reimbursement rate for medicines varies depending on the recognition of the actual benefit:

  • 100% for drugs recognized as irreplaceable and expensive; 65% for drugs with major or substantial actual benefit; 30% for medicinal products with moderate benefit, homeopathic medicinal products, and certain magistral preparations; 15% for drugs with low medical benefit.

There is a deductible of € 0.50 on each box of reimbursable drugs. For example, for the purchase of a box of medicines of 10 €, reimbursable at 65% by the Health Insurance, the latter reimburses 6 € (6.50 € – 0.50 € deductible).

The pharmacist can use the ” third party payment ” system to avoid the patient having to advance the costs on the presentation of the vital card. The latter must not refuse the generic drugs offered when they exist. It will only pay part of the costs that are not covered by health insurance.

b) Inpatient care

Social security contributes to the costs incurred by the hospitalization of the insured or his beneficiaries. This coverage includes all the services provided by the hospital: medical and surgical fees corresponding to the procedures performed during the stay, medication, examinations, operations, etc.

Certain comfort supplements, such as a private room, telephone, or television, are not covered by health insurance.

In the event of hospitalization in a public establishment or in an approved private clinic, hospitalization costs are covered at 80%. The insured must pay 20% of the hospitalization costs which is added to a daily flat rate of € 20 per day of hospitalization.

In certain cases or for certain insured persons, coverage is equal to 100%:

  • From the 31st day of hospitalization,
  • Pregnant women to be hospitalized during the last 4 months of pregnancy,
  • Hospitalization following a work accident or occupational disease,
  • Hospitalization linked to a long-term illness,
  • Beneficiaries of complementary CMU or State medical aid (AME)…

In these situations, however, the insured must pay the flat rate of € 20 per day of hospitalization (€ 15 in psychiatric service), as well as the flat-rate contribution of € 24 which applies to heavy acts (when the price is greater than or equal to 120 €, or when the coefficient of the act is greater than or equal to 60). The latter only applies once per hospital stay, even if several major acts have been performed during the same stay. However, some people may be exempt from one and/or the other of these two lump sums (CMU-C beneficiaries, people with a long-term illness, an occupational disease, having suffered an accident at work, and pregnant women from the 6th month of pregnancy).

When the insured is admitted to an establishment, a request for coverage is sent to the affiliation fund. The “third party payment” system is then applied. The fund pays the establishment directly and the insured only pays the costs that remain the responsibility of the patient: user fee, daily package, and heavy-duty package.

c) Transportation costs

Transport costs may be covered if they are the subject of a medical prescription.

It is necessary for reimbursement in the following cases:

  • Transport related to hospitalization, whatever its duration,
  • Transport related to a long-term illness (ALD) if the person’s state of health does not allow him to move around on his own, Transport related to a work accident or occupational disease, Transport by ambulance when the state of health requires lying down, Long-distance transport, i.e. more than 150 km to go alone, Serial transport (at least 4 means of transport of more than 50 km one way, over a period of 2 months, for the same treatment),
  • Transport is linked to the care or treatment of children/adolescents in early medico-social action centers (CAMSP) and medico-psycho-pedagogical centers (CMPP).

Even prescribed by a doctor, the last 3 types of transport mentioned above require prior approval from the health insurance medical service. It is the same for transport by plane or regular boat.

Transport costs are generally reimbursed up to 65%. The patient remains responsible for the remaining 35% which is added to the excess of 2 euros per trip, up to a limit of 4 euros per day.

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