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Living in France? -
Understanding the French Healthcare System
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Thursday, 09 August 2007 |
The French Healthcare system is primarily a contributory system. This is perhaps most noticeable when treatment is required, as unlike the NHS, it is not a completely free service.
Assuming you have integrated into the French Health system through either CMU or CPAM, you will still require top up insurance, as the State will only pay a percentage of certain costs, leaving either you or your top up insurer to make up the difference.
At treatment stage, the amount you contribute depends upon two important factors:
Firstly, whether the doctor or institution you have been treated by is bound by the ‘Tarif de Convention’ or not, and secondly, whether you have a ‘Mutuelle’, or top up insurance.
What are these?
The establishments and practitioners in France are comprehensively classified by the state. The two principal classifications are Conventionée and Non-conventionée. Conventionée means that the doctor, consultant, hospital or clinic etc. has agreed to observe the price levels negotiated by their associations or in the case of hospitals by themselves with reference to their annual budgets. This price level is known as the Tarif de Convention and upon it the whole system of charging and re-imbursement is based. Both the state service and the French insurance companies use percentages of the Tarif de Convention to define the payments they will make.
Certain establishments and practitioners, especially consultants, are free to charge more than the Tarif but this is limited as it was established in the courts that the extra charged must be "tactful and reasonable." These extra charges are called Depassement d’honoraires and are on the increase. One should be careful; it is best to ask first before treatment commences.
Establishments that are non-conventionée are unusual and appear to be frowned upon by the system. For example, where CPAM, the organisation that administers the system, pays 80% to 100% of the Tarif in the case of establishments that are conventionée, the Tarif is reduced by 90% for the purpose of making the calculation where the establishment is non-conventionée.
Both public and private establishments may be conventionée and both are excellent. Your doctor will be able to advise you on this matter.
This is an association, usually an insurance company, which provides for top up or complimentary health insurance. This top up insurance allows for better reimbursement of health expenses by complimenting the percentage reimbursed by the French Social Security.
How it works:
Suppose you visit a doctor who works within the Tarif de Convention. The charge is € 20. The French Health System (CPAM) pays 70% which is € 14. A 100% plan would pay up to 100% of this 'Tarif de Convention' or up to € 20, and, as such, would pay the difference less a statutory €1 charge.
This is fine until one encounters a situation where the service costs 150% or 250% of the 'Tarif de Convention'. If the doctor, in the above example, had charged € 40, and you only had a 100% 'top up' policy (100% of the 'Tarif de Convention'), then you would be liable for the difference, in this case € 19 after the statutory charge. This is where the 150% and 300% plans come in, as they would have paid 150% and 300% of the 'Tarif de Convention' respectively.
As one can easily see, it is not difficult therefore fully understand why nearly all French people have a Mutuelle. If you are admitted to hospital you will be asked for your CPAM card and normally for your Mutuelle card. This is because there is always a part of the bill to pay which is not met by CPAM.
If you qualify for the maximum reimbursement because you have one of the thirty serious classified diseases, are to undergo significant surgery or have a long term illness, you will only pay for food and extras or "Depassements" as they are called, such as consultants fees in excess of CPAM scales. Normally your share will be between 5% and 10% of the total cost.
If however, you are admitted neither for surgery nor for one of the thirty diseases, for instance cancer, the position is quite different. In such cases CPAM pays only 80% of the scale leaving you to pay 20% plus Depassements, food etc. Your share then, is usually 25% to 30% of the total cost and you may be facing a bill for several thousands of pounds. Add ambulance charges, consultant’s fees, diagnostic costs etc. prior to admission and then after-care and the figure can become daunting.
To be insured only under the French State system and to take the risk is not an option. The risk if circumstances go against you is too high. You need a good Top-up as well.
Just how much top up cover do I need? |
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