How does Health Insurance reimburse health expenses?

Health Insurance

Health insurance protects the health of each insured person in his personal and professional life by guaranteeing him access to care. It covers all or part of the reimbursement of health expenses in the event of illness, maternity, or accident. What are the different missions of Health Insurance? What is the difference between Social Security and Health Insurance? Why is it necessary to strengthen health coverage with mutual insurance? Our comprehensive guide provides an update on Health Insurance, its missions, and how it works.

What is Health Insurance?

Health Insurance is a branch of Social Security that guarantees health protection to all insured persons. To promote its proper functioning, each insured contributes and in return benefits from coverage according to a defined scale. The scope of the health insurance includes:

  • Sickness, maternity, and invalidity: it covers all or part of your health expenses, pays daily allowances in the event of sick leave, and a pension in the event of invalidity.
  • Occupational illnesses, accidents at work, and death: it pays for care, pay daily allowances in the event of work stoppage, and a pension to beneficiaries in the event of death.

Note: the terms Health Insurance and Social Security are often used together. There is a difference between these terms. Social Security ensures all social risks for French people (healthcare costs, family benefits, pensions, etc.). Health Insurance refers only to the “health” branch of Social Security. It only covers the arrangements put in place to cover medical expenses.

What is the Caisse Primaire d’Assurance Maladie used for ?

The Caisse Primaire d’Assurance Maladie (CPAM) represents the Health Insurance for the socially insured . This local organization carries out a public service mission in each department of France. In particular, it performs the following functions:

  • the management of health insurance rights;
  • the payment of benefits due to social security (advances of medical expenses or reimbursement of care);
  • implementation of prevention campaigns.

To benefit from information related to your CPAM, you can go to the and select your fund by indicating the postal code of your place of residence.

How does Health Insurance reimburse health expenses?

Health insurance coverage is computerized. The Vitale card is an electronic card that contains all the profile information of the insured. During a consultation with a health professional, a withdrawal of prescription drugs at the pharmacy or hospitalization, the patient presents it to obtain partial or total coverage of medical care and equipment. The health insurance is then based on a reimbursement basis and a specific reimbursement rate to cover your health costs. In some cases, you can benefit from third-party payment, a device that allows you to have no costs to advance.

Good to know: in the event of forgetting the vital card or failure of the teletransmission system, a paper care sheet can be sent to the CPAM to benefit from the reimbursement of health expenses.

Health insurance and complementary health insurance: complementary organizations

The basic guarantees of Health Insurance are often insufficient to cover your health expenses. Subscribing to a mutual insurance contract allows you to strengthen your health cover and reduce your out-of-pocket costs. Also called complementary health or health insurance, the mutual intervenes after the reimbursement of the health insurance to partially or totally cover the remaining costs. Depending on the guarantees taken out, your mutual insurance company can cover:

  • The moderating ticket, that is to say, the part that remains your responsibility after the reimbursement of the Health Insurance;
  • Fee overruns, i.e. the share of the treatment or consultation tariff that exceeds the reimbursement basis of the Health Insurance;
  • Care not covered by Health Insurance (alternative medicine, osteopathy, etc.).

The 100% health or zero-cost plan implemented in January 2021 further strengthens the complementarity between Health Insurance and mutual health insurance. By subscribing to responsible complementary health insurance, you can benefit from eyeglasses, dental prostheses, and hearing aids covered at 100%.

Health Insurance reduces your health expenses by reimbursing all or part of your medical expenses. The remainder can be covered by mutual insurance. Remember to compare the offers of complementary health insurance to find the health contract that best suits your budget and your profile.

By aamritri

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