The reimbursements offered by mutual insurance companies are often a nebulous aspect for many people. Understanding how they work can be complex, but it is essential for managing health expenses optimally. Mutual insurance complements mandatory health insurance, thus covering costs not reimbursed by Social Security.
Their roles are varied and depend on many factors, ranging from your specific contract to the nature of the care received.
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The role and functioning of Social Security
Before diving into the details of reimbursements, it is essential to understand how Social Security works, as it is the first to intervene in the reimbursement of your medical care.
- Social Security covers part of health expenses, generally between 60% and 70% of the fixed base rate.
- This base rate, or convention rate, is determined by Social Security for each medical act.
- The remaining charge, called the co-payment, is what remains to be paid once Social Security’s coverage has been applied.
- Some costs, such as the hospital flat fee, are never reimbursed by Social Security.
Mutual reimbursements: how does it work?
A health mutual plays a fundamental role in covering health expenses that are not covered by Social Security. It mainly intervenes to complement or, in some cases, fully cover the co-payment.
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Each mutual contract is unique and offers various levels of coverage, ranging from dental, optical care, to specialized medical consultations. The percentage of reimbursement from the mutual is often calculated based on the convention rate of Social Security.
For example, a mutual offering a 100% reimbursement fully covers the co-payment, while one at 200% might also cover excess fees.
The types of reimbursements offered by mutuals
Mutuals offer various reimbursement options that adapt to specific needs, which can vary depending on the guarantees subscribed.
- Reimbursement as a percentage of the Social Security rate: This is the most common, expressed as a percentage, indicating how much the mutual covers compared to the convention rate.
- Flat-rate reimbursement: This is a fixed amount, for example for optical costs, where a maximum price will be reimbursed each year.
- Integrated reimbursements: Automatic, they occur directly after the reimbursement from Social Security, without the need for prior request.
Deadlines and procedures for obtaining a reimbursement
Obtaining a reimbursement from your mutual involves adhering to certain deadlines and procedures that ensure the smooth running of the process.
It is common for reimbursement deadlines to vary between organizations.
In general, once the reimbursement from Social Security has been made, the mutual automatically proceeds with its own reimbursement within a period ranging from a few days to several weeks.
It is advisable to regularly check the activation of teletransmission between your mutual and Social Security to ensure prompt coverage.
In the case of non-conventional expenses, a manual request may be necessary, accompanied by the required supporting documents.