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You’ve landed in France some months ago. You’ve eaten as many croissants as your body could handle. You’ve survived your hunt for a new apartment. You’ve found out that French people are not as rude as first warned (true story :). Now, it is time for you to enjoy the pleasure of the French health system.
Here is your survival guide to navigate the jungle of French administration.
Photo by rawpixel on Unsplash
Caisse d’assurance maladie, base de remboursement de la Sécurité Sociale or Tiers-Payant might have been some words you’ve already come across if you have been in touch with the French health care system. They don’t mean anything to you? No worries, here we’ll provide you with all the explanations.
First things first, let’s begin with the big picture. After having been seen by a health worker or buying some medicine at the drugstore, you will be in touch with two players:
The National Social Security
Your health insurance
Depending on your status, several social securities exist. If you’re a student you would belong to SMEREP or LMDE, and if you’re an employee it most probably be the Caisse Primaire d’Assurance Maladie -- whose website is https://www.ameli.fr/.
Founded after WWII in 1945, the Sécurité Sociale -- French people call it “la sécu” -- is the first player you’ll be in contact with. The Sécurité Sociale is the French institution that holds your reimbursement when you face costly health-related events. The Sécu defines a price for each treatment it reimburses: medical acts, services, medecine, products, etc. This reimbursement matrix is called “base de remboursement de la Sécurité Sociale”, also called BRSS. Wow 🤔
For instance, back in May 2017, the Sécu had set a specialist consultation price at 30€. Even if most of the time it’s higher, the reference price for the Sécu will always be 30€. This is the base de remboursement de la Sécurité Sociale, BRSS.
Then, the Sécu refunds a percentage of this given basis.
If you get back to our specialist doctor (let’s call him Dr Bob), the Sécu reimburses 70% of the 30€ basis it has defined, or 21€.
But wait, it is not that easy :) The Sécu cuts 1€ out of your final reimbursement. And by law, you’re the one who has to pay for this euro, neither the Sécu, nor your health insurance can pay for it.
At the end, The Sécu will reimburse 20€ and not 21€ for your consultation at Dr Bob’s medical office.
In a nutshell:
The Sécu has defined the cost of a consultation for a specialist doctor at 30€
The Sécu refunds 70% of it this basis
It cuts 1€ of your final reimbursement amount
20€ is the amount of your reimbursement.
Tada! This is where Alan enters the game. For all the Sécu refunded cares and medical acts, health insurance providers base their refund on the Sécu one (remember the sweet BRSS). If you get back to Dr Bob, the BRSS is 30€. Alan has decided to refund 300% of the BRSS. So you will be refund of maximum 30€ x 300% = 90€.
Why does mean that limit:
If the final cost of your consultation is 40€, you will be refunded 40€ minus 1€.
If the final cost of your consultation is 95€, you will be refunded of 90€, minus 1€. So you will have to pay 6€ out of your pocket.
Now let’s go deeper into the jungle.
Photo by rawpixel on Unsplash
Secteur 1, 2, CAS and Optam sound familiar, but they’re still unintelligible to you. Pretty fair. We’re here to help you.
Doctors in France are split into three different sectors.
Sector 1 These doctors charge their patients the base de référence de la sécurité sociale (BRSS). You are fully refunded by the Sécu and Alan minus 1€. Most of the general practitioners (primary care physicians) are in this category.
Sector 2 These are the ones who go beyond the BRSS. Most specialist doctors fall into this bucket. Our role as a health insurance provider is to help you get refunded despite them charing more than the BRSS.
Sector 3 They are a few of them and their tariffs are totally free. Given that, they’re not really well refunded by the Sécu and health insurance providers.
If you don’t find a sector 1 doctor, or if you want to see a given one that is in sector 2 without spending too much money, you can check one criteria: is your doctor OPTAM or not? What does that mean? The meaning of the acronym is useless to your understanding. The only thing you need to know is that if your doctor has signed the OPTAM, it means that he is committed to respect an average excess rate of the BRSS.
You can find this information on Ameli.fr, a website like Doctolib, or even you can ask your doctor when making an appointment.
Here you are. You’ve found a great doctor, doctor Bob - and you’re well refunded. Bravo! Don’t forget to declare him as your “médecin traitant”, meaning your reference doctor.
To foster end-user good practices and limit the global health expenses, the Sécurité Sociale has made it mandatory for you to see your médecin traitant before seeing any specialized doctor (except for ophthalmology, gynecology, odontology, psychiatry). If you don’t respect these guidelines and see a specialist before having seen your “médecin traitant”, the Sécu and you health insurance provider will refund you less.
__And how can I do that? __
There are two ways to do that:
Ask you doctor to do it for you; but note, you’ll need your Social Security Number and carte vitale to do that (if you don't have it, we have prepared for you a guide on how to get a Social Security Number in France).
Or you can fill in this paper document and send it to your Sécu.
So imagine you need to see a dermatologist.
1: First go to see Doctor Bob. If he is sector 1, you’ll be fully refunded.
2: He gives you a prescription to see your dermatologist.
3: You choose a sector 2 dermatologist that is OPTAM compliant to be well refunded both by the Sécu and your health insurance provider.
4: You do your consultation.
5: Everything is ok:) And, the cherry on the cake, you are well refunded.
Voilà, you are now a French health care system superstar. If you have any other questions, we are always here to chat with you on our website.
Loves from Alan.