What is a mutuelle and how does it work?

18 May, 2021

Lets start with the question; who can have a mutuelle? Here at First Assurances, we offer mutuelle products for both people with carte vitales, and also those that haven't got theirs yet. This is particularly helpful for those who are applying for their CDS (carte de sejour) and require health insurance but don't have a carte vitale yet. We offer a range of coverage from just hospitalisation, to fully comprehensive cover.

I have a quote but what does it mean??

When you get a mutuelle quote, it tends to be full of percentages and numbers and it can be very confusing. Your mutuelle tops up what social security (CPAM, AMELI, AMO) pays you. The refunds are not based on what you have paid, but based on the Base de Remboursement de la Sécurité Sociale (BRSS). This is the guidance amount that AMO gives for every procedure, appointment, consultation item etc to be charged, however most things are charged at a higher rate than this, particularly at the dentist for example. You are reimbursed however based on the BRSS, by both AMO and your mutuelle.

This is easiest to explain with an example. (these figures are not based on the actual BRSS in this example)

You go to the doctor and you pay €130 for your appointment. AMO says that the BRSS for this appointment is €100.

AMO will normally reimburse you between 60% and 70% of the BRSS. Lets say here, you get €70 back.

If your mutuelle coverage for this appointment is 100%, then you will receive 100% of the difference between the €70 refunded by AMO and the €100 BRSS. So €30. If you have 200% coverage, you would get upto twice the difference (capped at what you have actually paid), and so on, always capped at what you actually paid.

Some items will show an amount for an item (quite often for optical cover). This is the amount per beneficiary you have available per period to spend on that item (yearly, 2 yearly etc) depending on your contract.

Where the coverage is shown as 'frais réels', your mutuelle will top you up to what you have paid.

How do the reimbursements work?

When you sign up to your mutuelle (with a carte vitale; the case is different if you don't have one, please get in touch with us in this case) your adhesion is communicated with AMO and your teletransmission is set up. You will receive a Carte Tiers Payant from your mutuelle provider within about 2 weeks of signing up. Hand this over with your carte vitale and this gives the doctor/pharmacy/hospital the details of your coverage.

For some things, you pay upfront and within a few days, the money comes back from AMO and your mutuelle. Some things are 'prise en charge' and will be paid directly by AMO and your mutuelle to the supplier and you do not pay up front. Other items need to be paid for and you transmit your receipts over to your mutuelle (and sometimes to AMO too) for reimbursement. AMO needs to have made their contribution before your mutuelle will pay out, as their payment is based on what AMO has already covered. Most mutuelles have an online client space that you can upload your receipts onto for your refunds.

Hopefully this little article has given you a bit of a better idea what a mutuelle is and how it works!

If you would like a quote then please get in touch!