What does a mutual insurance company reimburse? Complete deciphering of care

Routine care: consultations, medications and tests

Medical consultations: who pays what?

During a consultation with a general practitioner or specialist, the Health Insurance reimburses 70% of the agreed rate. But you are still responsible for:

• The co-payment (30% of the agreed rate)
• Fee overruns if the doctor does not adhere to the basic rate
• The flat-rate contribution of €1, never reimbursed by the mutual insurance companies

Example: A consultation with a sector 1 general practitioner costs €26.50. Health insurance reimburses €17.50(70% of €25, minus €1 participation). Without Mutual, you still have €8 to pay. With a mutual insurance company covering the co-payment, you will not have to pay anything, except for excess fees.

Good to know: Mutual insurance companies often offer reimbursements of up to 150% or 200% of the base rate, ideal for covering the overruns of specialists.

Medications: what is covered?

The reimbursement of medicines depends on their Medical Service Rendered (SMR):

• Drugs with major or large SMR ➝ 65% covered by Social Security
• Moderate SMR ➝ 30%
• Weak SMR ➝ 15%
• Medicines not reimbursed ➝ 0%

The complete mutual insurance All or part of the co-payment according to the contract. However, certain medications deemed to be of comfort are not covered.

Example: An antibiotic at €10 reimbursed at 65% will cost you €3.50. A 100% mutual insurance will cover this €3.50, but a basic mutual insurance may not cover anything.

Hospitalization: how much is left to pay?

Hospitalization generates high costs: Stay, medical procedures, surgery, single room… Fortunately, a good health insurance company can save you a lot of expenses.

Expenses covered

Case in point: A 5-day hospitalization with a single room at €70/night will cost €350 in addition. A mutual insurance company covering €50/day will leave you with €100 to pay.

Dental care: coverage often essential

Dental care is among the most expensive and poorly reimbursed by Social Security. Fortunately, the mutual insurance company plays a major role, especially for prostheses and orthodontics.

Basic Care

• Scaling, cavities, extractions: Reimbursed at 70% of the agreed rate (e.g. €30 for a cavity ➝ €21 reimbursed, €9 paid or covered by the mutual insurance company).

Dentures

• Crowns, bridges, implants: Poorly or poorly reimbursed by Social Security.
• With 100% Health: Some crowns (metal, ceramic on visible teeth) are fully covered.
• For other cases: The mutual insurance company reimburses according to a percentage of the basic rate or an annual flat rate (e.g. €300/year for prostheses).

Example: A crown billed at €600 with a social security reimbursement of €120 leaves you with €480 to pay. A mutual insurance at 300% of the Social Security rate would cover up to €360, leaving you with €120 to pay.

Opticians: how to get reimbursed?

The reimbursement of glasses depends on the 100% Health and mutual insurance guarantees.

Glasses and Lenses

• 100% Health: Frame + lenses fully supported on a specific range.
• Non-100% Health Frames: Reimbursement limited by the Health Insurance (e.g. €0.05 for a frame). The mutual insurance company offers a Annual Fee (e.g. €150 for frames + lenses).
• Contact lenses: Not reimbursed except for specific pathologies, but some mutual insurance companies provide a flat rate (e.g. €100/year).

Example: A pair of glasses at €300 excluding 100% Health with a mutual insurance package of €200 will leave you with €100 to pay.

Audiology: hearing aids and reimbursements

Since the 100% Health reform, hearing aids have been better covered.

Hearing aids

• Devices in the 100% Health basket: Fully reimbursed by the Health Insurance + mutual insurance company.
• High-end devices: Limited reimbursement (e.g. €400/ear by the Social Security, mutual insurance depending on the contract).

Example: A hearing aid costing €2,000 with a social security reimbursement of €400 and a mutual insurance covering €1,000 will leave you with €600 to pay.

Other reimbursements: what a mutual insurance company covers (or not)

• Alternative medicine (osteopathy, acupuncture, etc.): Not reimbursed by Social Security, but increasingly covered by mutual insurance companies with an annual flat rate (e.g. €100/year).
• Thermal treatments: Partially covered (65% of care, 70% of consultations), the mutual insurance can supplement (accommodation, transport).
• Contraception, non-compulsory vaccinations, smoking cessation: Some mutual insurance companies offer specific packages.

How to choose the right health insurance company?

• Assess your needs: Need a good optical reimbursement? Dental? Routine care?
• Compare offers: Pay attention to the levels of coverage and exclusions.
• Look at the waiting limits and waiting periods: Some mutual insurance companies limit the annual reimbursement or impose a wait before being covered.

The good deal: Use an online comparator to find the health insurance company best suited to your profile and budget!