Just like the RIB document, you will be often asked to provide your Carte Vitale. Not only when seeing a doctor, hospital or pharmacy but also as proof of residency. Really?
Yup, the Carte Vitale is an important document to obtain when moving to France. It is very commonly asked for by service providers and banks when you need to provide proof of residency.
What is a Carte Vitale used for?
‘La Carte Vitale‘ essentially is a personal healthcare card to prove your affiliation and coverage by the ‘Assurance Maladie‘.
L’Assurance Maladie is the mandatory health insurance that you will benefit from when you are a fiscal resident of France and pay your social charges.
When you have an appointment with a healthcare professional, you will be asked for your Carte Vitale.
By using the card you will either avoid having to advance the healthcare expenses and/or you will be reimbursed automatically.
Is everything covered by the Assurance Maladie with my Carte Vitale?
Well, it depends. I mentioned earlier that you can avoid having to advance the healthcare expenses by using the Carte Vitale.
However this is limited to the reimbursement percentage of the mandatory health insurance (l’Assurance Maladie) and your complimentary insurance (Mutuelle).
Prices of healthcare professionals in France
In order to determine what and how much is covered, we first need to understand how healthcare professionals set their prices. The France healthcare system has various pricing levels called sectors.
Often, you will read or hear about reimbursement percentages, such as 70% or 300%. I’ll get to that later.
Sector 1
As mentioned earlier, the Assurance Maladie is the mandatory health insurance and they have determined what things may cost. This is an agreement between the mandatory health insurance and the professionals.
Professionals in sector 1 will therefore not charge more than the prices set by the Assurance Maladie in this agreement.
For example, a consultation with a general practitioner is set at a fixed price of €25.
A sector 1 general practitioner will charge you €25 including taxes for a consultation.
And in this specific example, the reimbursement percentage, called ‘Taux de remboursement’, by the Assurance Maladie for this consultation is 70%.
There is also a fixed €1 contribution, called ‘participation forfaitaire de 1€’, that you have to pay and will be deducted from your reimbursement.
So, the sum for your reimbursement is €25 * 70% = €17.50 – €1 = €16.50.
Meaning you would have to pay €8.50 (sum is: €25 – €16.50) for this consultation.
If you have a Mutuelle insurance, they will reimburse you the remaining 30%, i.e. €8.50, depending on your contract.
Sector 2
How much sector 2 professionals charge you?
Sector 2 professionals can charge you more than a sector 1 professional. And most of them are what they call ‘Secteur 2 OPTAM‘* or ‘Secteur 2 OPTAM-CO‘**.
OPTAM and OPTAM-CO are both an agreement between the health insurance and professionals to set fixed prices for their services.
Thanks to this agreement, sector 2 OPTAM professionals can charge more but they will always respect the price guidelines in the agreement.
A reimbursement calculation example by the Assurance Maladie
Coming back to the reimbursement percentages and using the consultation as an example again. A general practitioner in sector 2 may charge more than €25 and in this example will charge you €50.
The health insurance, Assurance Maladie, has determined that the ‘Base de remboursement de la Sécurité Sociale‘ for consultations is €23. They will reimburse 70% minus your €1 contribution.
What you will receive from the Assurance Maladie is: €23 (Base de remboursement de la Sécurité Sociale) * 70% (Taux de remboursement) – €1 (Participation forfaitaire de 1€) = €15,10
But the difference, €50 – €15,10 = €34,90, needs to be paid by you or your mutuelle.
Understanding the reimbursement percentages of your mutuelle
Your mutuelle contract will determine how much will be reimbursed and it’s worth doing your research before subscribing to a contract.
The Mutuelle insurance company will always use the base amount as a reference and this amount is considered 100%. You can choose a coverage that works well for you, for example a 300% coverage.
This means that your mutuelle will cover/reimburse up to 300% the base amount for your additional expenses – hope this makes sense.
Calculation example for the reimbursement by your mutuelle
Let me give you another example. For the €50 consultation with a sector 2 OPTAM professional you still have to pay €34,90.
With a 300% mutuelle insurance, the insurer would reimburse a maximum of €23 * 300% = €69 and never more than the actual expenses.
250% would be €23 * 250% = €57.50
200% would be €23 * 200% = €46
150% would be €23 * 150% = €34.50
100% would be €23 * 100% = €23
To cover the remaining additional expenses of €34,90, you need a mutuelle contract with a reimbursement percentage of more than 150% for doctor consultations (sum is: €34,90 / €23 = 151.74%).
OPTAM Abbreviations explained
* OPTAM is the abbreviation for Option Pratique Tarifaire Maîtrisée. You might also find older terms ‘CAS‘ (Contrat d’Accès aux Soins) or ‘DPTAM‘ (Dispositif de Pratique Tarifaire Maîtrisée) but they are all identical and replaced by the term ‘OPTAM’.
** OPTAM-CO is the abbreviation for Option Pratique Tarifaire Maîtrisée Chirurgie et Obstétrique and the same as OPTAM but tailored to surgeons and obstetricians.
Sector 3
Professionals in sector 3 are free to charge whatever they want. And no matter what they charge, the Assurance Maladie will only reimburse €0.61 for a consultation with a general practitioner and €1.22 for a consultation with a specialist.
Very important to know
Your Carte Vitale needs to be updated once a year and/or when your situation changes. This can be easily done by visiting a pharmacy and ask them to update your card.
You could ask: ‘Bonjour, Est-ce que vous pouvez mettre à jour ma carte vitale ?‘
If you forget to do this, your card becomes invalid and can no longer be used. You would then have to apply for a new card and this can take a while.
Closing thoughts
In theory La Carte Vitale is a brilliant system to simplify the administration of your medical expenses and reimbursements. And also to prevent having to use the old paper declarations, called ‘Feuille de soins’.
However it’s not flawless and we would strongly suggest always asking for an invoice and payment receipt from your healthcare specialist as proof, in case something goes wrong.
Unfortunately this has happened to us more than once. One time our general practitioner received the reimbursement payment instead of us. We then had to go see the doctor to pick up the money in cash.
Or a professional who only processes their declarations at the end of each quarter causing a huge reimbursement delay – yes this happens.
In the end, problems, errors or mistakes will always be resolved and having a Carte Vitale makes your life a whole lot easier in France!
Useful links
La Carte Vitale: https://www.service-public.fr/particuliers/vosdroits/F265
Reimbursement of medical care in France: https://www.service-public.fr/particuliers/vosdroits/N418
Prevention of advancing medical expenses ‘Tiers Payant‘: https://www.service-public.fr/particuliers/vosdroits/F167
Own contribution: https://www.service-public.fr/particuliers/vosdroits/F165
Affiliation with the Assurance Maladie: https://www.service-public.fr/particuliers/vosdroits/N31750
Mutuelle and government aid: https://www.service-public.fr/particuliers/vosdroits/N20286
Healthcare pricing sectors: https://www.service-public.fr/particuliers/vosdroits/F17042
