A benefit described as 100% does not necessarily repay your entire bill. When reading a French reimbursement statement or choosing top-up health insurance, separate the provider’s price, the reimbursement base used by Assurance maladie and your policy benefits. These can be three very different amounts.
Who pays which part?
France’s public health insurance pays according to the treatment and your circumstances. Its calculation generally uses an official reimbursement base, known as BR, which may be lower than the amount charged. Your complementary insurer then contributes within the limits of your policy.
The ticket modérateur is the share of this base left after public reimbursement. It is only one part of your possible out-of-pocket cost. Extra fees, statutory patient contributions, medical deductibles and uncovered services may also remain payable. French contrats responsables do not reimburse the relevant statutory contributions or medical deductibles; exemptions may apply through the public system depending on your circumstances.
Reading percentages and euro allowances
If a benefit states “150% BR, Assurance maladie included”, the ceiling applies to the combined reimbursement from both insurers. It means neither 150% of your invoice nor a full additional 150% paid by the complementary insurer. Reimbursement cannot exceed the actual eligible expense, and applicable statutory deductions must still be considered.
A euro allowance works differently. Check whether the limit applies each year, per insured person, per item or per appointment, and whether public reimbursement is included. An unused allowance for one benefit is not a cash balance you can transfer to another type of treatment.
Dental care and medicines: useful distinctions
Reimbursable consultations and treatment provided by a dental surgeon are generally covered at 60% of the official tariff, subject to exceptions. Treatment provided by a medical stomatologist may follow different rules. For dental prostheses, check the quotation and the relevant treatment category before estimating reimbursement.
For medicines, ignore the old coloured reimbursement stickers. Check the rate and reimbursement base on your statement or ask your pharmacist. Different medicines can have different reimbursement arrangements, and some are not reimbursable.
Optical care and 100 % Santé: check the category
The 100 % Santé scheme covers defined optical, dental and hearing benefits. Having nothing left to pay depends on selecting eligible treatment or equipment, meeting the reimbursement conditions and holding qualifying cover, such as a contrat responsable or Complémentaire santé solidaire. It does not apply to everything sold by a provider. For glasses outside the scheme, obtain an itemised quotation and a written estimate from your insurer.
Before a major expense
Send your insurer the provider’s quotation, including treatment codes. Ask for the expected public reimbursement, the complementary payment and your remaining share. Check any waiting periods and allowances already used. This gives you a more practical answer than a percentage viewed on its own.
Use our France health insurance comparison tool to compare benefits for your needs. If a line is unclear, contact Alperea Assurances and we can review it with you.
Sources in French: Ameli: co-payments, dental care, medicines, optical care and Service Public: complementary health insurance.
