How to calculate the reimbursement of the mutual?

How to calculate the reimbursement of the health insurance?

First step before involving the mutual: the repayment of the Sécu. The rates for care are determined by agreement between the healthcare staff and the health insurance fund. The reimbursement basis for social security (BRSS) consists of the part that is reimbursed by social security (level 1), the fixed contribution from social security that you have to pay, and the out-of-pocket payment (level 2 or additional part).

The process is as follows: With your vital card, your request for reimbursement from Social Security is automatically triggered. Only the approved sector 1 doctor will use the rate set in agreement with the health insurance. For the others, there will be an excess of fees, more or less borne by your mutual insurance company, which takes care of the moderation ticket, that is, the difference between the reimbursement basis set by Social Security and what you actually paid.

Be aware that for certain health expenses it may be wise to choose supplementary health insurance.

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How to calculate the reimbursement of the mutual health insurance?

The level of cover depends on the guarantees included in your contract, calculated on the basis of the health insurance’s reimbursement basis. The amount reimbursed by your supplementary is expressed as a percentage of the convention tariff (TC) of the health insurance or BR (reimbursement basis).

  • “100% TC”: Total coverage (Health insurance + supplementary) can reach 100% of the reference rate. Not to be confused with 100% of actual expenses! This means that the moderation ticket is reimbursed by the supplementary health insurance, but you must pay for any excess fees. It is actually a basic contract whose relatively low contributions do not allow you to demand more reimbursement. You can’t win on every point!
  • “150% TC”, “200% TC” or “300% TC”: The refund base will be 1.5 times, 2 times or 3 times higher than the reference rate. Again, don’t confuse this with actual expenses. This type of contract is more solid than the previous one and covers to a greater or lesser extent both self-payments and fee excesses.
  • An amount in euros can also appear on your guarantee table, corresponding to a fixed rate for the year “I use daily contact lenses and my mutual insurance company reimburses me 100 euros a year, which does not represent all my expenses, but a good third” Isabelle testifies.

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Examples of mutual insurance reimbursements

Let’s say you make an appointment with your GP for unexplained abdominal pain. If it is a sector 1 approved doctor, you pay 25 euros and get reimbursed 70% of the sum of the health insurance minus the mandatory participation in euros, i.e. 16.50. With your complementary health, you will be reimbursed for the remaining 30% under the moderation ticket, that is 7.50 euros.

For a pair of class A glasses for which you pay 125 euros, you will be reimbursed 22.50 euros by the health insurance (60% of the reimbursement basis of 37.5 euros -9 euros for the frame and 14.25×2 for the glasses-). In connection with equipment from the 100% Health basket, a responsible health insurance company will e.g. cover the entire deductible and deductible, and more precisely 40% below the deductible (€37.50 x 40% = €15 ) and €87.50 for deductible (Source: National Union of Complementary Health Insurance Organisations).

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