Health insurance: understand your refunds

Why did Health Insurance pay me so little? 

All include lump sum payments and medical deductibles.

John is irritated, and especially he doesn't understand.

Why is his latest Health Insurance claim so low?

He spent €30 at his GP and only €15 was paid by the Sécu.

And it's even worse for Jeanne: her scaling, which cost her €48, has not been refunded at all.

Of course, we understand Jean and Jeanne's frustration, but they do not have to contact their health insurance fund.

These unpleasant surprises, or reduced reimbursements, correspond to their contribution to lump sum contributions and medical deductibles.

But what are we talking about?

This is an effort required of a large majority of insured persons to preserve our health care system.

Specifically, during a consultation with the doctor, a radio or a medical biology analysis, insured persons put 2 € out of their pocket with a maximum of 50 € per year.

That's called the lump sum.

And there are also the medical deductibles.

It is the same logic of sampling but this time it applies to the boxes of medicines: 1 € per box, paramedical procedures performed by nurses or physiotherapists: 1 € also and sanitary transport: 4 €.

For a maximum also of 50 € per year.

Remember that between the lump sum contributions and the deductibles, an insured may owe up to €100 each year.

For more details, see our article on the subject on ameli.

Let's go back to Jean's case.

What happened to him?

Well, a few weeks before he went to the doctor, he went to the pharmacy with his prescription to pick up four boxes of drugs reimbursed by the Social Security.

Thanks to his Vitale card, he paid nothing.

But beware, the counter of his medical deductibles has been incremented by 4 €.

1 € per box.

€ 4 which will be deducted from the reimbursement of his next visit to the doctor.

Hence the 15 small euros that were paid to him, and hence his surprise.

Jeanne now.

Its status is special because it benefits from the paying third party because of its ALD.

With her Vitale card, she does not pay the health costs related to her ALD.

However, like Jean, for every treatment performed or every medicine purchased, his counter of franchises and lump sums is incremented.

And often, she is not aware of it, because as long as her care remains within the framework of her ALD, nothing is taken from her.

On the other hand, as soon as it exits, the Sickness Insurance deducts from its reimbursements the amounts  

that have accumulated and may then be significant over months or years.

So that's what happened with Jeanne's scaling, for which the Sécu didn't reimburse anything.

It is often during dental, ophthalmological or dermatological care that third-party payers realize that they contribute to the lump sum contributions and medical deductibles.

So how can we avoid these unpleasant surprises?

That is, to better understand what has already been taken and what needs to be taken.

There are two actions to be taken for this and both are in the ameli account.

First, go to your payments.

You will see in each of your refunds, the contributions that have already been deducted. The famous 1, 2 €, 4 €.

But to get an overview, go from my payments in the section “Lump Sum Deductions and Franchises”.

Here you see the total of the amounts you paid in the current year.

And above all, for third-party policyholders, the amounts that remain to be deducted from future repayments.

You know everything now, or almost.

The same applies to insured persons in ALD who never carry out care outside their paying third party and for whom the amounts accumulate: €50, €100, €200, sometimes more over several years.

For these, CPAM sends a notice of sum to be paid with a possible settlement directly online via the ameli account.

From "My Payments", select "Pay Debt" and enter the notice reference.

It is indicated on the mail you received from the Health Insurance.

The account then proposes to settle all or part of the amounts due.

Select the slice or slices you want to pay and enter your credit card number, expiration date, and cryptogram.

We hope that the lump sum payments and medical deductibles are no longer secret to you.

To understand everything about this topic, see the article available on the website ameli.fr, under the heading “Refunds” then “What remains at your charge”