Our advice to limit the remaining charge

Have you ever consulted a healthcare professional and not been reimbursed for the full amount of the service?

This is called the remaining charge. That is to say the difference between the reimbursement of social security and the costs actually incurred.

Discover our advice to limit this expense!

Update your vital card

It is essential to update your health card every year to ensure effective care in your health journey.

This is a quick and easy process that promotes the renewal of rights with the Caisse Primaire de l'Assurance Maladie ( CPAM ).

Updating your carte vitale allows you to update your administrative data.

This will avoid malfunctions during the computer entry of your data and therefore payment refusals.

Your file will be processed in the best conditions and you will be reimbursed on your health expenses as soon as possible.

Whether with a general practitioner or a specialist, updating your vital card guarantees reimbursement of your health expenses at the right reimbursement rate and within a relatively short period of time (in less than a week).

Where can I update my vital card?

Updating your vital card is a simple, quick operation that anyone can do.

You can do it at:

• a pharmacy: the majority of pharmacies are equipped to update information on the vital card. You can do it yourself from the self-service terminals provided by the pharmacy. Otherwise you can ask the pharmacist to perform the operation for you;
• social security via the terminals made available;
• of all Primary Health Insurance Funds ( CPAM );
• of some health facilities.

Create your Ameli account

You must create an Ameli account to access the Caisse Primaire d'Assurance Maladie (CPAM) online services.

Before opening your Ameli account, you must:

• your bank details are already registered with the Caisse Primaire D'assurance Maladie (CPAM);
• your vital card is active.

Once these two conditions have been met, you can create your Ameli account securely from the home page of the website https://assure.ameli.fr by clicking on "  I create my account  ".

You will need to fill in:

• the last seven digits of your bank account details (RIB), already transmitted and used by the Primary Health Insurance Fund (CPAM) to reimburse your services;
• the serial number of your Vitale card.

Your Ameli account will be created after filling in the requested information and validating the form.

Respects the coordinated care pathway

Declare your attending physician

If you are over 16, you must designate the attending physician of your choice and declare it to social security by completing the “ Declaration of choice of attending physician ” form available on  www.ameli.fr .

Your attending physician is responsible for:

• your care and your medical follow-up;
• coordinate care by referring you, if necessary and with your agreement, to a corresponding doctor . This is usually a medical specialist. Your attending physician can also refer you to hospital or other doctors;
• manage your entire medical file;
• provide you with personalized prevention;
• set up the care protocol to be adopted in the case of a Long-Term Condition (ALD).

The attending physician may be:

• a general practitioner or a medical specialist;
• a contracted doctor from sector 1 or sector 2;
• a doctor who has signed the Controlled Tariff Practice Option (OPTAM);
• a doctor who has signed the Option of Controlled Tariff Practice in Surgery and Obstetrics (OPTAM CO);
• a non-signatory physician.

You are free to change your attending physician at any time.

You are also free to choose the corresponding doctor to whom you wish to go. This is a free and individual choice!

We advise you all the same, to follow the recommendations of your attending physician in the orientation towards a specialist.

Your attending physician will write a letter describing your state of health for the attention of the specialist.

When you go to the latter, you must present this letter to him.

For the proper coordination of your care, the specialist will keep your general practitioner informed of your state of health.

Am I obliged to follow the coordinated care pathway?

Respecting the coordinated care pathway is not an obligation.

However, if you are off course, you will see the amount of Social Security reimbursements reduced by 40%.

If you do not declare your attending physician to social security or if you consult a specialist directly without being directed by your attending physician, the social security coverage rate will be reduced and your participation will be increased.

Your complementary health (mutual) will not cover this increase either, and therefore, the rest to be paid will be significant.

If you do not follow the coordinated care pathway and you consult a doctor who practices fee overruns , the social security coverage rate will be reduced and your participation increased.

Your complementary health (mutual) will not cover the increase or the overruns of fees, and therefore, the rest to be paid will be even more important.

In which cases would I normally be reimbursed?

If, in the event of an emergency or travel, you consult a specialist directly without having been referred by your attending physician, you are not considered outside the coordinated care pathway.

You follow the coordinated care pathway if you directly consult certain specialists, such as:

• gynecologists for check-ups;
• ophthalmologists;
• psychiatrists or neuropsychiatrists for young people aged 16 to 25;
• stomatologists.

If you have an exonerating long-term condition (ALD) or a chronic disease, if you follow a sequence of care and you consult a specialist directly without having been directed by your doctor, you are not considered outside the coordinated care pathway

You also respect the course of coordinated care if you consult another doctor in the absence of your attending physician.

Check in which sector the healthcare professional works 

Sector 1 Doctor

A doctor who applies a fixed rate, called a convention rate equal to the social security reimbursement base , is called a contracted doctor .

The contracted doctor practices in sector 1 and does not apply excess fees .

Sector 2 Doctor

The non-contracted doctor practices in sector 2 and applies a free tariff .

Beyond the convention tariff corresponding to the social security reimbursement basis, the doctor in sector 2 practices fee overruns.

For optimal reimbursement from social security, it is best to consult approved doctors practicing in sector 1.

The doctor signing OPTAM or OPTAM CO

The physician signing OPTAM or OPTAM CO undertakes to:

• apply the convention rate without applying excess fees for part of its consultations;
• practice fee overruns controlled within the framework of OPTAM and OPTAM CO with a rate less than or equal to 100% of the agreement rate.

Know the status of your doctor

The health professional's file available in the Health Insurance health directory tells you whether the health professional practices in sector 1 or sector 2 and whether or not he is a signatory doctor of the health insurance. 'OPTAM or OPTAM CO.

Use your third-party payment card

In order to reduce your expenses, always remember to present your third-party payment card to health professionals, in pharmacies, laboratories, radiology practices, at medical auxiliaries, opticians, dentists, hospitals, etc.

The third-party payment exempts you from advancing the costs supposed to be borne by your complementary health insurance (the mutual insurance company). It is responsible for paying the healthcare professional directly and automatically.

The role of complementary health insurance is to partially or totally cover the health expenses that remain your responsibility after reimbursement from social security.

You will then only pay the healthcare professional the remainder, that is to say the amount that is not covered, neither by social security nor by your complementary health insurance.

Reinforce your guarantees for better coverage

The challenge is to choose the right complementary health insurance.

Be sure to choose health insurance that is well suited to your specific needs and meets your expectations and your budget.

Indeed, when the needs in terms of care increase, modifying your insurance contract or changing complementary health insurance proves to be essential.

Two options are available to you. You can either subscribe to a reinforcement on a position or increase your guarantees by opting for a superior offer with better support.