What is a state-approved “responsible” supplementary health insurance plan? | MIA Assurances

When it comes to choosing a company health insurance plan for your employees in France, you’ll hear talk of state-approved, “responsible” plans, healthcare baskets and care pathways. State-approved, “responsible” plans were introduced in France following a reform of the health insurance system. It’s important to understand how they work so that you can choose the right health insurance and advise your employees in France.

Why were state-approved plans introduced?

In 2016, the French Health Insurance body decided to bring in a reform to make French people aware that the cost of medical care was on the rise and reduce the deficit built up by the public system. Also, added to the fact that company supplementary health insurance plans became compulsory, this reform made it possible for many French citizens to obtain better coverage of their medical expenses.

In 2019, a further reform known as “100% Santé” (100% Healthcare) was added, requiring supplementary health insurance providers to cover 100% of the cost of approved glasses, dentures and hearing aids, with no out-of-pocket expenses. In practical terms, this means that health professionals agree to market 100% healthcare plans, guaranteeing no out-of-pocket expenses for your employees.

How to recognize a state-approved, “responsible” plan?

The public health system has published a detailed set of specifications that must be met if a supplementary health insurance plan is to be classed as state-approved or “responsible”. A certain number of minimum benefits are required, and some reimbursements are denied while others must be accepted. The insurer may not reimburse more than provided for under the plan or less than the minimum threshold. Almost all supplementary insurance plans in the French market are now state-approved.

In return for optimum reimbursement levels, your employees must follow the coordinated care pathway, meaning they must choose a general practitioner and cannot consult a specialist directly (with the exception of gynecologists, dentists, ophthalmologists, and pediatricians), without first having seen their primary care doctor. They should also check on the ameli.fr website whether their doctors have signed up to the OPTAM agreement (Option pratique tarifaire maîtrisée or Controlled Pricing Option) as their reimbursement will be lower if they choose a doctor who has not signed up this system.

State-approved supplementary plans reimburse the “ticket modérateur” (i.e. what is left to pay after the Social Security reimbursement) and the flat-rate daily hospital charge. It never covers: the flat-rate contribution of one euro applied to treatments and procedures, consultations, medical deductibles, supplements, and excess fees where the insured member has not followed the care pathway.

What impact will this have on coverage?

When the reform came into force, many French people saw their reimbursement levels drop because their supplementary insurance providers were required to comply with the specifications for “state-approved” classification. To compensate for this problem, insurers have created so-called “top-up” plans to reimburse the out-of-pocket expenses payable after the reimbursement from Social Security and the supplementary health insurance plan. As an employer, it is therefore recommended to offer your employees a top-up plan, whether optional or compulsory.

Why choose a state-approved health insurance plan for your employees?

As an employer, it is strongly recommended that you opt for a state-approved supplementary health insurance plan. You will then benefit from an exemption from Social Security contributions on the portion of the premium you pay. In addition, the tax applied to a state-approved plan is 7% compared to 14% for non-state-approved plans. Also, for your employees, the portion of the premium they pay will be deducted from their taxable income.

NB: as an employer you must pay at least 50% of the premium. You can choose to go further and fund your employees’ health insurance plan in full: a helping hand that will make a difference in terms of employer brand!

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