What is the complementary health insurance (AMC)?

Principle of the AMC?

It is all the organizations offering supplementary health services which supplement the services of the compulsory health insurance scheme. It brings together, depending on the social status of the beneficiaries, both optional and compulsory schemes and exists in the form of individual contracts as well as group contracts.

The AMC is offered by three types of organization, under two forms of contract.

The three types of organizations guaranteeing AMC coverage

These three types of insurers are differentiated by the specific rules that govern them:

  • Mutuals governed by the Code de la Mutualité are also known as mutuals 45 (from the year of creation of this statute).
  • Provident institutions are governed by the Social Security Code.
  • Insurance companies are subject to the Insurance Code. They can be in the form of commercial companies, but also in the form of a mutual insurance company.

Forms of AMC

The forms of contracts vary according to the quality of the subscriber.

The collective contracts are group contracts subscribed not by the beneficiaries of the guarantee themselves, but by an association (union or professional branch, etc.) or a company whose members adhere to the collective contract.

Example : since the ANI law, employees systematically benefit from the group health contract that their employer must take out.

The individual contracts are established and signed directly by the insured, the individual contract covers a single person with the status of insured as well as his dependents from the family unit (spouse and children). They are mainly taken out by TNS (craftsmen, traders, farmers, liberal professions, etc.) and by retirees who do not benefit from the provisions of the ANI law.

To note : collective contracts were originally offered only by provident institutions. While the subscription of individual contracts was only offered by mutual insurance companies and insurance companies.

But since the implementation of the obligation of the ANI law requiring employers to take out a group contract for the benefit of all their employees, mutuals and insurance companies can now offer collective contracts. Provident institutions having modified their status, by creating structures whose management falls under the Mutuality Code.

Is complementary health insurance compulsory?

Except for people covered by the employee scheme who are required to join and contribute to the group contract set up by their employer under the ANI law (with contribution covered at least 50% by the company) , there is no obligation to take out complementary health insurance.

Why take out complementary health insurance?

Subscribing to complementary health insurance is interesting since the insurance can cover all or part of the costs of care left to the responsibility of the socially insured person by the compulsory health insurance scheme. This also makes it possible to benefit from third-party payment, which avoids having to advance treatment costs. Via the Vitale card, the health professional is credited with the amount of the reimbursement by Social Security on the basis of the convention rate and the amount of the co-payment by the complementary health insurance.

Good to know: employees who consider their guarantees insufficient can subscribe individually to a contract supplementing their care by acting as a 3rd level as additional supplement after intervention by Social Security and group health supplement.

How to get reimbursed?

In addition to the use of third-party payment, which avoids disbursing the costs of care paid for directly by the compulsory scheme and the complementary health insurance, the beneficiary of a complementary health contract will be reimbursed on the basis of the guarantees provided for in his contract on supply to their insurer or mutual insurance company of the statement of costs issued by Social Security or the invoicing of actual costs incurred in the event of care services not covered by the compulsory scheme if reimbursement is provided for in the contract (in particular in terms of natural medicine in higher-end formulas).

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