What is a medical deductible?

Implemented in 2008 via article 52 of the Social Security financing law, the medical deductible is a device aimed at limiting State expenditure on health. It is a sum of money for which the insured remains liable after reimbursement by the health insurance.

It applies to medical expenses for adults and concerns most medical acts, medical transport, and medication. It applies in particular to laboratory analyses, consultations with a general practitioner or specialist, x-rays, etc.

Let’s take an example. If an insured pick up a prescription drug from a pharmacy that costs €12 and includes a €2 deductible, he must pay €2 out of pocket.

If its amount varies according to the medical procedure, a fixed deductible of €24 is automatically applied to medical expenses of more than €120.

In the context of hospitalization, the flat-rate deductible becomes a hospital flat rate. The latter is of the order of:

€15 per day in a psychiatric unit,

and €20 per day in a clinic or hospital.

When the health insurance does not fully reimburse a service or treatment, the medical deductible can be combined with the co-payment. The insured must therefore pay the part of the expense remaining at his expense, as well as the deductible.

Good to know: the medical deductible is different from the flat-rate contribution of 1 euro. The latter corresponds to a participation of the insured up to 1 euro for consultations, medical acts, and laboratory analyses.

Is the medical deductible reimbursed by the mutual?

The primary objective of medical deductibles is to empower policyholders and dissuade them from over-consuming care and drugs. It is for this reason that Health Insurance has set up partnerships with so-called “responsible” mutuals , which do not cover it.

These health insurances represent a major part of the contracts offered on the market. However, certain “non-responsible” supplementary health insurance can allow you to benefit from reimbursement of the medical deductible.

Who are the patients exempt from deductible?

While many policyholders are affected by the medical deductible, many can benefit from an exemption.

Insured persons under the age of 18 on January 1 of the current calendar year.

Pregnant women from their sixth month of pregnancy and up to 12 days of the baby.

Young girls aged 15 to 18 for acts and drugs related to contraception

Insured persons earning modest incomes and benefiting from the CMU

Foreigners in an irregular situation eligible for state medical aid

People with certain long-term conditions (ALD): disabling stroke, coronary disease, cystic fibrosis, etc.

Victims of a terrorist act for care related to the event

Beneficiaries of aid for the acquisition of complementary health insurance (ACS)

Recipients of a military disability pension for care related to their disability

At the same time, certain medical procedures allow full reimbursement and reimbursement by Health Insurance, without the application of a deductible. This is particularly the case for preventive acts organized for colorectal cancer and for breast cancer, preventive acts in a post-professional context, and nicotine substitutes, for which reimbursement by National Health Insurance is fixed.

Amount of the medical deductible and flat-rate contribution

The amount of the medical deductible depends on the type of procedure performed. He’s from :

0.50 euro per box for drug benefits,

0.50 euro per paramedical act,

2 euros per medical transport.

However, if these medical acts are carried out in the context of hospitalization, then no deductible is deducted by the Health Insurance.

For certain heavy acts whose price is equal to or greater than 120 euros, a flat-rate deductible deduction of 24 euros is made. If several heavy acts are performed during the same hospitalization or consultation, this lump sum payment is only to be paid once.

However, the lump-sum payment of 24 euros does not concern:

emergency transport,

magnetic resonance imaging (MRI) procedures,

radio diagnostic procedures.

The exemptions are the same as for the classic medical deductible.

At the same time, to limit patient expenses, Social Security has implemented a protocol for capping the amounts payable. These ceilings are daily, i.e. the amount of the deductible paid during the same day cannot exceed:

2 euros for paramedical acts,

4 euros for medical transport.

And to better protect patients, an annual cap has also been put in place. Thus, all of the medical deductibles paid during the same year cannot exceed the amount of 50 euros.

Good to know: the fixed contribution of 1 euro also has a ceiling of 50 euros, which can be combined with that of the medical deductible. The total amount of the two deductibles cannot, therefore, exceed 100 euros per year.

Withdrawal of the medical deductible: how does it work?

The amount of the medical deductible is deducted by Health Insurance:

either by direct deduction from the refund,

or by deduction during the next medical act.

The method of deducting the medical deductible depends above all on the policy of the insured.

For policyholders without third-party payment, the amount of the medical deductible is directly deducted from reimbursements made by Health Insurance. It is then indicated in the reimbursement statements sent by Social Security.

For policyholders with third-party payment, the amount of the deductible is deducted from the next reimbursement. If the insured does not receive any other reimbursement, the amount of the medical deductibles are to be paid directly to the Health Insurance, after receipt of an explanatory letter. The same applies if his care is all covered under third-party payment.

If your health contract is non-responsible, your mutual insurance covers the medical deductible. You will have nothing to settle, nor any procedure to carry out. However, the majority of mutual contracts on the market are responsible.

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