I am at 100 percent, should I take out mutual insurance?

The assumption of 100% of the medical treatment from social security can lead to the belief that we can do without mutual insurance. However, this is a big mistake. It is true that the ideal would be for 100% of care to be taken into account by health insurance or safety, but the realities are quite different. There are several types of care that health insurance or mutual insurance do not cover. Why keep your health insurance despite 100% coverage? Find the answer to this question here.

Does 100% coverage cover all treatments?

Covering 100% of health care costs is one of Social Security’s powers. It only applies in circumstances that are clearly defined in the health insurance agreement. It can be compared to an exemption from self-payment.

In slightly more accessible language, it is the patient’s dispensation from payment of the part of the health expenses that is normally awarded to him after reimbursement by the health insurance. This exemption granted by social security is only awarded to a well-defined part of the person’s health expenses.

Despite this, it is not excluded that other health expenses may entail significant costs and are very little or poorly covered by health insurance. This is why supplemental insurance is very useful for covering medical expenses such as excess charges, overheads, paramedical expenses, optical or dental equipment expenses.

If it is necessary to cover alternative medicine or other costs, the supplementary health insurance can also take them into account.

The concept of “100% health” and “100% social security coverage”

“100% health” is a system introduced by the public authorities from the beginning of 2021. This system promotes the signing of a “responsible” contract with a supplementary health mutual.

This contract will allow the recipient to enjoy a basket of care and equipment that can be reimbursed by health insurance and mutual insurance. The health and equipment basket covers three types of health services. These are hearing aids, optical and dental.

“100% health” is therefore completely different from “100% reimbursement from social security”.

The preservation of the mutual in the case of 100% coverage of the social security and the issue of exemption from the co-payment

Signing up for supplementary health insurance can be very practical and useful for all other types of care and medical examinations that are not part of the care protocol.

These treatments and medical examinations are therefore not subject to 100% reimbursement as for optical costs and dental prostheses.

Depending on the mutual insurance taken out, it is possible to get coverage in other forms of services such as the hospital package, the private room, excess, vaccines, etc.

The moderation ticket is, in a way, the rest of the health expenses that you have to pay when the health insurance has reimbursed its share as agreed. It covers all medical expenses that are reimbursable. This concerns consultation, analysis and examination, prescription of medicine or treatment, hospitalization etc. When it comes to 100% coverage, the beneficiary is exempt from this ticket, which is therefore in turn taken into account by the health insurance.

Application cases for 100% support

100% coverage of health expenses by Social Security occurs only when it comes to recipients of an exculpatory long-term affection certificate (ALD).

This ADL certificate can be appealed by the attending physician in case of serious or chronic diseases capable of absorbing sufficient financial resources or requiring long-term care. In these cases, the doctor in the health insurance provides everything that is necessary as care for the patient thanks to the ADL certificate.

When it comes to an “exculpatory” certificate, it allows 100% health coverage of health care costs directly related to your ADL under the Social Security Tariff Base.

The exception therefore only applies to the medical treatment of the conditions declared according to the treatment protocol or the regimen established by the medical college responsible for monitoring your ALD. This prerogative is granted according to the care protocol for a set period. It can be extended at the end of the period laid down in the protocol.

We also advise you to read: The ranking of the best senior mutuals at the moment

The difference between the moderation ticket, the balance due and the unsupported costs

The moderation ticket represents the part that the health insurance is under no obligation to reimburse. Despite this, it is not equal to the remaining charge.

This principle appears in the health insurance agreement and concerns fee excesses and certain fixed contributions. We can mention the fixed contribution of €1, the hospital’s fixed rate, the emergency patient’s fixed rate, medical deductibles, etc. These non-refundable fees are taken into account in most healthcare transfers.

Expenses not covered by health insurance

Costs not normally taken into account by the insurance are not reimbursed at “100% coverage”. These fees vary. First of all, there are the excess fees for healthcare professionals. Secondly, there are treatments, medicines and examinations which will not be reimbursed by the health insurance.

It is also necessary to add the sanitary devices, the costs of which are clearly higher than those provided by social security for this purpose. Finally, there are day passes and other types of passes.

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