/Mutual Health Insurance : How Does It Work?
Mutual Health Insurance

Mutual Health Insurance : How Does It Work?

The Mutual health insurance comes in addition to the health insurance of social security. It protects you and your family against illness or accidents. A mutual is not mandatory, but it can be imposed by some employers who will provide it to you at the time of signing your contract. I explain here everything you need to know about mutual health.

Mutual health, how does it work?

The mutual health insurance can first take several names, such as complementary health or health insurance. It covers all expenses, or part of the costs that are not covered by social security insurance.

As you have probably heard, social security has structural problems of deficit, which pushes this organization to only partially reimburse the expenses for our care, our medicines, our radios, our surgeries, our expenses of hospitals, etc.

The coverage of social security is decreasing and it is here that the mutual intervenes, taking each year an ever larger share. It acts in addition to the “safety”, which is why it is often called “complementary health”.

The different insurance or mutual health insurance contracts

First of all, you need to know that two types of partners offer their services. There are the insurance companies, which are primarily commercial companies and who will first want to make a profit. Then, we find the mutual’s, which are governed by the code of mutuality, which are non-profit companies, and operate on the principle of solidarity. Mutual health insurance is as under:

  1. Educators Mutual Health Insurance
  2. Federated Mutual Health Insurance
  3. Western Mutual Health Insurance
  4. Liberty Mutual Health Insurance
  5. Mass Mutual Health Insurance
  6. Northwestern Mutual Health Insurance
  7. Medical Mutual Health Insurance
  8. Mutual Omaha Health Insurance

The different formulas and the coverage rate

Whether it is a mutual health or health insurance, the operation is exactly the same. It will simply check that the main guarantees are present, and understand the operating system.

It is therefore important to assess at what level of coverage your mutual entitles you. To do this, one must take note of the reimbursement base defined by social security. You will have all the prices for consultations, medications, or various care and medical procedures.

In spite of that, it is here that it is complicated since the tariffs of the social security are generally much lower than the real costs. Mutual health Omaha Insurance offers you several coverage levels, at 100, 150, 300 or 400%. The higher the percentage, the better you will be reimbursed, but the more the mutual will be expensive.

Example: a consultation costs 100 € in real costs, social security indicates that this type of consultation costs only 50 €, and it reimburses you 70% of 50 €, 35 €. If we could believe that a 100% mutual will pay the entire amount, this is not the case at all. It will only pay the remaining part of 50 €, in the end, you will pay 50 € from your pocket to reach the 100 € of departure.

It should be known that on many high health expenses, such as dental prostheses, optics, or orthodontics, the share of social security is really very small. It is therefore necessary to check the guarantees of your mutual, so that the most expensive positions are those with the best reimbursement rate.

The guarantees of the mutual

This is an important choice when deciding on the ideal deal for you. The mutual guarantee corresponds to the benefit you will be entitled to under your contract (dental expenses guarantee, hospitalization expenses guarantee, optical costs guarantee )

The basic guarantees are generally the same from one insurance to another, the level of coverage will change. The mutual insurance company therefore guarantees the reimbursement of part or all of the expenses of an accident, illness or maternity:

  • Medical consultations (general practitioners or specialists)
  • Hospitalization costs: surgery, daily cost …
  • Medication
  • Biological analyzes
  • Optics: frames, lenses, lenses …
  • Dental care
  • Prosthetics and orthodontics
  • Medical procedures (physiotherapists, home nurses, speech therapists …)
  • orthopedics
  • Prostheses other than dental (hearing …)
  • Spa treatments
  • Health assistance services
  • The service of the third-party payer (To not advance the payment of your care)

It will sometimes be possible to remove warranties, in case you are young, that you have no particular vision problem, so the optical warranty will be of little use for example.

Conversely, you can also add additional guarantees, and depending on your situation, it is often these guarantees that will tip the balance from one insurer to another. One can thus find the premium at the birth of a child, the foresight which is a guarantee of invalidity or of incapacity in the event of an accident, but also of the assistance (repatriation, guard of animals, help-housekeeper, funeral packages … It is also possible to find guarantees for the reimbursement of medicines that are not recognized by social security, such as acupuncture or osteopathy.

Mutual third party paying

The third-party payer is an option that is found in many mutual or insurance, and allows you to pay nothing for some of your health costs. The co-payment, or your share, is immediately paid by your mutual because of an agreement with various health professionals.

We can benefit in most cases, whether for our pharmacy, laboratory, radiology, but also the optician or many medical auxiliaries, and of course in case of hospitalization.

To benefit from it, it is first necessary that the insurance company or the mutual offers the third-party payer, which is not always the case. It is also necessary that the health professional who is the “third party”, provide his agreement, again, it depends on the situations. Third-party payment can be a basic guarantee, or a paid option.

The extra health supplement, what is it?

To complete the guarantees provided by the social security and mutual health, there is the additional health. It allows a 3rd level refund for better coverage.

It is intended especially for all those who have significant expenses in some health posts, and whose different mutual’s do not allow a good care. This is the case when our mutual is imposed by our employer, but it does not offer sufficient guarantees for dental care or optics for example.

There are usually two types of contracts for extra health supplements. The first is a specific contract that comes in addition to the mutual. Refunds are then made on request, based on the coverage of the mutual beforehand. The second contract is a strengthening of the lawyer mutual insurance already in place. We no longer take into account the guarantees and the level of coverage of the mutual, but we refund directly according to the additional.

It should be noted that repayments are usually much longer with an additional health supplement. This is not ideal if you have to pay quickly for specific and high cost care.