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Home " Special Edition " Reimbursements at the pediatrician: how does it work?

Reimbursements at the pediatrician: how does it work?

by | Jun 2, 2020 | Special Edition, Information, Parents

Trying to understand the reimbursements after a visit to the pediatrician can indeed be very complicated. Especially since in this medical specialty there are different reimbursements depending on the age of the child and the reason for the medical visit. This article aims to explain to you, as well as possible, how the treatment and reimbursement of a consultation with a pediatrician is done. 

The complexity of managing consultations

Pediatric consultations are reimbursed by social security and also by mutual health insurance companies. It is also important to specify that pediatric rates, unlike general medicine, vary according to the age of the child, regardless of the sector of activity of the practitioner. Compared to 6-16 year olds, consultation fees are notably higher for children under 6 years old. 

In addition, it should be noted that mandatory examinations are to be expected 8 days after the birth of your child. And this, during the 1er month, from 9e or 10e months, between 1 and 2 years and between 2 and 6 years. These different appointments allow us to monitor your child's growth, his or her good development and the absence of abnormalities. These appointments also aim to give certain vaccines or to verify that they have been done.

However, the price and coverage of these mandatory consultations are different and vary from one appointment to another. Their price also depends on the sector of activity of the pediatrician. The same will obviously apply to the reimbursement of these consultations with the pediatrician.

Sector 1 and sector 2: what is the difference in reimbursement?

Like general practitioners, pediatricians are also divided into two distinct sectors. The sector 1, concerns the pediatricians under agreement who fix their prices according to the basic tariff imposed by the Social Security. Pediatricians in sector 2 have free fees and can therefore set higher rates.  

The categorization by sector is therefore related to the question of fees, an essential element in defining the reimbursements of consultations with the pediatrician by the Social Security and complementary health insurance. 

A sector 1 professional bases the consultation fees on the reimbursement base defined by the Social Security.

Sector 2 doctors are free to set their own fees. They can charge rates higher than those established by the Social Security. However, it is good to know that OPTAM professionals in this sector have a maximum ceiling that must not be exceeded (about 60 euros).

The OPTAM or Option Pratique Tarifaire Maîtrisée (controlled pricing option) is a contract signed between the Assurance Maladie (French National Health Insurance) and doctors under contract practicing (or having the possibility of practicing) in sector 2. The purpose of this system, which is offered by the Assurance Maladie to doctors under contract, is to improve access to care by limiting excess fees.

It is therefore important to find out about your health care provider's area of practice before you consult. This way, you can avoid unpleasant surprises when it comes to your reimbursements!

The reimbursement of a consultation with a pediatrician by the Social Security

The Social Security reimbursement rate for pediatric consultations is 70 % of the conventional rate. It is important to know that the reimbursement of the pediatrician by the Social Security also depends on his convention. 

Below is a table summarizing the Social Security coverage for an appointment with a pediatrician according to sector and agreement.

Physician consulted Reimbursement basis Reimbursement rateAmount of the refund
Sector 1 pediatrician for a child under 6 years old  32,00 € 70 %`22,40 €
Sector 2 pediatrician in OPTAM* for a child under 6 years of age  32,00 € 70 % 22,40 €
Non-OPTAM sector 2 pediatrician for a child under 6 years old  32,00 € 70 % 19,60 €
Sector 1 pediatrician for a child over 6 years old  28,00 € 70 %`19,60 €
Sector 2 pediatrician in the OPTAM* for a child over 6 years of age  28,00 € 70 % 19,60 €
Non-OPTAM sector 2 pediatrician for a child over 6 years old  23,00 € 70 % 16,10 €
*A pediatrician with the OPTAM (Option Pratique Tarifaire Maîtrisée)  

Billing and reimbursement at the pediatrician's office do not necessarily rhyme

The important thing to remember about reimbursement is that what you are billed by the pediatrician is not the amount you will be reimbursed. 

If the pediatrician bills you for 60€ in Sector 2 not OPTAM, then you will be reimbursed 16.10€ (see table above). If he charges you 40€, you will also be reimbursed 16.10€! And this is the basis of all Social Security reimbursements: this reimbursement is based on the famous "base of reimbursement" which is different for each medical act. 

Let's take glasses for example: the reimbursement base for a single lens is only 12.04€! And in this case, the rate is no longer 70% but 60%, so the social security reimburses 7.22€ per single lens (which is obviously generally well below the price charged by the optician).

The difficulty is that these bases and the associated rates are never the same. Through this article you will know them at least for pediatricians.

Additional reimbursement of a visit to the pediatrician by the health insurance company (optional)

The vast majority of French people have a health insurance plan. Only 5 % of French people do not have a complementary health insurance, because it has a cost. Moreover, companies are obliged to offer a complementary health insurance to their employees, which reduces the number of people not covered. Nevertheless, few people know how it works.

Complementary health insurance supplements the Social Security reimbursement in cases where the latter does not fully cover the costs (i.e. in many cases...) Below are two summary tables with the lowest and highest reimbursement rates for all consultations with a specialist (and therefore a pediatrician) in sector 2.

The reimbursements of complementary health care are variable. For example, the reimbursement base of 100 % corresponds to basic contracts. The mutual insurance company covers 100 % of the Social Security reimbursement base (BRSS).

For a mutual insurance with a coverage of 100 %

Physician consulted Price of the consultation Social security reimbursementMutual insurance reimbursementTotal reimbursedReste à charge
Sector 2 pediatrician with OPTAM** - under 6 years old 60,00 € 22,40 € 9,60 € 32,00 € 28,00 €
Non-OPTAM sector 2 pediatrician - under 6 years old  100,00 € 19,60 € 8,40 € 28,00 € 72,00 €
Sector 2 pediatrician with OPTAM** - over 6 years old  35,00 € 19,60 € 8,40 € 28,00 € 7,00 €
Pediatrician of sector 2 not OPTAM* - over 6 years old  60,00 € 16,10 € 6,90 € 23,00 € 37,00 €
*Within the limit of the expenses incurred
**A pediatrician with the OPTAM (Option Pratique Tarifaire Maîtrisée)  

Without exceeding fees and in sector 1, the mutual insurance company will cover 100 % of the co-payment. This co-payment is the part that remains payable by the insured person after reimbursement by the Assurance Maladie.

The percentages (100 %, 150 %, ...) in a health insurance plan determine your coverage for the different items. 

A complementary health insurance plan at 100 % does not mean that you will be fully reimbursed. A 100 % coverage corresponds to a 70 % coverage from the Social Security and a 30 % coverage from the mutual insurance company. This means that the mutual health insurance and the Medicare will cover 100 % of the Social Security reimbursement base.

If you want to be fully reimbursed, consult a doctor who is a sector 1 doctor, i.e. he or she must practice the convention rate of the Social Security. If the fees are exceeded, you will generally have to pay the difference between the amount of the excess and the basic rate.

For a mutual insurance company with a reimbursement of 400 %

Physician consulted Price of the consultation Reimbursement basis Social security reimbursementMutual insurance reimbursementTotal reimbursedReste à charge
Sector 2 pediatrician in OPTAM**-. under 6 years old  60,00 € 32,00 € 22,40 € 105,60 € 128,00 € 0 €
Non-OPTAM sector 2 pediatrician - under 6 years old  100,00 € 32,00 € 19,60 € 92,40 € 112,00 € 0 €
Sector 2 pediatrician in OPTAM**-. over 6 years old  35,00 € 28,00 € 19,60 € 92,40 € 112,00 € 0 €
Pediatrician of sector 2 not OPTAM - over 6 years old  60,00 € 23,00 € 16,10 € 52,90 € 69,00 € 0 €
*Within the limit of the expenses incurred

If you choose a mutual insurance with optimal coverage (400 %), you will no longer have to pay any remaining expenses. It is important to subscribe to a complementary health insurance with strong guarantees if it meets your health needs and those of your children under 16. But be careful, a high level of coverage always means high premiums. So adapt your contract to your real needs to avoid paying too much for your contract.

In the end: how to avoid getting out your calculator every time?

There are online reimbursement calculators on the internet. We propose you the calculator of Good-Insurance.com. The tool is easy to use, just enter the price charged by the pediatrician for the consultation. You must then indicate if you are a member of a mutual insurance company or not, in which case, specify the level of coverage of your complementary health insurance. The tool calculates the remaining cost if there is one.