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I have been registered with CPAM for more than a year now and haven't used the doctor much, but when I have I'm very confused about how much I can expect to be reimbursed or how I can even know.

Most resources I see, for example, claim that most doctor visits are covered "about" 70%. But for my last consultation I paid 25€ up front, and was reimbursed 14€ (less than 60%). I also saw a specialist for some imaging and paid 72€ out of pocket. I was then reimbursed 38.69€ which is only 54%.

Update: So I found my account statement on the ameli.fr site, and for the imaging it broke things down like:

Montant payé: €72.00
Base de remboursement: €56.70
Taux: 70%
Participation forfaitaire: (€1.00)

So they reimbursed me 70% of 56.70, and also deducted a 1 euro "participation forfaitaire". How would I know what the "base de remboursement" is as opposed to the amount I actually paid up front? What's the "participation forfaitaire"?

I ask in particular because I'm shopping around for mutuelle, but I don't even understand my existing coverage.

  • This does not seem to be about expatriation. – fkraiem Mar 4 '18 at 18:06
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    I don't get why you're being downvoted. This is a perfectly relevant question. CPAM is ridiculous a lot of the time and can be downright impossible for a foreigner to be able to figure out. FWIW I've been here 2 years and still have no mutuelle for this reason. – la femme cosmique Mar 7 '18 at 14:16
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    I don't know about your medical situation. But I can say that as a 30yo lady who has thyroid issues, needs a lot of blood tests/scans, needs an MRI, the MRI was the only time I considered it. I was priced at 40 eur/month to cover everything, and I do not use > 40 eur per month. Your mileage may vary, but good luck getting the mutuelle guys in Paris or Orsay to be very clear about anything! It may be worth it for you, but it really depends on your avg medical spending. Get a quote and compare it against what you may spend now, is the only advice I can give you unfortunately :( – la femme cosmique Mar 10 '18 at 12:31
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    And afaik hospitalisation in emergency is actually covered by CPAM most of the time. So it's mainly mutuelle for expensive scans (e.g. MRI) or expensive medications. Most meds are largely covered by CPAM; I think I pay something like 1,50 eur for thyroid+BC, compared with hundreds in the US. UNLESS you want to go to a private hospital (which are usually not as good in France as the public ones - you need mutuelle for that). – la femme cosmique Mar 10 '18 at 12:33
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    Ditto @lafemmecosmique my situation is pretty similar actually. Most mutuelle offers I got were in the 40eur/mo range, though I also wanted good dental and optical coverage. But even with the optical benefits it didn't seem to quite add up for what I'd actually be spending without the mutuelle. That said, I still just wish I understood how the above CPAM coverage broken down and why I'm only reimbursed on a percentage specific amount, not the actual cost. I guess it's based on some base average cost for a procedure but I can't find a useful guide to those base costs... – Iguananaut Mar 12 '18 at 16:30

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