This note is a direct extension of the Securing and Improving Our Health System study published by the Sapiens Institute in September 2020, and aims to extend the analysis on a particular aspect: that of the role of complementary health, under the Responsible Contract. It is also part of the current work of the High Committee for the Future of Health Insurance (HCAAM), which currently focuses on the place of supplementary health and provident insurance in France.
In fact, the coverage guarantees for supplementary health contracts, taken out individually and especially collectively, within the framework of the company, are not free. A framework was defined by the health insurance reform law of 2004: the Responsible Contract, which sets obligations for supplementary health insurance, such as that of reimbursing a minimum amount in optics, and prohibitions, such as that of not reimbursing certain fee overruns above a determined amount.
Failure to comply with this framework induces, for “non-responsible” contracts, a surcharge of 7 points for the Additional Solidarity Tax (TSA) – ie 20.27% against 13.27% for responsible contracts. It should be noted that the TSA is passed on and consequently settled by subscribers, individuals and companies. In addition, for companies, the deduction of the contribution relating to the health coverage of their employees (under social charges and corporate tax) is subject to the fact that the contract is “responsible”. However, this deduction is an economically essential element for the company to cover the cost of this coverage.
When it was created in 2006, the constraint was virtuous and simple: the additional guarantees should not hinder the regulation of the care path by health insurance. Then, the Responsible Contract degenerated, over time, into an extremely finicky straitjacket of very precise rules, the climax having been reached since early 2020 with the “100% health” system, which provides for total reimbursement obligations. on certain types of prostheses and strict limitations on certain others, in terms of optics, dentures and hearing aids.
Ultimately, the Responsible Contract has gradually led complementary health insurance companies to become hyper-specialists in the financing of these three areas (optics, dentistry and hearing aids). This movement took place to the detriment of a desirable differentiation of the guarantee / price ratio of the coverages offered, according to the needs and means of the insured, but above all to the detriment of the financing of the remainder to be paid (RAC) of the insured in the event of wholesale. health incident, such as hospitalization and Long Term Disorders (ALD).
This logic ultimately led to the separation of small and large risk: Health Insurance saw its share (78.2% in 2019) increase in the Consumption of Healthcare and Medical Goods (CSBM) since it covers at 100% the costs of care excluding excess fees and non-refundable care for ALD; while OCs have taken an increasing place in “small risk”. This distribution had however been very widely rejected during the last presidential campaign, because it does not respond to any medical or medico-economic logic.
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Josette Guéniau is a professional and former director of health insurance, who has been advising complementary insurers for more than 10 years, in particular on the subjects of regulation, innovation and marketing strategy. As such, she has been interested for more than 5 years in the contribution of teleconsultation in the management in terms of access and quality to health but also in its financing.
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