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What obligations does the employer have with regard to mutual assistance?

Verified 26 March 2021 - Directorate for Legal and Administrative Information (Prime Minister)

All private sector employers (companies and associations) are obliged to offer supplementary collective health cover to their employees (with exceptions). An individual who employs an employee at home is not concerned. Some employees on short-term contracts may be exempted from membership of the collective mutual society and benefit from a health payment by the employer.

The employer must pass on the benefit all its employees , irrespective of their length of service in the company, of a scheme for the additional reimbursement of health costs.

The company freely chooses the insurer from whom it negotiates the insurance contract.

The employer must send a membership slip to the employee who does not have to take any steps. He then receives a certificate of affiliation to the health supplement.

The social partners in the branch may recommend an organization. In this case, this recommendation must be made after a prior call for competition.

Coverage of the employees' beneficiaries (children or spouse) is not compulsory, but the employer (or the social partners) may decide to cover them as well.

Compulsory collective cover must meet the following conditions:

In the case of multiple employers, an employee already covered by a collective agreement of one of his employers may refuse to subscribe to the other agreements. They must provide proof of this protection to other employers by means of an annual proof of membership.

In the event of suspension of the employment contract, cover must be maintained when the employee is in the process of receiving compensation (e.g. sick leave). On the other hand, the employer is not obliged to maintain the mutual insurance scheme when the suspension is not compensated (for example, parental leave). Employees whose contract is terminated for any reason other than gross negligence shall be entitled to maintenance of this coverage for a period equal to the unemployment benefit period (up to a maximum of 12 months).

Minimal care basket

The supplementary company health must cover at least the following guarantees (care basket):

  • Entire user fee on consultations, documents and benefits reimbursable by sickness insurance, subject to certain exceptions
  • Entire daily hospital fee in case of hospitalization
  • Dental expenses (prostheses and orthodontics) up to 125% of the conventional tariff
  • Optics costs on a flat-rate basis per 2-year period (annually for children or in the event of changes in vision) with a minimum of care fixed at €100 for a simple correction, €150 (or €200) for a complex correction

Guarantees of a contract called responsible

The health supplement may be a so-called contract responsible in your company. In this case, health expenditure shall be covered as follows:

Tableau - Main services of a responsible contract signed or renewed from April 1, 2015

Benefits

Compulsory care

Excluded support

Optional support

Doctor's fees

Moderator Ticket

  • Exceedances of fees and increase in the user fee related to non-compliance with the care pathway
  • Flat-rate participation of €1
  • No limit if the doctor is adhering to the contract of access to care
  • Limited support if not

Medicines

TO SMR.: titleContent major (refunded to 65%)

Moderator Ticket

Franchise (fixed fee)

TO SMR.: titleContent moderate and low (refunded to 30% and 15%)

No obligation to take charge

Homeopathy

No obligation to take charge

Hospitalization

Daily package in full, without limitation of duration

Moderator Ticket

  • No limit if the doctor is adhering to the contract of access to care
  • Limited support if not

Optical

Moderator Ticket

Limited as follows:

  • A pair of glasses every 2 years or less (annually for children or in case of vision changes)
  • Frame at the height of €100 maximum (for contracts entered into or renewed from 1er January 2020)
  • Minimum and maximum limits depending on the complexity of the equipment (e.g. for a single lens, between €100 and €420 for contracts entered into or renewed on or after 1er January 2020)

    • Dental

    Moderator Ticket

    Thermal cure

    No obligation to take charge

    FYI  

    since 1er january 2022, the responsible contracts provide for the acceptance by the complements of the practice of paying third party (waiver in advance of fees) on the equipment and care of the basket 100% health (optics, dentistry and audiology).

    Additional benefits

    The health supplement may offer additional benefits, for example:

    • Third-party payer
    • Assistance service (housekeeping, childcare, etc.)
    • Prevention and support (e.g. screening)

    Affected employees

    The employer must offer mutual assistance to all employees, including apprentices.

    However, it may grant a waiver of membership of the company Mutual Society to certain employees, in particular:

    • Fixed-term employment contract (fixed-term contract) of less than 3 months
    • Contract of assignment less than 3 months (interim)
    • Part-time (up to 15 hours per week).

    These employees may:

    • either subscribe to the supplementary health cover offered by their employer,
    • or request to be exempted from payment in respect of health.

    However, this possibility is not open if the compulsory collective cover is at least 3 months, regardless of the duration of the contract.

    The health payment can also be implemented:

    • at the initiative of the social partners (by collective agreement in the sector or by company agreement),
    • by unilateral decision of the employer.

    Others employees may be exempted, at their request, of the obligation of membership:

    • Employees who are covered individually when the compulsory collective scheme is introduced or when they are hired if later. The exemption shall apply until the expiry of the individual contract
    • Employees who are beneficiaries of the solidarity health supplement. The exemption applies until the date on which the employee ceases to benefit from the solidarity health supplement
    • Employees, including beneficiaries, who receive benefits under another employment of one of these schemes: supplementary compulsory collective health, local health insurance scheme of Alsace-Moselle, supplementary health insurance scheme of the electricity and gas industries (CAMIEG), mutual health insurance of public and local government officials, in particular.

    In the case where the employee contracts 2 successive contracts of less than 3 months and the overall duration of the 2 contracts exceeds 3 months, the health payment is due only under the first contract.

    Where several fixed-term contracts are concluded with the same employee, but not in succession, the health payment must be taken into account on a contract-by-contract basis.

    Calculation of the employer contribution

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    General case

    The health benefit is funded by the employer.

    The amount of payments shall be calculated each month on the basis of a reference amount to which a coefficient shall be applied.

    This reference amount corresponds to the employer's monthly contribution to the financing of the collective cover of the category to which the employee belongs. It shall take account, where necessary, of the remuneration of the employee.

    If the amount of the contribution cannot be determined for the category of employee, the reference amount shall be €16.34.

    The coefficient applied to the reference amount shall be:

    • 105% for employees on permanent contracts
    • 125% for employees on fixed-term contracts or on assignment contracts.

    Example :

    if an employer makes a lump-sum contribution of €60 for each of its employees in a certain category, for an employee on a permanent contract of this category who works 50 hours per month, the reference amount is calculated as follows: 60 x (50/151,67) =19,78, to which the coefficient of 105%. The monthly amount to be paid for this employee is €20.77 (19.78 x 105%).

    The employer shall be exempt from social security contributions on such payments, except as regards the CSG-CRDS and the social package in the companies of at least 11 employees.

    Alsace-Moselle

    The health benefit is funded by the employer.

    The amount of payments shall be calculated each month on the basis of a reference amount to which a coefficient shall be applied.

    This reference amount corresponds to the employer's monthly contribution to the financing of the collective cover of the category to which the employee belongs. It shall take account, where necessary, of the remuneration of the employee.

    If the amount of the contribution cannot be determined for the category of employee, the reference amount shall be €5.45.

    The coefficient applied to the reference amount shall be:

    • 105% for employees on permanent contracts
    • 125% for employees on fixed-term contracts or on assignment contracts.

    Example :

    if an employer makes a lump-sum contribution of €60 for each of its employees in a certain category, for an employee on a permanent contract of this category who works 50 hours per month, the reference amount is calculated as follows: 60 x (50/151,67) =19,78, to which the coefficient of 105%. The monthly amount to be paid for this employee is €20.77 (19.78 x 105%).

    The employer shall be exempt from social security contributions on such payments, except as regards the CSG-CRDS and the social package in the companies of at least 11 employees.