What is the employer's obligation for supplementary health care?
Verified 05 January 2024 - 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, subject to exceptions. This coverage may be provided in particular by mutual insurance. An individual employing a homeworker is not concerned. Some employees on short-term contracts may be exempted from the collective health supplement and receive a health payment from the employer. Here are the rules to know.
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General case
The employer must pass on the benefit all its employees, irrespective of their length of service in the company, complementary company health.
This coverage allows the employee to supplement his or her reimbursement of health expenses in addition to the part reimbursed by the Social Security.
Coverage of the employees' beneficiaries is not compulsory, but the employer (or the social partners) may decide to cover them as well.
Example :
A person may apply for exemption from the health costs scheme set up in his or her company if he or she is already covered, including as a beneficiary. This coverage is provided through a compulsory group health scheme (compulsory family scheme for which the membership of family members, spouses, former members, children, is compulsory in the same way as that of the employee).
Employee with multiple employers
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.
Employee whose contract is suspended
The employee is compensated by the employer or social security
Coverage must be maintained when the employee's employment contract is suspended, whatever the cause.
Example :
Occurrence of sickness, maternity, accident or in case of partial activity or adjustment leave
The employee is not compensated
The employee must get closer to his employer to know whether or not the mutual is maintained.
Employee whose contract is terminated
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 period of unemployment compensation within the limit of the duration of the last employment contract.
Such retention of guarantees may not exceed 12 months.
Compulsory collective cover must meet the following conditions:
- The employer's financial contribution must be at least equal to 50% the contribution (the remainder to be paid by the employee)
- The contract must comply with a set of minimum guarantees (minimum care basket)
- The contract is compulsory for employees, except in cases where the employee may refuse mutual assistance.
If the company is subject to a collective agreement or to a branch agreement, it must respect what is provided for in these texts.
In fact, minimum guarantee levels or a minimum contribution level to be devoted to the financing of guarantees may be imposed on the company by branch agreement.
In all cases, the employer and the employee representatives may negotiate an agreement within the company itself.
In the case of a branch agreement, the company agreement must provide for guarantees at least as favorable as that branch agreement.
If these negotiations are not successful, it is a unilateral decision the employer who is implementing the health supplement.
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 the Health Insurance. However, there may be 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.
The supplementary health must comply with the specifications of the contract responsible.
In this case, the contract is performed as follows.
What the contract supports is called “responsible”
Benefits | Support |
|---|---|
Routine care (visits and drugs at SMR.: titleContent major reimbursed to 65%) | 100% of the social security reimbursement basis |
Daily Package | 100% unlimited duration |
Routine dental care (consultations and care such as scaling or treatment of cavities) | 100% of the social security reimbursement basis |
Optical | 100% the social security reimbursement basis. For optical costs that are beyond the conventional rate, the health add-on may offer, cumulatively, limited support as follows: |
The contract must be joint and several: the insured cannot be submitted to a health questionnaire or be priced according to his state of health.
What is not supported by the contract called “responsible”
- The flat-rate contribution of €2 for each consultation carried out by a city doctor in an establishment or hospital, within the limit of €50 per year per person
- The medical allowances left to the insured person for medicinal products and medical transport. The amount of the deductible shall not exceed €50 per year per person.
- The increase in the insured person’s contribution for not appointing a treating doctor or consulting another doctor without a prescription from the treating doctor (‘out of care pathway ")
- Excess fees where the insured person consults a specialist to whom the law does not allow direct access without going through a doctor.
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)
No, some employees may be exempt from membership at their request, 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).
One agreement This branch may also provide that the obligation to cover health care costs is ensured for these employees through the health payment.
This arrangement consists of an employer's contribution to the financing of the supplementary cover.
In the absence ofagreement in the industry or, where the latter so permits, a company agreement may also provide for this alternative form of cover.
Please note
In order to benefit from this health payment, the employee must be covered by a responsible contract.
He shall produce a certificate from the body with which he has signed a health care supplement contract.
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.
Example :
An employee on a 3-month fixed term benefits from the health payment.
If his contract is renewed, he shall not be entitled to that payment by way of renewal.
Except in the case of exemption, he must therefore be affiliated to the health insurance scheme at the end of 1er CDD.
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 receiving the complementary health solidarity. 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.
The employer's contribution to the health payment is calculated differently depending on the area concerned:
General case
The health benefit is funded by the employer.
The amount of the health payment corresponds to the sums which the employer would have been obliged to pay if the employee had received collective cover.
If it is not possible to determine the amount that the employer should have paid, the reference amount is set at €20.75 for 2024.
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 :
The employer's contribution is a flat rate and equal to €20.
The employee works 35 hours a week. He's on fixed-term contract for less than three months. The compulsory collective agreement does not guarantee him a supplementary health coverage of at least 3 months.
- Since the employee is full-time, his or her proration coefficient is 1 (151.67/151.67)
- This coefficient applied to the flat-rate contribution (€20), the reference amount remains €20
- Since the employee is on a fixed-term contract, the increase coefficient is 125%.
Thus, the amount paid to the employee is €25 (€20*125%).
The employer shall be exempt from social security contributions on such payments.
However, such payments shall be subject in full to 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 the health payment corresponds to the sums which the employer would have been obliged to pay if the employee had received collective cover
If it is not possible to determine the amount that the employer should have paid, the reference amount is set at €6.93for 2024.
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 :
An employer shall make a lump-sum contribution of €60 for each of its employees of a certain category.
For a CDI employee in this category, who works 50 hours per month., the reference amount is calculated as follows: 60 x (50/151.67) =19.78, to which is applied the coefficient of 105%, the employee is on a DTA.
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.
However, there is no exemption for CSG-CRDS and the social package in the companies of at least 11 employees.
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Obligations of the employer
Content of the compulsory mutual association
Aid for supplementary health insurance schemes