History of cross-border healthcare reimbursement difficulties
At the end of 2015, the compulsory transition to CMU for those insured under private insurance made it difficult for them to access healthcare in Switzerland. New cross-border workers then chose the LAMal to benefit from the reimbursement of care provided on each side of the border.
Until the end of 2016, a cross-border worker insured with the LAMal had the possibility of taking out supplementary health insurance with the Swiss insurer of his compulsory basic insurance.
At the start of 2017, the situation changed. The FINMA (authority which controls Swiss insurance funds) has prohibited Swiss insurers from offering insurance contracts (other than the LAMal base) to people who do not reside in Switzerland.
During all these years and until 2019, the cross-border worker insured at CMU or LAMal was therefore limited in terms of reimbursement of cross-border healthcare.
Mutual and complementary insurance offers
To overcome this depletion of coverage, French mutuals have created numerous complementary health insurance contracts intended to reimburse both care provided in Switzerland and care provided in France. These complementary health insurances are mainly intended for CMU policyholders. A few, more rare, are aimed at LAMal policyholders.
Among these products, few of them succeed in offering a convincing range of services both on the French side and on the Swiss side.
The year 2019 was marked by the arrival of new, more comprehensive products aimed at both LAMal and CMU policyholders. These products now offer excellent reimbursements for both treatments made in Switzerland and those made in France.
Overview of the shortcomings of existing products
Before describing the new coverages, let’s identify some shortcomings of the previous insurance policies. Existing products are often handicapped by one of the 4 main flaws below. Frequently, they even accumulate several of these faults.
Healthcare in Switzerland reimbursed on condition that the CPAM intervenes
When one is treated in Switzerland while being insured CMU, reimbursement of the CPAM is not systematic . It is subject to many restrictions. In practice, the intervention of the CPAM is rather rare.
In practical terms, after having benefited from healthcare in Switzerland, the cross-border worker with this type of French mutual has little chance of receiving reimbursement. This type of mutual requires a CPAM statement to reimburse its share!
This is particularly the case for the beneficiaries of the cross-border employee who do not benefit from the reimbursement of the CPAM if they seek treatment in Switzerland.
Healthcare in Switzerland reimbursed on the basis of French rates
The cost of healthcare in Switzerland is significantly higher than that of healthcare in France. For example, in France, a visit to a general practitioner costs 25 € while it costs around 150 CHF in Geneva.
By having subscribed to a supplement which reimburses this visit to Switzerland at 150% of the French rate, the insured will receive a maximum reimbursement of € 37.50 . Compared to the costs actually paid, this amount is too low to make such insurance really attractive.
Contracts mostly unsuitable for LAMal policyholders
For lack of anything better, many LAMal policyholders subscribe to cross-border mutuals that are ill-suited to their basic insurance.
This is particularly the case with regard to hospitalization. A LAMal insured can automatically be hospitalized in Switzerland in the common ward of a cantonal hospital thanks to his basic insurance.
If this insured has subscribed to a mutual insurance company in France which indicates reimbursing 100% of the Swiss DRG rate in the event of hospitalization, then he will not receive any reimbursement from the French mutual insurance company because everything will have already been covered by his LAMal base!
Reimbursement ceilings applied to care provided in Switzerland
Finally, the French contracts which cover healthcare in Switzerland are almost unanimously capped in terms of the annual reimbursement amount. For example, the contract of an insurance company provides that it will not reimburse more than € 30,000 / year for care provided in Switzerland.
If this limitation is generally not a problem in terms of outpatient care (visits to the doctor), it is not realistic for hospital care and more particularly access to Swiss clinics.
Indeed, it is difficult to envisage having serenely access to Swiss clinics by means of additional insurance which caps reimbursements at € 30,000 / year. The very high cost of care in Swiss clinics can quickly exceed this amount depending on the length of stay and the type of care provided. The sums remaining in charge can become astronomical!
Fortunately, over time, the obstacles with which frontier workers had to contend were reduced with the arrival of new products that were better constructed and more suited to the daily realities of cross-border healthcare networks!
New complementary insurance for cross-border workers insured with LAMal
For once, in terms of health insurance, one of the particularly interesting novelties of this year 2019 concerns cross-border workers insured with LAMal.
The new covers intended for LAMal policyholders offer the following advantages to subscribers:
- access to healthcare in Switzerland with no annual ceiling for reimbursements
- access to 100% of Swiss clinics without any restriction, insured persons benefit from a room with 2 beds and the free choice of doctor
- in France, 100% reimbursement of costs that remain chargeable after the intervention of the CPAM
- 80% reimbursement of scheduled care in EFTA countries
- a high ceiling for dental care in France as well as in Switzerland or in Europ…