Que sont les secteurs 1, 2, 3 ?
In France
Relations between medical practitioners and the national Social Security system are governed by a healthcare agreement. The purpose of this agreement is to:
- Set the price of healthcare services
- Determine the level of reimbursement
Your medical cover depends on the sector of healthcare
Doctors in sectors 1 and 2 are under contract with the healthcare system, while doctors in sector 3 are not.
If you see a doctor in sectors 1 or 2, you will be fully or partially reimbursed by the Social Security authority. If your doctor is in sector 3, however, you will not be reimbursed. Fees in sector 3 tend to be higher as practitioners usually devote more time to their patients, as in the case of psychiatrists, for example.
To avoid any surprises, we suggest you check which sector your doctor belongs to before making an appointment.
What is the difference between sectors 1 and 2 ?
Doctors in sector 1 apply the standard consultation charge set by the Social Security authority, otherwise referred to as “agreed rates” or “sector 1” rates, while doctors in sector 2 are authorized to set their own higher charges, referred to as “sector 2” rates. In this last case, the consultation fees are higher than those set by the Social Security authority and can vary from one doctor to another. The additional fee over the agreed rate will not be reimbursed.
How much does the Social Security authority reimburse if I consult a doctor in sectors 1 or 2?
If your doctor is in sector 1 or sector 2, you will receive the Basic Reimbursement rate. This is equal to 70% of the agreed rate.
This agreed rate is slightly lower in sector 2 than in sector 1 so your level of reimbursement will also be slightly lower. So if you wish to consult a doctor in sector 2, we suggest you choose one who has signed up to the OPTAM agreement (see below). If you have a complementary healthcare contract – or mutuelle − you may be reimbursed for the remaining 30%.
OPTAM
What does OPTAM mean?
OPTAM (Option Pratique Tarifaire Maîtrisée) or OPTAM-CO refers to a controlled pricing agreement between French Healthcare Insurance and doctors in sector 2. Its purpose is to moderate the additional fee charged over the agreed rate by practitioners, who are free to set their own consultation charges in this sector. OPTAM-CO applies to surgeons and obstetricians. OPTAM replaces the system referred to as CAS, for Contrat d’Accès aux Soins or Access to Care agreement.
OPTAM is a win-win agreement. Patients receive a higher rate of reimbursement from the national Social Security system, so have less to pay out of their own pockets, while doctors are able to build up a loyal patient base and enjoy the same benefits as practitioners in sector 1 and can set their own consultation fees.
What are the objectives of OPTAM and OPTAM-CO?
- Improve access to healthcare for patients
- Control overruns in the fees charged
- Reduce the outstanding amount payable by users
Additional cost?
I would like to consult a doctor in sector 2 who has not signed up to the OPTAM agreement. Will my complementary healthcare contract meet the additional cost?
It depends on your contract, since the level of coverage can vary considerably. Before taking out complementary health insurance, we suggest you carefully read the information on each healthcare sector and the terms applicable to excess consultation fees.
