Cover for cosmetic surgery: reimbursements by mutual insurance companies and the social security system

The blog of Dr Arié Azuelos in Paris

When it comes to cosmetic surgery, the subject of reimbursement can often be confusing. Many patients wonder under what conditions a procedure can be partially or fully covered by Social Security or their mutual insurance company. Dr Arié Azuelos is a signatory to the OPTAM (Option Pratique Tarifaire Maîtrisée) agreement, enabling his patients to benefit from more advantageous reimbursements.

Social security reimbursement criteria for cosmetic surgery

In most cases, Social Security does not cover surgery for purely cosmetic purposes. These procedures are considered to be medically unnecessary. However, some operations may be reimbursed if they are justified on medical grounds. It is essential to understand the eligibility criteria before planning a procedure.

Procedures eligible for Social Security reimbursement

Reconstructive surgery to correct a congenital deformity, a deformity caused by an accident or illness, or to improve a patient’s quality of life, may be covered by Social Security. Here are some examples of procedures that are often covered:

Breast reconstruction after cancer
Breast reduction if the volume causes significant back pain
Obesity surgery (reduction of excess skin after massive weight loss)
Correction of certain malformations of the face or body

For the operation to be reimbursed, a request for prior agreement must be submitted to the Social Security. This document, drawn up by Dr Arié Azuelos, justifies the medical need for the operation. If the request is accepted, reimbursement may be total or partial.

The role of mutual insurance companies in reimbursing cosmetic surgery

In addition to Social Security, mutual insurance companies play a crucial role in covering healthcare costs, including those relating to cosmetic surgery. However, as with Social Security, mutual insurers do not generally cover purely cosmetic surgery.

Cover provided by mutual insurers

Mutual insurance companies can intervene in two types of situation:

Supplementary reimbursement for procedures covered by Social Security: If the operation is partially reimbursed by Social Security, some mutual insurers can supplement this reimbursement, covering part of the excess fees or additional costs.
Coverage of excess fees: In cosmetic surgery, excess fees can be frequent, particularly if the operation is carried out in a private setting. Some mutual insurers offer fixed rates or specific reimbursement rates for this type of excess, provided that the operation is medically justified.

The OPTAM agreement: advantageous reimbursements for patients

Dr Arié Azuelos is a signatory to the OPTAM (Option Pratique Tarifaire Maîtrisée) agreement, offering his patients more advantageous reimbursement terms while guaranteeing a high level of care.

What is the OPTAM agreement?

The OPTAM agreement is a voluntary scheme for doctors. By signing up to this agreement, practitioners undertake to limit their excess fees, enabling patients to benefit from better reimbursement terms from the French social security system and mutual insurance companies.

Benefits for patients

Improved reimbursements: By opting for a surgeon who has signed up to the OPTAM, patients benefit from reimbursement based on conventional tariffs, even in the event of moderate excess fees.
Better cover by mutual insurance companies: Mutual insurance companies are more inclined to top up reimbursements when the procedure is carried out by a healthcare professional who is a member of the OPTAM.

This can represent a significant saving for patients, particularly in reconstructive surgery where there can be substantial extra charges.
Patients are therefore strongly advised to check whether their surgeon is a member of the OPTAM before planning an operation.

Cosmetic surgery: how can you maximise your reimbursement?

To maximise your reimbursements, it is advisable to follow these few steps:

Check the eligibility of the operation: Before going ahead with an operation, discuss with your surgeon whether it will be covered by Social Security. If the operation is considered to be reconstructive, a request for prior agreement will need to be made.
Choosing a practitioner who is a signatory to the OPTAM: Opting for a surgeon who is a signatory to the OPTAM means that you will receive better reimbursements from the Social Security and your mutual insurance company.
Consult your mutual insurance company: Each mutual insurance company offers different contracts in terms of reimbursement of excess fees. It is therefore advisable to contact your mutual insurance company to find out the precise conditions for reimbursement.