Sector 1 or 2 approved doctor: price and reimbursement

What is a registered doctor?

Prices regulated by Health Insurance

The medical agreement between health professionals and Health Insurance defines the fees received by private doctors, as well as the level of reimbursement for care.

The prices charged by doctors and the amount used as the basis for reimbursement by Health Insurance differ depending on the doctor’s discipline (general practitioner or specialist) and their sector of activity.

Medical convention

The agreement between private doctors and Health Insurance specifies the fees that doctors can charge for different medical procedures.

This regulation aims to regulate prices in order to ensure a certain equity in access to care.

Impact on patients

Thanks to this regulation, patients often have a lower out-of-pocket cost when they consult a registered doctor, because the fees are limited and reimbursement is guaranteed by Health Insurance.

What is the difference between sector 1 and sector 2?

Sector 1 approved

Sector 1 brings together doctors applying the rate set by Social Security (conventional rate).

By charging agreed rates, these doctors ensure better access to care, by limiting the remainder payable by patients.

Sector 2, or approved sector with free fees

Sector 2, or the regulated fee-free sector, brings together doctors authorized to exceed fees “with tact and moderation.

For example, a specialist may charge 50 euros for a consultation, including an excess of around 25 euros.

These excesses are not covered by Health Insurance, but by complementary health insurance (if the contract provides for it).

Sector 3: non-contracted doctors

Sector 3 corresponds to a completely free price for consultations. These are practically not reimbursed:

• 0.61 euros with a general practitioner;
• 1.22 euros with a specialist.

Why choose a registered doctor?

For reimbursement of health insurance

Health Insurance reimbursements are based on the convention rates:

• For a general practitioner in sector 1, the price of a consultation is, for example, 26.50 euros.
• The patient is reimbursed on the basis of 70%, that is to say 16.50 euros, from which 2 euros of fixed contribution must be subtracted.

For reimbursement from mutual insurance

It is the supplementary insurance of the socially insured person which covers the remaining 30% (always based on the convention rate).

With a non-contracted doctor, reimbursement of health costs will be less or non-existent.

A mandatory duty of information

The patient has the right to be informed about the amount of procedures and services offered during a consultation (prevention, diagnosis, care) and about excess fees.

This information must be displayed in the practitioner’s waiting room.

How much does a consultation with a registered general practitioner cost?

The price of consultations for children and adolescents up to 16 years old is subject to specific pricing.

General practitioner approved by sector 1

A sector 1 approved general practitioner does not charge overcharges, with some exceptions.

The consultation is set at 26.50 euros, the basis of reimbursement is also 26.50 euros: or 16.50 euros (after deduction of the two-euro package).

General practitioner approved by sector 2

The sector 2 approved general practitioner undertakes to charge moderate fee overruns for clinical and technical procedures.

• Health Insurance reimburses the patient at 70% based on 23 euros.
• Once the two-euro package has been deducted, the reimbursement rate is therefore 14.10 euros.

The amount of excess fees is the responsibility of the patient (possibly from their complementary health insurance).

Sector 2 and CMU approved doctors

A social security member affiliated to the CMU-C and consulting a doctor in sector 1 benefits from 100% reimbursement.

A social security member affiliated to the CMU-C and consulting a sector 2 doctor is reimbursed 100%, but may benefit from special treatment so as not to pay the excess fees.

How much does a consultation with a specialist practitioner cost?

Sector 1 approved specialist

The specialist approved by sector 1 sees his consultation rate also fixed.

In 2024, the standard rate for a consultation with a specialist (for example, a dermatologist or cardiologist) is 30 euros.

Sector 2 approved specialist

The approved sector 2 specialist has free fees and excesses remain the responsibility of the patient.

A consultation can then easily be billed between 50 and 100 euros or more, depending on the specialty and location.

What is the Optam-CO contract?

For surgery

The Optam-CO contract, “Controlled practical pricing option – surgery option”, is a system offered to doctors by Social Security.

This is a contract which allows specialist doctors, particularly surgeons, to charge controlled prices for certain surgical procedures.

Greater transparency

With the Optam-CO contract, doctors must respect quality of care and price criteria, which commits them to a certain transparency towards their patients.

Controlled fees

Optam-CO doctors must respect agreed rates for certain procedures.

In return, they can benefit from advantages such as simplification of administrative procedures and financial assistance when opening their practice.

How are you reimbursed abroad?

In the European Union

If staying in an EU country, policyholders holding the European Health Insurance Card (EHIC) benefit from medical care in accordance with the rules of the country of stay.

Outside the European Union

Outside the EU, taking out travel insurance for medical expenses is recommended since only urgent care will possibly be covered.

What reimbursement for a non-approved doctor?

For a non-approved doctor, reimbursement by Social Security is very low.

Basic reimbursement

Social Security reimburses a percentage of the basic rate set for each medical procedure, but for non-contracted doctors, the latter is lower.

For example, if the consultation rate for an approved general practitioner is 26.50 euros, that of a non-approved doctor may not be taken into account at this same rate.

Fee overruns

Non-contracted doctors can charge free fees, which means they can charge whatever they want.

Fee overruns are not reimbursed by Social Security. This can result in significant out-of-pocket costs for the patient.

Reimbursement by complementary health insurance

Some mutual or complementary health insurance companies can cover part of the costs incurred with a non-approved doctor, but this depends on the contracts.

In certain cases, they can reimburse on the basis of the agreed rate, which can leave a significant remainder.

How do I know which doctors are approved?

Via the health insurance professional directory

Health Insurance offers an online directory of health professionals. You can search for doctors by specialty, location and sector of activity.

This service clearly indicates whether a doctor is in sector 1, sector 2 or not approved.

Via the Order of Physicians

The Order of Physicians can also provide information on doctors, including their agreement status.

You can search their website by name or specialty for details of the practitioners.

By asking the doctor

When you make an appointment, do not hesitate to ask questions regarding the agreement sector and the excesses practiced.

In the doctor’s office, the prices charged must be displayed, including the mention of the agreement sector.

From his mutual

Your mutual or supplementary health insurance can provide you with information on approved doctors in your region, as well as on the reimbursements provided according to their sector.

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