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Mutuelle "contrat responsable" (et solidaire)

Depuis la mise en place du parcours de soins coordonné, la plupart des contrats d'assurance complémentaire santé des mutuelles et compagnies d'assurance se présentent sous l'étiquette "contrat solidaire et responsable".

Une mutuelle sans questionnaire de santé

Avant la création du contrat de mutuelle solidaire et responsable, les assureurs en complémentaire santé pouvaient soumettre les bénéficiaires à un questionnaire de santé en fonction duquel ils acceptaient ou non d'assurer la personne. Et en prime, ils déterminaient aussi le tarif de cotisation selon les réponses...

Un assureur peut toujours demander de remplir un questionnaire de santé pour une complémentaire classique (contrat non responsable). Mais c'est interdit pour la souscription d'une mutuelle solidaire et responsable.

Qu'est-ce que le contrat solidaire et responsable?

Ce n'est pas un simple slogan marketing développé par les assureurs et les mutuelles. Le contrat solidaire et responsable doit respecter des règles d'assurance et de remboursement définies par l'État en contrepartie d'une fiscalité avantageuse pour les compagnies.

L'état applique une fiscalité différente selon les caractéristiques de la complémentaire santé. Objectifs:

  • favoriser la politique de maîtrise des dépenses de santé,
  • lier le système public avec la Sécurité Sociale et le système privé des mutuelles, dans cette démarche.

Mutuelle et Assurance: pas de différence

Il n'y a aucun distinguo fiscal entre mutuelle et assurance. Vous souscrivez un contrat de complémentaire santé solidaire et responsable, indifféremment, auprès de chaque type de structure juridique. Les seules différences sont celles que l'on trouve en faisant un comparatif de mutuelle: les prix, et les garanties.

Le gouvernement a simplement voulu que les mutuelles santé ne remboursent pas les franchises telles que le 1 € sur les actes médicaux, ou tout remboursement, lorsqu'un malade ne tient pas compte du parcours de soin coordonné.

Pourquoi ne pas interdire les contrats non responsable?

Les mutuelles étant dans un marché libre réglementé par l'Union Européenne, l'État n'a pas pu interdire les contrats de mutuelle et d'assurance complémentaire qui rembourseraient tout, y compris les franchises, les dépassements d'honoraires, ou encore les médecines douces.
D'où la mise en place d'une fiscalité dissuasive: de tels contrats sont plus lourdement taxés que les contrats responsables.

Un autre critère en faveur du contrat responsable: le tarif de cotisation, nettement moins cher qu'une mutuelle qui "rembourse tout". De fait, les mutuelles "responsables" représentent aujourd'hui la quasi totalité du marché. Les compagnies rechignent même à proposer des contrats de complémentaire santé classiques.

La taxation des contrats responsables

Le "contrat solidaire et responsable" était taxé à hauteur de seulement 5,9 % à son apparition en 2009. Une taxe appliquée sur les cotisations de mutuelle. Et qui représentait environ 35 € sur la valeur annuelle moyenne des contrats souscrits.
Les autres Complémentaire Santé, non solidaires, ont été en plus majorés d'une taxe sur les conventions d'assurance (TCA) de 7 % soit un surcoût annuel moyen de 42 €.

Hausse des taxes sur les mutuelles

Le problème de déficit des dépenses santé n'étant pas réglé, ces taxations ont subi des aménagements depuis leur création, avec des vagues de hausses successives. Tollé des mutuelles bien entendu, qui ont généralement augmenté leurs cotisations en conséquence. La hausse des taxes sur les mutuelles, y compris les contrats responsables, contribue à la hausse du prix des mutuelles en France.
C'est pourquoi la suppression de la taxe sur les mutuelles faisait partie des promesses électorales de François Hollande.

Conditions du contrat de complémentaire santé solidaire et responsable

  • l'organisme assureur ne doit recueillir aucune information médicale auprès de l'assuré (le fameux questionnaire médical),
  • les cotisations ou les primes ne sont pas fixées en fonction de l'état de santé de l'assuré (en principe),
  • l'assureur doit respecter l'esprit du parcours de soin, notamment en ne remboursant pas les franchises, la part du ticket modérateur majoré ou les dépassements d'honoraires des spécialistes consultés en dehors du parcours de soin.
  • le contrat doit intégrer certains remboursements minimum tels que le Ticket Modérateur sur les consultations, la pharmacie, les actes techniques ou le forfait hospitalier.
  • il doit prendre en charge deux actes de prévention(*) parmi une liste définie le 8 juin 2006 (conformément à l'article R 871-2 du code de la Sécurité sociale).
    • Scellement des sillons sur les molaires avant 14 ans
    • Détartrage annuel
    • Premier bilan du langage oral ou écrit pour un enfant de moins de 14 ans
    • Dépistage de l'hépatite B
    • Dépistage une fois tous les cinq ans des troubles de l'audition chez les personnes âgées de plus de 50 ans pour un des actes suivants :
      • Audiométrie tonale ou vocale
      • Audiométrie tonale avec tympanométrie
      • Audiométrie vocale dans le bruit
      • Audiométrie tonale et vocale
      • Audiométrie tonale et vocale avec tympanométrie
      • Ostéodensitométrie pour les femmes de plus de 50 ans, tous les 6 ans
      • Vaccinations suivantes, seules ou combinées :
        • Diphtérie, tétanos et poliomyélite : tous âges
        • Coqueluche et Hépatite B : avant 14 ans
        • BCG : avant 6 ans

(*) Ces 2 actes de prévention sont sélectionnés par la mutuelle et ne sont pas au choix du consommateur. Ils doivent être écrits dans les garanties de votre mutuelle.

Et si je ne veux pas de mutuelle avec contrat responsable?

Le contrat solidaire et responsable représente l'essentiel du marché de la complémentaire santé. Les contrats qui ne respectent pas ce cadre sont si chers, qu'il n'est pas très intéressant pour le consommateur de souscrire de telles mutuelles. Mieux vaut payer de sa poche quelques dépenses, comme la franchise à 1 euro, que souscrire une mutuelle trop chère.
D'autre part, comme nous l'avons dit, la plupart des compagnie de mutuelles santé ne proposent même plus d'offre non solidaire et responsable.

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