Optician zero co-pay: accounting for the 100 % Santé scheme

Quick answer. A 100 % Santé optical sale splits into three collection flows to be recorded separately: the statutory health insurance share (AMO), the complementary share (OCAM) settled through third-party payment, and the customer co-pay. On basket A (class A), which took effect in optics on 1/1/2020, this co-pay is zero.

An optical store rarely collects the full price of a sale from the customer. Between the statutory health insurer's share, the complementary insurer's share and any amount paid in store, a single pair of glasses generates two or three separate receivables, each with a different settlement timeline. Keeping this set of accounts means, first, splitting each flow correctly, then tracking the third-party-payment receivables until they are collected.

This article goes down to the entries for each refund flow. To understand the general third-party-payment mechanism and the logic of the scheme, you can first read our article on the way third-party payment works in optics, which sets the framework we put to work here.

The 100 % Santé reform offers a zero-co-pay package (RAC 0) on a selection of equipment, grouped in basket A (class A). It took effect in optics on 1/1/2020. A customer who chooses class A equipment pays nothing: the full amount is covered by statutory health insurance and by the complementary insurer.

Basket B (class B), by contrast, stays at a free price. Its coverage depends on the customer's complementary contract, and a co-pay may remain. An optician usually sells both: the frame may fall under basket A and the lenses under basket B, or vice versa. That is why the customer invoice must already distinguish the lines, before any accounting.

A useful point on the AMO/OCAM split. The often-quoted ratio (60 % AMO, 40 % OCAM) applies to the reimbursement base (BRSS), which is very low in optics: around 2.84 € for a frame and 2.29 € to 24.54 € for adult lenses depending on the correction. The complementary insurer then tops up to the price limit to reach RAC 0 on basket A. These base amounts come from the list of products and services (LPP) and are worth cross-checking against the current orders before any fine-tuning of your software.

Whatever the basket's composition, an optical sale breaks down into collection flows that must be isolated from the invoicing stage. Our firm's reading: the quality of an optician's accounting is decided 90 % on this split at the point of sale, not at reconciliation.

1. The AMO share: the receivable on statutory health insurance, transmitted electronically. It equals the reimbursement base times the coverage rate.
2. The OCAM share: the receivable on the complementary organisation (the mutual insurer), settled through third-party payment. Here, the OCAM is a payer, not a tax.
3. The customer co-pay: nil on basket A, it may exist on basket B and is paid in store (cash, card, cheque).

The net revenue of the sale is single: it is then split among these three debtors. In accounting terms, you record one revenue item (class 70 account) for the net total, the output VAT, and as the offset, as many third-party accounts as debtors.

The French General Chart of Accounts does not impose a dedicated chart for optics. The method we apply in client files is to subdivide the customers account (411) so as to track each type of third-party-payment receivable separately. This makes reconciliation and cash-flow monitoring easier.

At the sale, the entry debits the three third-party accounts (AMO, OCAM, customer) for their gross share and credits revenue and output VAT. As each share is collected, you clear the relevant third-party account by crediting it against the bank account. This directly applies the matching principle and the third-party tracking of the chart of accounts.

For reliable processing, a Pennylane accounting software connected to your till and your bank account automates much of the reconciliation. But the per-debtor split must be set up from the outset, otherwise automation simply propagates the imprecision.

The underrated risk is not the sales entry, it is the collection. The AMO and the OCAMs refund within variable timelines, and part of the claims can be rejected (NOEMIE-type transmission rejections, rights anomalies, unrecognised contracts). As long as a third-party-payment receivable is not matched, it remains an asset that has not yet reached your cash.

In optician files, the most frequent friction point is the build-up of small unmatched OCAM receivables, for lack of regular reconciliation between the organisations' statements and the transfers received. After a few months, the 411 account dedicated to the OCAM swells without anyone knowing whether those amounts will be settled.

• Reconcile each AMO and OCAM transfer with the third-party-payment statements, at least monthly.
• Identify and reprocess rejections without waiting for the year-end, as recycling deadlines are tight.
• Match the dedicated 411 accounts to bring out the receivables genuinely outstanding.
• Provision, where relevant, old receivables whose recovery becomes doubtful.
• Monitor the average collection time by type of payer (AMO, OCAM, customer).

A Qonto business account with categorisation of incoming transfers helps quickly trace the source of refunds, which speeds up reconciliation.

Recently, the owner of an optical store approached us because his third-party-payment customers account never cleared and was distorting his cash-flow reading. Reviewing his sales, the diagnosis was simple: a class A frame and class B lenses sold together, all recorded on a single global customer account. It was impossible to know what was owed by statutory health insurance, by the mutual insurer or by the customer.

In practice, the fix was to: split each invoice line by basket, open three subdivisions of the 411 account (AMO, OCAM, co-pay), redo the matching debtor by debtor, then set up a monthly reconciliation of the statements. Once cleaned, the OCAM account revealed unprocessed rejections that had slipped past attention for several months.

This kind of clean-up falls under the bookkeeping and review of a sector file, where knowing the refund circuit saves considerable time.

Two confusions come up often and deserve to be cleared up plainly.

The first concerns the supposed "OCAM tax". There is no OCAM tax for the optician to record. The OCAM is the complementary health insurance organisation, i.e. the mutual insurer that pays part of the sale through third-party payment. The tax that does exist is the additional solidarity tax (TSA), set out in article L862-4 of the Social Security Code. It is owed by the complementary organisations themselves, on the premiums of their health contracts. It therefore never appears in the optician's accounts.

The second concerns capped prices. Basket A is subject to price limits, with a frame at 30 € or less, and lenses capped by type. These caps are set by order and change: before configuring your prices or freezing an amount in a procedure, cross-check the values in force against the list of products and services and the pricing orders.

Our firm is registered with the Ordre des experts-comptables of Île-de-France, which governs the engagement to present your accounts and the attestation that concludes it. For the tax issues specific to your structure, see also our tax monitoring of your business, and more broadly our accounting support for opticians.