How does the state health insurance system work?
National medical insurance is organized by the:
- Régime Général (general fund) which covers 85% of citizens
- Protection Universelle Maladie (PUMa), which falls under the General Fund and covers everyone who is legally entitled to work in France
- Caisse Primaire d’Assurance Maladie (CPAM), the local area authorities which administer PUMa/the General Fund
There are some smaller insurance funds for specialist professions, such as doctors or agricultural workers.
In 2016 PUMa replaced the old system called the Couverture Maladie Universelle (CMU), although part of this is still in place: the CMU-Complémentaire, which is only for those on low incomes.
The system has been simplified and now gives access to public health insurance for all residents, whether or not they have been paying French social security contributions (cotisations sociales).
Overall, the system is paid for out of social security contributions and it is supplemented by private health insurance. It has thus attempted to bring the system into line with other healthcare models such as the UK’s NHS and open it up to overseas residents, simplifying its eligibility criteria.
French state insurance used to work on a reimbursement system, in which clients paid upfront according to the government-set baseline costs, and then claimed reimbursement (usually up to 70% of costs), but this is being phased out.
Now, doctors are not allowed to charge upfront costs – they are paid directly by the government instead. Reimbursement still applies to dental treatment, however, and some vision care.
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Who is eligible for state healthcare?
The state health insurance system is not just for French nationals but is also compulsory for overseas residents of France and for long-term visitors. Under the new rules, PUMa is now guaranteed if you have been resident in France for over three months in ‘a stable and regular manner’ (i.e. your principal home and your family base is in France) and if you intend to remain in the country for at least 183 consecutive days per year.
It covers employed expats, but it also applies if:
- you do not have paid employment
- you are under 65
- you do not have a pension from another EU state
- you are under 16
- you are an undocumented immigrant who has residency
At times, expats might be informed that they are not eligible for state healthcare if they have been resident in France for less than five years: this is not correct. If this happens to you, you can direct your local medical organisation to the Ameli (social security) website which will clarify the situation.
How do you apply to join the state health insurance system?
You will need to register with CPAM, although the organization which will evaluate the amount of your contributions is the Unions de Recouvrement des Cotisations de Sécurité Sociale et d’Allocations Familiales or URSSAF - the social security authority.
Your employer may do this for you, but check that they have done so as it is not a legal requirement for employers. If you do this yourself, it must be within eight days of starting your employment. You will also need to register for a social security number. To apply, you will need:
- application form 736
- birth certificate
- marriage certificates if you are intending to register your spouse as well
- deeds, lease or rent receipts (CPAM might not ask to see these, but be prepared)
- bank account details (any reimbursement will be paid directly into your account)
- proof of income
- a utility bill (to demonstrate that you will be living in France long-term)
You may need translations of some of these documents (for example, your marriage certificate) that have been certified by a French court.
You will have to register for a Déclaration de Médecin Traitant, in order to choose your doctor, too (usually this will be at your local clinic).
You will be able to register for your carte vitale (green card), which is your national health card, at the same time. You must take this with you to your GP or the hospital, as proof of your eligibility for treatment.
This can take time to be issued, however, so you may also request a document called an attestation de couverture sociale, which will prove that you are eligible for healthcare until your green card arrives. One expat reports that it took two years for their card to be issued, so your attestation is important.
You can also do this by post. CPAM has an English helpline: 3646 (from France) or +33 811 70 3646 (from abroad).
What is covered by the state health insurance system?
The following items are covered:
- outpatient care (e.g. GPs, dentists, specialists, midwives)
- diagnostic services (including some screening such as mammograms and colorectal screening)
- prescription drugs
- home care
- hospice care
- vision care (co-pay)
- some dental care (co-pay)
- appliances and prostheses
- transport relating to healthcare
If you fall ill, your doctor may send you to either the state hospital or a private one: there is no difference in treatment, but check which system you are entering.
If you have a serious, long-term condition such as cancer, then you will not have to pay as much when you visit your doctor: the health insurance system prioritises severe illnesses.
France also offers free preventative medical checks every couple of years, which are tailored to your particular requirements, such as your age. If you need to be referred to a specialist, check the costs with your doctor first (you may have to pay more upfront if you choose your own specialist).
You do not need a doctor’s referral to see a gynecologist, a pediatrician or an opthamologist. If you become pregnant, your doctor will organize blood tests and issue you with a document stating that you are going to have a baby. You will need to send this off to the Assurance Maladie Fund and the Family Allowance Fund.
Are retirees covered by state medical insurance?
You will be covered as an expat retiree if you:
- are from the EU/EAA
- have your main residence in France
- are receiving a pension from your home nation and have a valid SI form (this form replaced the E121 and E126 forms)
Previously, it was necessary to re-register with CPAM every year, but under PUMa this is no longer required and your coverage will be continuous.
Are students covered by state medical insurance?
Health insurance is compulsory for international students, but you may need to take out private cover. You will be covered under PUMa if
- you are under the age of 28 by October 1st of the current university year
- you are enrolled on a degree program for 4+ months
- your home nation is outside the EU or Switzerland
If you are outside the EU, you will need to register with the state health insurance system for Students’ Social Security.
If you are from a EU member state, your EHIC will cover you. You will not be eligible for PUMa if you are resident in France for under 183 days: students are not usually classified as ‘residents.’ You may prefer to take out private insurance as the EHIC is primarily intended for emergency care.
Will your family be covered by your insurance?
Children under 16 are automatically covered. You can apply to have your dependents, such as a spouse, included in your health coverage.
Is dental treatment covered by state health insurance?
Dental treatment is also covered by the national health system but because it is regarded as specialist treatment, it may have restricted reimbursement rates, and orthodontic treatment, for example, may not be not covered. Your child’s dental care should be reimbursed by 100%, however you are likely to have to cover 30% of your own costs yourself.
What are the contribution rates for state health insurance?
Contribution rates are re-evaluated by the government every year and are calculated on:
- earned income
- pension income
- property rental
- investment income
- bank interest
- capital gains
Residents pay approximately 8% of their income per annum (this is based on the previous two years’ tax returns). Some UK incomes may include tax credits – a benefit of any Double Tax trade treaties – which already include a credit for social charges. If you are on a pension, you may be charged a reduced rate.
If your household income falls below a certain threshold (which varies depending on the number of people in your household), you may find that you are either exempt from paying or eligible for free supplementary health insurance coverage (CMU-C). It may also be possible to take out supplementary private heath insurance (Aide pour une Complémentaire Santé or ACS).
Why buy private health insurance?
There are a number of reasons why you might choose private health insurance cover in France, for example:
- to close the 30% reimbursement gap
- if you are a foreign student who has been living under six months in France and is thus not covered by state insurance
- you work for an employer who has an arrangement with a mutuelle
Private medical insurance may also offer quicker diagnosis and treatment than the state system, and a broader range of choices in terms of hospitals and surgeons.
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What is covered by private health insurance?
Private insurance covers a full range of medical services and prescriptions. A basic package will cover:
- hospital care
- limited dental treatment
More extensive packages will cover appointments with and treatment from the following:
- other specialists
Before buying private medical insurance in France, always check if pre-existing conditions are excluded and if so, for how long.
How much does private health insurance cost?
Numerous variables can have an impact on the cost of private health insurance in France.
The most important variables are:
- Age (the higher the more expensive)
- Area of cover (i.e. just France or other areas too? If those other areas include any of the US, the Caribbean, Singapore, China, Hong Kong or Dubai this can significantly increase the overall price)
- Product choice (higher end insurance products are more expensive)
Other variables include:
- Payment frequency
- Country of residence
As so many variables have an effect on the cost of private medical insurance in France it becomes very difficult to give accurate estimates without knowing the full details of the coverage required. However, as a very rough guide, using a standard profile of a 40 year old British male with no deductibles, no co-insurance, a middle tier plan/product, all modules included and worldwide coverage excluding the US, a ballpark price of around £4,000/$5,000 might be expected. Were coverage to be expanded to include the US then the premium could increase to almost double that amount.
Which companies offer private health insurance?
There are a number of big private health care insurers in France, and most expats select these if they opt for private cover. These include:
- Bupa Global
- Cigna Global
- Pacific Prime
If you are in a specialized profession yourself, there are a number of smaller providers who specialize in any exigencies that may affect you. Consult your employer or a professional organisation.
Glossary of health insurance terms
assurance - insurance
l’assurance maladie / Sécurité sociale or Sécu - the state health insurance system
cotisations sociales - social security contributions
j\'ai une carte EHIC - I have an EHIC card
l\'assurance santé privée - private health insurance
mutuelle - mutual organisation
santé - health
Sécurité Sociale Etudiante - student’s Social Security
services de santé, soins de santé, soins médicaux - healthcare
tariff conventionné – the government-set fixed fees charged by doctors and hospitals