French Health Care for Expatriates

Several international surveys have described French health care as among the best in the world. This is available to everyone resident in France - French national or foreigner and whether salaried, working as an independent artisan or professional, unemployed or retired. 

CMU or Universal Health Cover 

The enactment of Couverture Maladie Universelle (CMU or Universal Health Cover) in January 2000 means that all resident in France are obliged by law to join the State Health system. In local terms, this means affiliating to the CPAM or Caisse Primaire d'Assurance Maladie. There are penalties for residents who do not join, although such penalties have yet to be enforced.

The Value of CMU

CMU is important for expatriates, whatever their country of origin, but especially so for EU citizens. All EU countries have highly developed systems of social security, paid out of general taxation. Among other functions, EU social security ensures that no one is denied access to proper medical treatment for want of money.

The Advantages of CMU 

Many national systems lack choice - and patient service - so these State offers are often supplemented or replaced by Private Medical Insurance (PMI) schemes. Overseas PMI suppliers can be expensive and have considerable disadvantages compared to the French system of national health assurance:

• Nearly all exclude pre-existing medical problems
• Few are comprehensive, most excluding GP fees, prescription charges for drugs and pills, and dental and optical care
• Premiums are high, and rise rapidly with age, and companies can refuse insurance if the claims experience is poor.

None of these drawbacks apply to CMU and its associated Santé Complémentaire or Top-Up insurance.

The Basic System of CMU

Like others, France uses taxation to fund health care for residents but unlike Britain for example, France operates an insurance system. This is a mixed system with the bulk of cover coming from State assurance, and top-up cover coming from mutuelles or private health care insurance companies. All medical facilities are part of the State system but you choose your own doctors, specialists, medical or hospitals. 

• You pay directly for medical treatment. 
• Up to recently, you would receive in return a feuille de soins, a brown receipt form offered by doctors, pharmacists and hospital staff. This is recognised by Caisse Primaire d'Assurance Maladie (CPAM) as a legitimate medical payment. More commonly now, your Carte Vitale (attesting membership of CPAM) will be register your treatment and payment, and reimbursement will be automatic. 
• You are reimbursed by CPAM according to your income level and the Tarif de Convention (or approved treatment cost) currently in force. 
• If you have a Carte Blanche or top-up insurance card from your chosen mutuelle with its santé complémentaire, your treatment will be recorded and the appropriate balance reimbursed.

What CMU Provides 

The CMU decrees that on average 70% of the cost of medical treatment will be reimbursed to you and your family but the exact figure received depends on:

• the treatment needed and its costs
• and the income of the patient. 

It is the interaction of these two factors that determines the specific level of CPAM repayment:

1. The agreed price of the treatment is set by the Ministry of Health and known as Tarif de Convention. Repayments range from below 60% of this amount to full repayment of 100%. This is the level for:

• major surgery
• major diseases such as cancer
• disability and other long term care; this is especially important as this can be a prohibitive cost if arranged through PMI.

2. The income levels of you and your family. There are taxable income levels below which 100% of the Tarif de Convention is reimbursed, based on your status as a single person/couple/couple with dependants. Tariffs for these categories can be supplied by the CPAM offices.  

What CMU Will Cost

No payments are due from low-income singles, couples or families (tariffs available from CPAM). Low-income families, including many retired expatriates, are entitled to a free top-up policy. 

For people above the minimum income levels, the contribution (cotisation) is 8% of the difference between the appropriate family threshold level and taxable income - marked on the French income tax return in the row with two asterisks as relevant fiscale de revenu. CPAM will make these calculations.

Expatriates who have come to live in France, whether working or not, need to prove their income to CPAM. This is most easily done with a French tax return. However these tax returns are submitted one year in arrears, in February each year, so those who have not declared themselves as tax residents need to show evidence of income. This can be another country's tax return, or evidence of income such as payslips, pension statements, or earnings from capital such as bank deposits, coupons from government bond holdings or share dividends.

European Conventions and Forms E121 and E106

EU Expatriates who have retired to France pay nothing provided that they have a Form E121 . This puts an expatriate in France onto exactly the same legal basis as a French national. E121 should be obtained from your former country of residence. It proves:

• that you have paid the appropriate social security taxes in that country
• have now reached the official retirement age
• are receiving a State pension. 

Generally this is 65 for men (and wives who have not worked or paid social security taxes) and 60 for women who have, and have also paid separate social security taxes. In France, husbands and wives - or acknowledged partners - are treated as one taxable unit. So if there is a significant difference in age between partners, then birth and marriage certificates are all that is needed to bring both partners under CMU.

EU Expatriates below these age groups, or those who do not meet the qualifications described above, may be entitled to a Form E106. This may give full State cover, depending on your individual circumstances, but probably not for more than 2 to 21/2 years. After that you lose all entitlement to any State medical cover until you can meet the qualification above (official retirement date and receipt of a State pension). 

Expatriates resident in France, and without either E121 or E106, are legally required to join and pay for affiliation to CPAM. (Note: it a good and necessary investment as well as a legal requirement).

The Purpose of Top-Up Insurance for CMU

The CPAM repays only a percentage of medical costs, and also excludes ambulance costs, the "hotel costs" of a stay in hospital, and the use of a private room. In addition modern dental and optical treatments are often very much higher than the Tarif de Convention.

A santé complémentaire from one of the many mutuelles gives many choices. These range from:

• self-insurance or having nothing and paying the difference between cost and CMU
• having more or less of the extras not covered by CMU paid for with policies that range from 100% to 200% of the Tarif de Convention.

This choice must be an individual one, and should depend on your state of health, need for regular medication, and the size and age of family. It is important to take advice from an insurance broker on what is best and what the cost might be. Not all mutuelles offer cover people to over 70 - and some have an earlier cut-off date of 65.

How to Join the CMU

CMU is relatively new and sometimes the offices of CPAM interpret what is a complicated law in different ways. In particular there can be a Catch-22 situation in that a Carte de Séjour may be difficult to obtain without evidence of health cover, but affiliation to the CPAM needs a Carte de Séjour.

However any expatriates refused cover because of age, or trapped by the bureaucracy of a CPAM, can take out a complementaire and so get an attestation provisiore and temporary social security number. This means that you  are immediately covered for any medical mishap both by the French State system and your chosen mutuelle.

Visit a local CPAM office - or arrange a meeting with a CMU officer making a regular visit to the local Mairie - and ask for affiliation. Affiliation should then take place that day either as attestation provisiore, if not all the documents are available, or as attestation d'affiliation. In the former case you have two months to supply all the necessary documentation. Either way, claims from that day forward are covered by CPAM and, if either the provisional or final documents are not offered at that time, you must request them and ensure that the date on the attestation and the date the application was made are the same.

Tthe information needed to fill in the form, the declaration en vue de l'immatriculation d'une pensionne, ou de sa veuve, ou d'un orphelin is as follows:

• Proof of identity: passport or Carte de Séjour
• Details of place of birth, wives' and mothers' maiden names
• Exact address in France with proof of ownership (deeds) or rental agreement
• Date of permanent arrival in departément
• Proof that you have lived in France for at least 3 months, such as provided by utility bills, rent statements, or mortgage payments or a notarised statement of home purchase
• Marriage and birth certificates, if partners are to be included
• A RIB (Relevé d'identité Bancaire) provided by your bank
• Evidence of income for at least the previous 12 months, whether in France or elsewhere Or an avis d'imposition or latest French tax bill.

Further Information and Contacts

• Information from the French Government Web site (in French)
• AMELI Assurance Maladie en Ligne (in French)

© 2003 Russell Taylor