CMU, Summary of French health care
France: Health Care Options
Update summer 2011: following pressure from the European Commission, France has relaxed conditions for EU/EEA expats' access to the CMU. The present conditions for the CMU are thus less restrictive than what is mentioned below. The details will be updated once the new circular has been studied.
In 2007, the French government restricted access to public French health care for European Union expats not in paid activity. More precisely, it was access to the CMU de base that was restricted. This caused a stir in British press and negotiations between the French and British governments to limit the damage. The French government position was softened several times. This page discusses your options for health care in France. At the end, the French government position is explained, followed by a legal analysis.
This is a brief summary. For more details, read the main page about health care in France.
The principle of medical cover in France is that you must earn your entitlement to cover in one way or another.
Employment, Self-employment, Retirement, EU/EEA Rights
This is the main way of obtaining medical cover.
In all cases under "1" to "8", your dependents are covered if they are not entitled to their own public health care by virtue of their own activity.
If each spouse in a married or PACS'ed (civil partnership) couple are entitled to medical cover under one of these schemes, they remain covered independently.
In a couple, common children may be covered by both parents' health care or by one or the other parent according to the parents' choice.
1. If you are employed by a French employer and have worked more than a certain period, you are covered by the CPAM (Caisse Primaire d'Assurance Maladie) or the MSA (Mutuelle Sociale Agricole). The MSA is primarily for agricultural workers.
By special provisions in French law, certain freelance journalists, authors and others who are paid royalties fall in the employment category even if they have no employment contract.
AGESSA.ORG explains health care for this latter category of mainly authors. The main principle is that French publishers withhold social security charges from the royalties. Authors paid by foreign publishers must pay both employer's and employee's social security charges in France, based on the net royalties paid from abroad. In principle, professional expenses can be deducted.
2. Self-employed, artisans, farmers and small business owners pay social security contributions. For the medical cover, they pay to the RSI (Régime Social des Indépendants) scheme.
The new super-simplified scheme known as auto-entrepreneur does away with the majority of the former complications of being self-employed in France. No minimum turnover is required (except that if you declare no income at all during twelve successive months, you will lose your entitlement to the scheme) and there are no minimum contributions (with one exception, see later), only a flat percentage rate in social security charges based on turnover, paid once and for all monthly or quarterly. Income tax can be a flat tax paid monthly or quarterly once and for all, or regular income tax, depending on income level and your choice. There is no complicated book-keeping or need for an accountant. Obtaining medical cover by declaring yourself auto-entrepreneur may well be cheaper than opting in to the CMU.
However, auto-entrepreneurs are not automatically exonerated from the local business tax called CFE (which is one of two taxes replacing the former taxe professionnelle). The CFE is based on the value of real estate used by the business (whether rented or owned), and there is an annual minimum tax between €200 and €2,000, the minimum tax being defined locally. The minimum tax is due even if you earn less. However, after this problem was exposed on TV in 2010, the government was forced to do something about this. We are currently waiting to know how this will be changed. You are automatically exonerated from the CFE in the calendar year of business creation and the two following calendar years. If the purpose is to obtain health care, it is still worth paying this tax, which in most cases is much cheaper than a private medical insurance.
3. If you are posted temporarily to France by a foreign employer in the EU/EEA or Switzerland, or if you post yourself temporarily to France as self-employed, then you may be covered by your home country via an E101. The home country issues this, and you take it to the CPAM to obtain medical benefits. Dependent spouse/partner and children are added to the cover by the CPAM according to the E101.
4. If you are retired from another EU/EEA Member State, they should issue an E121 that you take to the CPAM to obtain rights.
5. If your home country has issued you with an E106 in cases where you are expatriated without working, you obtain cover during its period of validity by taking it to the CPAM.
Pre-retirement and other inactivity
6. If none of the family members has a right to cover through the options above, the CMU can set in to cover the family under certain conditions.
The CMU is in fact two distinct schemes:
- 6a. Basic CMU provides the same medical cover as the CPAM gives to employees. The basic CMU is contribution based. You pay 8% of the part of your worldwide income that exceeds the limit set for the basic CMU. Beware that the value of worldwide real estate and capital, as well as your lifestyle, can be taken into account too.
- 6b. Complementary CMU covers the gap between the basic cover provided by the CPAM, the MSA, the RSI or the basic CMU and 100% of the contractual fees agreed between the public health care and the medical professions. The complementary CMU is given at no cost to certain low-income families as a social benefit. Beneficiaries never pay anything to any medical professional, even those who exceed the public fee levels, contrary to other schemes.
The CMU is intended to assure that all legal residents of France have a medical cover. To benefit, you must have lived legally in France more than three months, and in order to establish legality of your residence, you must already have been covered by a non-CMU medical insurance and have had sufficient financial resources. These conditions fall away after 5 years' continuous and legal residence in France, after which you are entitled to the CMU under the rules applying to French nationals.
As an exception, if you had already emigrated to France on or before the 23 November 2007, then you can remain in or join the CMU on the same conditions as French nationals.
7. If you are not entitled to the CMU and your income is below the limit for the complementary CMU, you can still apply to the CPAM for Aide Médicale de l'Etat under Article L 251-1 of the Code de l'action sociale et des familles without fulfilling any residence criteria. You must have been in France more than 3 months, although dependent children are immediately covered.
Claim form for AME.
8. If you are not entitled to the CMU and you are not a beneficiary of the Aide médicale de l'Etat, urgent medical intervention will be paid under Article L 254-1 of the Code de l'action sociale et des familles regardless of the duration of the stay in France or its legality.
9. If none of this works, you can take out a private medical insurance, but they may not accept you if you already have medical conditions. Check out my list of some private providers of health care in France.
The CMU Controversy from 2007
After many confusing articles on this subject, the official position from the French government was softened in December 2007 and updated on their site http://www.securite-sociale.fr/comprendre/europe/europe/cmu_inactifs.htm on the 14 December 2007 and again on the 24 January 2008 and the 8 February 2008.
Government position January 2008
The new position is essentially the same as before, with the very important difference that expats who had already emigrated to France no later than the 23 November 2007 AND who have or have held an E106 may join the CMU on the same criteria as French nationals. This detail is explained in their FAQ question 6.
Government position December 2007
The following is a translation of the stated government position in December 2007. This is the current position, except for the concession mentioned above.
Government position September 2007
The following is a translation of the stated government position in September 2007. The position has now changed, but this translation is still useful as reference.
The references to the Directive 2004/34 http://eur-lex.europa.eu/LexUriServ/site/en/consleg/2004/L/02004L0038-20040430-en.pdf are correct. The EU freedom of movement depends for inactive persons on sufficient financial resources and medical insurance, as well when arriving as while living in another Member State. Only after 5 years’ continued and legal residence in another Member State would the person concerned obtain the right of permanent residence in the host country (Art. 16), and from that moment, restrictions on social security would cease. Also, the restrictions only concern people who have not been working in the host country at all.
BUT: Article 37 stipulates that “this Directive shall not affect any laws, regulations or administrative provisions laid down by a Member State which would be more favourable to the persons covered by this Directive.” In other words, if French law gives you better rights than this Directive, then this Directive has no effect on that French law.
As for French immigration law:
Art. L121-1 of the French Immigration Code (Code de l’entrée et du séjour des étrangers et du droit d’asile) stipulates that an inactive person has the right to remain in France if he has a medical insurance (assurance maladie). It does NOT say that it has to be a private insurance. “Assurance maladie” is also the official term for the French NHS. As the CMU cannot be acquired during the first 3 months’ residence, it is necessary at least to have a private insurance covering the first 3 months.
As for French social security law:
The purpose of the CMU, when created in 1999, was expressly, as stipulated in the law, to assure that every person living in France could benefit from public health care:
“Law number 99-641 of 27 July 1999 creating a universal medical cover. Article 1.
It is created, for the residents of Metropolitan France and the overseas departments, a universal medical cover that guarantees for everybody the cost of treatment via a medical insurance system, and for persons whose incomes are amongst the lowest a right to a complementary insurance protection and exoneration from having to advance money.”
Next, the Social Security Code http://www.legifrance.gouv.fr/WAspad/RechercheSimplePartieCode?commun=CSECSO&code=CSECSOCL.rcv itself: “Article L111-1
The organisation of social security is founded on the principle of national solidarity. It guarantees workers and their families against risks of every nature that could reduce or invalidate their capacity to earn money. It equally covers cost of maternity, paternity and family allowances. It assures, for every other person and for his or hers family members residing in France, cover for illness cost, maternity and paternity as well as family allowances. This guarantee is exercised through affiliation of the interested persons and their dependent family members to one or more mandatory systems.”
« Preliminary chapter: Persons affiliated to the general system because of their residence in France
Every person residing in Metropolitan France or an overseas department in a stable and regular way depends on the general [health care] system when he or she has no right to medical services from any other health care system.
The persons affiliated to the general system in the conditions stipulated in Art. L380-1 must pay a contribution when their income exceeds an amount defined by decree, revised every year to account for price evolution. This contribution is defined as a percentage of income.”
The Social Security Code and the CMU law do provide better medical cover for all residents of France than the EU Directive 2004/38. Hence, that Directive cannot be used to cancel the effects of the Social Security Code and the CMU law for inactive EU nationals.
The Immigration Code just says you must have a medical insurance. Art. R121-4 of the Immigration Code further says: “The cost on the social assistance system that a foreigner mentioned in Art. L121-1 can constitute is evaluated notably by taking into account the amount of non-contributive social services granted to him ...”
As the CMU discussed here is a contribution based system for income over €9029 a year (2011), services provided by the CMU should be taken much less in consideration than other social services.
Because of the Social Security Code and the CMU Law, once you ARE resident in France and have lived there more than 3 months, you DO have the right to join the CMU and to remain in the CMU until pension age, when an E121 will assure your rights. These texts have NOT been updated to reflect the intention of the government, as expressed in the notice. In order to refuse inactive Britons access to the CMU, the National Assembly would have to uproot the foundation of the CMU universal health care system, and they have NOT done that.
Throwing you out of the CMU, or refusing you entry, would be a violation of the Social Security Code and the CMU Law. Such a violation could be successfully challenged in court. Low-income families can apply for partial or total legal aid to minimise legal costs.
This is not the first time the government has tried to implement cost cuttings in a panic, and it would not be the first time they lost in court, as it recently happened when they illegally cut unemployment rights for those already accepted under the old rules. You don’t need a large legal machine to beat the government in court.
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