Health Care in France
Sécurité sociale in France mostly refers to public health care, although it strictly speaking also refers to family and child allowances, public old age pension and various social security expenses of general order. Americans should beware of the possibility of misunderstandings if they use the American term "social security" when they refer to public old age pension.
You must be covered for medical expenses when moving to France. It is a condition for the visa and the residence permit for those who must obtain these papers. Even if as an EU/EEA/Swiss national you are not obliged to ask for a residence permit, you must still be covered for medical expenses one way or another.
General public cover from France
If you will be working as an employee in France, then the employer must deduct contributions for health care and other social charges from your salary, and they must themselves pay in addition. This is also true if you are working for an employer not established in France. They must still pay for French health care, except if a bilateral agreement or EU regulation stipulates otherwise. As an employee, you will be covered by the CPAM (Caisse Primaire d'Assurance Maladie) or the MSA (Mutuelle Sociale Agricole). The MSA is primarily for agricultural workers. You must register at your local office, in person or by post. Registration typically takes 1-2 months.
Any dependents are covered too if they don't have their own entitlement to health care, for example via the spouse's employer. The main cases for covered family members are your spouse, registered partner of any sex (PACS), partner living in a marital way, any natural or adopted children below 16 of you or the covered spouse or partner; 18 in case of apprenticeship; 20 if under education; there is no age limit if they are unable to work because of permanent disability or chronic illness. If both parents are working, the children can be registered as dependents on both parents' health care.
When registering, you must provide documentation to prove your entitlement and a French bank account number to receive the refunds. They also ask for a birth certificate. Public French health care typically refunds 70% of medical expenses within the rates agreed with the public, 80% of hospital expenses and 35% of certain medicine that is estimated to be less efficient. When using medical services, be sure to ask if they are conventionné secteur 1 before booking. That means that they adhere to the fees recognised by the public French health care. If they are conventionné secteur 2, they decide their own fees. You get the same refund as if you had used a sector 1 professional and you pay the additional expenses yourself.
If you do not want to pay the remaining part yourself, you can sign up with a complementary medical insurance. Mutual insurance companies call that cover mutuelle. They do not require a health declaration, and existing conditions are covered. Other insurance companies may ask for a medical declaration. Often, a French employer will suggest a complementary insurance, but you are free to choose. Your employer's cover may or may not be more expensive than a cover you find yourself. It typically costs between €30 and €50 a month per adult, less for children. You choose the level of cover you want from your complementary insurance. Some are designed to cover up to 100% of the rates agreed with sector 1. Others refund higher fees. Some provide extensive cover for glasses and dental work, for example. Some provide cover for the type of dental work that the public French health care will not refund. In most cases, except for hospital in-treatment, you pay for medical services and then claim a refund from the CPAM or the MSA and your complementary insurance.
At pharmacies, you can register your entitlements to refunds, so that you don't have to pay anything. Some general practitioners do the same. If you use your green carte vitale, then the refund will be processed automatically. Otherwise, you get a receipt known as feuille de soins for services and volet de facturation for medicine that you must send to the CPAM. Be sure to be registered before you send any claims for refunds. Keep copies of all the claims, and verify that all are refunded in 1-2 months time. Note that an ordinary invoice is not accepted, except from hospitals. In the case of pharmacy receipts, the pharmacist or you must stick the small labels with barcodes (vignettes) that you find on all refundable medicine on the receipt. If the pharmacy doesn't process your carte vitale and gives you a receipt instead, then ask for a facture subrogatoire if you have a complementary insurance, or they may refuse to refund. The pharmacies don't automatically do this, and you may have to insist. If your complementary insurance accept télétransmission, then the CPAM or the MSA automatically transmit information about your medical expenses to the insurer that then automatically refund you. You must first ask for this to be set up. Until it is set up, and in cases where it cannot be set up, you must send the CPAM or MSA refund statements to your complementary insurance in order to get refunds. Don't forget the facture subrogatoire in the case of pharmacy bills, and keep all the copies of medical prescriptions if you claim the refund yourself, as medicine is not refunded without presentation of the prescription
You can choose your general practitioner, but you have to stay with him or her and let him or her decide which specialists you are too see. If you bypass your general practitioner or if you don't declare one, you will obtain less refunds.
If you are self-employed or run a small business, then you must pay into the public cover as well. It is not handled by the CPAM but the RSI (Régime Social des Indépendants) scheme, but otherwise it works as above. You are covered from the day you register the business.
Retirees keep their entitlement to public health care once the retirement age is reached.
Unemployed keep their right during unemployment.
Low-income public cover from France
If your income is below the amounts stated here, then you may qualify for free complementary cover, CMU complémentaire.
It is your worldwide household income over the last 12 complete calendar months that is used to calculate the monthly income. Real estate, capital and lifestyle may be taken into consideration. Income must be declared even if it is not taxable in France.
In that case, if approved, you never pay anything for health care, whether in sector 1 or 2. The professional obtains a refund from the CPAM, the MSA or the RSI. You don't advance payment to any medical professional either.
If your income exceeds the limit set for the CMU complémentaire, you may still obtain financial assistance to help you pay for a private complementary insurance if your income doesn't exceed the CMU complémentaire limit by more than 26%. You don't need to apply separately for this. Just file a demand for CMU complémentaire, and the most favourable of the benefits you qualify for will automatically be granted. Read more about the l'aide pour l'acquisition d'une assurance complémentaire santé on Service-Public.fr.
You can only obtain the CMU complémentaire if you had suitable health care and income when you moved to France, in conformity with the EU legislation defining the conditions for free movement of persons.
Alternative public cover from France
In a few cases, you are not obliged to pay into any public health care scheme. If so, you can choose between private insurance and voluntary public insurance, CMU de base. The CMU de base provides the same cover as the CPAM cover described above. If your annual household income is lower than these limits, then the cover is free. Otherwise, you pay 8% of the income that exceeds that amount. For the cover year starting 1 October 2007, the worldwide calendar year income of 2006 is used. Real estate, capital and lifestyle may be taken into consideration. Income must be declared even if it is not taxable in France. You cannot apply the first 3 months after arriving to France.
You can only obtain the CMU complémentaire if you had suitable health care and income when you moved to France, in conformity with the EU legislation defining the conditions for free movement of persons. Read my page about CMU restrictions for further information and alternatives, such as State Medical Aid or simple self-employment. My article in the Expat Telegraph "Mind the Gap in French health care" details the self-employment option, although it does not mention the much simpler auto-entrepreneur option that was introduced after the article was written.
Private medical insurance
Libre Assurance Maladie. Independent site informing how to legally opt out of the public French healthcare system.
When you are not paying into a public scheme and you have not chosen the CMU de base, then you need private medical insurance. If your stay in France is so short that a travel insurance policy will cover it, then that is satisfactory for immigration, but it will not refund ongoing treatment; only emergencies. For longer stays, there are special insurance policies available. Cost is typically €1500 per year and upwards per person. A family cover is available from some insurers and will be cheaper per person. Some insurers refund what corresponds to 100% of the sector 1 fees without excess, including preventive and ongoing treatment, while others focus on new medical conditions only, impose an excess and include a list of exotic cover and private treatment. The latter are typically more expensive.
When you compare the cost of private and public insurance, take into
account the following:
A la Carte Healthcard (Ireland)
Cover from the EU/EEA country where you last worked
In certain cases, it will be the country where you last worked that pays the expenses, if you have paid into their health system for the required length of time:
If you go on retirement in another EU/EEA country.
If an employer sends you on assignment in another EU/EEA country and the assignment is not expected to exceed two years. The cover can be extended up to a maximum of 5 years. The same is the case for self-employed.
In the case of persons of any nationality who have paid at least 2-3 years in the UK, the UK will provide up to 2 years cover in another EU/EEA member state if you are not working and therefore not paying into the local health system. Other countries like for example Denmark do not provide this cover.
In these cases, you must ask for documentation for your cover from your local health authority, in the case of the UK the DSS in Newcastle. With the documentation, you can register for public health care at the CPAM in France and obtain your refunds through them, as if you were an ordinary worker in France.
Temporary cover from non-EU/EEA countries
France has bilateral social security agreements with many countries. In the case of temporary assignments, these agreements may stipulate that the employee remains covered by his home country.
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