Guide to health insurance in France

Anyone working in France will have health contributions automatically deducted from their salaries, enabling the state to care for all citizens, regardless of age or income. Patients are free to choose which doctor they want to sign up for, and in most cases an appointment with a GP will cost a flat fee. The majority of the cost is then reimbursed by the state, usually in the region of 70 per cent, leaving the rest to be covered by the patient.

To make up the difference of what the State does not cover, it is common in France to also subscribe to a private medical insurance policy, known as a mutuelle (mutual society). Employees of France Médias Monde, must join the company's policy (Gras Savoye) as part of their benefits package. Students in France can either choose to be covered by their parents' mutuelle or select their own individual one.

Most policies, including FMM's, will reimburse the remaining 30 percent of your general healthcare costs, including emergency hospital treatment. The cost of private care depends on the type of cover required, as well as factors such as the age of the applicant. Very few mutuelles ask for your health details prior to approval. Basic packages tend to focus on hospital care and medicine, but may include limited cover for dental treatment.

Unlike health insurance in some other European countries, however, the French private cover does not guarantee faster treatment nor is it associated with private practitioners. It simply acts as a way of bridging the 30 per cent gap left by the state cover.

State insurance does not cover consultations with psychologists and psychoanalysts, osteopaths or chiropractors, however. It is therefore important to find a policy which covers any specialist treatments you may require.

This especially applies to anyone moving to France with an existing illness or chronic condition. It's imperative to acquire international private medical insurance which covers your specific condition, in order to ensure you receive the same treatment in France as you do at home. It's therefore important to start researching and comparing plans before moving, in order to ensure you obtain the best possible cover for your condition.

The majority of specialist practitioners are independent, but are paid from the public health funds. The price of their services are fixed by the state, but some carry a surplus charge  which must be paid by the individual if their mutuelle doesn't cover it.

Some policies, for instance, may refer to 100 per cent cover, which at first glance can appear misleading. This only refers to state-fixed tariffs, such as the standard charge for a consultation with a GP. Any surplus charged will not be covered by the mutuelle, and is therefore payable by the individual. It may seem complicated at first, but understanding the health care system is part of the process of integrating into the French way of life, so don't be afraid to ask for advice.

Dental care is covered by the health service, but comes with its own tariffs and reimbursement rates. General dental treatments are reimbursed in the same way as other care that falls under the specialist category, but more advanced procedures will include reimbursement at a lower rate, due to the cost. It is therefore important to ascertain what dental cover, if any, prior to committing to a specific private plan.
 

ADDITIONAL INFORMATION
 

Information about social security is available online, e.g. the Service Public site (www.service-publique.fr) and the Assurance Maladie site http://www.ameli.fr  - it stands for Assurance Maladie en ligne), where some information is available in English.  There are a number of books (in French) about social security, including Tous les Droits de l'Assuré Social (VO Editions), and consumer magazines regularly publish supplements on various aspects of social security, particularly pensions and health insurance.  For information in English about the French social security system, you can call the French Health Insurance Advice Line, set up by the CPAM of Manche but available to all residents. (08 20 90 42 12).

ELIGIBILITY AND EXCEPTIONS

Your entitlement to health and other social security benefits depends on your nationality, your work status (e.g. whether you're employed, self-employed, or retired) and your residence status. 

Unless you're covered by a reciprocal social security agreement, you must normally contribute to French social security for a certain period before you're eligible for benefits.  For example, you must contribute for three months before being entitled to family allowances, and you must contribute for at least a year before claiming maternity benefits. 

Different periods of salaried employment are required to qualify for ‘cash' benefits (prestations en espèces), e.g. disability payments, and benefits ‘in kind' (prestations en nature), e.g. free medicines.  For example, for prestations en espèces you must have been in salaried employment for at least 120 hours in the last quarter, while for prestations en nature you must have been salaried for at least 200 hours.  Full details can be obtained from your local social security office.  If you no longer meet the qualifying conditions, your benefits are extended for a maximum of a year from that date.  (Benefits are extended indefinitely for the long-term unemployed, provided they're actively seeking employment.)

If you don't qualify under any of the categories below, don't have private health insurance and your annual income is below E6,965, you may be entitled to the most basic of state healthcare, known as Couverture Maladie Universelle (CMU), a programme introduced in January 2000 and intended to ensure that all French residents have social security cover.  Information is available from your local CPAM office and on a dedicated government website  http://www.cmu.fr

UK citizens should contact the Longbenton Contact Centre for Non-Residents Helpline [sic], Department of Work and Pensions (formerly Department of Social Security), Benton Park View, Newcastle-upon0Tyne, NE98 1ZZ, UK (0191-203-7010), which can send you a useful booklet (no. SA29) entitled Your social security insurance, benefits and healthcare rights in the European Economic Area.  Further information is available from the websites of HM Revenue & Customs http://www.hmrc.gov.uk and the Department of Work and Pensions itself  http://www.dwp.gov.uk 

EU NATIONALS

If you're an EU resident visiting France, you c an take advantage of reciprocal healthcare agreements.  You should apply for a certificate of entitlement to treatment at your local social security office (or a post office in the UK).  The paper form called an E111 has been superceded by a plastic card called a European Health Insurance Card (EHIC), and there have been a number of changes to procedures and conditions of use.

First, an EHIC must be applied for (by post, phone, or internet) at least a month before travel and cannot simply be obtained the same day from a post office.  AN EHIC covers only one person and not a family, as did the E111, but it is valid for three to give years (an E111 had to be renewed annually).  However, you must continue to make social security contributions in the country where it was issued and, if you become a resident in another country (e.g. in France), it becomes invalid in that country.  Although an EHIC entitles you to much better cover than an E111, (which covered only emergency hospital treatment, whereas the EHIC covers ‘any state') it still doesn't entitle you to 100 per cent reimbursement of all medical expenses in France. Rather, it gives you entitlement to the same cover as a French resident, i.e. normally around 70 per cent of routine healthcare and treatment costs.  You can still receive a large bill from a French hospital, as the National Health Service assumes only a percentage of the cost!  You're therefore recommended to enquire about the availability of ‘top-up' insurance plans, covering the balance of costs.

If you do incur medical costs in France, you must obtain a treatment confirmation (feuille de soins) and go to the local CPAM, the authority which deals with health insurance, to apply for reimbursement, which will be sent to you or credited to your UK bank account.  Details of the procedure are included in the booklet that comes with the EHIC form.  Note that it can take months for medical expenses to be reimbursed.

As soon as you have a permanent address in France, even if this is within the six month period the EHIC covers you for, you must obtain an E106 (for people below retirement age) or an E121 (for retirees), which is available in the UK from the Inland Revenue's International Pension Service (0191-218 7777).  This form entitles you to cover while you transfer out of your home country's system (you must inform the relevant authority, e.g. the Department of Work and Pensions in the UK) and into the French system.            

 British visitors or Britons planning to live in France can obtain further information about reciprocal health treatment in France from the Department of Work and Pensions' Medical Benefits department (0191-218-7747) or, if they're of pensionable age, from the Pension Service (0191-218-7777) and about the new EWHIC from the post office (0845-606 2030) and via the internet (e.g. http://www.dh.gov.uk/travellers

EMPLOYEES

France has social security agreements with over 40 countries (including all other EU countries and the US),whereby employees on a short-term assignment in France can continue to make contributions to social security in their home country and be eligible for social security benefits in France.  An EHIC is required for the first year of employment and forms E102 and E106 for an extension.  The maximum period to which this arrangement applies is usually five years, although you may be required to contribute to French social security if you work in France for more than two years. 

The exact terms of social security agreements vary from country to country  and you should check before starting work in France.  However, if you qualify to pay contributions abroad, it's usually worthwhile doing so, as contributions in most countries are much lower than those in France. 
If you're from a country which doesn't have a social security agreement with France and are employed in France, your employer must declare you to the URSSAF and pay social security contributions on your behalf.

 If you require just health insurance, it's much cheaper to take out private health insurance than pay high French social security payments.  Private health policies also offer a greater choice of health facilities and may provide a wider range of benefits than social security.

STUDENTS

If you're a student following a standard course at a French state-supported institution, you're normally covered by French social security.  However, if you're attending a private institution, e.g. the American University of Paris, or are following a non-standard program, e.g. French language and culture classes, you must have (and must produce evidence of) private health insurance.  Those coming to France under an exchange scheme must be covered for healthcare by the exchange authorities. 

REGISTRATION

If you're working in France, your employer will usually complete the necessary formalities to ensure that you're covered by social security.  If he doesn't, you must obtain confirmation that you're employed in France (déclaration d'emploi) and register at your local CPAM.  Your town hall will give you the address or you can find it under Sécurite Sociale in your local yellow pages.  In certain cases, you will need to visit the Relations Internationales department of social security, e.g. if you're retired with a pension in another EU country.

           
 You must provide your personal details, including your full name, address, country of origin, and date and place of birth.  You will also need to produce passports, cartes de séjour and certified birth certificates from your dependants, plus a marriage certificate (if applicable).  You may need to provide copies with official translations, but check first, as translations may be unnecessary.  You will also need proof of residence such as a rental contract or an electricity bill.

When you've registered, you will receive a registration card (Carte Vitale), which looks like a credit card and contains a smart chip (puce).  The card has your name and your social security number (No. d'Immatriculation de l'Assuré) printed on the front.  (Social security numbers are issued by l'Institut National de la Statistique et des Études Economiques/INSEE.)  Additional information is coded into the chip, which is needed to process any  claim for reimbursement or services.  Contrary to some fears, there's no detailed information regarding your health or medical condition on the chip, although these may be included on the Carte Vitale 2, intended to supercede the Carte Vitale in 2006.

Along with a Carte Vitale (attestation) containing a list of those entitled to benefits on your behalf (bénéficiaires), i.e. your dependants, and the address of the office where you must apply for reimbursement of your medical expenses.  (This address is normally indicated in small type just above your name and address and is easy to miss.)  Dependants include your spouse (if he isn't personally insured), dependent children under the age of 16 (or under the age of 20 if they're students or unable to work through illness or invalidity), and ascendants, descendants, and relatives by marriage supported by you and living in the same household. 

 If you move home, acquire or need to change or transfer beneficiaries or find any errors in the information on your attestation, you must inform your CPAM.  If a social security official makes a regular visit to your town hall, you may be able to make changes to your records and ask questions during a scheduled visit. 

 The date when your entitlement to social security benefits expires is shown on the certificate (droits jusqu'au...).  Just before the end of the year when your benefits expire, you should receive a new certificate, along with instructions as to how and where to update your card.  There are machines in most public hospitals and in some town halls in which you can simply insert your Carte Vitale and update the chip.  Alternatively, you can post the card to the office that sent it to you and ask for it to be updated.  Make sure you keep your certificate in a safe place, as you may be required to show it if you require services from a medical practitioner chemist who isn't linked to the card system or whose computer is out of order.

CONTRIBUTIONS

Social security contributions (cotisations sociales or charges sociales) are calculated as a percentage of your taxable income, although for certain contributions there's a maximum salary level.  Contributions start as soon as you're employed or start work in France and now hen you obtain your residence permit (carte de séjour).  Contributions are paid directly to the Union de Recouvrement des Cotisations de Sécurité Sociale et d'Allocations Familiales (URSSAF), which has 105 offices throughout France.  URSSAG offices collect contributions for their area and send them to the central social security agency (Agence Centrale des Organismes de Sécurité Sociale/ACOSS) that distributes funds to the various benefit agencies (e.g. CNAF, CNAV, and CRAM).  It's possible to pay contributions monthly (actually, you pay ten monthly installments from January to October based on an estimated total contribution; any necessary adjustment is made in November or December); you must apply before 1st December for monthly payments from the following 1st January. 
 

The total social security contributions for employees (salarié) are an average of around 60 per cent of gross pay, some 60 per cent of which (i.e. around 35 per cent of gross pay) is paid by employers.  The employees' portion comes to around 25 per cent of gross pay.  All contributions are withheld from pay cheques, so no action is required (except to mourn the loss of so much hard-earned money).  Salaried employees come under the general regime for salaried workers (régime général des travailleurs salariés).  There are special regimes for agricultural workers (régime agricole), called MSA or GAMEX, and for miners, seamen, railway workers and obligatoires).  It's also possible to make voluntary contributions (if you can't think of anything better to do with your money). 

BENEFITS

Under French social security you're entitled to health, sickness, and maternity, work injury and invalidity, family allowance, unemployment, and old age, widow(er)'s and death benefits, each of which is described below.  With the exception of health benefits, these are known as ‘cash' payments (prestations en espèces).  Health benefits are known as payments ‘in kind' (prestations en nature), e.g. free medicines.  Most social security benefits (allocations) are paid as a percentage of your salary rather than at a flat rate, subject to minimum and maximum payments.  You must have been employed for a minimum period and/or earn a minimum salary to qualify for certain benefits, as detailed below. 

HEALTH BENEFITS

To qualify for health benefits you must have been employed for 600 hours in the last six months (or for six months at the minimum wage), 200 hours in the last quarter or 120 hours in the last month.  There's no minimum qualifying period during the first three months after registration. 

SICKNESS BENEFIT

To qualify for sickness benefit you must have been employed for 200 hours in the past three months or six months at he minimum wage.  To qualify for extended cash sickness benefit you must have been insured for 12 months before your incapacity and for 800 hours of employment in the past 12 months.  This includes 200 hours in the first 2 of the last 12 months or 2,080 hours at the minimum wage, including 1,040 hours during the first 6 of the last 12 months.  Employees who aren't automatically covered by sickness insurance can contribute voluntarily.  As with unemployment benefit, sickness benefit is paid as a percentage of your previous salary (e.g. 50 per cent) rather than at a flat rate.  A leaflet explaining sickness benefit is available from CPAM offices (listed on http://www.ameli.fr   Information is also available on the Service Public website http://www.service-public.fr

MATERNITY BENEFIT

To qualify for maternity benefit you must have been insured for at least ten months before your pregnancy began and have been employed for 200 hours in the first 2 of the last 12 months or have been made six months' contributions.  Benefits are payable for an extra two weeks before the birth if there are complications and for up to 12 weeks for multiple births.  A monthly allowance or milk coupons are available for four months after the birth.  Benefits are also paid for adoptions.  Employees who aren't automatically covered by maternity insurance can contribute voluntarily.. 

WORK INJURY AND INVAILIDITY BENEFITS

Industrial accident insurance pays all medical and rehabilitation costs associated with work injuries (accident de travail) and provides a pension for you or your dependence in the case of injury or death.  Insurance starts from your first day at work, with the variable contributions paid wholly by your employer.  A benefit of 60 per cent of earnings is paid (up to a maximum amount) during the first 28 days of disability and thereafter 80 per cent of earnings.  Self-employed workers are excluded and are covered under the state sickness insurance programme.

In the case of injury resulting in permanent total disability, a pension equal to 100 per cent of average earnings during the last 12 months is paid from the day following the accident.  In the case of partial disability, average earnings are multiplied by between 0.5 and 1.5 depending on the degree of disability.  A lump sum payment is made if a disability is below 10 per cent.  All necessary associated medical treatment, surgery, hospitalization, medicines, appliances, rehabilitation and transportation are paid 100 per cent by social security.  Those over 60 with at least 80 per cent invalidity are also entitled to an allocation compensatrice tierce personne (ACTP).