French Health Care for Expatriates
Several international surveys have described French health care as amongst the best in the world. Subject to qualifying conditions, this is available to everyone resident in France – French national or foreigner, whether salaried, working as an independent artisan or professional, unemployed or retired.
Social Security (Health Insurance)
Access to the French State Health system has been restricted in recent years. Changes in November 2007 meant that non-working immigrants into France from the UK under state retirement age were not eligible for affiliation to CPAM (Caisse Primaire d’Assurance Maladie) if they did not have the form S1 (replacing E106, E109, E121) issued by HMRC or the DWP until they had been fully resident in France for five years. The S1 is issued on the basis of your recent NI contributions record or retirement status. This meant that there was likely to be a gap of at least three years after the S1 expired unless you reached state retirement age when the S1 would again be provided. Private health care was necessary for any time when the S1 was not available.
Challenges to this position since then have finally started to bear fruit, and the November 2007 circular, which barred early retirees from access to the health system unless they had five years legal residence, has now been withdrawn.
It is clear from the new guidance that the French authorities have been obliged to withdraw the earlier circular due to non-compliance with EU rules on the right of free movement of persons within Europe. A residence permit (carte de séjour) is not required to reside in another Member country so any EU national is entitled to relocate to France, provided they have sufficient resources and can prove that they hold health insurance. In theory, possession of any type of S1 form should suffice for this process.
Unfortunately, this right of admission is less automatic for existing early retirees in France whose current insurance is provided by a private health insurer. In addition, some early retirees arrive from the UK without any access to form S1. Those who are in these categories can expect a harder time gaining access to the system, although logic and common sense is on their side.
The Value of Social Security
Social Security 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 Social Security
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 Social Security and its associated Santé Complémentaire, or top-up insurance.
The Basic System of Social Security
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.
☛ You pay directly for medical treatment.
☛ Your ‘Carte Vitale’ (attesting membership of CPAM) will 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 Social Security Provides
The Social Security 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
☛ 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 is known as the 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 Social Security 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 S1 (ex E121). This puts an expatriate in France onto exactly the same legal basis as a French national. Form S1should 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 Social Security.
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 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), or are resident for five years.
The Purpose of Top-Up Insurance for Social Security
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 Social Security
☛ having more or less of the extras not covered by Social Security 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 to people to over 70 – and some have an earlier cut-off date of 65.
How to Join Social Security
Visit a local “Caisse Primaire Assurance Maladie” (CPAM) of which there is a nationwide office network, or arrange a meeting with a Social Security 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 all the documents are not 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.
The 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
☛ Details of place of birth, wife’s and mother’s maiden names
☛ Exact address in France with proof of ownership (deeds) or rental agreement
☛ Date of permanent arrival in departement
☛ 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 two full French tax years, whether in France or elsewhere, or an ‘avis d’imposition’ or latest French tax bill.
We hope that this guide will ease your path into the French Health Service. For clients who will need private health care for a limited period, we give you details of local companies offering healthcare insurance.
The Spectrum IFA Group
06 42 23 94 95
The advice and recommendations contained in this guide are based on The Spectrum Group’s understanding of current legislation and may be subject to change. No liability can be accepted for any change of interpretation or practice relating to any tax or legislative measure or the introduction of any new measures that may affect this advice and recommendations.
Thanks to Rob Hesketh for preparing this article.