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France uses taxation to fund healthcare for its residents but unlike Britain it also operates an insurance system. This is a mixed system with the bulk of cover coming from state assurance, and top-up cover from mutuelles or private healthcare insurance companies. All medical facilities are part of the French state system but the choice of doctor, specialists and hospitals is up to you.
It is obligatory to become part of the French social security system. This can be done by visiting a local CPAM office – or arrange a meeting with a social security officer who makes regular visits 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 if you do have all the documents. If the former you have two months to supply 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 the date on the attestation and the date the application was made are the same. (A list of the nine pieces of information needed to fill in the form can be found on the AngloINFO website.)
When you have medical treatment, you pay for it and then the treatments and payments are registered on your carte vitale (the membership card for the Caissse Primaire d’Assurance Maladie) and reimbursement to your bank account is automatic.
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 depends on the treatment needed, its costs, and the income of the patient.
It is the interaction of these factors that determines the specific level of CPAM repayment:
- The agreed price of the treatment is set by the Ministry of Health and is known as tarif de convention. Repayments range from below 60% of this amount to full repayment of 100%.
- 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.
- 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 differ-ence 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.
Expats 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 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.
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 much higher than the tarif de convention.
A santé complémentaire from one of the many mutuelles gives many choices. These range from paying the difference between cost and social security and 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 over the age of 70, and some have an even earlier cut-off date of 65.