2. Registering with the Health Service

1. 2.1 Seeking Employment
2. 2.2 Starting a Business
3. 2.3 Working in UK & Living in France
4. 2.4 Persons of Retirement Age
5. 2.5 Early Retirees
6. 2.6 European Visitors
7. 2.7 International Visitors
8. 2.8 French European Health Insurance Card

2.1. Seeking Employment

If you are relocating to France to work for an French employer, you will be registered with the health service through your employer.

You will pay contributions into the health service together with your other social security contributions.

If you are relocating from within the EEA then, until you get employment in France, you need to obtain temporary cover via the social security authorities in your home country, using a Form E106 obtainable from them.

You need to present the form to your local Caisse Primaire d’Assurance Maladie (CPAM).

The use of Form E106 means that you will not need to pay French social security health service contributions for the duration of the E106, or until you enter employment, whichever is sooner.

Once you enter employment in France then the E106 ceases to be valid, and you need to start paying social security health contributions.

However, the entitlement to full E106 cover only applies if you have a satisfactory national insurance contribution record in the UK for, at least, the last two full tax years prior to your departure from the country.

So, if you have paid into the UK social security system for (say) 25 years, but you have not done so for the last two tax years, you do not have any entitlement to cover from an E106! In these circumstances, until you find employment, you will need to take out private medical insurance.

The precise duration of the E106 will also depend on when you vacate the UK, and few would get the full 2.5 year cover. Those with a full contribution record up to the point of their departure, and vacating the country mid way through the year (with contributions paid up to end of June), would normally be the only ones entitled to 2.5 years.

If you are coming from the UK the Form E106 is supplied by the UK Pensions Service

2.2. Starting a Business

If you are relocating to set up your business, then you will register in the health service as part of the process of business registration. This will take place at one of the business registration centres, called the Centre des Formalites des Enterprises (CFE) e.g. Chambre de Commerce/Metiers.

You will pay contributions into the health service with your other social security contributions.

As with those seeking employment in France, if you are relocating from within the EEA you should obtain a Form E106 from your social security authority, which is available on the same terms as those outlined above for those seeking employment.

2.3. Working in UK & Living in France

If you and your family are relocating to France from a country within the EEA, but you are continuing to work in your home country then you need to obtain the same Form E106 from HM Revenue and Customs or the DWP Pensions Office, which you need to present to the local Caisse Primaire d’Assurance Maladie (CPAM).

The use of the Form E106 will enable you and your family to obtain continuing medical cover in France whilst you continue to work in the UK. Alternatively, you may be issued with an E109, which covers dependants living in France, for someone living and working in another Member State.

No health care contributions will be payable in France, as you will pay social security contributions in your home country.

2.4. Persons of Retirement Age

A 'retired person' as someone with no professional activity, who is of the age of retirement of their country of origin, and in receipt of a State pension.

We can also include in this category those persons under the age of retirement, but in receipt of long term incapacity benefit.

If you are relocating from within the EEA and you are a retired and in receipt of a state pension, or you suffer from long term incapacity then, in order to register with the French health service, you will need to bring with you Form E121 from the social security authority in your home country. This form should be presented to your local Caisse Primaire d’Assurance Maladie.

Someone on long term incapacity benefit is likely to be entitled to receive full reimbursement of all the medical costs relating to their condition, provided it is classified as a Affection de Longue Durée – (ALD) by the French medical authorities.

A 'dependant' younger spouse of someone reaching State retirement age is also granted cover under an E121.

The definition of just what is regarded as being 'dependant' includes all those in a married relationship or in a civil partnership. Thus, even though your spouse may have an independant source of income, they would be admitted as a dependant. Only in the case of those not married, or in a civil partnership, would it normally be necessary to prove financial dependancy.

The decision as to who is dependant is not made by the French authorities, but by your country of origin. Some local health authorities in France have been known to contest dependancy status, but the cases have been rare, and generally not upheld.

In the event that the holder of an E121 dies before their 'dependant' younger spouse reaches retirement age, then the surviving partner will continue to retain health cover through the E121 for 12 months.

If you have not reached retirement age by the end of this period, then you can make application to the French health authorities to be admitted to the State health insurance system, on grounds of 'accident of life' provisions, which also cover the dependant spouse in the event of divorce. You would be required to pay health contributions, but these would be related to income, and those on a low income would be entitled to free cover.

On this basis, a dependant younger spouse of a retired person should always be able to obtain State health cover in France.

2.5. Early Retirees

If you are relocating from within the EEA to retire to France under the age of retirement, then the use of Form E106 is available on the same terms as outlined above in Section 2.1.

Once cover under Form E106 has expired then, hitherto, it has been possible to obtain continuing health cover in France under the Couverture Maladie Universelle (CMU).

However, in November 2007 the French Government introduced new rules that deny access to the CMU for early retirees from the EEA who do not take up employment, or start a business.

This private health insurance will also need to cover trips back to your home country, as you will not be eligible for a European Health Insurance Card, only available to those in the State system.

However, there are four important qualifications to the new rule on private health insurance for early retirees.

i. Medical Condition

Under the new regulations there is provision for those who later develop a medical condition that makes it impossible for them to obtain private medical insurance, to make application to join the CMU.

Although this would seem to exclude those who relocate with an existing medical condition, it remains to be seen just how the local health authorities interpret the regulations. Thus, it may well be that someone who has suffered from a life-long serious medical illness, or disability, would be admitted to the CMU.

You will need to prove a refusal of private health insurance on medical grounds in order to make application on this basis.

If you become affiliated to the CMU on medical grounds, then your spouse and dependants also automatically become affiliated.

ii. 'Accident of Life'

The same provision also applies to those who relocate to France and later suffer some other 'accident of life', such as death of spouse or divorce. Such persons are also entitled to make application to join the State health system, the CMU.

If you become affiliated to the CMU as a result of an 'accident of life', then your spouse and dependants also automatically become affiliated.

This provision would also enable a 'dependant' younger spouse of a retired person who dies to retain their health cover.

iii. Loss of Employment

If you take employment, or start a business in France, which later ceases (either through termination of contract, or because business does not succeed), then you will be able to make application to join the CMU.

This is because the new regulations only exclude those relocate without employment and remain 'inactive'. Once the cycle of 'inactivity' is broken, should you later become involuntarily unemployed, you would be entitled to continue to receive health cover, initially through your work based Caisse, but later through the CMU.

As to what is considered 'involuntary unemployed' would need to be determined by your circumstances. However, a temporary employment contract that came to end would certainly fulfill the criteria. Similarly, a new business you started that proved to be unsucessful would constitute circumstances that, prima facia, would entitle you to cease the activity and apply for affiliation to the State health system. You would need to check with your Caisse as to the application of the rule in your case.

You can read more at A Strategy for Health Cover.

It is also worth noting that if you run a business in France (during which you will have paid health and retirement contributions), you can retire at 60, and then receive health cover in your retirement.

iv. Five Years Residence

Once you have been resident in France for 5 years, you will be entitled by law to join the CMU. Accordingly, if you arrive in France with two year cover through an E106, then the maximum period for which you will be required to take out private health insurance would be 3 years.

If you live outside the EEA and you relocate permanently to France as a retired person, you will need to check with the relevant authority in your home country whether there are any reciprocal agreements with France.

You will almost certainly be required to take out private medical insurance, as you will need to justify you have the resources not to be a burden on the French social security system and to have health insurance cover. This cover will need to be taken out before you will be granted your long-term residence permit.

Ultimately, however, if you establish a right of long-term residence in France, you will be able to make application to the CMU for State health insurance cover.

2.6. European Visitors to France

2.6.1. European Health Insurance Card

Visitors to France from the EEA and Switzerland are entitled to receive reduced cost, or sometimes free health treatment, through reciprocal health agreements that have been entered into between the countries.

In the past, in order to gain access to treatment that was reimbursable, those visiting France as tourists have been required to complete a Form E111.

Since 2004 this has now been replaced by the European Health Insurance Card (EHIC).

Every member of the family who is travelling will need their own card and, in the case of those from the UK, the card is valid for up to five years.

The EHIC is not a passport to unlimited health care in France. The entitlement is to such health care as is 'necessary', on the assumption that you will be expected to receive continuing treatment when you return home.

You can apply for an EHIC by phone or by post or through the post office in the UK. You can also make an On-Line Application

2.6.2. Reimbursement of Costs

If you need medical treatment whilst you are in France as a visitor, then you will normally need to pay for the treatment. You will be given a receipt (called a feuille de soins), which you can use to obtain a refund.

If you are hospitalised during your stay you will normally find that around two-thirds of the costs are picked up directly through the social security system, although there will be residual costs you will be asked to pay, in the same manner as if you were resident in France.

To make application for a refund for medical treatment you need to go to the local office of the Caisse Primaire d'Assurance-Maladie (CPAM) or send the form to them with details of your EHIC. You will need to sign and date the receipt form, failing which you will not obtain reimbursement.

Not all the costs will be refunded and the precise amount will depend on the circumstances. As a general rule, you will be refunded about two thirds of the costs, although most medicines are funded at a lower rate.

If you have taken out travel insurance it may provide cover for those residual costs not covered under the EHIC system.

To be able to get a fuller picture of the levels of reimbursement that apply in France you need to read our subsequent pages on the operation of the health service in France, as the picture is a complicated one.

2.7. International Visitors to France

If you are visiting from outside of the EEA then you need to establish if any reciprocal agreement exists between your home country and France. If necessary, you will need to take out private health insurance for the visit.

2.8. French European Health Insurance Card

If you have relocated permanently to France and travel elsewhere within the EEA, then you will need to apply for a ECIC (la carte européenne d'assurance maladie) from your local Caisse. The period of validity of the French ECIC is one year.

If you are eligible for a ECIC you will need a card for everyone who is travelling with you, including children under the age of 16 years.

If you are too late in applying for a ECIC before you travel, you may be able to get a certificate from your local Caisse giving you three months cover.

Even if your to not get a certificate, and you later seek reimbursement of health costs incurred abroad, take your receipts to your Caisse and you may still be able to obtain reimbursement, on the same basis as if you were in France!

If you are travelling outside the EEA area then you should check with your local Caisse on any reciprocal arrangements that France may have with the country you are proposing to visit.

Even though no agreement may have been signed, you may still be able to receive reimbursement of some of your medical costs. Make sure you keep all the bills.