2. Health Insurance Cover in France

1. 2.1. S/E Health Insurance Cover
2. 2.2. Health Cover for Self-Employed
3. 2.3. Health Cover for Cross Border Workers
4. 2.4. E121/S1 Health Cover for Retired Persons
5. 2.5. Health Cover for Early Retirees
6. 2.6. European Health Insurance Card (EHIC)
7. 2.7. Travelling Abroad from France

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2.5. Health Insurance in France for Early Retirees

i. S1 Health Insurance Cover

If you are relocating to France from within the EEA, and you are under the age of retirement, then the use of S1 is available on the same terms as outlined previously in Section 2.1.

Until 2007, once cover under an S1 (formerly E106) had expired then it was 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 denied access to the health system for early retirees from the EEA who do not take up employment, or start a business at the expiry of their E106.

Only those early retirees who were legally resident in France on 23rd November 2007 were allowed to remain in the CMU.

Since this time those who have relocated to France under the age of retirement with the intention of living off their capital and/or early retirement pension have been obliged to take out private health insurance at the expiry of their E106/S1.

Nevertheless, in July 2011, following representations from the EU Commission, the French authorities issued new regulations, ostensibly to comply with EU regulations on the free movement of persons.

However, the new regulations are very obtuse, and there remains a degree of uncertainty about them.

There is growing evidence that France is continuing to apply a 5 year residence rule for early retirees, and concern by the EU Commission that France is not fulfilling their obligations under EU regulations.

In a statement in 2011 the Commission advised us as follows:

'The Commission welcomes the central role that the new Circular (No. DSS/DACI\2011/225) of 9 June 2011 provides to Regulation ((EC) No 883/2004) concerning coordination of social security rights in the EU in the assessment of a citizen's right of access to the French CMU (health insurance cover).

The new Circular requires the authorities to assess whether a person is habitually resident in France. This is consistent with the EU rules: when an EU national is habitually resident in France, he or she is entitled to equal treatment with French nationals as regards access to the CMU.

The Commission has still to take a decision on whether it will drop the infringement procedure. The Commission will monitor carefully how this new Circular is applied in practice by the French authorities. '

As if to emphasise their concern, and just how closely they will be keeping an eye on how France implements the new circular, the words above in bold were in that form when sent to us by the EU Commission.

Nevertheless, despite the lack of clarity, and the potential uncertainty that exists the application procedure is as follows.

In theory, your admission into the health system should be automatic, but it is by no means self-evident that this will occur.

Accordingly, you may well need to be prepared to be resolute and persistent in order to obtain access.

Given the procedural formalities involved in making an application for admission into the health system, we recommend you make at least tentative enquiries of your CPAM three months before the expiry of your S1. Be aware, however, that, in accordance with normal procedures, most CPAMs seek a letter of confirmation from the UK authorities that the S1 will not be renewed. The UK authorities do not normally issue such a notice until one month prior to the expiry of cover under the S1. So although you would be well advised to make an early enquiry to your CPAM, you may not be able to make much progress until this letter is received. Practice varies and we cannot be definitive.

In order to make application you need to complete the application form CMU - Demande de Protection de Base. Print it off, complete it, and include all the necessary documentation with it.

If you are refused admission by your CPAM then you need to appeal against the decision. We are finding that some intransigent CPAMs are yielding when pushed hard by those who are aware of their rights and the procedures.

Your local CPAM are required by law to justify their decision to you, which they must do so in writing. You should not be put off by a verbal refusal from a local official. Insist on a letter of explanation to which you are entitled.

If the CPAM are not prepared to give you a letter explaining their reasons, then you should make a written complaint to the Conciliateur of the CPAM. The CPAM will have their contact details, which is normally the local CPAM office. It is important you send the letter by recorded delivery.

If you do have a letter of refusal you have an automatic right of appeal to a local board, called the Commission de Recours Amiable (CRA).

The way the CRAs operate is somewhat opaque, but the appeal procedure is very simple. A recorded delivery letter must be sent to the CRA within two months of the (written) decision you contest. You are not required to attend a hearing. The absence of a response from the CRA with one month implies a rejection of your appeal.

If the CRA do reject your appeal, then within two months you can take the matter to the social security and health tribunal - the Tribunal des affaires de sécurité sociale (TASS).

If you also wish to make a complaint to the EU Commission, then you can do so at EU Citizens Complaints. You can also e mail to SG-PLAINTES@ec.europa.eu.

We would urge you to complain to the EU if you are refused access.

ii. Private Health Insurance

The right of access into the French health system is even less automatic for those who are already live in France using private health insurance.

Neither is it automatic for those with no entitlement to an E106/S1, and who are obliged to take out private health insurance.

If you are insured via a private health insurer you can only later make application to the health system in the event of a 'change of circumstances'.

These 'change of circumstances' are as follows:

• A reduction in income making it impossible to continue with private insurance;
• The cost of the private insurance becoming too onerous by the necessity to receive treatment for the insured or a member of their family;
• Loss of cover due to loss of employment, death of spouse or partner, or divorce;
• Other unspecified reasons outside of the control of the applicant that led them to lose their current private health insurance.

At this early stage, it remains unclear just how local health authorities in France will interprete the new regulations, and it seems likely that additional guidance will need to be provided to them by the government.

In particular, there is no income/cost threshold stated in the July 2011 circular which could be used determine whether the cost of private health insurance had become 'too onerous'. Unless further guidance is issued, the matter will be for local CPAMs to determine.

If you are privately insured, remember also that the insurance will 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.

iii. Five Years Residence

Once you have been legally resident in France for 5 years, then there is an automatic right of entry into the health system, the CMU.

Accordingly, if you are unable to transfer to the health system from private health cover, or you have no entitlement to S1 cover, then the maximum period for which you will be required to take out private health insurance would be 5 years.

However, if you are applying to enter the system having been insured privately, then you may be required to demonstrate that this insurance was sufficiently comprehensive to meet the test of having been 'legally resident'. Anecdotal evidence suggests that provided the cover ensures that you have not become a 'burden' on the health system, your private health policy will be accepted. So if your policy does not cover visits to the doctor, (for which you will simply then have to pay the standard fee), but covers all other treatment, it seems likely most CPAMs will accept this as sufficient cover.

iv. Persons from Outside of the EEA

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 residence in France of whatever duration, you will be able to make application to the CMU for State health insurance cover.

The indications are that the French authorities are applying the same 5 year rule as outlined above, although we are seeing many different local intepretations of the regulations.

In some cases it seems easier for those outside of Europe to get into the CMU than it does for European citizens!

Accordingly, all we can advise is that if you arrive in France with a residence permit and suitable health cover, once you have established at least three months residence you should consider making application for admission to the CMU. If you are successful, the cover should last at least for the duration of your residence permit, which may then be renewed.

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