Guide to French Health System
3. Protection Universelle Maladie (PUMA)
- What is PUMA?
- How Much do You Pay?
- How to Apply for PUMA
3.1. What is 'Protection Universelle Maladie (PUMa)'?
Since 1st January 2016 France has had in place a universal system of healthcare, called the Protection Universelle Maladie (PUMA).
In practice, there has been a universal system in place since 2000, but it has not been unified, requiring that households needed to change their insurance regime upon a major change in family or employment circumstances. This could result in a temporary loss of health cover.
So the reform has been really more about ensuring continuity of health cover.
As the Minister of Health, Marisol Touraine, stated at the time: "Il ne s'agit pas de créer un nouveau droit mais de garantir les droits existants. Nous voulons faciliter la vie de millions de Français qui doivent engager d'importantes démarches administratives alors que ces droits leurs sont acquis."
The Couverture Universelle Maladie (CMU), which formerly protected those not covered through employment/business-based schemes, was abolished with the introduction of PUMa.
PUMa grants an automatic and continuous right to health care in France to those who are legally resident in the country, and without the need for any administrative formalities upon a change in circumstances.
The determination of your charge for affiliation to PUMa, called the Cotisation Subsidaire Maladie (CSM) is simply extracted from your income tax return, although as we show in subsequent pages, few households actually pay the charge, due to the exemptions that apply.
The former CMU-Complémentaire, for those on a low income who pay no charge remains in place, although it is now called the Complémentaire Santé Solidaire (CSS).
As far as expatriates are concerned, access to the system for early retirees is complex, as you can read at Health Insurance for Early Retirees in France.
Retired expatriates from within the EEA who are covered for health insurance through their S1 are not part of PUMa, as they are covered directly by their home country, with administration of their cover carried out by the local health authority (CPAM). They pay no PUMa charge.
The same applies to those on long-term disability benefits from their home country and cross-border workers, if they hold an S1 certificate.
If you are not from within the EEA then to apply for PUMa you will need to demonstrate you have a right to live in France through a residence permit (carte de séjour).
Entitlement to access has historically depended on legal residence of at least three months duration, although ostensibly a five-year residency rule remains in place for EEA early retirees.
As the regulations state: 'La Puma ne modifie pas les dispositions règlementaires existantes applicable aux migrants qu’ils soient permanents ou du passage pour UE/EEE ou Suisse ou non-EEA.'
3.2. Family Members
The PUMa changes include an alteration to the basis by upon which individuals are registered in the health system.
Hitherto, spouses and other family members had been attached to the insurance regime of their partner as a 'dependent' in order to obtain their health cover.
This system of 'ayant droits' has been abolished by PUMA, so that all eligible persons have been granted an individual right to healthcare, which they will maintain for their lifetime.
This significantly improves the status and rights of economically inactive spouses/civil partners.
Nevertheless, this change does mean that the economically inactive spouse of a business owner or salaried person in France does now have to make their own application for health care, rather than as a dependant of their partner, an issue we considered in our Newsletter article Access to Health Care for EEA Residents.
Dependant family members of those with a S1 certificate of exemption have not lost their S1 attachment rights, and neither will they lose them in the future.
This is because the new law specifically excludes from PUMA those in receipt of a foreign pension who obtain their health insurance cover from their own home country.
Article 160-6 of the Code de la sécurité sociale states that among those excluded are:
"Les personnes titulaires d'une pension étrangère qui ne bénéficient pas par ailleurs d'un avantage viager d'un régime obligatoire de sécurité sociale français lorsque, en application d'un règlement européen ou d'un accord international, la prise en charge de leurs frais de santé ainsi que de ceux des membres de leur famille qui résident avec elles relève du régime étranger qui sert la pension."
This clause is merely a legal technicality, so that S1 households do not pay a charge to the French health system. They are also exempt from social charges on their pension.
Accordingly, those who hold an S1 certificate of exemption will only nominally be affiliated to PUMA (for the purposes of administration), as European Regulations grant them and their family members entitlement to health cover via the certificate.
In relation to an enquiry concerning UK expatriates in particular, the French social security authority advised us that: 'La cotisation PUMa ne s'applique pas aux personnes bénéficiant exclusivement d'une pension de retraite britannique, résidant en France et n'y exerçant en parallèle aucune activité professionnelle, à condition que celles-ci puissent justifier par la fourniture du formulaire S1 qu'ils relèvent du régime'.
In the case of existing dependants not covered by an S1, the law states that there will be no change to their arrangements, whose current status is protected until 2020, when they will have cover in their own right.
Dependant adult family members can, if they wish, become registered before this date, but there is no obligation to do so.
Next: PUMA Charge
Back: Getting Health Cover in France
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