3. Protection Universelle Maladie (PUMA)

  1. What is the PUMA?
  2. Application Process for PUMA
  3. Free Health Insurance (CMU-C)
  4. Assistance with Voluntary Insurance

3.1. What is the '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 health care in place since 2000, but the system has not been unified, requiring that households needed to change their insurance regime on 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: "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, has been abolished.

PUMA now 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 on a change in circumstances.

This means, for instance, that for those who used to hold their healthcare through the CMU there no longer be any need to make an application for renewal each year.

The cotisation maladie payable for affiliation to PUMA is simply be extracted from your income tax return.

The CMU-Complémentaire, for those on a low income who pay no charge remains in place.

However, such is the limited scope of liability to the charge that in fact few households are liable for the charge.

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 contribution to the PUMA.

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 in order to make application to the PUMA you will need to demonstrate that 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 5-year residence 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

As part of the PUMA changes, there has been a change to the basis by which individuals are registered in the health system.

Hitherto, spouses and other family members have been attached to the insurance regime of their partner as a 'dependant' 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, the 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 amongst 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, in order 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 an 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.

3.3. PUMA Charge

Some important changes have taken place for the PUMA charge in 2019 (which will apply in 2020), which we have set out in our Newsletter article PUMA Health Charge Exemption Doubled. We will be updating this page when the dust has settled.

The PUMA charge is called la cotisation subsidiaire maladie (CSM).

The insurance rate of the CSM is 8% of eligible income above a minimum threshold.

i. Who is Liable?

Those who are liable for the Cotisation subsidiaire Maladie (CSM) are those who fill both of the two following conditions:

• That you have no professional activity (business or salaried), or that you have have a professional activity, but your income from this activity is no greater than €3,923pa (2017), provided in the second case you also have capital income above the exemption threshold;


• That you are not in receipt of any kind of pension or unemployment benefit.

In relation to pension income, the regulations make no distinction between State retired pensions and early retirement pensions/annuities. They merely reiterate the clause set out in Article L380-2 of the Code de la sécurité sociale, which states individuals are only liable if:

'Elles n'ont perçu ni pension de retraite, ni rente, ni aucun montant d'allocation de chômage au cours de l'année considérée. Il en est de même, lorsqu'elles sont mariées ou liées à un partenaire par un pacte civil de solidarité, pour l'autre membre du couple.'

This clause means that a couple would be exempt if only one of them was in receipt of a pension.

The position of early retirees on a pension remains open to some interpretation, but it seems that the law is being interpreted widely and that anyone with a pension is being exempted from the charge.

More specifically, exempt households are:

  • Those who obtain health cover in France via an S1 certificate of exemption, who are insured for health from their home country. This mainly affects EEA nationals on a State retirement pension, but it also includes anyone else who holds a S1 certificate, provided they have no professional activity in France;

  • Economically inactive households with capital income less than a minimum threshold, which in 2018 is €9,807pa (2017 income);

  • Business owners and salaried employees with a professional income greater than €3,923 a year (2017 income), as they pay their usual social security contributions;

  • Households in receipt of a retirement pension, annuity, widow's pension or disability pension.

The position of those who are covered for health through a private health insurance policy is not stated in the regulations, but many expatriates with such policies have received a demand for payment of the health charge. Once again, the issue needs some legal clarity. There are a number of cases pending in the courts.

ii. Eligible Income

For those with no professional activity, the only income that is assessed is income from capital sources, called 'revenus de patrimoine'. That is to say, investment income, rental income and capital gains.

In addition, if your income from such sources is below a minimum threshold you are also exempt from the charge.

For 2018, if the total net sum of your revenus de patrimoine is no greater than €9,807 (2017), you will be exempt.

Only those with a low income-earning professional activity (as above) would have this income taken into consideration in the calculation on a progressive basis. If the professional income is no greater than €1,986 (2017) it is ignored.

A married couple or those in a civil partnership each benefit from the above exemption threshold, meaning (broadly speaking) a couple would be exempt if their revenue de patrimoine was no greater than €19,614 2017 income).

For the purposes of determining the amount payable the authorities can also take into consideration your lifestyle (train de vie), an assessment that will particularly affect those households living on their capital resources. Details of this process have yet to be published.

In your first year in France, without any previous tax returns having been made, the authorities will assess your contribution level on the basis of your tax return and income in your previous country of residence. If your income has reduced significantly since this time (often the case) then you need to make clear this is the case and provide appropriate and clear evidence. The charge is applied on a pro-rata basis for those not in PUMA for a full year.

iii. Calculation

The insurance contribution rate is 8% of net eligible income.

With the abolition of 'dependant' status (ayants droits) under PUMA, those liable for the CSM will be assessed on the basis of their own eligible income, plus half of the joint revenus de patrimoine they earn with their spouse/civil partner.

As the regulations state: 'La cotisation subsidiaire est individuelle : elle est due par chaque assuré à titre personnel sur ses revenus du capital.'

By way of example, an individual with an annual net personal (capital) income of €15,000 and who also enjoys joint net income of €25,000 in revenus de patrimoine with their partner.

In such a case the calculation is:

  • €27,500 (€15,000 + €12,500)
  • €27,500 - €9,807 = €17,693
  • €17,693 x 8% = €1,415
  • CSM = €1,415

The same assessment is made on the income of their spouse/partner, with each one liable for their own CSM charge.

iv. Payment of the Charge

The charge is levied in November each year.

It is payable either in one single payment or in three equal payments over 90 days for each payment, but only on request. If payment is not made within 30 days of the demand, there is a 5% penalty plus 0.4% interest for each month of non-payment.

v. Challenging the Assessment

If you wish to contest the imposition then you need to write to URSSAF with your documentary evidence.

If they are unwilling to accept your challenge you are entitled to appeal to the Commission de Recours Amiable (CRA) in the agency, which you need to do so within two months of receipt of the bill, and ultimately appeal to a local court, the Tribunal des Affaires de Sécurité Sociale (TASS).

3.4. CMU-C

If you are on a low income affiliation to the PUMA is free of charge, as you will be covered through the CMU Protection Complémentaire (CMU-C).

3.5. Aide Complémentaire Santé.

If you are above the threshold for free affiliation, you may be able to obtain assistance towards the costs of complementary 'top-up' health cover. You can read more at Assistance with Top Up French Health Insurance.

Next: Application Process to PUMA

Back: Getting Health Cover in France

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