Stratagems for Getting Health Cover
Tuesday 01 May 2012
With the French government still refusing to budge on granting early retirees access to the health system, what options are there available?
It is clear from the stream of e mails we receive each week that there must be thousands of British and other European expats living in France unable to access the health system.
As a result, many of you have been obliged to take out often expensive private health insurance, which frequently fails to offer full cover due to pre-existing medical conditions.
In the worst cases, some of you are obliged to live in France without any health insurance, either because you cannot get private cover, or because it is too expensive.
We continue to remain in regular contact with the European Commission concerning this issue, and we are grateful to those of you who have taken our advice to complain to them about your circumstances.
The latest position we have from the Commission is as follows:
'The Commission has been monitoring how the new Circular is being applied in practice to see whether this is in line with the letter and the spirit of Regulation 883/2004. As a result of this monitoring process, we have serious concerns that the French authorities are continuing to refuse admission to the CMU in breach of EU law. The Commission has raised these concerns with the French authorities and hopes that a resolution of this difficult matter can be found soon.'
The statement does at least give some glimmer of hope, and it may well be that further progress will be made after the forthcoming French presidential elections.
In the meantime, what can you do? Here are a few options to consider:
- i. Appeal
- ii. Change of Circumstances
- iii. Residence Permit
- iv. Auto-Entrepreneur
- v. Aide Médicale de l’Etat
If you are refused health cover by your local Caisse primaire d'assurance maladie (CPAM) you should make a formal appeal against the decision to the local appeal panel, the Commission de Recours Amiable (CRA).
No legal assistance is necessary, and you can pull together an appeal letter using the information contained in our Newsletters, notably the fact that refusal is contrary to European law.
There is no guarantee that you will be successful, and we know of many cases where the CRA have turned down appeals.
However, this has not universally been the case, and sometimes the threat of an appeal has been enough for the local CPAM to somehow miraculously change their position.
If you are turned down by the CRA you have a further right of appeal to a court of law, for which you are likely to need legal assistance.
ii. Change of Circumstances
Under even the restrictive provisions of existing French legislation it is possible to obtain access to the health system on a change of circumstances arising from an 'accident de vie'.
These change of circumstances are:
- 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.
Internal guidance given to the local health authorities in January remains ambiguous on whether health authorities have the discretion to allow early retirees access to the CMU on the expiry of the 'S' form cover where the applicant has been refused private insurance cover due to a pre-existing medical condition.
The guidance (Lettre Réseau DDGOS-7/201211/01/2012) states:
L’examen par la Cpam d’une demande éventuelle de CMUB repose donc sur l’appréciation du motif pour lequel la personne indique ne pas pouvoir souscrire une assurance privée: si elle est non assurable, la CPAM peut demander à l’intéressé de fournir les lettres opposant un refus d’assurance par différentes compagnies, notamment au motif de maladies préexistantes. La CPAM ayant géré la personne jusqu’alors, elle est d’ailleurs capable d’identifier si l’intéressé relève d’une ALD, sans avoir à en connaitre le motif médical précis.
So you will need to make application and argue your case. We are aware of a large number of cases where this has occurred, although there are probably an equal number who have been refused, despite the fact that they appeared to have a valid case. The difficulty is that it is all down to local case by case determination, and there seems no rhyme or reason to some of the decisions. Neither do we believe that local appeal decisions are collated and used as precedent at a national level.
iii. Residence Permit
The above guidance also makes it clear that those who hold a residence permit are granted the right of access to the CMU.
However, it needs to be a particular kind of residence permit, called a CE-séjour permanent-toutes activités professionnelles.
Such permits are ordinarily only available if you are registered self-employed, but we are aware of prefectures who seem willing to issue them to early retirees without the need to prove they run a business.
We did discuss this issue in a recent Newsletter, to which you might be best to refer, at Health Cover and Residence Permits
We consider for some of you this is a potentially fruitful approach as we know of a number of cases where it has worked.
If you set up business in France you are no longer an ‘early retiree’, which then enables you to gain automatic right to the French health system.
One of the advantages of setting up as an auto-entrepreneur is that you do not need to demonstrate any turnover for two years before you then cease to be able to retain the status.
We do not advocate abusive uses of this approach (previous abuses of the health system by expats are why we are currently in this position), but if you do have even the germ of a business idea you wish to pursue this is a painless way to obtain health insurance cover, as well as business registration.
Finally, if you have no means of health cover, you are on a low income, and you have been resident for at least three months, then you should consider making application for cover under the health regime of last resort, called the Aide Médicale de l’Etat (AME).
To be entitled to access the AME your income must not pass certain thresholds, which differ by family composition, as follows:
- One Person - €7,771
- Two People - €11,656
- Three People - €13,988
- Four People - €16,319
You should make application to your local CPAM.
Five Year Rule
And remember, even under present rules, once you have been resident in France for 5 years, you have an automatic entitlement to the health system.