France's New Universal Health Care System
Wednesday 03 February 2016
A universal system of healthcare has been introduced in France, so what are the implications for expatriates?
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 France 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 is 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, 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 will no longer be any need to make an application for renewal each year.
The cotisation maladie payable for affiliation to PUMA will simply be extracted from your income tax return.
The CMU-Complémentaire, for those on a low income who pay no charge, will remain in place.
Legal Residency Requirements
However, the introduction of PUMA makes no change to the legal residency requirements, which continue to state that to be entitled to health care you must reside in the country in a manner that is 'stable et régulière'.
As far as EEA residents are concerned, the first of these tests is easily accomplished, for the law merely requires that in order to open your rights you must have been resident for a minimum of three months, and then to live in France at least six months a year.
Strictly speaking, the régulière test continues to be a problem for economically inactive early retirees from Europe, for it requires you have health insurance cover and be resident for at least five years.
In guidance issued as part of the introduction of PUMA early retirees with under 5 years' legal residence are excluded from PUMA unless there was a change in their circumstances whilst resident in France that prevents them continuing to obtaining private health insurance.
It states: 'Si vous êtes ressortissant de l'EEE/Suisse et que vous êtes « inactif » : vous êtes dispensé de la production d'un titre ou document de séjour mais vous devez justifier de ressources suffisantes et d'une assurance maladie « complète ». Toutefois, dans certaines situations (perte imprévisible de revenus, perte de la couverture maladie liée à la perte d'emploi du conjoint, etc.), votre demande d'affiliation sur critère de résidence pourra être étudiée par votre caisse d'Assurance Maladie.'
There is nothing new in this position, as it merely reiterates the law that has been on the statute book for several years.
What is surprising is that the statement continues to be made, for it is contrary to the assurances the French authorities have given to the European Commission on their operational framework concerning the rights of early retirees, in order to ensure compliance with European regulations.
Under European law, in order to obtain access to the health system in a Member State the only test that can be applied is that you have been 'habitually resident' in the country.
'Habitually resident' is generally taken to mean that you have relocated to another EEA country, and that you have been resident for at least three months.
Under Article 1(j) of EU Regulation No 883/2004 EEA nationals who are habitually resident in another EEA country have an automatic entitlement to affiliation to the health system in the same manner as nationals of that country.
In 2014, as a result of intervention by the European Commission, France ceased to apply the 5-year residency rule, and the French government have been obliged to allow early retirees into the system on three months residence, despite that fact that they have simply never publicly acknowledged a change in policy.
Last year, as no problems were being reported to them, the European Commission closed the file on the issue, stating:
"We can confirm that the Commission has closed the infringement that had been registered against France concerning access to the Couverture Maladie Universelle ("CMU") for non-active EU citizens residing in France.
The Commission's services are satisfied that the French authorities have changed their practice and now correctly apply the habitual residence test as set out in Regulation (EC) No 883/2004, when assessing applications by non-active EU citizens to join the CMU.
What now remains unclear is whether as a result of PUMA France is backsliding on the undertaking they have given to the European Commission or simply that the French government wishes to continue to deter applications from economically inactive persons under retirement age.
We do occasionally hear of reports from readers who have been refused access to the health system, but more often than not this is merely the result of a stance taken by misinformed front-line staff who have not applied due procedure, by not referring the application to the Nimes central processing centre.
To the best of our knowledge all applications referred to the centre have been approved.
What Should Early Retirees Do?
On the basis of the assurances France has given to the European Commission newly relocating early retirees from Europe should continue be able to obtain access to the health system after three months' 'stable et régulière' residence.
However, the 'régulière' test implies that you have health insurance cover during this period.
Accordingly, early retirees might be best advised to either:
- Take out a private health insurance policy for a fixed temporary period, after which you should make application to your local CPAM, and request that the application be referred to the Nimes processing centre.
- Alternatively, establish a small business as a Micro-Entrepreneur, which then grants you automatic access to the health system, and later make application to PUMA if you no longer wish to continue with the business.
In respect of the second option, it is worth noting that the law restricting access to early retirees only applies to those who arrive in the country with this status, and who remain economically inactive.
Although it has yet to be tested in the courts, a period of business activity would appear to break this cycle and thereby remove the disqualification on cessation of the business.
However, setting up the business needs to be more than a paper exercise, for legal cases in France have found against expatriates who have simply set up a business to 'work the system'.
If you are refused access we would be most interested in hearing from you, as would the European Commission.
You can contact us at email@example.com.
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 '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 professionally inactive spouses.
However, dependent 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 the case of existing dependents 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.
Dependent adult family members can, if they wish, become registered before this date, but there is no obligation to do so.