The French health care system is widely regarded as the best in the World. This is not necessarily because France spends more money on health care than other countries. Whilst France's health care spending of 12.1% of GDP,  is near the top of OECD league table, it is still significantly less than the USA (16.6%) and on a par with Germany (10%). It is more to do with the successful health care outputs from the system, a higher Doctor-to-Population ratio and the high life expectancy rates in France (79.5 years for males, 85.5 years for females).

SOURCE: OECD Health Expenditure 2023

If you are planning on moving to France and to live here for more than 3 months at a time, there is a legal requirement for you to have health insurance coverage in France. There are 4 different ways to arrange healthcare coverage in France:

• Private health insurance - you can arrange comprehensive private medical insurance to cover your stay in France
• Private-State health insurance - you can buy-in to the French state insurance scheme under the PUMa scheme
• State health insurance - you apply to join the French universal health care system and receive your Carte Vitale medical card
• Reciprocal healthcare - if you are a citizen of another European Union country or from an EEA country (Iceland, Liechtenstein and Norway), Switzerland or (after 30 December 2020), from the United Kingdom, then you may be covered by a reciprocal healthcare agreement. 

To understand each health insurance option and which one will suit your particular circumstances, you firstly need to understand how the French healthcare system operates.

Healthcare system in France

The health care system in France is a universal system. What this means is that it is largely financed by government national health insurance scheme which covers the whole population. The system is mainly paid for by mandatory health contributions paid by employers, employees and the self employed. Further funding is provided from tax revenues paid to the central government and partly by the patients who pay a small percentage of the actual cost of the health care treatments.

In France, the majority of hospitals are state-run, although there are a number of non-profit independent hospitals (which are linked to the public system), as well as private for-profit hospitals. Most hospital doctors, nurses, technicians are employed by the State. However, most General Practitioners, Dentists, Osteopaths, community nurses, etc, are privately employed, but they draw the majority of their income from the state health insurance fund.

The Health Ministry in France is responsible for publishing a list of treatment costs, drug prices, etc; and also the various levels of funding/reimbursement.

Fabien Pelissier, is Director of Fab Insurance, a business dedicated to assisting ex-Pats set up health insurance in France. Fabien and his team have helped thousands of clients navigate their way around the French healthcare system. He is especially useful in enabling clients to meet their initial long stay visa requirements of having a valid health insurance for France.

He has come up with a useful analogy to best describe how the health care system works in France. He states that

" . . .the best way to think about the healthcare system in France, is to think of a big sponge cake . . "

The main sponge of the cake is the standard health care treatment. This has a number of layers. This represents how much the state will reimburse or pay for the various treatments.

For most expensive treatments, especially long term hospital treatments and operations, the French state will pay for 100% of the care. So both layers of the cake.

But for other treatments, such as Dental care, Opticians, Physio, etc; the Government only pays a proportion of the treatment cost. So this is just the bottom layer of the cake. 

As an average, the state health care system in France reimburses patients for around 70% of most health care costs (80% of most prescription drugs, 60% of dental care, 80% for glasses, etc). Normally, the patient will pay upfront for the treatment costs, by presenting his or her carte vitale (a nationally-issued credit card for health care). The carte vitale automatically deducts the proportion of the treatment costs provided by the state and the patient will then only pay for the portion of the treatment not covered by the State. 

The patient either has to pay the additional cost themselves, or more commonly, they will have a supplementary health insurance plan (called a Mutuelle) which covers them for most of these additional costs. This is the top layer of the cake.

Most people in France have a Mutuelle insurance plan, which is usually run by non-profit organisations. This supplementary health insurance usually covers them for most of the additional treatment costs and they will be re-imbursed direct to their bank account once the Mutuelle receives the payment receipts. This is normally done automatically by the Pharmicist or Dentist, but sometimes it involves sending off a paper copy to the offices of the Mutuelle.

In between, there is the cream of the cake. So for example, if you receive a prescription from your Doctor, it will usually cover medicines which directly treat the ailment (such as anti-biotics). But it will also include additional items which may assist the recovery (so anti-inflammatories or paracetemol). These additional items are not covered by the State and they may or may not be covered by your Mutuelle health insurance either (it depends on your particular plan). 

Just to give you an example, my son last year had to have quite a serious operation on his back. When we received the invoice from the hospital in Montpellier, the €12,000 cost of the operation and 5 nights stay in the hospital was fully covered by the French health system, but we did have to pay €1.50 euros for two bottles of water. Yes, you read that correctly - one euro 50 centimes out of a total bill of €12,000.

Now comes the icing and the cherry on top of the cake. Although health care in France is a universal health system, it is not fully state run. All patients have the option to select private treatment. So patients in France are not tied to a particular General Practitioner or Consultant. They can elect to be treated by whoever they wish (within reason). So a patient requiring an operation may shop around to find the best Consultant Surgeon they wish to perform the operation and the best hospital they wish to deliver the care. The State will still fund the majority of the treatment costs, but only up to the same level that they would have paid for treatment in a public hospital. To pay for the additional costs, the patient can either make a direct payment to the private hospital, or they can take out a more extensive Mutuelle supplementary health insurance plan (see Mutuelle below).

Arranging health insurance coverage in France

As we stated in the introduction, there are 4 ways of arranging health insurance coverage in France:

1. State health insurance 
2. Reciprocal healthcare 
3. Private-State health insurance 
4. Private medical insurance 

Each option is often determined by your particular circumstances. So, for example:

• Employment or Self-Employment - if you fall into this category, then through your social security contributions on your salary or on your business revenue, you will be paying into the French State health insurance system. You will still need to apply for your carte vitale, but your contributions will be taken care of. Most employers will also offer a Mutuelle supplementary insurance (which may or may not be subsidised by the Employer).
• Retired - if you are in receipt of a state pension from a European Union member country, or an EEA country, Switzerland and the United Kingdom; then you can apply for an S1 certificate (or S2 certificate) from your home country. This will provide reciprocal health care coverage based on the standard reimbursement rates set by the French State. You can also apply for a Mutuelle supplementary health insurance to cover most of the non-reimbursed health care costs.
• Cross border workers and non-retired spouse/partner - if you live in France (and are economically inactive) but your partner or spouse works permanently in another European Union member country, EEA country, Switzerland or United Kingdom - then you can apply for an S1 certificate from your home country in a similar way to retired people. This option also applies to dependant children living in France.
• Non-European - if you don't come from a European country, then you are able to buy-in to the French health care system under a special scheme called PUMa ((Protection Universelle Maladie). Alternatively, you can arrange a comprehensive private medical insurance policy to cover you in France.
• Economically inactive - if you are below State retirement age and are in France either looking for work or are non-working, then you are able to buy-in to the French health care system under the PUMa scheme. Alternatively, you can arrange a comprehensive private medical insurance policy.
  
  

Fabien Pelissier, also points out that in France it is no longer possible for a spouse or legally recognised partner to 'piggy back' onto the main recipients health insurance (except in the case of S1 certificate reciprocal health care). Each person will need to apply for their own health insurance option. 

1. State health insurance in France: Applying for a Carte Vitale in France

If you are employed in France, normally your employer will register you with the relevant health care fund (the body that collects your social contributions and pays these to the Government).

For self-employed people, unless you work in Agriculture, there are two steps to obtain a Carte Vitale. During the establishment of your business in France (a micro-enterprise or sole-trader), you will firstly register with a body called the Caisse Primaire d’Assurance Maladie (or CPAM for short). To register with this organisation, you will need the following information:

• proof of address
• passport
• birth certificate, marriage or divorce certificates or any other documents that support any change of name
• SIRET number (your individual company registration number)

You will then receive a document (called an Attestation) which is a critical document. This provides proof that you are now part of the heath care system and most importantly, it will contain your social security number. Once you have this, you are then eligible to complete a form to apply for your Carte Vitale.

Once you obtain your Carte Vitale, you will pay your health insurance contributions as part of your general social security contributions (calculated on your business revenue and normally at around 25% of earnings).

Tony Mason advises that this option is especially interesting for a lot of people moving to France, who are below retirement age and who are still economically active. He states that: 

" . . . setting up as a self-employed micro-enterprise in France offers the quickest way into the French health care system. You do not need to wait for 3 months to apply for your Carte Vitale. This maybe especially important if you are a UK citizen looking to establish French Residency . . . "

2. Reciprocal healthcare in France: Applying for a S1 Health Certificate

If you are a UK citizen and you are in receipt of a State Pension and/or you are UK tax payer and you are looking to permanently leave the United Kingdom, then you will be covered by a reciprocal healthcare agreement. 

Similarly, if you are the spouse/partner of a 'Cross-border worker' who works permanently in another European Union country, EEA country or Switzerland and United Kingdom; then you can also benefit from reciprocal health care.

You will join the French health system and receive its benefits in exactly the same way as a French citizen or an Ex-Pat covered by the Carte Vitale. Those health costs that are covered by the French health care system will be directly reimbursed by the health system in your home country. This happens automatically, so you don't need to do anything about it or even to know that it is happening.

However, you will still have to fund the part of the health care costs that aren't covered by the French State (through a Mutuelle supplementary health insurance). 

If you are planning on moving to France, you will need to apply for an S1 or S2 certificate from your home country health care system prior to arrival. In the case of UK citizens, this form can be obtained from HM Revenue and Customs in Newcastle. Once you have arrived in France, you then need to send this certificate to your local CPAM office and follow the same procedure outlined above. In the case of UK citizens, you will also need to notify the Department of Work and Pensions (DWP) that you have moved permanently to France.

Tony Mason describes a couple of benefits from arranging your health care coverage in France using an S1 or S2 certificate:

• you won't pay any social charges on your pension income because your health care is not funded by France
• If you have a spouse/partner who is not yet in receipt of state pension, they can still be included on your S1 form and will then be covered for health care as your dependent

3. Private-State health insurance in France: applying for the PUMa health scheme

So the State universal health scheme in France is quite easy to understand. You pay your social contributions as an employee or as a business owner, you register with the relevant health care fund and away you go. But what happens if you do not pay social contributions in France or if your earnings are below €8,000 per year? Well this is where the PUMa health care scheme comes in. This scheme was introduced in France in 2016 as a way of simplifying the health registration system and ensuring that everybody was covered. 

Under the PUMa scheme, anybody who is living permanently in France (whether they are French or Foreigners) for more than 3 months and who doesn’t qualify for health cover in any other way, may apply to join PUMa under the classification 'sans activité professionnelle' or non-active people.

The scheme is contributory. Fabien Pelissier states that although the formula for calculating the contribution may appear complex

" . . . in relation to most French bureaucracy, it is actually quite simple . . ".

Basically, people earning below €9,274 euros per year, will pay nothing for the PUMa scheme. People earning above this amount, will have to contribute to the scheme, although there are generous personal allowances. Individuals will receive a personal income allowance which is exempt from contributions (currently €20,568 per person). Only earnings above this amount will qualify for contributions. Annual earnings above €20,568 are 'taxed' at 6.5% to provide for the contribution to the PUMa health scheme (up to a maximum of €370,000 of eanings).

To give you an illustration, if you are single person and you receive an income of €50,000 per year, then your PUMa contributions will be €1,913 euros per year.

However, if you are a couple and you have a joint income of €50,000 euros per year, then your PUMa contributions will be just €236 euros per year (because the personal eanings allowance for a couple is €46,368 euros). 

However, there are a number of important exemptions. Fabien says that certain types of income can be excluded from the calculation, such as State pensions and Invalidity Pensions (but not private pensions), as well as income from employment (where social security contributions are paid). So the only income that is really included for the contributions calculations, is passive income, such as dividends on investments, self-employment dividends and rental property income. The other thing to remember about PUMa, Fabien adds, is that it is based on

". . . World-wide income, not just income in France, although there are upper limits on what income can be taxed . . ."

Fabien highlights certain requirements you need to meet in order to apply for the PUMa scheme.

• you need to provide documents related to your residence in France (so if you have a Carte de Sejour, Long Stay Visa, etc)
• you need to provide statements of your income from previous years
• you also need to provide clear evidence that you are not eligible to receive an S1 certificate from your home country

Fabien is also keen to dispel some myths about the PUMa scheme

• the scheme applies to both French and non-French citizens
• you do not need a permanent address in France (a résidence principal)
• you do not need to hold a residency permit in France (although this will change for UK nationals from 30 June 2021)
• if you have modest earnings, you will still qualify for PUMa but will not pay any contributions

Fabien says that for a lot of non-active people such as early-retirees, job seekers or non-European retirees,

" . .  the PUMa scheme provides a very inexpensive or even zero-cost method of accessing high quality health care in France . . ." 

4. Private medical insurance in France

For certain individuals, maintaining a pre-existing private medical insurance plan and extending it to cover them when they are living in France, maybe a viable option. Tony Mason explains that for individuals who intend to live in France for a few years and then eventually return to their home country, keeping in the existing private medical plan may make sense.

". . .  in situations where the cost of private health insurance increases significantly with age, or where individuals have a pre-existing health condition, remaining in the current private medical scheme, rather than opting-out for a few years, could be the safer option . . ."

Another situation where Tony has seen a number of his clients elect to keep their existing Private Medical cover, has been where the individual remains under the specialist care of a Consultant or Health Specialist. In these situations, the individual values the peace of mind of being able to access a Medical Specialist who has intricate knowledge of their treatment.

Mutuelle supplementary health insurance in France

Whichever option of health insurance you choose in France, the fact remains that you will still probably need to arrange a 'top-up' insurance. Most people in France choose to take out a complementary insurance policy - a mutuelle - to cover the percentage of their health care costs not reimbursed by the French state system. These are offered by a range of insurance companies, most of them non-profit organisations. As somebody who has a mutuelle health insurance, I can tell you that it is eye-wateringly complicated. I still don't fully understand all the exemptions and codes and bands of reimbursement. If you think the rules of Cricket or Rugby are complicated, multiply that by a factor of 10.

There is such a range of different levels of cover. You can get 100% cover, 200%, 300%, 400% . . . on and on. If you ever get invited to a French dinner party and the conversation turns to the subject of La Mutuelle - firstly, you need to leave immediately. But secondly, never make the mistake I once made and admit that you only have the basic 100% cover. Your new friends will look at you with a combination of disgust and bewilderment. It is like you have poured bleach into your childrens' drinks. Someone will ask you " . . . do you not value your family's health? . . .". And then old Xavier or Olivier will pipe up that " . . . my company's mutuelle covers me for 350% . . .". This comment will be met with jealous looks around the table. Wives will look at husbands, the husbands will look at their shoes.

The first thing to say is that having a mutuelle is not obligatory. If your income is low - below certain thresholds set by the government (9,032€ a year (single person) or 13,547€ for a couple - then you may be eligible for a special mutuelle scheme called the complémentaire santé solidaire. This effectively offers you a free or a very low cost mutuelle insurance.

Secondly, you don't have to take out a mutuelle to apply for a Carte Vitale or provide it as part of your French Residency application.

But it does make a lot of sense to arrange a mutuelle plan and it will generally save you money in the long run. The fact that it is a mutual fund, the members of the fund effectively insure each other. So the cost of the insurance is not determined by your previous medical history. You will have to complete a questionnaire and medical questions will be asked, but this is not as significant as in the case of private medical insurance policies.

Tony Mason explains that the different levels of cover are related to the French government's published guidelines on treatment costs. So for example, a hip replacement may be costed at €7,500 nationally and this is what the French state will fund you up to. However, the cost of a hip replacement at a hospital in Perpignan, is going to cost a lot less than at a hospital in Cote d'Azur or at a private clinic in Paris with a nationally renowned surgeon.

" . . . if you happen to live in an expensive area, then you will need to take out mutuelle health insurance that will cover you for twice the French State's guideline cost (200%) or if you want to be able to choose the very best Consultant available, then you may need to have insurance cover at least 4 times the guideline cost for that operation (400%). This is an over-simplification, but that is how it generally works . . ."

Thinking of moving to France ?

If you are planning on moving to France, then the following articles provide more information on aplying for a long stay visa for France, retiring in France, opening a bank account, setting up health care in France and the best regions in France to live.