Healthcare in France – An Introduction

Introduction:

Although being expensive to maintain – the World Health Organisation has stated that France spends 11% of GDP on healthcare and outranks major countries on this basis – France offers a wide choice of general practitioners and healthcare specialists. For those who have experience of the health system in France and, for example, the UK, the contrast in standards can be startling.

The French social security system is largely funded by the contributions of employers, employees and the self-employed. For example, employees pay more than 20% of their gross salary, deducted at source. A significant proportion of this money goes towards public healthcare to which every legal resident of France has access, provided they are affiliated to or registered with the basic French State health system. If this is not possible, they must have private health insurance, reimbursed in accordance with the terms and conditions of their policy. To permanently reside in France, you are legally required to have health cover.

The S1 form:

Under the EC Social Security Regulations, EU expats arriving in France in possession of EC health Form S1 from their country of origin are eligible to register for basic French State healthcare for the period of the S1’s validity, and is at the expense of the issuing Member State. When EU expats receive their State retirement pension, they have a right to EC Health Form S1. No other sort of pension counts for this purpose.

EU expats arriving in France without an S1 and who do not work or ‘inactive’ are in a vulnerable situation. If they have no right to any other State health cover whatsoever, they can apply to CPAM (French health office) for basic CMU Couverture Maladie Universelle , which is a State health system unique to France. Permanent residence and basic CMU become a right after 5 years of legal and continuous residence in France, however before 5 years, the situation is extremely muddled. Why, you ask? Well, this is because CPAM’s are autonomous and apply the rules in an inconsistent way across the country. Consequently, there is no guarantee of success. Some applications have been accepted and some not. Thus this route cannot be relied on for basic French State health care.

CPAM’s rules are laid out in the 10-page French Government Circular of 9 June 2011. They work on a case by case basis. One example: if before 5 years you can establish that unforeseen events – and difficulties outside of your control – have led to the loss of health cover which, up to then, you possessed, CPAM’s may decide to grant basic CMU. Otherwise, such non-active EU expats are required to purchase private health insurance.

For more on this see Healthcare changes in France – what you need to know.

State healthcare:

When a person is affiliated to, or registered with, the basic French State health system, part of the cost of their medical treatment is covered by the State. If a person has neither State nor private health cover, they will be billed for medical treatment and have to pay for it out of their own pocket.

To compare the NHS and private sector in the UK with the same in France is akin to comparing apples with oranges. There is no great difference in the quality of care between private clinics and public hospitals in France and there is not necessarily any great difference in price. Being treated in private clinics in France does not mean avoiding waiting lists for the simple reason that, in general, waiting lists such as those in the UK are rare in France and going into a private ‘conventionné’ clinic does not mean you will have to foot the entire bill.

In France, unlike in the UK, treatment, whether private or public, is not free at the point of delivery. Even if you are affiliated to, or registered with the basic French State health system, when you see a doctor or specialist, you first pay their bill and are then get reimbursed at a later date. For example, the State refunds 70% of the cost of a visit to a médecin traitant (your GP) and 80% for hospitalization.

For more information on the level of reimbursement see Healthcare – are you covered?

When you affiliate to, or register with, the basic French State health system, you will receive your carte vitale (green card) which you must present whenever you visit a doctor, specialist or hospital, and when you purchase prescribed medicines. The French health system has in recent years undergone the most substantial changes to the way it works since it started in 1945. This makes the situation ever changing, and increasingly complex.

Your médicin traitant:

Since 2006, to qualify for the maximum State reimbursement possible, you must register with a médecin traitant – see How to Affiliate. If you attend a group practice you still have to nominate a particular doctor, but should that person be unavailable and you need to be treated by another member of the practice, the rate of reimbursement will be the same.

Children under 16 years of age must have the declaration signed by a parent or guardian however members of the same family can have a different médicin traitant. If the GP or specialist is not your médecin traitant then the rate of reimbursement may be only 30%. but there are exceptions to the reimbursement rule – for more information see below.

You are free to choose your own GP and can change at will by submitting a fresh declaration, which will cancel the original one.

The Tarif de Convention

In France all medical treatments from a routine visit to a GP to major surgical procedures have a tariff (cost). Medical practitioners and hospitals/clinics who adhere to this official tarif de convention are defined as conventionné. Those that do not are defined as non-conventionné and can charge what they like – If you go to a non-conventionné you will have to cover the cost yourself.

However the vast majority of practitioners (around 97%) are conventionné , and a private clinic can be, and very often is, conventionné. So ‘going private’ in France does not have the same connotation as that same phrase would imply in the UK.

Dépassements:

However, being treated at by a conventionné doctor or establishment does not guarantee the amount that you pay and the reimbursement you receive. Although you may be treated by a medical practitioner classed as <i?conventionné he or she may charge more than the Tarif de Convention provided it is “reasonable and tactful” to do so. For example, some surgeons may charge more than the tarif de convention for their services. This supplementary charge is called a dépassement. Although medical procedures by those practitioners called Secteur 1 rarely attract depassements, such excess fees are far more likely for those practitioners called Secteur 2. All doctors and specialists must display their charges in their offices. Dépassements are not inevitable and are more likely to be applied in some parts of France than others. For instance, they are commonly applied in Paris and the Côte d’Azur regions, perhaps because they are perceived to be more affluent. Thus you are advised to always ask beforehand whether dépassements will be charged.

Complementary health insurance:

UK people call this their top up Insurance, French people call it their mutuelle. Even when you are affiliated to or registered with the basic French State health system, a fundamental principle of healthcare funding in France is the element of personal contribution. To make up some or much of the shortfall in State reimbursements, most permanent residents purchase complementary health insurance.

Note: Top up (complementary) health insurance is optional and works solely in tandem with the State health system and must not be confused with a purely private health insurance policy. It is imprudent not to have top up, especially as regards heavy hospitalization which can be costly (remember, the State only refunds 80%).

Those within the State health system may be eligible for financial aid or healthcare vouchers to help purchase a complementary health insurance. Information is published on a government web site and sets out the annual revenue threshold limits which must not be exceeded in order to benefit from this aid – called Aide Complémentaire Santé (ACS) Your top-up premiums will depend on your age and level of cover required. An important principle with top-up insurance is that the State must be proved to have paid its share before the top-up insurer will pay their share in accordance with the terms and conditions of your particular policy. Therefore you must be affiliated to or registered with one of the basic French State health systems beforehand. No medical questions are asked when acquiring a top-up policy. Top-up policies can include some or most of the cover for dépassements but the extent of any such cover will vary according to the particular policy you choose from the range.