PUMA, Social Protection, and Social Charges in France

Implemented in 2016, PUMA (Protection Universelle Maladie) ensures medical coverage for all legal residents in France, regardless of their employment status, granting access to healthcare services even to those not actively working.

Individuals must enroll in the French Sécurité Sociale after three months of legal residence, as per the Code of Social Security (CSS), highlighting the government’s commitment to comprehensive healthcare coverage. However, there are exceptions for certain groups, such as expatriate workers sent by U.S. employers, who may be ineligible for up to five years.

Additionally, specific categories already covered for healthcare, like employees of international organizations and retirees with pensions from other EU countries (or the UK, as this is one of the post-Brexit agreements), are exempt from PUMA. For example, British pensioners can apply through something called the S1 program, reflecting nuances in coverage based on employment status and existing arrangements.

Determining the contribution level for PUMA (if any) involves evaluating a resident’s income and means. Some individuals covered by PUMA may be subject to the CSM (cotisation subsidiaire maladie), a healthcare cost contribution, meaning you’ll have to pay annually to be part of the French system.

Exemptions from the CSM include those earning a modest income (less than 50% of the PASS – PASS being an index worth 46,368€ in 2024 or 3864€ net per month), married or PACSed partners with a low combined income (under 1 x PASS), minors, and recipients of French or EU retirement (including British retirees), invalidity, or unemployment pensions.

However, those not meeting these criteria may be liable for the CSM, typically around 6.5% of worldwide passive income over a certain threshold. Although U.S. source passive income is exempt from French income tax per the US-France tax treaty, it is still subject to the CSM.

It is actually quite straightforward. If your income exceeds 0.5 times the PASS (Plafond Annuel de la Sécurité Sociale), which is €46,368 in 2024, you likely need to pay the CSM.

However, the nature of the income may make you exempt from the CSM, for example, if the income comes from a state pension in the EU or UK.

For simplicity, let’s assume 100% of your income is potentially CSM taxable. Then, if you’re making €50,000 (or equivalent in a foreign currency) as a single person, you can expect to pay: €50,000 – €23,184 = €26,816 * 6.5% = €1,743 in CSM tax.

Using the same example for a couple, you would calculate it as follows: €50,000 – (€23,184 x 2) = €3,632 * 6.5% = €236.08 in CSM Tax.

Finally, the same scenario with a child would make you exempt from CSM tax, as the child’s presence allows for an additional “PASS allowance.”

Registration into the French social security system is not automatic. You need to download a form called an “ouverture de droits” and file it with CPAM to join French healthcare. PUMA facilitates a specific process allowing for an “ouverture de droits,” ensuring everyone residing in France can be covered.

Once the process is completed (currently, the average delay is 6-7 months after application, varying by location in France) and approved, an “attestation de droits” is issued by “La Sécu,” enabling the application for a Carte Vitale and top-up health insurance (a “Mutuelle”).

Given that Social Security in France typically covers only a portion of healthcare expenses, even French natives opt for a Mutuelle.

For non-EU citizens residing in France permanently, having a Mutuelle is mandatory, so you should make sure you have the right mutuelle in France. A key benefit of a Mutuelle is that it often covers the full cost of services, even with a private dentist or optician, minimizing out-of-pocket expenses. While luxury items like Gucci frames might not be fully covered, you can still receive a quote from the optician without any excess or deductible.

Technically, a 1€ deductible is applied to every claim, but it’s practically negligible. Interestingly, the government’s decision to increase this deductible from 1€ to 2€ to prevent system abuse was met with significant public disapproval, emphasizing the importance to the French of minimal medical expenses. Rest assured, in France, you will receive excellent medical care without the burden of excessive bills, allowing you to allocate your hard-earned money to other aspects of life.

Fabien will be joining us on our upcoming webinar Visas & Residency in France: Making the Move in 2024 on Thursday 18th April 4pm UK  / 5pm France time. Find out more here or sign up now!