PUMA, Social Protection, and Social Charges in France

Introduced in 2016, PUMA (Protection Universelle Maladie) is France’s universal health coverage system, designed to guarantee access to public healthcare for all legal residents, regardless of their employment or income status. PUMA is a cornerstone of the French social security model, reflecting the country’s commitment to health as a basic human right.

Under PUMA, anyone who has been legally residing in France for at least three consecutive months can apply for health coverage through their local CPAM (Caisse Primaire d’Assurance Maladie) office. Once approved, beneficiaries receive an attestation de droits, which confirms their rights to access state-funded healthcare services, such as GP visits, specialist appointments, hospital care, and more.

Eligibility and Exceptions

While PUMA covers the vast majority of residents, there are a few exceptions:

● Expatriate Workers: If you’re temporarily assigned to France by a non-EU employer, you may not be eligible for PUMA for the first five years of residence. During this period, private international insurance is usually required.

● International Organisation Employees: Staff employed by bodies like UNESCO, the OECD, or diplomatic missions are often covered under separate healthcare arrangements via their employers or international treaties.

● EU/UK Pensioners: Thanks to reciprocal agreements, retirees receiving pensions from EU member states or the UK can often bypass PUMA and instead register with CPAM via the S1 form, which transfers healthcare entitlements from their home country to France.

Is French Social Security Free?

While PUMA provides access to healthcare, it’s not entirely free. Some residents may be required to pay the Cotisation Subsidiaire Maladie (CSM), an annual contribution based on income.

Who Pays the CSM?

You may be liable for the CSM if you meet all the following conditions:

1. Residency: You reside in France on a stable and legal basis.

2. Low Professional Income: Your annual professional income is below 20% of the Plafond Annuel de la Sécurité Sociale (PASS), which is 47,100 € in 2025, making the threshold 9,420 €.

3. High Capital Income: Your annual capital or investment income exceeds 50% of the PASS, i.e., 23,550 € in 2025 .

If you receive replacement income such as pensions, disability benefits, or unemployment allowances, you’re typically exempt from the CSM.

How Much CSM Should I Expect to Pay?

The CSM is calculated using the following formula:

CSM = 6.5% × (Capital Income – 0.5 × PASS) × [1 – (Professional Income / (0.2 × PASS))]

For example, if you’re single, have no professional income, and earn €50,000 from investments:

● 50,000 € – 23,550 € = 26,450 €

● 26,450 € × 6.5% = 1,719.25 €

For a couple with the same capital income and no professional income:

● 50,000 € – (23,550 € × 2) = 2,900 €

● 2,900 € × 6.5% = 188.50 €

Note: Having a child may provide additional allowances, potentially reducing or eliminating the CSM liability.

How to Apply to “La Sécu”

Enrolment in the French social security system isn’t automatic. After residing in France for three months, you can apply by submitting the “Demande d’ouverture des droits à l’assurance maladie” form to your local CPAM office. Processing times vary but typically take several months. Once approved, you’ll receive an attestation de droits, allowing you to apply for a Carte Vitale and a Mutuelle.

What is the Mutuelle?

A Mutuelle is a supplementary health insurance policy that covers the portion of medical expenses not reimbursed by the French public healthcare system. While Sécurité Sociale typically reimburses around 70% of standard medical costs (such as GP visits, prescriptions, and hospital care), the remaining balance, often called a co-payment, is left to the patient. A Mutuelle helps cover this gap, significantly reducing or even eliminating out-of-pocket expenses.

Although not legally mandatory for all, a Mutuelle is essential for most residents, especially retirees, the self-employed, or those without employer-provided health coverage. Without one, costs for dental work, vision care, hospital stays, and specialist visits can add up quickly.

Many Mutuelles now align with the “100% Santé” initiative, which ensures full coverage for specific categories of dental, optical, and hearing care, meaning you pay nothing at the point of service for selected products and services.

Technically, a 1 € deductible is applied to most medical claims under French law, but this amount is practically negligible. In 2024, the government attempted to raise this to 2 € to curb system overuse, but public outcry led to delays in implementation, highlighting how seriously the French value accessible, low-cost healthcare.

Understanding PUMA, the CSM, and the role of Mutuelles is essential for non-EU residents in France. By staying informed and proactive, you can ensure comprehensive healthcare coverage and avoid unexpected charges.