Why do we pay for healthcare?

There are only two occasions where healthcare is completely free in France; pregnancy and poverty

26 August 2009
By

WE ARE retired, aged 73 and 65 and have lived in France since November 2005. Lately we have read varying reports of who is entitled to free healthcare.
If ours is not completely free and we have to take out top-up insurance to reimburse the percentage of medical costs not paid for by the state, does that mean a French person in the UK will only have a percentage of their healthcare paid for by the NHS?
L. and F. T.

There are only two situations in which healthcare is completely free in France - ie. with no percentage to pay out of your own pocket or through top-up insurance (known as a mutuelle).

One is pregnancy, where everything is free from the 33rd week until 12 days after the birth, this is for both the mother and child.

The other is where the family income is below a defined poverty threshold, this is called the CMU complémentaire (CMUC) and it replaces the need for top-up insurance. The current ceilings are €7,447 for one person or €11,170 for two. Details can be found at www.cmu.fr

The latest ceilings (plafonds) can be found by clicking here. (Opens a pdf file).

There is no equivalent to French top-up insurance (which is applicable to both French and non-French residents) in the UK because of the country’s different healthcare rules. In the UK free healthcare rights are based on residency.

Below are the key situations relating to the payment of healthcare in France.

Serious illnesses
If you have French state health cover, the following situations can qualify you for reimbursement of 100% of the set state tariffs (tarif de convention), though note some doctors are allowed to charge above the tarif de convention for their work (see below).

■ A list of 30 serious illnesses including cancer, heart disease and insulin-dependent diabetes, are usually covered at 100%.

■ Most surgery is covered at 100% if it is above the KC50 level. This code refers to seriousness (the higher the number the more serious), though in fact KC50 is not very high. For example, if the surgery requires anaesthetic and an operating theatre it will almost certainly be KC50 or more.

■ Certain other serious illnesses, for example any illness classified by the attending doctors as being of long duration. A stroke is an example.
In the case of hospitalisation exceeding 30 days the condition is automatically classified as of long duration. It should not be taken for granted that your illness, even if it is on an official list, will automatically attract the 100%.
You need the support of your doctor who, if he or she agrees, will register your condition with the cpam. If the latter accepts you at 100%, they will send you a letter of confirmation.

A French pension
You have the right to basic state health cover if you become entitled to a French state pension. Any health beneficiary of the pension holder (eg. a spouse) is also covered.
The CMU complémentaire may be available if you are below the thresholds.

Working in France
You are required to pay social security contributions and to affiliate to French social security. You are then covered for basic state health care. Again, you may be entitled to CMU complémentaire.

Self-employed people
The RSI (Régime Social des Indépendants) is the appropriate caisse (health social security body) for most self-employed people and they can advise about the CMU complémentaire. More information (in French) can be found at www.le-rsi.fr

The assessment of resources of self-employed people for this purpose is subject to special rules.

Five-year residency rule
Under current rules new arrivals in France who are not of state retirement age and have not worked here and do not plan to are not entitled to reimbursements under the state healthcare system until they have been in France for five years. At this point a right to “permanent residence” can be acquired, subject to the authorisation of your prefecture.
This then gives you the right to apply for the CMU - a system which allows state healthcare to those who are not entitled to it through working. Whether you have to pay towards this or you get it free, will depend on your income.
Prior to this such new arrivals need full private health insurance.

Accidents of life
If you have been legally residing in France and you are suddenly confronted with completely unforeseen circumstances which create serious problems as regards access to health cover, then the accident de la vie may apply to you.

This could include separation from, or death of, a spouse or refusal of private full-cover health insurance due to a serious illness unknown before coming to France. You must supply full proof of your situation and supporting documents to your Cpam who will investigate your circumstances. This may lead to the granting of basic CMU and possibly also the complementary version.

Financial help from the UK
Health forms E121, E106 and E109: entitlement to one of the above UK-issued E-forms means that once you have registered it with your local Cpam it provides you with basic French state health cover at the UK’s expense. Each validated health beneficiary of the E-form holder is also covered.

Long Term Incapacity Benefit (LTIB)
This is a UK benefit which gives entitlement to an “enhanced” E121 which will provide 100% reimbursement for most areas of healthcare. LTIB stops on receipt of a UK state retirement pension.

When the Department for Work and Pensions (DWP) issues the LTIB E121, a cross is put in its “invalidity” box. When LTIB changes instead to a state retirement pension, the DWP re-issues the E121 with a cross in the “old age” box rather than the “invalidity” one.

Previously this resulted in instances of Cpam reducing the French state health cover from 100% incapacity reimbursement to the standard 70-80% to which the old age pension entitles you.

Now a LTIB recipient covered by an E121 can continue to receive 100% state health cover when their LTIB is converted, subject to an assessment and confirmation of their continued medical incapacity by their Cpam.

Why 100% does not mean a full refund

EVEN if you receive “100%” reimbursements - for example for treatment of certain serious illnesses - you will not necessarily get all the money you paid out back again.

Almost all doctors are secteur 1 or secteur 2.
On seeing a secteur 1 doctor, a patient with no special conditions or circumstances will be entitled to have a set percentage of a standard state fee for a medical service reimbursed. The standard fee is called the tarif de convention.

For example, to see your GP would cost €22 and you would be reimbursed 70% (watch out - if you do not have your own GP - médecin traitant - or you see another doctor without passing via him or her, you get a lesser percentage: this is called going hors parcours de soins - “outside the care route”).
The part left for you or your private insurance is known as the ticket modérateur.
People on “100%,” on the other hand, are covered for the full tarif de convention.

If a doctor you see is secteur 2 (also called honoraries libres) this means they can charge more than the tarif de convention. In this case, even if you get a “100%” reimbursement it will not cover this surplus. A private top-up (mutuelle) may cover some or all of it - a 100% one will cover 100% of the tarif de convention - none of the surplus - but some are 200% etc.)

A tiny minority of doctors and specialists are secteur 3 - you get about €1 of refund and have to pay for the rest.

Most people also have some deductions on refunds called the €1 participation forfaitaire and franchises médicales - a kind of tax on medicines and some medical acts, paid by everyone except the “free” categories we have outlined (eg. people on the CMUC).

Some maths for you

HERE is a general example of the breakdown of reimbursements (reimboursement) between state and top-up (mutuelle) if you visit a doctor working under the sector 2 regime with a €50 tariff.

The sécurité sociale reimburse you at 70% of €22 (the base tariff of the sécurité sociale) which is €15.40.
A further €1 is taken off (la participation forfaitaire) and is non reimbursable leaving the state to pay you €14.40.

100% indicates that a mutuelle will reimburse up to 100% of the base tariff, meaning up to €22. So the mutuelle covers: 100% of the base tariff, that is €22 minus the €14.40 already covered by the sécurité sociale and the €1 fixed cost.
Thus it pays €6.60. So the amount you pay is €50 - €14.40 - €6.60 = €29

200% indicates that a mutuelle will reimburse up to 2x the base tariff, meaning up to €44 (2 x €22).
So the mutuelle covers: €44 - €14.40 = €28.60.
So the amount you pay is €50 - €14.40 - €28.60 = €7

300% indicates that the mutuelle will reimburse up to 3x the base tariff, meaning up to €66 (3 x €22 euros). So the mutuelle covers:
€66 - €14.40 = €51.60
So the amount you pay is just the €1 forfait. Note: You never get given more than you paid.

subscribe newsletter image
Stay informed, have your say, join the community
Boost your inbox with our editor’s pick of news and information about France for residents and second homeowners
By joining the newsletter, you agree to our Terms & Conditions and Privacy Policy
See more popular articles
The Connexion Help Guides
Updated! Brexit and Britons In France
Featured Help Guide
What Brexit means for British residents, second homeowners and visitors in France - now and after December 31, 2020.
Get news, views and information from France