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Navigating the healthcare E-maze

Connexion edition: January 2008

2007 has seen changes that impact the lives of people of all nationalities - not just British nationals - who come to live in France. The central theme has been CMU and the rights and terms of residency. Here we tackle some of practical issues of healthcare in France.

THE E-FORMS
The transfer or use of your UK NHS rights and their conversion to French NHS rights is implemented under EU regulations by the “E” Forms for residents and by the new EHIC for visitors. The most used of these forms are:

1. The E106.
This is for early retirees. It provides cover for up to two years and is available to people who have worked and paid National Insurance Contributions (NIC) for the two years before taking early retirement. If only one person in a family qualifies for an E106 it covers other family members as “Dependant Beneficiaries” as well. Its primary purpose is the provision of healthcare for workers and their families moving within the EEC.

We have been told by an authoritative source that its use for early retirees applies to the UK only:

Entitlement to an E106 is for a person who takes up residence in another EC Member State under state pension age and does not intend to work. People who retire early to another Member State before a UK state retirement pension becomes payable and are not in receipt of any other UK social security benefit or pension, are non employed and, therefore, strictly outside the scope of regulations.

However, because EEC Regulation 1408/71 assumes a link between social security cash sickness benefits and healthcare, the UK can provide healthcare cover with an E106 for a limited period only, to early retirees who continue to have an underlying entitlement to UK short-term incapacity benefit, irrespective of whether it is actually paid. They are in effect still regarded during this period as workers covered by the regulations who are insured in the UK but resident in another Member State.

Entitlement to short-term incapacity benefit is, in turn dependent on a person’s recent past payment of UK NIC contributions when in work. It does not depend on contributions paid during the whole of a person’s working life. The maximum period of entitlement is about two and a half years following payment of the last contribution. When underlying entitlement to cash benefit ceases so does eligibility to healthcare cover in the EEA with a form E106

2. The E121
This is for retirees. It provides cover without time limit subject to unchanged circumstances. A changed circumstance might be returning to the UK to become resident. If there is only one person in a family that qualifies for an E121 it covers other members of a family as “Dependant Beneficiaries” as well. The E121 may be issued on the grounds of Long-term incapacity benefit as well and the same terms regarding Dependant Beneficiaries apply. It may also be issued to a surviving widow if she receives a widow’s pension.

3. The E109
This provides cover for the family in France of a person remaining resident, working and paying NIC in the UK.

4. The EHIC (European Health Insurance Card).
This is for visitors. A visitor is a person residing in a stable and regular manner in the UK for more than 6 months and visiting France for less than six months in a year.

All the above options are acceptable under the new regulations and those who are entitled to one of them are not affected.

POST ARRIVAL
These are the steps to take:

1. Visit CPAM
(Addresses are in the telephone directories). If possible, select a nearby big town or city that may have an International Relations department that is used to dealing with people becoming resident and understands English. Pay a visit, submit your papers, and ask for help. Do not delay as the E-forms remain inactive until submitted and accepted.

2. Taxation
On becoming resident you become tax resident. It is important to understand that you must declare your worldwide income although you may not have to pay tax in France on any income that is compulsorily taxed at source. Many CPAM branches do not accept people into the healthcare system until they are satisfied that their income has or will be declared.

3. Register with a doctor
Since July 2005 France has adopted the Family Doctor system just like the UK. Registration is not compulsory but failure to do so will result in receiving lower reimbursements. This can be expensive especially for visits to specialists who are free to fix their own fees if you have not registered with a doctor. Registration is made using a Form S3704 which you and your doctor sign then send to CPAM.

Common problems you may encounter

Dependant Beneficiaries
You may encounter a problem obtaining an endorsement on an E106 for a relative who does not qualify for an E106 himself or herself. We have heard of many such situations. In three recent cases an impasse has been reached with both the UK and the French Authorities denying responsibility for endorsing the Form.

The UK Authority was correct as EU regulations provide that it is only the member state in which the applicant now resides that can take a decision on the definition of the word “dependant” under its law.

Similar problems can arise in the case of the E121. Here the UK Authority issues this Form only to a Holder if only one member of the family meets the qualifying conditions. The French Authority should indent on the UK Authority for a duplicate using an E107 to do so. Usually this is sorted out by the UK Authority sending the E107 to France and asking for it to be completed and returned. Recently there has been a case in which a CPAM centre has refused to accept a person as a Dependant Beneficiary as he had an income and was not financially dependant on his wife. After a lengthy process through the appeals procedure a government legal department over-ruled CPAM’s refusal and this has gone some way towards establishing case history.

Fall-back

The above section deals with those that have entitlement and is the easy part of the equation. Others must rely on the Fall-back option which in the past has been CMU (Law 99-641).

Now it is private full cover insurance, no longer illegal for those who are left with no alternative. Private stand alone insurance has disadvantages compared with state supported top-up insurance. Notably, exclusion of pre-existing conditions, chronic conditions support, and claims excesses.

The insurance industry is unable to underwrite such items at an affordable price. In fact in the light of state deficits on healthcare accounts one wonders if it can be afforded anyway without greater patient co-insurance. Do not let this deter you, look at the offerings carefully. It does not cost you more than time to make an application and to obtain a quotation including a statement of terms and conditions. They may vary widely.

There is an additional and very important reason. There is reason to believe from a preliminary reading of the new regulations that under certain conditions CPAM may cover uninsurable conditions. If this proves to be correct it may be useful to have evidence of refusal of a condition.

It is recommended that if you have special medical conditions that you talk with your CPAM centre allowing time for the information to circulate.

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