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A new look at how 'Puma' healthcare changes affect expats

Universal reimbursements system seems to retain similar principles to old CMU

This year saw a change to French healthcare with the replacement of the former universal reimbursement system (‘CMU’) under which family members could be dependent (‘ayants droit’) on someone in the system by the new Protection Universelle Maladie (Puma) where everyone has their own individual healthcare rights determined by residence.
We look at the change and how you may be affected.

What is Puma?
Puma is the name for the new ‘universal’ French health reimbursements system which came in at the start of 2016. It is concerned with an individual right to healthcare based on residence in France. Previously health rights were considered primarily a right derived from having paid into the system (sécurité sociale) via cotisation payments on work income or a right you held via being ‘attached to’ someone else as their dependant (ayant droit, meaning ‘having the right’).

Questions were raised when the changes were announced a year ago as to whether expats’ rights would be affected, for better or worse, by the change but, so far, this does not appear to be the case in either direction for most people.

A spokeswoman for the Direction de la Sécurité Sociale (DSS, the government branch in charge of social security) told Connexion at the time that it would not deprive anyone who is already in the system in their own right, of their entitlements, and that dependants would keep their rights if they were stable, legal residents.

State healthcare reimbursements website also states “if you are an adult ayant droit of an insured person you will continue to benefit from healthcare cover without any change.”

This policy change follows years of controversy over the healthcare rights of non-working (early-retiree) EU citizens who moved to France, known as ‘inactives.’

They were considered to pose a problem because they had no healthcare rights from previous work in France and were not able to benefit from the European S1 form system through which EU state pensioners have their healthcare paid for by the country paying their pension. (If applicable though, they could have healthcare as ayants droit of their spouse/civil partner.) France insisted they needed comprehensive private healthcare policies replacing the cover usually provided by the state.

Prior to the controversy, ‘inactives’ were able to join the Couverture Maladie Universelle (CMU), the old scheme designed to fill in contribution gaps, notably for French people who had not paid enough cotisations due to being out of work, disability etc. This allowed people to enter the reimbursements system on the basis of an annual subscription if their household income was above a certain threshold (otherwise for free).

Under the new rules this did not apply until five years’ residence, the point at which EU citizens legally gain a ‘permanent right of residence’ in France under EU rules.

The EU then raised questions over France’s policy. The European Commission told Connexion in 2011 that it expected France to treat EU citizens who were ‘habitual residents’ the same as the French – which was not the case because French people could gain healthcare rights after three months’ residence, regardless of whether or not they had paid into the system.

At that stage the rules allowed for exceptions where early-retirees could join the CMU early but, in theory, only if they proved exceptional, unforeseeable circumstances preventing them from having a private policy.

Some people with pre-existing conditions that would be excluded from private policies, cancelled plans to move to France and many expats told of difficulties obtaining the CMU.

Under pressure from the EU, there were some tweaks over the years, notably in 2013 when all applications from EU early-retirees were centralised in Nîmes. Since then Connexion has not heard of early-retiree expats being refused entry to the CMU, despite the fact that the ‘exceptional circumstances’ rule has officially remained in place. However, some people have continued to use private insurance as their main health cover, sometimes taking ‘hospital-only’ and paying for other costs (doctors, medicines…) themselves.

As of January 2016, the CMU was abolished because Puma was said to render it unnecessary. Healthcare is now said to come as a right of being a stable, legal resident (including having been established in France for at least three months and then spending at least six months of a given calendar year in France). As a result, a specific scheme aimed at resolving the problem of residents who have not paid enough cotisations or who cannot be attached to a partner is no longer required.

What did this actually change?
So far, it appears it has changed little – though some people with very small businesses could find healthcare costs them more (see below about the cotisation).

Puma is claimed to have simplified matters as people now only have to prove residency as opposed to rights based on either contributions made through a current or previous job, being attached to a spouse/civil partner with rights, or applying for the CMU subject to annual renewal.

It is also said to simplify validating people’s rights when changing working status (eg. from self-employed to employed or unemployed) and when changing marital status, because the individual right to healthcare continues unchanged and (apart from in the case of certain ‘special work regimes’) people may remain with the same healthcare caisse. The latter refers to the body dealing with their health reimbursements, such as a local Cpam, or, for many self-employed people, RSI.

Initially it was thought the new system might remove the requirement of private policies for early retirees. However the latest rules continue to say that ‘inactive’ EU citizens should show they have ‘comprehensive healthcare’, unless there are special situations such as a “sudden, unexpected loss of income or loss of healthcare linked to a partner losing their job etc”. In practice then, it appears nothing has changed, however where
early-retirees are allowed into the system this will now be referred to as “gaining affiliation on residence criteria” as opposed to “obtaining the CMU”. The justification for this continuing despite the new ‘universal’ system, seems to be that France’s strict interpretation of EU law links recognition of long-term residence rights for newcomers from the EU (between three months and five years) to them not being a burden on social security – including the healthcare system.

However, Connexion sees no evidence that entry to the French system for early-retirees that request it has become more difficult to obtain. Furthermore, the Cpam English-speaking helpline said requests from ‘inactive’ EU citizens continue to be processed by Nîmes.

The new rules also still provide for those ‘inactive’ people (ie. people not in receipt of a French or EU state pension or long-term incapacity benefit and not paying in through work) to pay to belong to Puma if they have income above a certain ceiling. This ‘cotisation maladie’, was set at the same level as the CMU subscription.

In reality then, ‘abolishing’ the CMU largely seems to have meant retaining similar principles – but they are now seen as an integral part of a ‘universal’ system, not a patch to resolve gaps in the usual way of doing things.

The CMU used to be officially allocated for one year at a time and people had to apply to renew it before Septem­ber 15 each year, declaring their income and showing their continuing domicile in France, for example with three electricity bills.

The government site states “people in the health system are no longer going to be contacted and asked, sometimes each year, to show their right to have healthcare”, and says cotisation levels will be checked by reference to income tax declarations.

However, the Cpam English-speaking helpline told Connexion that early-retiree EU expats in the system will continue to have to fill out forms annually...

How is the cotisation worked out?

It is still based on 8% over a certain ceiling, which this year was €9,654. 

One technical change is that it should now be 8% of ‘income from capital’ over this ceiling, however it appears that the Cpams will consider incomes of truly ‘inactive’ people to be essentially ‘from capital’ as they are assumed not to have ‘non-capital’ incomes such as state pensions or salaries. It is also possible for caisses to consider lifestyle when calculating the amount (eg. if someone has a conspicuously luxurious one).

Workers will now have to pay the cotisation if their income from work is below a threshold set at 10% of the social security ceiling [PASS – a figure set annually, used in certain social security calculations], which represents €3,861 in 2016. Progressive adjustments, however, will be made to the calculation of the cotisation so that it is comparatively reduced for people with earnings near this level, as compared to people with only half this work income, who will now pay the 8% on other incomes in full.

This may affect some people who previously obtained very ‘low-cost’ healthcare access via small ‘auto-entrepreneur’ businesses with very minimal turnovers (other small businesses previously had minimal levels of health cotisations to be paid but this has now been abolished).

If ayant droit status was abolished, how is it that you may still claim via a partner?
Firstly, if someone is a spouse or civil partner (or dependant child) of an EU citizen with an S1 form, EU rules allow for them to have healthcare as their dependant. This is not changing with the new Puma system.

Also, dependant minors are still ayants droit of parents/guardians, with the exception of 16-17-year-olds who make a request to be covered individually.

As for other situations, if you were an ayant droit of someone when the rules changed on January 1, 2016, you may remain so until the end of 2019, by which point you will need to become a Puma member in your own right.

With individual rights you will have a separate account on state healthcare website and your caisse will calculate your reimbursements individually, pay them into your bank account and issue you with separate receipts. You may opt to change to this before if you wish by applying to your caisse on this form:

Otherwise, the general rules state that a spouse, civil (or pacs) partner (or even in some cases a long-term unofficial partner living with an person in the system for over 12 months and genuinely dependent on them), may join Puma by being attached to their partner’s caisse, though they will technically not be considered attached to their partner as their ayant droit.

Despite the new ‘individual’ status, the new rules say they will not pay a cotisation as long as their partner is not earning enough to benefit (see above).

A DSS spokeswoman said: “Puma works for everyone independently of nationality. “If one of the partners works and pays in, in France, and their work income is higher than 10% of the PASS €3,861 they exonerate their inactive partner who is a resident of France.”

What happens if you are both ‘inactive’?
The DSS spokeswoman said: “In this case each of the members of the couple must pay an individual cotisation, calculated based on the income of the household, pro rata 50% for each of the members. This share-out can be altered by the couple to reflect the ‘real’ difference in their individual incomes if they wish.”

Does the CMU-C ‘top-up’ still exist?
Yes, this system which ‘tops-up’ the non-reimbursed part of healthcare for those on the lowest incomes still exists unchanged.

It is the ‘CMU de base’ (basic CMU) that has officially been abolished.

What will happen to rights of expats after Brexit?
It is unclear, as it would be one of the matters to be agreed in the Brexit negotiations. In particular, the S1 is an EU arrangement.

International law expert Vaughan Lowe QC recently told the House of Lords he felt the government should consider offering to compensate its loss, such as by paying for expat pensioners’ healthcare directly.

If that was not the case, British expats who are not in the French system through work or, for example, through a French pension would, like other non-EU foreigners, probably be eligible to join Puma – with a cotisation if appropriate – if they had long-term French residence rights (which could be subject to an application for a carte de séjour) depending on what agreement is reached between the UK and EU.

If you have a question on this topic send it to and we will consider it for an answer in a future edition

PLUS: For more on Puma, French healthcare in general and the reimbursement system, including new reforms, see our updated Healthcare in France 2017 helpguide. 

The guide is available in print or .pdf format, price €9.90 (+P&P) from the Help Guides section of this website or via selected newsagents across France.

Alternatively you can order a copy by calling Nathalie on 06 40 55 71 63 or 0844 256 9881 from the UK. The number of printed copies available directly from us is limited so order early to avoid disappointment.

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