France has a free or small-cost option for people on low incomes

France has a ‘free top-up’ system to help people on modest means. The current scheme, the complémentaire santé solidaire (CSS), has existed since 2019 and replaced two previous programmes called Couverture Maladie Universelle complémentaire (CMU-C) and Aide pour une complémentaire santé (ACS).

CSS beneficiaries receive financial support from the state towards their top-up cover, which can, for practical purposes, be organised either directly via their Cpam, or via a mutuelle, institution de prévoyance, or private insurance company.

CSS beneficiaries are exempted from having to pay any upfront fees to doctors, dentists, and health auxiliaries (nurses, physiotherapists, etc.). They are also not required to pay the forfait hospitalier daily fee in hospitals. 

Drugs and medicines in pharmacies, as well as medical devices (canes, wheelchairs, bandages, prosthetics, etc.), are also covered with no upfront costs. Beneficiaries also have free access to many glasses, dentures, and hearing aids.

Doctors may not charge beneficiaries any dépassements, although there are rare exceptions, such as specific requests for out-of-hours consultations or home visits that are not medically necessary.

You can apply for CSS online through your Ameli account under Mes démarches, or by sending in or dropping off at your Cpam the form. You need to provide information about your household and combined incomes. It is possible to have the CSS for the whole household.

When you apply, you are required to choose a body that will act as your top-up insurer, but this can simply be your Cpam. If you already have a top-up insurer, you should continue with it if it is on a list of eligible providers.

Eligibility for CSS is determined on the basis of your income level. For those earning the lowest incomes, CSS is free. 

For others whose incomes are not deemed sufficiently low, a financial contribution is required, but it is lower than the full cost of taking out an ordinary mutuelle. The calculation for this contribution takes into account the claimant’s income level and age.

People who obtain the RSA income support benefit will automatically be signed up for CSS. Access will also be facilitated for pensioners on the Aspa pension top-up, who will automatically be sent documents allowing them to sign up.

If you are on a workplace scheme, you can opt out of this to join the CSS.

Self-employed workers who are struggling with financial, medical, social, or family problems can access a new help service called – logically enough – ‘Help’. This is run by Assurance Maladie, Urssaf, Caf, and the pension service in partnership. It starts with a questionnaire. Assurance Maladie says a relevant local body will get in touch to propose solutions for your situation.

Two criteria for calculating your CSS contribution 

Beneficiaries of the CSS are required to pay a modest contribution if their income reaches a certain level. If so, contributions are calculated on the basis of income and age levels. The CSS contribution is guaranteed not to exceed a maximum of €1 per day and per person.

Income is assessed based on actual income from all sources, but minus various welfare benefits and certain other incomes such as children’s educational grants. People who own their own home or live with someone free of charge have an additional set amount added to their income calculation called forfait logement (e.g., €76.29 for a person living alone).

The government gives the example of a jobseeker aged 45 with a dependent child aged 15, who has monthly income of €1,500. The person would be entitled to CSS with a contribution of €14 for themselves and €8 for their dependent child, for a total of €22.

Once you have obtained the CSS, it automatically continues if you are on the RSA or Aspa income support benefits, or the ASI benefit for disabled people. Otherwise, cover only lasts for a year and you need to apply to renew no less than two months before the cover ends, giving the same information as for the first application.

See here a simulator to check eligibility.