GUIDE TO HEALTHCARE
The French healthcare system has long been considered one of the best examples of universal care at affordable rates. Kate McNally takes a closer look
Our guide to what is covered by the state and the top-up insurance available
Perhaps the first thing to point out about the French healthcare system is that, unlike the NHS, it is not free. Admittedly, the NHS isn’t really free either as it is financed by National Insurance contributions, however, most primary care in the UK either at the doctor’s surgery or hospital is funded from these payments and patients are not usually asked to put their hands back in their pockets.
In France, you help fund the state healthcare system via the general charges sociales (welfare state taxes) in a similar fashion, but you are also expected to pay a certain percentage of any healthcare services you use – the percentage varies depending on the type of treatment, though for most necessary healthcare it remains a relatively small percentage. The idea of a contribution towards personal costs has its roots in France’s socialist ideal in which everyone works together to fund society’s needs, but within this structure there must also be an element of each individual taking a share of personal responsibility.
As a wide comparison, you could see the French healthcare system as an amalgam of the UK’s free NHS and the USA’s unfunded healthcare state. In reality, it is much closer to the NHS model that it was initially based on back in 1945, and has long been considered one of the best examples of universal healthcare at affordable rates.
HOW DOES IT WORK?
In France, anyone who works in the country (therefore paying the equivalent of NI contributions) and anyone legally living in France on a permanent or semi-permanent basis (even if not in work) is, de facto, eligible for state-assisted healthcare. Access was simplified at the beginning of 2016 with the introduction of PUMA (la protection universelle maladie) which replaced the former CMU (Couverture Maladie Universelle) – the principal change being that PUMA has simpler administrative procedures.
The state healthcare system operates via what is known as the Carte Vitale – the importance of this yellow and green plastic card is reflected in the name. It effectively acts as a person’s identity card within the French welfare state, including the health sector, and obtaining your Carte Vitale from the local CPAM (Caisse Primaire d’Assurance Maladie), is probably the first thing you should seek to do when moving to live in France on a permanent basis. Thereafter, the state percentage of any health costs you incur are refunded via the Carte Vitale system.
But what about the share of healthcare costs not covered by the state? As these can be quite expensive for some treatments, for example physiotherapy or orthodontic work, and indeed some care such as osteopathy and the non-medical costs of a stay in hospital are not state-funded at all, most French people opt for an additional private health insurance known as a mutuelle.
Since January 2016, it has become compulsory for private companies to provide employees with a company private health insurance policy, known as a mutuelle collective. The company must contribute a minimum 50% of the mutuelle’s cost, and employees in theory are obliged to join the scheme unless they have a good reason for not doing so. ( This new law does not apply to public sector organisations.) Many private companies have long had a mutuelle collective in place as a staff perk, with many also extending rights to employees’ immediate family members.
For the rest of the population – civil servants, job seekers, students, pensioners, the self-employed – the only option is a mutuelle under a contrat individuel, and these generally offer less favourable terms. However, the cost of a mutuelle is not comparable with private health cover in the UK. It’s generally affordable and the majority of people in France have one,
albeit offering greater or lesser cover according to their needs and financial means.
But be warned – the mutuelle marketplace is crowded and competitive, so it is advisable to ask French friends or even the local doctor for recommendations to be sure that your choice of mutuelle is right for your needs. You can get a basic idea of costs and cover by looking at online comparison sites, but don’t use them to make a selection as most of these sites are either linked to, or receive commissions from, insurance companies and are not therefore offering independent advice.
The small print of a mutuelle contract, in particular the reimbursement calculation, is not simple to follow. You need to look carefully at what each mutuelle offers, both in terms of cover (basic and options) and compare this with your actual or likely needs, and understand clearly how much they actually reimburse. The latter may be indicated as a fixed amount or in percentage terms. Beware of the percentage indication because this signifies a percentage of the tarif de convention ( TC) – i.e. the fixed price set by the state and upon which the state payment contribution is based. If the health practitioner adheres to the TC and the mutuelle states you will receive 100% of the TC, then you will be effectively reimbursed for all the share of the fee not covered by the state contribution. However, if the practitioner does not adhere to the TC, as many specialist practitioners do not, then they are free to set their own prices which may be much higher than the TC, but the mutuelle will still only pay for your share of costs up to 100% of the TC, leaving you to pay the rest of the actual cost ( see example overleaf). Because of this anomaly, it isn’t unusual to see some mutuelle reimbursements indicated as 150%, 200% or even 400% for more specialised treatments. Also be aware of the conditions for changing your options and ending your contract. Termination ( résiliation) conditions in particular can be quite specific, requiring notice given well in advance within a certain time window, and it is almost impossible to end a contract before it has run its course.
PRICING AND MARGINS
Prescription medicines are strongly subsidised by the French welfare state, which some believe leads to an over-readiness on both the part of patients to ask for them, and doctors to prescribe them.
The French state sets the price of prescription medicines and from 2016 raised the payment made to pharmacists per box of medicine on sale or return from 80 centimes to €1. In return, pharmacies have agreed to increase the sale of generic products to 85% of sales, and to lower the margins on certain medicines.
Firstly, choose a doctor and advise CPAM of your choice – the idea being that regularly going to the same doctor provides better coordinated care, and in return the state offers greater reimbursements for health costs. Though the cost of a doctor’s visit is €23, 70% of this cost (minus the symbolic €1
The mutuelle marketplace is crowded and competitive
always charged to the individual) is reimbursed via the Carte Vitale. Plans are afoot for this 70% to be billed by doctors directly to CPAM, with patients paying just the 30% upfront. More importantly, a doctor’s prescription ensures free or partially funded medicines, while a doctor’s referral to a specialist, such as a skin or heart specialist, also guarantees a contribution to costs from CPAM. In general, it works out cheaper to go with the flow of the French system, that is always pass via your doctor.
Reimbursements are made direct into your bank account, with CPAM payments generally taking a couple of days and payments from your mutuelle around a week.
Before leaving the UK, apply for the S1 form from the Department for Work and Pensions. This will cover your health costs in France on a temporary basis until you enter the French employment system, or for pensioners* receiving the UK state pension this will cover your health costs for the first three months, at which point in both cases you will be eligible for state healthcare cover under the PUMA regime.
Early retirees moving to France are no longer eligible for the S1 form, but equally become entitled to PUMA after three months living in the country.
* The S1 form proves that you have reached retirement age, have paid the required number of social security contributions and are receiving a state pension.