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

Living France - - Contents -

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.

THE 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.

RE­IM­BURSE­MENTS

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.

S1 FORM

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.

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