French Healthcare

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HEALTHCARE IN FRANCE

French Healthcare by Saul Brownstein, French tax and property solicitor at Sykes Anderson LLP solicitors

Please note that taxation and property are complex subjects and you should not take or refrain from taking any step without full independent advice on the particular facts of your case. The content of this article is of a general nature and no liability is accepted in connection with it.

Many of those who take the plunge and move to France have either reached French retirement age (60) or are close to it and living on a UK private pension. One of their principal concerns is whether they will be able to get healthcare treatment in France, should they need it. Indeed, one of their main reasons for going may be the availability of top-quality healthcare with the absence of waiting lists if required.

That said, healthcare is one of the principal reasons for moving to France in the first place ! According to the World Health Organisation in 2000, France had the best healthcare system in the world, on which it spends more than it spends on defence (!). Perhaps some of the below helps to explain why.

Unlike in the UK, the French system is not free at the point of delivery. Rather, every patient must pay for his treatment and is later refunded to a certain extent. Some treatment is totally refunded, other less so (see below). Therefore, for the expatriate, it is not so much a matter of having to pay as how to get this refund.

In France, every medical treatment has a recommended price. Those who adhere to this are called "conventionné", those who do not "non-conventionné". The latter can charge what they like but the former can include "private" establishments. However, rather like notaries, even those who follow the fixed prices can on occasion charge extra, if, for example, there are complications, but such extra charges must be "tactful and reasonable". It's obviously best to establish what they are likely to be in advance, if you can.

There are three main ways that a UK national can use the French healthcare system without paying outright. All are through European Union reciprocity. The onus for requesting the form most suitable to you (for example, pensioners should certainly get hold of an E121) is on you, and you should request it with plenty of notice.

The relevant forms are:

E111 : this covers emergencies for short-term ("temporary") visitors to another member state and is not a substitute for proper travel insurance;
E106: this is a certificate of entitlement to certain benefits which a UK national can use in France because he would be entitled to them in the UK - this should be used by those who are retired (i.e. will not be working in France) but have not yet reached UK retirement age. Entitlements under it last for a maximum of two years and in many cases only one year, and then you must pay contributions in France until and unless you are eligible for an E121;
E121: this entitles UK pensioners (i.e. having reached UK retirement age and in receipt of a UK state pension - you will be asked for proof) officially resident in France to the same healthcare treatment to which they were entitled in the UK, to the extent that the French system provides it (e.g. may not include nursing help). It can also cover those on long-term incapacity benefit and those receiving severe disablement allowance. It covers you for the rest of your life or until you leave France.

Since January 2000 anyone resident in France for three months or more has been obliged to affiliate to the French system, and is thus entitled to basic health treatment (CMU), but must contribute some 8% of taxable income over €6,505 (2003 figure) per household, payable quarterly. These contributions are known as the CSG and the CRDS. Those holding an E106 or E121 are not required to contribute but are still refunded for medical treatment as a Frenchman would be. Also, if one half of a couple is covered by the E121 the other is automatically covered whether or not they would be entitled to an E121 in their own right (and they can request an E121 from the UK authorities). This includes both married couples and those in "concubinage notoire" - i.e. common law couples.

Those who move to France holding no "E" form should in theory pay into the French system from their arrival. This can create problems as year x's payments are determined by reference to year x-1's income, which in the case of high-flying executives in their last year before retirement, can be a large sum.

It is best to register with your local healthcare provider (CPAM) as soon as you arrive in France, or shortly after. You will usually require proof of residence to do so. Under the loi Sarkozy of 2003, the "carte de séjour" is no longer compulsory, but it is still possible to obtain one and it can be extremely useful in oiling the wheels of the French state. If you do not have one, another proof of residence may be acceptable (e.g. a utility bill). Please note that once you register, so as to be able to take advantage of the French health system, it will be very difficult if not impossible to argue that you are not tax resident, so it is best to think everything through in advance. You should show your CPAM any of the above "E" forms which might exempt you from paying contributions in France. You do not need to register with a particular doctor; you just go wherever you want.

The most important fact to remember is that the French system usually only refunds around 70% of medical costs. (Only a few serious illnesses such as cancer are covered to 100%.) It is therefore imperative to obtain private insurance for the remainder. Of course, you can decide whether to have comprehensive cover or merely for more serious illnesses. For example, if a doctor's appointment costs €20 you might be happy to fund 30%, or €6, from your own pocket. You might be less happy to cover 30% of an operation which costs €20,000 (not including one's food in hospital, ambulance fees, private room etc. none of which are reimbursable). The best policy, if you can afford it, is one which pays out the full difference between the state's contribution and your bill without limitation or exception.

This complementary insurance can be obtained in the UK as well as in France. The advantage of the UK is that it is set up in English and help is usually available in English if you should come to make a claim. On the other hand, the French insurer has greater insight into its country's system due to its proximity. If you are eligible for cover by the French system, it is in fact illegal to provide or to buy comprehensive medical insurance but some coverage from a "mutuelle" - i.e. the complementary coverage - is essential.

The fundamental principle is that you, as a UK national resident in France, are "only" entitled to whatever the equivalent Frenchman would be entitled to. You must therefore be well prepared for the particular facets of the French system. Also be aware that you may not simply be able to return to the UK for NHS treatment at any point although there is no reason why you cannot in principle retain your UK private insurance. Finally, if you move to France and are not yet entitled to a UK state pension, think about making voluntary NI contributions to the UK system (usually, but not necessarily, form taxed income). The state pension itself may be nothing to write home about, but with it comes the right, via the E121, to free French healthcare, when the time comes.

Sykes Anderson LLP advises on all aspects of French and UK tax.
Please contact us on 020 7398 4700.
Bury House, 31 Bury Street London EC3A 5JJ
Tel 020 7398 4700 Fax 020 7283 6585
DX 729 London/City
E-mail: solicitors@sykesanderson.com

Those who have experience of the health system in France and, in the UK, the contrast in standards is amazing. There are two inter-related factors that give France this enviable position.

Funding. The French spend a lot on healthcare (10.4% of GDP In 2002) which, until recently was almost twice as much as the UK.

Options. Patients may choose their doctor, specialist, hospital/clinic by whom they are treated. Furthermore as the state will only meet a proportion of medical/dental costs (on average around 70%) this choice is extended to how residents of France fund the difference.

How is healthcare structured and funded in France ?
There is no huge difference in the quality of care between private and public hospitals in France and not necessarily any great difference in price. Being treated in private clinics in France does not mean avoiding waiting lists, as, with a few specific exceptions, waiting lists such as those in the UK do not exist anyway. So why this similarity in the price and quality of healthcare?

"Tarif de Convention"

In France all medical treatments from a routine visit to a GP to major surgical procedures have a tariff. Medical practitioners and hospitals/clinics that adhere to this tariff are defined as "conventioné" ; those that do not are defined as "non-conventioné" and can charge what they like. Perhaps surprisingly the vast majority (around 97%) are "conventioné". There are practical and cultural reasons why "conventioné" healthcare predominates. So a private clinic can still be "conventioné". "Going private" in France therefore does not have the same connotation as that in the UK.

"Depassements".

Life would be so straightforward if you were being treated in a "conventioné" establishment and you could be certain of the rate of reimbursement and the amount you would have to find yourself. Unfortunately even though you may be treated by a medical practitioner who is "conventioné" he or she can charge more than the "Tarif de Convention" provided it is "reasonable and tactful" to do so. So, a surgeon who has extra qualifications or experience in other countries may charge extra. This supplementary charge is called a "depassement". "Depassements" are not inevitable and are more likely to be applied in some areas more than others. For instance, they are commonly applied in Paris and the Cote d'Azur regions, maybe because they are perceived to be more affluent.

Funding and elements of Personal Contributions.

Whichever way you choose to affiliate to the French health system a fundamental principle is that a personal contribution will be required. 100% cover is available for some serious conditions e.g.; cancer. But a simple diagnosis does not automatically mean 100% cover. Each case must be scrutinised on its individual clinical merits. And even if 100% cover is granted it will only be for that condition and will not include any "depassements".

"Top up" Insurances/Polices Complémentaires.

Most residents of France fund their personal contribution via a "top up" insurance policy. There are a wide variety of providers (including at least 3 UK insurers) offering an extensive range of plans to meet individual circumstances. Again this vital element of choice is apparent. Someone who is in general good health may only wish cover for the really expensive items e.g.; hospitalisation. Routine visits to a doctor would be funded out of his own pocket. On the other hand someone on regular medication may require a plan that would cover this. (prescribed medicines are reimbursed 35% or 65% by the state).

Premiums. Will depend on age and level of cover required. An important principle with these "polices complémentaires" is that the state must be proved to have paid its share before the insurance will pay the difference. It follows that you should actually be affiliated before contemplating the purchase of such a policy.

How do expatriate affiliate ?

On 1 January 2000 legislation came into force whereby it became obligatory for all legal residents of France, irrespective of nationality, to affiliate to the French health system. There are a few exceptions to this law but probably the biggest single category of affiliates is those that do so via E Forms.

The information provided below is aimed at those who are retired or have taken early retirement or perhaps live in France but still have their own business registered in the UK or another EU state. It is not really relevant to those who may be employed by a UK parent company and are working in France on a temporary basis. Such employees will have a full administrative support organisation behind them.

Most expatriates settling in France will affiliate to the French health system via the "Caisse Primaire Assurance Maladie" (CPAM) of which there is a nationwide network of offices.

E Forms.

If you are a EU national who comes to live in France then it is possible to affiliate to the French health system via various E Forms. There are several of these forms but the two principal ones are E121 and E106. The most well known form is E111 which provides for emergency medical treatment on temporary visits to another EU state. E111 is invalid for permanent residents of France.

E121.

This will be issued to those in one of the following categories:

People of state pension age and in receipt of a state pension.
people in receipt of Long Term Incapacity Benefit
People in receipt of Severe Disablement Allowance.

As long as you continue to be in receipt of the state pension/benefit the E121 will continue to be valid.

E106.

For those who are under state retirement age but become residents of, but not working in France, this form can be issued. It will usually have a maximum validity of 2 years and is usually less. Exactly how long E106 (issued from the UK) will be valid for depends on:

The amount of National Insurance contributions paid in the last 2 UK Income Tax years.
The month of arrival in France.
Whether you were employed or self-employed.

It will also be issued to those in receipt of Short Term Incapacity Benefit as long as this benefit continues to be paid.

These forms are issued by the Department for Work and Pensions (DWP) (in the UK) at Newcastle upon Tyne. See www.dwp.gov.uk/international/index.asp

If you feel that you qualify for either of these forms then you should specifically request it. Leaving the decision to the DWP as to what form is issued can lead to unnecessary delay. For example they could issue a E104 which details the NI contributions paid, but this form alone will not be sufficient to obtain affiliation to CPAM.

Along with any E Form you must provide proof of residence in France. This normally means providing a residence permit ""carte de séjour".

Affiliation via Residence Criteria

If you are not an EU National or you do not qualify for an E Form then you are able to affiliate under pure residence criteria. However unlike with E Forms, whereby your basic healthcare costs are without charge, affiliation under this criteria does involve a financial contribution. The contribution is calculated as 8% of the difference between 6609 Euros and the household income after deducting allowances. The household income after deducting allowances is expressed in the form of the "revenu fiscal de reference" which is stated on your French income tax statement, the "avis d'impot". If you have not completed a French tax return then other reasonable proof of income will be accepted. However the calculation of any contribution other than by the "revenu fiscal de reference" is likely to result in a higher contribution being paid.

Finally

Whether you affiliate via E Forms or residence criteria it is emphasised that a personal contribution will still be required to fund the difference between the reimbursement by CPAM and the full costs. Individual circumstances are just that and further advice should be sought.

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