The French Social Security System I - Health, maternity, paternity, disability, and death

2018

A - Health, maternity and paternity insurance

Payer :

Health, maternity and paternity insurance benefits are provided by:

  • the local Health Insurance Funds (Caisses Primaires d'Assurance Maladie/ CPAM) in metropolitan France
  • the General Social Security Funds (Caisses générales de sécurité sociale/ CGSS) in France’s Overseas Departments.

Universal Healthcare Coverage (“Couverture maladie universelle”/ CMU) was rolled out in 1999 to cover health care expenses for individuals not belonging to a compulsory health insurance scheme. Eligibility was conditional  either upon the payment of a given amount of contributions or upon completing a given number of hours of work during each reference period.

On January 1st, 2016, CMU was replaced by a universal healthcare system (PUma). This system guarantees coverage of healthcare expenses (formerly known as "benefits in kind") with no gap in coverage in the event of a change in circumstances (work-related, family, or residential) for all individuals who:

  • are working, or
  • have been residing in France (including Guadeloupe, French Guiana, Martinique, Reunion Island, Saint Barthelemy and Saint Martin) on a stable and ongoing basis for at least 3 months.

To qualify for daily benefits when prescribed medical leave for a period of less than 6 months, the claimant must have worked at least 150 hours in the 3-month period before being prescribed medical leave (or paid contributions on earnings amounting to at least 1,015 times the hourly SMIC in the previous 6-month period).

To continue receiving cash benefits after 6 months of leave, the claimant must have worked at least 600 hours in the previous 12-month period or have paid contributions on at least 2,030 times the hourly SMIC prior to going on leave. The claimant must also have been registered with the health insurance scheme for at least one year.

Persons who are not employed are also entitled to healthcare coverage if they have been residing in France on a stable and ongoing basis for at least 3 months. Their income will determine whether they are liable to the specific 8% PUma contribution.
Persons who meet the following criteria are liable to this annual contribution:

  • those with no employment income or whose income from employment in France amounts to less than 10% of the annual Social Security ceiling (i.e. less than 3,973  € in 2018),
  • AND whose investment or property income (real estate and other property income, investment income, etc.) amounts to more than 25% of the annual social security ceiling (i.e. 9,933 € in 2018). Contributions will be calculated differently depending on whether income is less than 5% of the annual social security ceiling or between 5% and 10% of that amount. Additionally, this contribution is prorated if the insured was only covered by the PUMa scheme for part of the year.

The health insurance system covers health expenses (reimbursement of healthcare costs) for insured persons and their minor dependents, and cash benefits (daily sickness benefits for temporary incapacity for work) for insured persons.

1 - Healthcare expenses

Scope of application:

"Carte Vitale"

The carte Vitale is a card with an embedded microchip that certifies entitlement to health insurance. It is issued to all persons aged 16 and over and contains all of the administrative information the patient's health insurance fund needs in order to reimburse their healthcare expenses. Depending on personal circumstances, it also contains the information needed to use the third-party payment system (meaning that the patient does not pay amounts upfront that will later be reimbursed either by the health insurance system or by his/her supplementary insurance, which kicks in once the patient has been reimbursed by the national system.
Parents can apply for a separate carte Vitale for children ages 12 and up.

Healthcare expenses cover medical and paramedical expenses as well as medicines, orthopedic appliances, and hospital costs. Insured persons are entitled to such health benefits both for themselves and for beneficiaries not covered by any social security scheme in their own right.

Under the new Universal Healthcare Coverage system (Protection Universelle Maladie/ PUMA), which was rolled out on January 1st, 2016, adults can no longer be considered beneficiaries, even if they are not employed. Only minors continue to be considered beneficiaries up to September 30th of the year in which they reach the age of 18, whether or not they are enrolled in certain educational programs, and provided that they are not employed.

However, minors over the age of 16 can apply to be insured in their own right.

Scope of coverage:

a) Physician and outpatient care

From the age of 16, all patients must choose a treating doctor ("médecin traitant") who will provide referrals as part of the “coordinated care pathway” system. The treating doctor’s role is to keep the patient’s personal medical record up to date,  prescribe further medical investigations, or refer the patient to hospital services or other health-care professionals (physiotherapists, nurses, etc.). The treating doctor can be either a general practitioner or a specialist. Patients can change their treating doctor by notifying their local health insurance fund.

Medical procedures are reimbursed at the normal rate when carried out or recommended by the treating doctor, given that the patient is following the coordinated care pathway. However, if the patient has not registered with a treating doctor or consults a specialist doctor directly, they will be refunded at a lower rate and pay more out-of-pocket than if they had stayed within the coordinated care pathway.

Patients may see a doctor other than the treating doctor directly under certain circumstances: in the event of a medical emergency, the absence of the treating doctor or his locum, or if the patient is far from home. Gynecologists, ophthalmologists and psychiatrists may also be consulted directly without a referral from a treating doctor. In such cases the practitioner will indicate the "special circumstances" applying on the medical claim form ("feuille de soins").

The patient is generally required to bear part of the medical cost ("ticket modérateur"). In special cases however, such as for women more than 6 months pregnant or long-term illnesses, the patient is exempted from the co-payment. A doctor's appointment within the healthcare pathway system is reimbursed at a rate of 70%.

The patient's out-of-pocket payment will be higher if the healthcare pathway system is not followed.

Reimbursement rates are listed online on Ameli.fr

On top of the co-payment (“ticket modérateur”), the patient is responsible for a number of other charges: a flat-rate charge for extensive procedures, a €1 charge for visiting a doctor and for examinations and tests and a flat charge for medicines, paramedical procedures and travel for medical purposes.

  • The flat-rate charge for extensive procedures is €18 and applies to medical or surgical procedures costing upwards of €120 or with a weighting factor above 60. This charge applies whether the procedure is performed in a doctor's surgery or a hospital. Certain procedures are exempted from this charge as well as persons who, for health reasons, have 100% statutory health insurance coverage [See b) Treatment that includes hospitalization].
  • All patients are required to pay a €1 flat charge for a visit to or procedure performed by a doctor, as well as for X-ray examinations and laboratory tests. Such charges may not exceed €4 per practitioner or laboratory per day, or €50 per calendar year.
  • As of 1st January 2008, a flat charge also applies to medicines, non-hospital procedures performed by allied health professionals and travel expenses for medical purposes. This charge is €0.5 per item of medicine and paramedical procedure and €2 per journey, and is capped at €50 per person per year for all procedures, €2 per day for paramedical procedures and €4 per day for travel.

Minors (under 18 years of age), women who are more than 6 months pregnant and those covered by the supplementary CMU program are exempted from paying these different charges.

To ensure that the amounts refunded to patients correspond with actual expenditure (including the co-payment) and that the Funds are not required to reimburse medical expenses without controls, the health insurance organizations have entered into national agreements with doctors and allied health professionals.

Under this system there are different "secteurs" within which practitioners may choose to work, and which apply different rates of reimbursement:

  • Secteur 1 doctors adhere fully to the national agreement and charge the official rates negotiated with the health insurance system. When they see patients within the coordinated healthcare pathway, the reimbursement rate is 70% of the official fee.
  • Secteur 2 doctors set their fees freely. The amount of their fee that exceeds the official rate is not reimbursed.
  • Doctors who have adhered to the Controlled Pricing Practices Option (“Option de pratique tarifaire maîtrisée”/ OPTAM) charge a moderately higher amount than the official fee. The reimbursement basis is the same as for “Secteur 1” doctors, along with a rate of 70% for patients following the coordinated healthcare pathway.

Practitioners may also charge higher rates for patients who are not referred by or registered with a treating doctor or who have not followed the "healthcare pathway" system.

Medicines

Medicines are supplied on prescription. The social security system covers a portion of the cost of medicines included in the positive list of reimbursable pharmaceutical products. Certain medicines are reimbursed on the basis of a reference price determined according to the price of the lowest-priced generic equivalent.

Reimbursement rates vary between 100% and 15% depending on the recognized "medical service rendered".

The third-party payment system.

Through the third-party payment system, the patient does not pay medical expenses upfront. As from January 1st, 2017, this system covers pregnant women and patients with long-term illnesses (LTI). Patients in these categories no longer pay upfront for their appointments with medical professionals as part of their maternity or LTI coverage.

"Assurance Maladie" pays the healthcare professional directly for the appointment or medical procedure.

Pharmacists can use the "third-party payment" system, meaning that the patient does not pay the full charge upfront if they show their health insurance card (“carte Vitale”). The patient must accept any generics that are offered and will only responsible be responsible for the portion of the fees not covered by the national health insurance system.

b) In-patient care

The French social security system contributes to hospital costs incurred by insured persons and their dependents. The system covers all hospital services, including fees for medical and surgical procedures performed during the patient's stay in the hospital, medication, examinations, etc.

Certain extras such as a private room, a telephone, or a television are not covered by the public health insurance system.

In the case of hospital stays in public hospitals or private clinics operating within the social security framework, hospital costs are covered at a rate of 80%. Patients are required to pay 20% of their hospital expenses, plus a 20 € daily fee.

In some cases or for certain insured individuals patients receive 100% coverage:

  • from the 31st day of hospitalization,
  • pregnant women needing hospitalization from the 4th month of pregnancy onwards,
  • hospitalization resulting from an industrial accident or illness,
  • hospitalization for a long-term illness,
  • those with complementary CMU or State Medical Aid (Aide Médicale d'Etat/ AME) coverage, etc.

In these situations, they are still required to pay the €20 flat fee (or €15 in a psychiatric ward) as well as the €18 flat-rate charge for extensive procedures (costing €120 or more or with a weighting factor of 60 or more). This flat-rate charge is payable only once during any hospital stay even if several such procedures are performed. However, some patients may be exempted from paying either or both of these two charges (those with CMU-C coverage, patients with a long-term illness, a work-related illness, or an occupational accident injury, and pregnant women from the 6th month of pregnancy).

The €18 flat-rate charge for extensive procedures costing upwards of €120 or procedures assigned a coefficient of 60 or above, is payable only once during any hospital stay even if several such procedures are performed.

Note: Some hospitals or clinics impose excess charges which are not covered by the social security health insurance system. Hospital and clinic rates as well as reimbursement rates are available online on ”Annuaire santé”.

When the insured is admitted to hospital, an application for coverage is submitted to the relevant Fund. The "third-party payment" system then applies. The Fund pays the amounts owed directly to the health care institution while the insured is responsible only for the co-payment, the daily fee and the flat-rate charge for extensive procedures.

c) Transportation expenses

Transportation expenses for medical services can be covered if they have been prescribed.

A prescription is necessary in order to be reimbursed for the following:

  • Transportation in connection with a hospitalization, regardless of length,
  • Transportation in connection with a long-term illness (LTI) if the person's state of health does not allow him/her to travel independently,
  • Transportation in connection with an industrial accident or illness,
  • Ambulance transportation when the person's state of health requires him/her to lie flat,
  • Transportation in connection with statutory verifications (appointment for a medical verification, with a medical evaluator, or with an accredited prosthesis supplier.

Even with a doctor's prescription, the following types of transportation require prior authorization from their Health insurance fund's medical team:

  • Long-distance transportation, or more than 150 km one way,
  • Frequent transportation (at least 4 trips of over 50 km one way over a 2-month period for the same treatment,
  • Transportation for children and adolescents enrolled in early-intervention medical-social centers (centres d'action médico-sociale précoce/CAMSP) and medical-psycho-pedagogical centers (centres médico-psycho-pédagogiques/ CMPP),
  • Commercial airline or boat transportation.

Transportation expenses are generally reimbursed at a rate of 65%. The patient bears the remaining 35%, plus the minimum charge of €2 per journey up to a maximum €4 in any one day and 50 euros per year.

Supplementary health insurance

Supplementary insurance covers healthcare expenses that are not covered by the compulsory basic scheme.

If insured persons do not have group supplementary insurance through their employment, they can take out supplementary insurance with a mutual fund, provident fund or insurance company.

Supplementary Universal Health Insurance Coverage ("CMU-C") provides those whose income is below a given ceiling with free 100% coverage for their medical expenses.

However, if a person’s  income exceeds the ceiling for entitlement to CMU-C (up to 35% higher), a grant toward the cost of a mutual or private insurance plan ("Aide au paiement d'une complémentaire santé" / ACS) can be awarded to help pay for supplementary insurance. The amount of this grant (from €100 to €550) is based on the beneficiary's age.

  • More information is available on cmu.fr

2 - Cash benefits

a) Daily cash benefits

Daily cash benefits are subject to income tax as well as to social security withholdings:

  • 0.5% for the social debt repayment contribution (CRDS);
  • 6.2% for the general social contribution (CSG)

In the event of incapacity for work, medical leave must be prescribed by a doctor. The insured must submit the medical leave form to their local health insurance fund (CPAM) within 48 hours. Daily cash benefits are only payable as from the 4th day of absence from work (3-day waiting period)

Daily benefits amount to 50% of the insured’s basic daily wage. This is calculated based on an average of the insured’s gross salaries (subject to contributions) for the 3 months prior to going on medical leave, or for the 12 months prior to the leave period if their employment is seasonal or periodic, with a cap of 1.8 times the applicable monthly minimum wage or Smic (2,697.24 euros as from January 1st, 2018). If the insured has 3 dependent children, daily benefits are increased to 66% of the insured’s basic daily wage beginning from the 31st day of medical leave. 

For long-term illnesses, the daily benefit can be paid for a maximum period of three years from beginning to end date for each illness. For all other illnesses, the maximum number of daily benefit payments over a 3-year period is 360.

b) Daily compassionate care leave allowance

The daily compassionate care leave allowance is subject to tax and CSG (7.5%) and CRDS (0.5%) withholdings.

This allowance is paid to persons who have been granted compassionate leave to look after a terminally ill family member (ascendant, descendant, sibling) or trusted person ("personne de confiance"), or who have used their compassionate leave to cut back to part-time work for that purpose.

If the recipient stops work completely the allowance is payable for 21 days at a rate of €55.38 per day. If the recipient reduces the number of hours worked to part time, it is payable for 42 days at half the full-time rate, or €27.69.

Maternity and paternity insurance

Maternity and paternity insurance covers:

  • pregnancy and delivery-related costs,
  • cash benefits during the mother's pre- and post-natal leave,
  •  the mother's and/or father's adoption leave
  •  and the father's paternity leave.

1 - Maternity-related healthcare

Once pregnancy has been confirmed, the doctor or midwife will report it to the patient's local healthcare fund. To be entitled to prenatal care under France's maternity insurance system, the pregnancy must be reported before the end of the 3rd month.

Entitlement to benefits is determined using the same criteria as for health insurance. It is determined at the estimated date of conception, or if the patient is not eligible at that date, at the date of prenatal leave.

All compulsory pre-natal examinations (compulsory prenatal appointments, birth preparation classes, and complementary laboratory tests), are covered at a rate of 100%. Moreover, between the sixth month of pregnancy and the twelfth day following birth, all medical expenses are covered at a rate of 100%, whether or not they are pregnancy-related. The mother is also exempted from the €1 charge and the flat charge for medicines, paramedical services and travel.

As from January 1st, 2017, the third-party payment system applies to all medical care that is covered by the maternity insurance system at a rate of 100% and provided by non-hospital-based health professionals. This means that the patient does not pay for any care upfront as Assurance Maladie pays the healthcare professional directly for the appointment or procedures performed.

2 - Daily maternity and paternity benefits

Daily benefits are paid when the eligible person stops working. They are awarded to female salaried workers during pre- and post-natal leave, and to fathers under France's paternity leave program. For adoptions, daily benefits may be shared between both parents. To qualify for these benefits, the insured person must have paid the requisite amounts in contributions or worked the requisite number of hours, and must also have been registered with the social security system at least 10 months prior to the expected date of delivery or the child's date of arrival in the household.

The length of maternity leave is determined by the number of children the insured is expecting and her other dependent children.

Length of maternity leave
Family circumstances Length of prenatal leave Length of postnatal leave Total length of maternity leave
1 child expected and fewer than 2 dependent children or children born viable 6 weeks 10 weeks 16 weeks
1 child expected and already 2 dependent children on a permanent and ongoing basis 8 weeks 18 weeks 26 weeks
Twins expected 12 weeks 22 weeks 34 weeks
Triplets expected 24 weeks 22 weeks 46 weeks
Daily maternity/paternity benefits are subject to income tax.

If the pregnancy causes a medical condition, prenatal leave can be extended by an additional two weeks.

With the approval of the doctor who is monitoring her pregnancy, an employee can take part of her prenatal leave after delivery.

Additionally, in the case of premature births (more than 6 weeks before the expected date of delivery) the maternity leave period is increased by the number of days intervening between the date of delivery and the date 6 weeks before the expected date of birth.

The paternity leave period is 11 consecutive days for the birth of 1 child, or 18 consecutive days in the case of a multiple birth.

Finally, adoption leave is 10 weeks, or 22 weeks for the adoption of more than one child. If the adopted child is at least the 3rd child in the household, the leave period is extended to 18 weeks. If the father and the mother are eligible for benefit payments during their parental leave and if the parental leave is shared by the parents, the period of leave is extended to 11 days, or 18 days if more than one child is adopted.

The amount of the daily maternity, adoption or paternity benefit payment is equal to the average daily wage of the 3-month period preceding pre-natal leave up to the monthly social security ceiling (€3,311 as of January 1st, 2018) after deduction of the employee's share of statutory and contractual social contributions and taxes (flat rate of 21%). As of January 1st, 2018, the daily payment cannot exceed €85.99.

B - Disability insurance

Payers :

Disability pensions are awarded by:

  • the local health insurance funds (caisses primaires d'assurance maladie/ CPAM);
  • the Île-de-France region health insurance fund (caisse régionale d'assurance maladie d'Île-de-France – CRAMIF), for the Paris region;
  • the general social security funds (caisses générales de sécurité sociale/CGSS) for the overseas Departments;
  • the social security fund (caisse de sécurité sociale/ CSS) in Mayotte.

1 - Disability pension

Disability pensions (except for the caregiver top-up) are subject to income tax and social security withholdings. This means that the following deductions are made before payment:

  • 0.5% social debt repayment contribution (CRDS),
  • 8.3% general social contribution (CSG)
  • 0.3% additional solidarity contribution for autonomy (CASA)

Disability insurance is an outgrowth of health insurance and is intended to compensate disabled persons for the loss of earnings resulting from a decreased ability to work or earn a living.

A disability pension is awarded to an insured individual whose disability was not caused by an industrial accident or illness and who:

  • has not reached statutory retirement age (62 for those born in 1955 and later),
  • has suffered at least a 2/3rds reduction in earning capacity or capacity for work;
  • had been insured for at least 12 months at the time s/he stopped working,
  • had worked for at least 600 hours or paid contributions on a salary equivalent to 2,030 times the hourly minimum wage (SMIC) over the same period.
Pension calculation

There are three categories of pension, depending on the degree of inability to work:

The 1st category applies to disabled persons who are still able to perform some form of gainful activity. The pension amounts to 30% of the SAM* (salaire annuel moyen: Average Annual Earnings). The maximum monthly amount is equal to 30% of the social security ceiling (€980.70).

The 2nd category applies to disabled persons who are unable to perform any form of gainful activity. This pension amounts to 50% of the SAM*.  The maximum monthly amount is equal to 50% of the social security ceiling (€1,634.50).

If a disabled person has been placed in the second category but needs a caregiver in order to perform the ordinary activities of daily living, the amount of the basic pension is then increased by 40%. This increase cannot be lower than an annual minimum amount which is re-evaluated on April 1st of each year. The maximum monthly amount of the third category disability pension is €2,742 (€1,634.50 + €1,107.49).

*The SAM represents the earnings accrued and credited to the insured person's old-age account during their ten highest-earning years (salaries liable to contributions, up to the annual social security ceiling).

Minimum: the disability pension, whatever the category, cannot be lower than a guaranteed minimum amount (€282.77 per month).

Entitlement to a disability pension can be revised or suspended at any time according to the claimant's circumstances (a change in health status resulting in a change of category, resuming employment, or reaching statutory retirement age).

Recipients of disability pensions are entitled to health/maternity benefits that are covered at a rate of 100%. They must however pay the flat charges on medical procedures, paramedical procedures, medicines and transport but are exempted of the €18 charge on major medical procedures.

If the recipient does not work, the disability pension is automatically converted into an old-age pension at the legal minimum retirement age (62for those born in 1955 or later). If they do work, they must apply for their retirement pension. Disability pension payments stop automatically when the recipient reaches the age at which a full pension is payable, regardless of the total period of insurance (67 for those born in 1955 or later), or before then if the recipient stops working.

2 - Widow's or widower's disability pension

The widow's or widower's disability pension is paid by the French health insurance system (“l’Assurance maladie) to the surviving spouse of a person who had been in receipt of, or who had been entitled to receive, a disability pension or an old-age pension.

To qualify, the surviving spouse must be under 55 years of age and suffer from a permanent disability reducing their ability to work or earn a living by at least two thirds.

The amount of the pension is equal to 54% of the pension that was paid, or would have been paid, to the deceased spouse. A 10% increase is granted to recipients who have had at least 3 dependent children.

This pension cannot be paid at the same time as a survivor's pension.

A 10% increase is granted to recipients who have had at least 3 dependent children.

More information is available on the Ameli website.

C - Death insurance

The death grant is paid to the relatives of the deceased person by the local Health Insurance Fund (in the case of Metropolitan France) or the General Social Security Fund (in the case of the Overseas Departments).

In terms of entitlement, priority is given to those persons who at the time of death were effective, total and permanent dependents of the insured person. If the deceased person had several dependents, the order of priority regarding payment of dependents is as follows:

  • a surviving spouse who was neither legally or actually separated from the insured person at the time of death, or a partner with whom the deceased had entered into a civil union (PACS),
  • the legitimate, illegitimate, adopted and foster children of the deceased,
  • the ascendants of the deceased.

For entitlement to a death grant, it must be established that during the three month period prior to their death, the deceased was either:

  • in salaried employment;
  • drawing unemployment benefits;
  • engaged in an activity equivalent to employed work;
  • a disability pensioner;
  • in receipt of industrial injury benefits with a disability rating at or above 66.66%.

For all deaths occurring from 1st January 2015, the death grant is a lump sum that increases annually. As of 1st April 2017, this lump sum is €3,415.

The death grant is exempt from CSG, CRDS, and social security contributions as well as from the inheritance tax.