Payers
Health, maternity and paternity insurance benefits are provided by:
France's universal healthcare system (PUMa) guarantees coverage of healthcare expenses for all individuals who:
Certain members are liable to a 6.5% alternative health care contribution (cotisation subsidiaire maladie/ CSM), on an earned-income and asset-tested basis:
The calculation basis for this contribution is capped at 8 times France's annual social security ceiling, which is €351,936 in 2023.
The French health insurance system covers health expenses (reimbursement of healthcare costs) for insured persons and their minor dependents, and cash benefits (daily medical leave benefits for temporary incapacity for work) for insured persons.
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 medications, 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 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
From the age of 16, all patients must choose a primary care physician (médecin traitant) who will provide referrals as part of the “coordinated care pathway” system (parcours de soins coordonné).
The primary care physician'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 primary care physician can be either a general practitioner or a specialist. Patients can change their primary care physician by notifying their local health insurance fund.
Medical procedures are reimbursed at the standard rate when carried out or recommended by the primary care physician, given that the patient is following the coordinated care pathway. However, if the patient has not registered with a primary care physician 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 primary care physician under certain circumstances: in the event of a medical emergency, the absence of the primary care physician 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 primary care physician. 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 pay part of their medical expenses (ticket modérateur) out of pocket. In special cases however, such as for women more than 6 months pregnant or long-term illnesses, the patient is exempted from this co-payment. A doctor's appointment within the coordinated healthcare pathway system is reimbursed at a rate of 70%.
The patient's out-of-pocket payment will be higher if the coordinated 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 medications, paramedical procedures and travel for medical purposes.
Members of the following groups are exempted from these per-procedure and flat charges:
To ensure that the amounts refunded to patients match actual expenditure (including the co-payment) and that the Funds are not required to reimburse medical expenses without any oversight, 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:
Practitioners may also charge higher rates for patients who are not referred by or registered with a primary care physician or who have not followed the "healthcare pathway" system.
Medications are supplied on prescription. The social security system covers a portion of the cost of medications included in the positive list of reimbursable pharmaceutical products. Certain medications are reimbursed on the basis of a reference price determined according to the price of the lowest-priced generic equivalent.
Reimbursement rates vary depending on the medication's recognized medical benefit:
There is a €0.50 flat charge for each item of reimbursable medication. For example, for the purchase of one item of medication priced at €10 and reimbursable at a rate of 65% by the French health care system, l'Assurance Maladie will reimburse €6 (€6.50 minus a €0.50 flat charge).
The third-party payment system
Through the third-party payment system (tiers payant), the patient does not pay medical expenses upfront. As from January 1st, 2017, this system covers pregnant women and patients with long-term illnesses (ALD). Patients in these categories no longer pay upfront for their appointments with medical professionals as part of their maternity or ALD 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 be responsible for the portion of the fees not covered by the national health insurance system.
Beginning January 1, 2022, anyone who goes to the emergency room but is not admitted to the hospital will be charged a flat fee of €19.61.
A reduced-rate emergency room fee (€8.49) is payable by:
Members of the following categories are not charged the emergency room fee (FPU):
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, procedures, etc.
Certain extras such as a private room, a telephone, or a television are not covered by the public health insurance system. However, these expenses may be fully or partially covered by the patient's supplementary health insurance provider or mutuelle.
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 not covered by the French health insurance system.
In some cases or for certain insured individuals patients receive 100% coverage:
In these situations, they are still required to pay the €20 flat fee (or €15 in a psychiatric ward) as well as the €24 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 CSS coverage, patients with a long-term illness, a work-related illness, or an occupational accident injury, women 6 or more months pregnant, children hospitalized within their first 30 days of life, etc.).
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 a hospital, an application for coverage is submitted to the health care fund to which they belong. 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.
Transportation expenses for medical services can be covered on the basis of a medical prescription:
A prescription is necessary in order to be reimbursed for the following:
Transportation expenses are generally reimbursed at a rate of 65%. The patient pays the remaining 35% out of pocket, plus the minimum charge of €2 per journey up to a maximum €4 in any one day.
Patients who meet the usual requirements for coverage can be reimbursed by the French health insurance system at a rate of 100% under certain circumstances (e.g. transportation in connection with an ALD or for treatment and testing in connection with an industrial accident or illness, transportation for women in their 6th month of pregnancy or more, those with Subsidized Supplementary Health Insurance Program [CSS] or State Medical Aide [AME] coverage, for urgent-care purposes, etc.).
Supplementary insurance covers healthcare expenses that are not covered by the compulsory basic scheme or services for which that scheme provides no coverage at all.
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.
Effective November 1st, 2019, CMU-C (supplementary universal health care insurance) and the ACS (grant toward the cost of a mutual or private insurance plan) have been replaced by the Subsidized Supplementary Health Insurance Program (Complémentaire santé solidaire/ CSS).
It enrolls insured individuals:
As of January 2022, subsidized supplementary health insurance (CSS) is awarded automatically and free of charge to new active-solidarity income (RSA) recipients.
CSS members' health insurance expenses are covered by their health insurance funds and by the delegated supplementary insurer (organisme gestionnaire) which they have chosen.
The 100 % Santé (100% covered) program
This program provides 100% coverage for a predetermined range (set aside as 100 % santé) of three types of medical equipment: audiology (hearing aids), optics (eyeglasses), and dental (dental prosthetics). It applies to holders of a supplementary health insurance policy that meets a set of government specifications (these policies, which are termed “responsable,” make up 95% of all currently available contracts) or those with Subsidized Supplementary Health Insurance (CSS).
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.
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). This waiting period does not apply to members with a registered long-term illness (ALD) who are prescribed medical leave as a result of that illness.
Daily benefits amount to 50% of the member'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 gross monthly minimum wage or Smic (3,144.96 euros as from May 1st, 2023). Even with a salary above €3,144.96, gross daily benefits cannot exceed €51.70.
A maximum of 360 daily benefits can be paid over any 3-year period. 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.
Daily cash benefits are subject to income tax as well as to social security withholdings:
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 (congé de solidarité familiale) 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 claimant stops work completely the allowance is payable for 21 days at a rate of €60.55 per day from 1st April 2023. 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 €30.28.
Maternity and paternity insurance covers:
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 medications, paramedical services and travel.
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.
Daily benefits are paid when the eligible person stops working. They are awarded to the mother during prenatal and postnatal 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.
*Reduced to 6 months as from 20th August 2023.
The length of maternity leave is determined by the number of children the insured is expecting and her other dependent children.
| 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 (or more) expected | 24 weeks | 22 weeks | 46 weeks |
With the approval of the doctor who is monitoring her pregnancy, an employee can take part of her prenatal leave after delivery.
In the event of premature delivery (fewer than 6 weeks before the expected date of delivery) the member's total maternity leave period is not shortened: the portion of prenatal leave not taken will be automatically added on to the postpartum leave entitlement.
In the event of late delivery, the length of the postpartum leave entitlement will remain the same and begin on the day of actual delivery.
Paternity leave
The duration of the paternity and childcare leave differs according to whether it is a single or multiple birth.
In case of birth of one child, the duration of leave is set at 25 calendar days, broken down into 2 periods :
In case of multiple birth, the duration of leave is set at 32 calendar days, broken down into 2 periods :
All leave must be taken within the 6 months following the child's birth.
Finally, adoption leave is 16 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 spouses decide to share their adoption leave, the leave period will be extended by 25 to 32 days as determined by how many children are being adopted and how many dependent children are already in the household. In this case, the parents will need to split their leave into 2 separate periods, the shorter of which must be at least 25 days (or 32 days if adopting more than one child). These 2 periods can be taken either one after the other or at the same time.
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 (€3,666 as of January 1st, 2023) after a flat-rate 21% withholding of the employee's share of statutory and contractual social contributions and taxes (including CSG and CRDS). As of January 1st, 2023, the daily payment cannot exceed €95.22 (prior to this 21% withholding).
Daily maternity and paternity benefits are paid every 14 days from the 1st day of entitlement (with no waiting period).
Payers
Disability pensions are awarded by:
Disability pensions (except for the caregiver top-up, majoration pour tierce personne) are subject to income tax and social security withholdings: the general social contribution (CSG), the social debt repayment contribution (CRDS), and the additional solidarity contribution for autonomy (Casa) at separate rates as determined by the member's financial means.
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:
There are three categories of pension, depending on the member's remaining capacity for work:
*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 (€311.56 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).
From 1st April 2022, Decree no. 2022-257 of 23 February 2022 amended the rules of aggregation between disability allowance and professional income, pursuing an objective of guaranteeing an additional gain for the insured practising a professional activity. In the case of an insured receiving a disability allowance and practising a professional activity, the payment of the disability allowance may be reduced or suspended if the resources (allowance + professional income or equivalent over 12
calendar months) exceed a certain threshold called the comparison threshold.
If the amount of the aggregated resources (allowance + professional income) is less than the comparison threshold, the allowance is not reduced. If the amount of the aggregated resources is greater than the comparison threshold, the excess observed is divided by 12 to obtain the amount of the monthly excess. The monthly allowance paid is then reduced by half of the excess recorded.
The comparison threshold upheld is the higher of:
and
Precision about the comparison threshold upheld: If the most advantageous amount is less than the gross annual SMIC, the comparison threshold upheld is the gross annual SMIC. If the most advantageous amount is greater than the annual Social Security cap (43,992 euros as at 1st January 2023), the comparison threshold upheld is reduced to the Social Security cap (1.5 the Social Security cap as of 30th July 2023).
Those drawing a disability pension 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, medications and transport but are exempted of the €24 charge on major medical procedures.
If the recipient is not in employment, the disability pension is automatically converted into an old-age pension at the legal minimum retirement age. 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, or before then if the recipient stops working.
ASI is not liable to the general social contribution (CSG) or to the social debt repayment contribution (CRDS). It is also income tax-exempt.
The additional disability allowance (ASI) is awarded as a supplement to a disability or disabled widow(er)'s pension to claimants whose monthly income is below a cap of:
The additional disability allowance is calculated on a means-tested basis. The amount of an ASI award is equal to the cap, from which the claimant's income is subtracted. For a claimant living alone (or with a spouse not claiming ASI), ASI cannot exceed €548,44 a month.
A claimant living alone with a monthly income of €500 will be awarded: €860 – €500, which comes to €360/ month in ASI.
The widow's or widower's disability pension (pension d'invalidité de veuve ou de veuf) is awarded 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 (disability or old-age) pension that had or would have been awarded to the deceased spouse. A 10% increase is granted to recipients who have had at least 3 dependent children.
A 10% increase is granted to recipients who have had at least 3 dependent children.
From age 55, the widow's or widower's disability pension is replaced by a widow's or widower's old-age pension, which is paid by their retirement pension fund.
This pension cannot be paid at the same time as a survivor's pension.
The death grant (capital décès) 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:
For entitlement to a death grant, it must be established that during the three month period prior to their death, the deceased was either:
The death grant is paid as a lump sum of €3,738.
Parents can apply for bereavement leave (congé de deuil parental) following the death of a child or dependent who was under the age of 25. This is an 8-day entitlement.
Parental bereavement leave benefits are liable to:
This period of leave must be taken over the course of the year following the child's or dependent's death and entitles claimants to daily benefits from the French health insurance system (l'Assurance maladie).
Daily benefits are calculated on the basis of the claimant's wages for the 3 months prior to the period of leave, or for the 12 previous months for those with seasonal or non-continuous employment, minus a flat-rate deduction to take account of statutory or collectively agreed employee's contributions and charges which are required by law.
Wages taken into account are capped at France's monthly Social Security ceiling (i.e. €3,666 for 2023). The maximum daily benefit award that can be paid during this bereavement leave is €95.22 per day after the flat-rate deduction of 21%, which takes account of compulsory employee's social security contributions and CSG and CRDS charges.
