Maternity/sickness and paternity insurance benefits are provided in Metropolitan France by the local Health Insurance Funds (Caisses Primaires d’Assurance Maladie) and in the Overseas Departments by the General Social Security Funds.
89% of the population have health insurance under the general scheme.
To qualify for benefits, the claimant must have paid a certain amount in contributions or worked a certain number of hours within a given reference period (contributions on an amount equal to 60 times the hourly statutory minimum wage or SMIC (€9 as of 1st January 2011) or 60 hours worked during the calendar month; or contributions on an amount equal to 120 times the hourly SMIC or 120 hours of paid employment within three calendar months; or contributions on 2,030 times the hourly SMIC or 1,200 hours worked during the 12-month period preceding the claim).
To qualify for cash benefits, the claimant must have worked at least 200 hours in the three-month period preceding the period of sick leave (or paid contributions on earnings amounting to at least 1,015 times the hourly SMIC in the previous six-month period). To continue receiving cash benefits after six months’ leave, the claimant must have worked at least 800 hours in the previous 12-month period, including 200 hours during the first three months of that period, or have paid contributions on at least 2,030 times the hourly SMIC during the 12-month period preceding sick leave, including at least 1,015 times the SMIC in the first six months. The claimant must also have been registered with the health insurance scheme for at least one year.
Recipients of an old-age or disability pension, cash sickness/maternity benefits or unemployment benefits, and recipients of an industrial injury pension with a disability rating of at least 66.66%, are also entitled to health benefits in kind, both for themselves and for their dependants.
Finally, regular and permanent French residents who do not qualify for maternity/sickness benefits in kind as insured persons or dependants, are nevertheless entitled to receive such benefits under the Universal Health Insurance Coverage (CMU) programme. Depending on their earnings, these persons may aor may not have to pay a contribution for such benefits.
The health insurance system provides in-kind benefits (reimbursement of healthcare costs) for insured persons and their dependants, and cash benefits (daily sickness benefits for temporary incapacity for work) for insured persons.
Medical and paramedical expenses as well as medicine, orthopaedic appliances and hospital costs are covered by health benefits in kind. Insured persons are entitled to such health benefits both for themselves and for dependants not covered by any social security scheme.
The dependants of an insured person include:
Scope of coverage:
All patients over 16 years of age must choose a treating doctor ("médecin traitant") who will refer them to the appropriate practitioners and hospitals and is responsible for updating their personal medical record. This so-called "coordinated care pathway" system does not apply to children. The treating doctor may be either a general practitioner or a specialist and must agree to act as the patient's treating doctor. Patients can change their treating doctor by making a new statement to their Health Insurance Fund.
The treating doctor maintains the patient's medical record and prescribes further medical investigations and referrals to other doctors, hospital services or health-care professionals (physiotherapists, nurses, etc.). All medical procedures carried out or recommended by the treating doctor are refunded at the normal rate, given that the patient is following the coordinated care pathway. If however the patient has not registered with a treating doctor or consults a specialist doctor directly, they are considered as acting outside the care pathway system and will be refunded at a lower rate than that which would apply if they had seen a treating doctor first.
The patient may see a doctor other than the treating doctor in the event of a medical emergency, the absence of the treating doctor or his locum, or if the patient is far from home. Gynaecologists, ophthalmologists and psychiatrists may be consulted without 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, as in the case of a severe, long-term illness requiring costly treatment (such illnesses being itemised on a special list), the patient is exempted from the co-payment. The co-payment will be higher if the patient is treated without being referred by a treating doctor.
The patient also bears various other costs, in addition to the co-payment: 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 €91. 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.
Since 1st January 2005, all patients have been required to pay a €1 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 new flat charge applies to medicines, non-hospital procedures performed by allied health professionals and travel expenses for medical purposes. This new charge is €0.5 per item of medicine and paramedical procedure and €2 per journey, and is capped at €50 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 six months pregnant and beneficiaries of the supplementary CMU are exempted from paying these different charges. None of the charges should be covered by the supplementary insurance providers.
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 organisations have entered into national agreements with doctors and allied health professionals.
Under this system there are three "secteurs" within which practitioners may choose to work, and which apply different rates of reimbursement:
The reform also allows practitioners to charge higher rates for patients who are not referred by or registered with a treating doctor.
The French social security system contributes to hospital costs incurred by insured persons and their dependants. The system covers all hospital services, including fees for medical and surgical procedures performed during the patient's stay in hospital, medication, examinations, etc. It does not cover the cost of non-medical extras such as a private room, telephone, television, etc.
Hospital costs are covered at a rate of 80%.
In some cases (after the 31st day in hospital or for certain surgical procedures), patients receive 100% coverage. They are still required to pay the €18 daily fee however (or €13.50 in a psychiatry department).
The €18 flat-rate charge for extensive procedures costing upwards of €91, is payable only once during any hospital stay even if several such procedures are performed.
When a patient is admitted to hospital, an application for coverage is submitted to the relevant Fund. The direct settlement system then applies. The Fund pays the amounts owed directly to the health care institution while the patient is responsible only for the co-payment, the daily fee and the flat-rate charge for extensive procedures.
In public and private non-profit health care institutions taking part in the public health service, the reference price for reimbursement ("tarif de responsabilité") by the Fund is the price charged by the hospital. In private hospitals, price schedules are set according to medical specialty under agreements concluded between regional hospital agencies and health institutions.
When the patient chooses, for personal reasons, to be admitted to a hospital whose rates are higher than those of the closest public or private hospital providing the services and care appropriate to the patient's condition, the Fund refunds the cost of the stay up to the reference price of the closest hospital.
Travel expenses for medical services are covered if:
The doctor prescribing the treatment or examinations will decide on the means of transport required. Certain journeys must be approved in advance by the Health Insurance Fund.
The patient bears 35% of the travel cost, plus the minimum charge of €2 per journey up to a maximum €4 in any one day.
For more information, visit the Ameli website.
To cover healthcare expenses that are not covered by the compulsory scheme, insured persons have the possibility of taking out supplementary insurance with a mutual fund, provident fund or insurance company. Persons on low incomes are entitled to supplementary Universal Health Insurance Coverage (“CMU complémentaire”), which covers all costs. Recipients pay no upfront costs and are also exempted from the €1 charge and the €0.5 flat charge. People whose income slightly exceeds the ceiling for entitlement to the supplementary CMU, can apply for a grant to contribute to toward the cost of a mutual or private insurance plan.
In the event of incapacity for work, a sick note must be obtained from a doctor. Daily cash benefits are payable as from the fourth day of absence from work.
The daily benefit is equal to 50% of the daily wage of the last three months up to a limit of 1/91.25 of the quarterly social security ceiling (€8.838), and two-thirds of the daily wage as from the 31st day of sick leave if the insured person has three or more dependent children, up to a limit of 1/547.5 of the annual social security ceiling (with maximum amounts - as of 1st January 2011 - of €48.43 and €64.57 respectively).
Minimum amount: beyond the first six months of sick leave, the daily benefit cannot be lower than 1/365th of the minimum disability pension (€8.71 per day as of 1st January 2011). If an increase is payable, the benefit cannot be lower than 1/365th of the minimum amount of the disability pension increased by a third, i.e. €11.61 as of 1st January 2011.
For long-term illnesses, the daily benefit can be paid for a maximum period of three years for each illness. For all other illnesses, the maximum number of daily benefit payments over a three year period is 360.
This allowance is paid to persons who have been granted compassionate leave to look after a gravely ill family member (ascendant, descendant, sibling) or trusted person (“personne de confiance”), or who have used their compassionate leave to reduce their hours of work for that purpose.
If the recipient stops work completely the allowance is payable for 24 days at a rate of €53.17 per day. If the recipient reduces the number of hours worked, it is payable for 42 days at a rate of €26.58.
For more information, visit the Ameli website:
Maternity insurance and paternity leave benefits are provided in Metropolitan France by the local Health Insurance Funds and in the Overseas Departments by the General Social Security Funds.
Maternity and paternity insurance covers pregnancy and delivery-related costs as well as 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.
Benefits in kind are provided to women who are insured, and to the spouses, daughters or daughters-in-law of insured males.
The claimant must notify their local Health Insurance Fund as soon as possible, and submit to various compulsory pre- and post-natal medical examinations.
Entitlement to benefits, determined at the estimated date of conception (or if there was no entitlement at that date, at the date of prenatal leave) is governed by the same conditions as applicable for health insurance. All compulsory pre-natal examinations are covered with no co-payment payable. Between the first day of the sixth month of pregnancy and the twelfth day following birth, all pregnancy-related costs are covered, also with no co-payment. The mother is also exempted from the €1 charge and the flat charge for medicines, paramedical services and travel.
Cash benefits are provided when the concerned person stops working. In addition to maternity cash benefits paid to women during pre- and post-natal leave, paternity leave benefits are paid to fathers. 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 ten months prior to the expected date of delivery or the child’s date of arrival in the household.
The amount of the daily benefit payment is equal to the average daily wage of the three-month period preceding pre-natal leave up to a quarterly ceiling of €8,838, after deduction of the employee’s share of statutory social contributions and taxes. The daily payment cannot be lower than 1/365th of the disability pension (€8.72) and cannot exceed €77.79 as of 1st January 2011.
Mothers are required to take a minimum eight weeks' maternity leave, but are entitled to a total 16 weeks (usually six weeks prior to the expected date of delivery and ten weeks after). Two additional weeks prior to delivery may be awarded in the case of a pregnancy with complications. With a doctor’s recommendation, the mother may also take part of the prenatal leave after giving birth. For a third child, leave is extended to 26 weeks (eight pre-natal and 18 post-natal). Mothers expecting twins or triplets (or more) are entitled to 12 weeks' and 24 weeks' pre-natal leave respectively, and 22 weeks of post-natal benefits. In the case of premature births (more than six 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 six weeks before the expected date of birth.
The paternity leave period is 11 consecutive days, or 18 consecutive days in the case of a multiple birth.
Adoption leave is ten weeks, or 22 weeks for the adoption of more than one child. If the adopted child is at least the third child in the household, the leave period is extended to 18 weeks. If the father and the mother are eligible to 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.
Disability pensions are awarded by the local Health Insurance Funds, the Regional Health Fund for Ile de France (in the case of the Paris region) and the General Social Security Funds (in the case of the Overseas Departments).
Disability insurance is an outgrowth of sickness 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 person under 60 years of age is regarded as disabled if suffering from a condition that prevents them from earning - in any gainful activity - a wage equal to at least a third of the wage normally paid for the job in which they were employed before stopping work or prior to the recognition of their disability status.
As for sickness/maternity benefits, claimants must prove that they have paid contributions or completed a certain number of hours of paid work prior to the date when they stopped working or prior to the recognition of their disability status: contributions on earnings equal to 2,030 times the hourly SMIC (Salaire Minimum Interprofessionnel de Croissance: Index-linked Guaranteed Minimum Wage) during the preceding 12 calendar months including 1,015 times the hourly SMIC during the first six months - or 800 hours of work in 12 calendar months including 200 hours during the first three months. They must also have been registered for at least a year with the social security system.
Pension calculation
There are three categories of pension, depending on the degree of inability to work:
Minimum: the disability pension, whatever the category, cannot be lower than a guaranteed minimum amount (€3,181.68 per year since 1st April 2010 increasing to €12,460.37 for persons requiring constant attendance).
Recipients of disability pensions are entitled to sickness/maternity benefits for themselves and their dependants, with no co-payment ("ticket modérateur", i.e. portion of the medical cost borne by the patient and designed to moderate demand). 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 statutory pension payment 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.
The widow's or widower's disability pension is paid by the local Health Insurance Fund, the Regional Health Insurance Fund for Ile de France (in the case of the Paris region) or the General Social Security Fund (in the case of the Overseas Departments). It is payable 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, suffer from a permanent disability reducing their ability to work or earn a living by at least two thirds, and have an income below a certain level.
The amount of the pension is equal to 54% of the pension that was paid, or would have been paid, to the deceased spouse.
For more information, visit the Ameli website.
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 dependants of the insured person. If the deceased person has several dependants, the order of priority regarding payment of dependants is as follows:
For entitlement to a survivor's pension, it must be established that during the three month period prior to their death, the deceased was either:
The death grant is equal to 90 times the insured person's daily earnings up to a ceiling of €8,838 as of 1st January 2011, and not lower than 1% of the annual ceiling, i.e. €353.52.
For more information, visit the Ameli website.
