To come under the compulsory general scheme two basic conditions must be satisfied:
The different forms of social insurance include :
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 SMIC 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 continue receiving cash benefits after six months, a one-year minimum registration period is required.
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. Depending on their earnings, these persons may also have to pay a contribution for benefits provided under the CMU.
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:
All patients over 16 years of age must choose a treating doctor 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 "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 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 medical auxiliaries.
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 particular medical services such as surgery), 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.
Supplementary health insurance programmes for people on low incomes
These programmes may cover all or part of the cost borne by the patient. Persons on low incomes are entitled to the “CMU complémentaire” (supplementary Universal Health Insurance Coverage), 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 CMU complémentaire, 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 up to a limit of 1/720th of the annual Social Security ceiling, 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 1/540th of the annual Social Security ceiling (with maximum amounts - as of 1st January 2010 - of €48.08 and €64.11 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 (€8.64 per day as of 1st January 2010). 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. €11.40 as of 1st January 2010.
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.
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 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 at least four calendar months prior to the expected date of delivery and must 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 insured person's basic daily wage after deduction of the employee’s share of statutory social contributions. The daily payment cannot be lower than 1/365th of the disability pension (€8.64) and cannot exceed the basic daily wage up to the Social Security ceiling, after deduction of social contributions and taxes (€77.24 at 1st January 2010).
As regards maternity leave, mothers are required to take a minimum eight weeks' 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 problem pregnancy. 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.
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 (€3,153.24 per year since 1st April 2009 increasing to €12,349.23 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" ). 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.
The disabled 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: http://www.ameli.fr/
The basic pensions of the general scheme are awarded by the Regional Health Insurance Fund, the National Old-Age Insurance Fund for Employed Workers of Ile de France (in the case of the Paris region), the Regional Old-Age Insurance Fund in Strasbourg (in the case of the Alsace Moselle region) or the General Social Security Fund (in the case of the Overseas Departments).
The reform introduced on 1st January 2004 maintains the statutory retirement age of 60 but introduces provisions allowing workers to retire early or continue working after 60.
The statutory age for entitlement to an old-age pension is 60. Workers may however claim their pension later if they so wish. It is also possible to claim a pension before the age of 60 in the case of extended periods of insurance or disability. Individuals who continue to work after the age of 60 and who have paid contributions for longer than the period required to obtain a full pension (this depending on the year of birth), can obtain an increase of their pension.
The amount of the pension depends on three different factors:
Average annual earnings are the adjusted earnings on which contributions have been paid. Under the 1994 reform which adopts a staged approach, the SAM is calculated on the basis of the 11 highest-earnings years for individuals born in 1934, the 12 highest-earnings years for those born in 1935, and so on. Since 1st January 2008, the SAM is calculated on the basis of the 25 best years for all individuals born after 2007.
Since 1st January 2004, persons having paid contributions for a minimum period determined according to their year of birth and age when they retire, have the possibility of retiring before 60, as shown in the table below.
| Year of birth | Retirement age | Number of quarters of contributions |
|---|---|---|
| 1949 | 59 | 161 |
| 1950 | 58 | 166 |
| 59 | 162 | |
| 57 | 171 | |
| 1951 | 58 | 167 |
| 59 | 163 | |
| 56 | 172 | |
| 1952 and after | 58 | 168 |
| 59 | 164 |
For persons under 65 wishing to draw their pension but without the total period of insurance required to receive a full pension, a reduction of the pension rate applies. This is determined according to the age at which the person retires and the number of quarters of contributions paid. For individuals born before 1944, the reduction rate is 1.25% per missing quarter with respect to the requisite period of contributions or age of 65. For individuals born in 1946 and 1948 it is 1.0625% and 0.9375 respectively and will be gradually reduced to 0.625% for people born after 1952.
Individuals with the requisite period of insurance for their year of birth, and who continue working after their 60th birthday, qualify for a pension increase. This provision is applicable as of 1st January 2004, with different rates depending on the period during which the contributions were paid. For quarters completed after 1st January 2009, the rate of increase is 1.25% for each additional quarter.
Individuals over 65 who have not completed the requisite total insurance period (all basic schemes included) will be awarded a 2.5% increase of the total period for each additional quarter worked over the age of 65.
The pension may be increased for the following reasons:
The reversion pension, like the widowhood allowance, is paid by the Regional Health Insurance Fund, the National Old-Age Insurance Fund for Ile-de-France (in the case of the Paris region) or the Regional Old-Age Insurance Fund in Strasbourg (in the case of the Alsace Moselle region).
The pension reform provided for the gradual phasing out of the widowhood allowance as of 1st July 2004, as well as payment of the reversion pension regardless of the number of years of marriage and, as of 2011, regardless of age. The 2009 Social Security Financing Act reversed this provision however, reintroducing an age requirement for a reversion pension.
The award of a reversion pension to a surviving spouse is not automatic but subject to specific conditions of age and income.
Reversion pensions are paid to surviving spouses or surviving former spouses aged at least 55, whose income is below a given level. The income to be taken into consideration is the survivor's personal income or that of the new household in the case of remarriage, civil union or common-law union. Persons whose spouse died prior to 1st January 2009 and who fulfilled the requisite conditions at the date, are entitled to a reversion pension from age 51.
The amount of the reversion pension may not exceed 54% of the deceased spouse's pension or the pension to which the deceased spouse would have been entitled.
The amount of the pension increases by €90.31 per month for surviving spouses with at least one dependent child under 16 years of age. A 10% increase applies for surviving spouses who have raised three or more children.
Persons not meeting the age requirement for a reversion pension may qualify for a widowhood allowance. This is a temporary benefit intended to support the surviving spouse until they find a job or go back to work. It is payable to any person not meeting the age requirement for a reversion pension and whose personal income is below a certain level. The amount of the benefit is €565.13 per month.
For the surviving spouse to be entitled to a widowhood allowance, the deceased spouse must have paid old-age insurance contributions during at least three months of the twelve-month period preceding their death, not including the month in which they died.
For more information visit the CNAV website at: http://www.cnav.fr/
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 €8,655 as of 1st January 2010, and not lower than 1% of the annual ceiling, i.e. €346.20.
For more information visit the Ameli website: http://www.ameli.fr/.
