If you’re American and researching a move to France online, it probably won’t be long before you come across a post pushing the benefits of free medical care. 

And although it’s true that France has an excellent public healthcare system, whether it really is ‘free’ for foreign nationals is a slightly more complicated question. 

Personal situation

How your health cover is organised in France depends on two things; your nationality and your personal situation.

If you are working in France then the situation is clear – you’re paying in to the system through your taxes and therefore you’re entitled to state-funded healthcare.

You can therefore apply for a carte vitale (health card) after three months of residency – full details on how to do that here. 

However if you have never worked in France then the situation is slightly different and here is where nationality comes into play.

Nationality

If you lived and worked in another country and then retired to France, your healthcare costs are usually covered by the country where you previously lived – known as your ‘competent state’.

For citizens of the UK or EU/EEA countries this is done via the S1 system – essentially after three months of residency you register in the French health system and get a carte vitale in the same way as people of working age. However, the cost of your healthcare is then reimbursed by your competent state, rather than by France. 

For citizens of non-EU countries that have a state-funded healthcare system, the reimbursement depends on whether there is a bilateral agreement in place.

Puma

There is, however, a slightly different system in place for people who fall between the cracks – including those who come from a country such as the USA which does not offer state-funded healthcare.

The Protection universelle maladie, commonly known as Puma, “guarantees any person working or residing in France on a stable and regular basis (residence in France for an uninterrupted period of more than 3 months) the right to cover their healthcare costs, on a personal basis and continuously throughout their life”.

The basic philosophy in France is that healthcare is a right, not a privilege, and people should be able to get the care that they need regardless of their financial circumstances. 

Puma is used for various groups including those who have taken early retirement to France and are not yet eligible for state pensions, but it’s also used for citizens of countries that either cannot or will not pay for their healthcare. 

It is not the same as Aide Médicale de l’Etat (AME) which provides health cover to undocumented migrants in France. 

How do I sign up for Puma?

The initial process is the same as registering for healthcare through the conventional system – you fill in the online form requesting registration in the French system, which can be found here.

The answers that you give will lead to you being registered under Puma, however you will still receive a carte vitale, which you use in the same way as everyone else to access healthcare. The Puma registration may, depending on your circumstances, make you liable for extra social charges (more on them below). 

The French system is a reimbursement model – you pay upfront for medical treatment or prescriptions, the medic then swipes your carte vitale and some or all of the money is reimbursed directly into your bank account. You can find a full explanation of how the French system works HERE. 

And is it really free?

Once you’re registered in the French system you are entitled to have your healthcare reimbursed by the state, but there is the issue of whether you need to ‘pay in’ to the system.

People who are working contribute to the system through taxes, but American retirees whose only income is a pension would not normally pay tax (apart from property taxes for those who own their own homes). The situation with taxation depends, however, on the tax treaty between France and the country that the pension comes from.

But even those who don’t pay tax may be required to pay social charges, including a contribution towards healthcare. 

In France, deductions from income come in two types – impôts (taxes) and prélèvements sociaux (social charges). You can find a full explanation of these here. They are both deducted from your income by the government, so in effect they are both taxes but technically prélèvements sociaux are not counted as a ‘tax’ by the French government.

Income from an overseas pension is usually tax free, and income from overseas such as rental income is usually tax free if you have already paid tax on it in your home country – depending on the tax treaties between France and your home country.

But ‘tax free’ doesn’t necessarily mean that you aren’t liable for at least some social charges, and these can include the cotisation de service de santé, which is intended to pay towards the health system.

The cotisation is calculated based on your income – just like a tax – and not on your health costs. It’s a flat fee that you pay per year, regardless of how much or how little you have used the French health service.

The amount is income related, but it can be up to around €2,000 a year. 

However, the amount you pay and whether you pay at all depends on your personal situation, income level and visa/residency card type. 

Do I also need health insurance?

The French healthcare model is one of reimbursement by the state, but most treatments are not refunded 100 percent.

For example a standard appointment with a family doctor or GP is €26, of which the state refunds 70 percent. The remaining €7.80 is paid either out-of-pocket by the patient, or by complementary health insurance if they have it.

Most people in France have a top-up insurance policy known as a mutuelle to cover the extra costs. Exact policy details vary, but most mutuelles will pay the remainder of the costs for all types of medical treatment although there are some things such as cosmetic procedures and certain types of dental treatment that are not fully covered. 

But in most cases your mutuelle will pay out and your total healthcare spend will be €0.

You will likely find the cost of a mutuelle considerably cheaper than health insurance in the US – the average price for a family of two adults and two children is €1,172 a year, or €98 a month, while for a single person it would be roughly half that. 

Privately funded medical care does exist in France, but it doesn’t necessarily get you better care than the state system offers, especially if you have an urgent or emergency medical system when you will be taken to the nearest state hospital.

Private insurance might get you some perks such as shorter waiting times (depending on available facilities near you), a nicer hospital room and perhaps guarantees of an English-speaking doctor (again depending on the facilities in your area).