Americans Helping Americans Abroad

Under French law, health coverage is universal and obligatory and everybody must contribute to the costs as a function of means.

What is PUMA?

PUMA (protection universelle maladie) became law on January 1, 2016. As the name implies, it is meant to ensure that all legal residents in France have medical insurance even if they are not, as was previously required, in the labor market. According to the Code of Social Security (CSS), you are considered to be covered automatically after three months' legal residence in France. (CSS Art. L. 160-1). Although the coverage is automatic, you still have to apply for a medical insurance account (ouverture des droits) at your local social security office (CPAM) before you can claim reimbursements or subscribe to complementary or mutuelle coverage for what French social security does not pay.

Exceptions to PUMA

Expatriate workers who are sent to work in France by their U.S. employers are ineligible for the PUMA for up to 5 years, and people self-employed in the U.S. who come to work in France are ineligible for up to 2 years.

During those periods, they will need to purchase private insurance. Certain people already covered for health costs are also ineligible; such as, retirees of international organizations, diplomats, people with pensions from EU countries. (CSS Art. L. 160-6)

Paying for PUMA

People whose earnings from employment or professional activity are more than about 8200€/year are considered to have contributed sufficiently to the national health system via payroll deductions paid by them and their employers, or by direct charges. They are not concerned by the PUMA.

On the other hand, people whose earnings from employment or professional activity are less than about 8200€/year will have their medical costs reimbursed by the PUMA and, as a quid pro quo, they may have to contribute to the costs of their care (CSS Art. L. 380-2). The premium is called the cotisation subsidiaire maladie (CSM). Again, it applies to people do not make a sufficient contribution based upon work or professional activity; that is, who earn less than 8200€/yr. Instead, the CSM of 6.5% is levied against their worldwide* investment income, minus an abatement (about 20,500€ in 2020 and indexed for inflation).

Americans resident in France are not notified of their status as beneficiaries of PUMA. It is when they file their French income tax declaration that they are “discovered” by the French tax authorities (the “fisc”). The fisc examines tax declarations to measure the criteria of earnings and investment income that subject the resident to the CSM. The names of those who must pay the CSM are sent to Urssaf, the social security collection agency. Urssaf sends a bill for the CSM at the end of November in the year following each year of coverage. In other words, if you attain three months of legal residency in 2020, you will be covered from that moment, but your first official notification will be when you receive a bill for 2020 medical insurance at the end of November 2021. It will be pro-rated for your first year of residence.

You must pay the total or arrange payments in three equal portions or contest the bill within 30 days. Note that the 30 days run through the December holiday season, so you should anticipate this if you plan travel.

You are not alone in not being told you have national medical coverage. The Sécurité sociale (Sécu), which manages the health system, does not know either! The Sécu only learns it has a newly affiliated member when that person files a request for “affiliation” (ouverture des droits) at a local office, the CPAM.

The approval can take months, depending upon the workload of the département where you live. In the meantime, if you need health care you must ask the provider for a feuille de soins, which shows what was done medically and how much you paid. You can later submit these documents to the CPAM for reimbursement.

When your application is approved, the Sécu will issue an attestation de droits that tells any medical provider of your enrolled status. You will be able to apply for a health card, the Carte Vitale, and for complementary insurance. You will receive a permanent social security number.

Calculation of the CSM

If earnings are less than 20% of the PASS and worldwide* investment income is greater than 50% of the PASS, the CSM (premium) is 6.5% of the passive income above the 50% abatement. In tabular form:



Wages or professional earnings

Threshold: 20% of PASS, about €8200

Worldwide* investment income

Abatement: 50% of PASS, about €20,500

Payment rate

6.5% of amount over €20,500

Income ceiling subject to CSM

8x PASS, ie, you pay on up to about €325,000

PASS (Plafond Annuel de la Sécurité Sociale) is the earnings ceiling for social security contributions, about €41,000/yr, inflation-adjusted annually. There is also a digressive calculation for people with 0-€8200 professional income, not treated here.

France's Constitutional Council has ruled that the CSM is not a “tax” (impôt de toute nature), but a quid pro quo. Therefore, ask your tax adviser if it is deductible as a foreign tax credit on your U.S. return.

CSS Art. L. 380-2 says that people who receive a pension are exonerated from the CSM and, so far, that seems to be respected. To our knowledge, the exoneration has been applied not only to French pensions, but to U.S. Social Security and other pensions as well. We cannot now confirm this as an absolute or assert that the applicable law, regulations or interpretation will not change.

French medical insurance has generally been a family affair. If one person of a family was employed, the whole family was covered. This is the concept of the ayant droit, a right derived from a familial link to the direct beneficiary. PUMA abolishes the status of the ayant droit by according a social security number and account to each individual, but the rights do not change. So, in the case of a couple, whether married or PACSed, if one partner earns more than the PASS threshold, 8200€, neither partner is subject to the CSM. If one partner is exonerated because of a pension, neither is subject to the CSM. In the case of a couple in which both partners are subject to the CSM, the abatement of 50% of the PASS is applied to each.

Private Medical Insurance

In France, private health insurance cannot substitute for obligations to the national health system!!

People covered by the PUMA who also have 1st euro (non-deductible) private insurance are, in effect, paying for redundant coverage and could consider the advantages and disadvantages of switching to complementary private insurance.

Those who subscribe to the 1st euro plan AARO offers through MSH have certain advantages, such as a much higher reimbursement rate (generally, up to 400% of the official French tarifs) than the Sécu's (usually around 70% of official French tarifs), without having to also subscribe to a complementary policy or to a mutuelle.

There may be coverage when traveling outside France, including to the U.S.. The MSH plan is portable for people who change their country of residence. When there are problems, service is in English.

While the private insurance will likely imply redundant coverage, those not subject to the CSM because of income levels or the exemptions described above will pay a premium only for the MSH coverage. On the other hand, those who have to pay the CSM in addition to the MSH premium might consider using PUMA as primary and changing to the MSH complementary version. This will retain the high reimbursement rates that a different complementary or mutuelle cannot provide.

*IMPORTANT Even though your income from investments in the United States may not be taxable by France under the bilateral tax treaty, this income is counted when calculating the CSM. The CSM is not a tax; it is a quid pro quo: health care in exchange for a contribution to medical costs.

These comments are not legal or professional advice from AARO. They are observations, whose sources and texts you may want to verify, that you may wish to consider if you plan to ask questions of URSSAF and/or to contest the bill for a cotisation subsidiaire that you have received. AARO declines responsibility for any consequences should the information provided prove to be inaccurate or incomplete.

The AARO health insurance plan is available in almost every country in the world. Check here to see which countries are covered and click on the country name to learn more about it.

Africa | Americas | Asia | Europe | Middle East | Oceania


Middle East


The Americas



Here are some frequently asked questions about joining the AARO expat health insurance program.

If you need more information or have questions, please use the Contact AARO page.

Who can subscribe to the plan?

American citizens who are living abroad. Their dependents need not be American citizens, but they must be living with the primary insured. The primary insured must be a member of AARO.

How long must I live abroad?

Your primary residence must be outside the U.S. for more than six months per year (at least six months plus one day).

When does coverage begin and end?

Coverage begins the first day of the month following acceptance by the insurer. Coverage remains in effect, as long as there is no interruption in payment of the premium and the insured remains a member in good standing of AARO. The plan only covers you for the time you are outside the U.S., except for the annual 30-day coverage in the U.S.

I currently reside in the U.S., but I will be moving to Germany soon. Can I sign up now?

You can join AARO now and join the healthcare plan when you have established your foreign address.

Do I have to be a member of AARO before I can join the insurance plan?

Yes you must be a member in good standing of AARO to join the plan. Information on joining AARO can be found on the AARO Membership Application page.

Will this plan also serve as travel insurance?

No, you will need to obtain a separate travel insurance policy that meets your specific needs.

Additional Q&As for enrollment, healthcare, claims, re-certification and online services can be reviewed when you download the pdfHealthcare Procedures Guide Book

Ready to Sign Up?

Go to the How to Sign Up page for instructions and forms.

MSH INTERNATIONAL is a world leader in the design and management of international healthcare solutions with over 330,000 insured members across more than 194 countries and 2,000 corporate clients.

MSH INTERNATIONAL, a subsidiary of SIACI SAINT HONORE GROUP, specializes in offering international health care and death liability insurance for a wide variety of clients including individuals, small businesses, NGOs and multinational organizations. AARO’s plan falls under the individual classification, and AARO members join the plan as individuals.

Concentration on Medical Expertise

MSH concentrates on providing knowledgeable medical expertise, taking into account each applicant’s risk factors at the time of application to the plan. Once an individual is covered, they provide additional medical expertise including:

  • managing serious medical cases
  • helping the insured get second opinions
  • coordinating assistance in case medical evacuation is required.

Easy Access and Service for our Clients

With clients around the world, providing easy access anytime is a major focus for MSH. Clients can contact staff directly or use a variety of online resources. Throughout MSH is committed to a caring approach to healthcare and 24/7 availability to its clients.

  • service by a global organization with 4 regional head offices in Calgary, Paris, Dubai and Shanghai providing 24/7 coverage
  • a multinational team of60 nationalities speaking more than 40 languages
  • claims can be made online via the new MSH mobile app or the MSH secure area on the website
  • online access to records, finding health professionals and making appointments
  • in many instances, MSH can offer direct billing, so the insured member has no outlay

1. Make sure you are a member in good standing of AARO.

Find out more about AARO membership.

2. Complete, date and sign the AARO Application Form.

Download the current pdfAARO Application Form.pdf

3. Complete, date and sign the AARO Medical Questionnaire.

Download the current pdfAARO Medical Questionnaire.pdf

4. Enclose the AARO Medical Questionnaire, and any supporting medical documentation as requested in the AARO Medical Questionnaire, in a sealed envelope addressed to “Medical Advisor.”

Please see the pdfAARO Medical Questionnaire Form for details.

5. Add the following documents to your application:

  • For all applicants, including dependents, copies of both sides of your identity card or the photo page of your passport
  • In order to waive the waiting period, a copy of your certificate of coverage (less than one month old) by your current comparable insurance company indicating the dates of coverage, previous guarantees, and the terms and conditions.

6. If you wish to include dependent children aged 20 to 25, include their school/university attendance certificate.

7. Enclose your first payment. This can be either by bank check in Euros or by credit card.

If you wish to use a credit card, complete the AARO Credit Card Debit Authorization Form. You can download the current pdfAARO Credit Card Debit Authorization Form.

8. Select a payment method and enclose the appropriate document for subsequent premium payments:

  • If you wish to use a direct debit authorization from a French bank account, complete the SEPA Mandate form. You can download the pdfMandate SEPA Form.
  • If you wish to use a credit card, you can make payments using the special page after logging in on the MSH website.

9. Enclose a bank account slip or IBAN number (French or other EU account) for the account where you want your reimbursements to be sent.

10. Send all these documents to our office in Clichy where the enrollment department is based:

23 allées de l'Europe
92587 Clichy Cedex – France

MSH informs you that:

As part of our duty to provide information and advice, please be advised of the following:

  • Our analysis and sales offers have been made on the basis of the information, needs and limitations that you expressed to us. Please note that the quality of the information communicated by the policyholder directly influences the quality and consistency of our offer.
  • It is very important that you carefully read the general terms & conditions of your insurance policy, in particular the paragraphs dealing with the exclusions, policy term, elimination and qualifying periods, as the case may be, definitions of the benefits and applicable measures in case of misrepresentation or missing information.

In case of a complaint, we recommend that you contact our company first. If the problem is still not resolved, you may also contact:

  • The Autorité de Contrôle Prudentiel [Regulatory Authority for Prudential Supervision], located 61 rue Taitbout 75009 PARIS – France, or
  • The Mediator of the Chambre Syndicale des Courtiers d’Assurance (Industrial Union for Insurance Brokers), responsible for claims from individuals: This email address is being protected from spambots. You need JavaScript enabled to view it.

Please also be informed that the information collected in the fulfillment of our business objectives may be used for the purposes of promoting, administering and fulfilling the contracts offered by our company.

As provided by the French law of January 6, 1978 on Data Protection (loi informatique et libertés), amended in 2004, you have the right to access and rectify any personal information that we have on file pertaining to you. You may exercise this right by writing to:


  • Direction Juridique : Season, 39 Rue Mstislav Rostropovitch 75815 Paris Cedex 17 France
  • L’Autorité de Contrôle Prudentiel et de Résolution (ACPR) : 4 Place de Budapest CS 92459, 75436 Paris

Please do not hesitate to contact us should you have any questions or concerns.