Under French law, health coverage is universal and obligatory. Contributions to healthcare costs are determined as a function of income and means.
What is PUMA? Who is Covered by PUMA?
PUMA (protection universelle maladie) became law on January 1, 2016. This ensures that all legal residents in France have medical insurance even if they are not in the labor market. According to the Code of Social Security (Code de la Sécurite Sociale, or CSS), you are considered to be covered automatically by the French Sécurité Sociale after three months' legal residence in France. (CSS Art. L. 160-1).
Exceptions to PUMA
There are a few exceptions. The following Americans resident in France are not covered by 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. 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, including employees and retirees of international organizations, diplomats, and people with pensions from other EU countries. (CSS Art. L. 160-6).
Paying for PUMA
The French government determines a resident’s level of contribution to PUMA in different ways, taking into account one’s income and means. Some residents covered by PUMA may be charged a contribution to the costs of their care called the cotisation subsidiaire maladie (CSM). To explain who might be charged the CSM, it is easier to start by listing who is exempt from the CSM.
People who have annual earnings from employment or professional activity greater than a modest level, currently 8800€ (equal to 20% of the PASS, or Plafond Annuel de la Sécurité Sociale, an amount revised annually) 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 do not have to pay the CSM.
This category also includes married or PACSed individuals (partners recognized legally) whose income is not sufficient, but whose partners earn sufficient income; and minors. So if either you or your partner declare more than 8800€ of income annually, neither of you will be charged the CSM.
Residents receiving French or EU retirement pensions, invalidity pensions, and unemployment are exempt from the CSM. If one partner of a marriage or a PAC is exonerated because of a pension, neither is subject to the CSM. To our knowledge, this exoneration has also been applied to U.S. Social Security pensioners. However, we cannot confirm this last point absolutely, or assert that the applicable law, regulations or interpretation will not change.
Therefore, residents who do not correspond to any of the categories listed above may have to contribute to the costs of their care via the CSM. In these cases, the CSM of approximately 6.5% is levied against an individual’s worldwide passive income over a threshold equal to 50% of the PASS (the threshold is currently about 22,000€/yr), and under a ceiling of 8xPASS, currently about 350,000€. Note that in the case of a couple, the threshold is doubled from 22,000€ to 44,000€/yr.
Though US source passive income is exempt from French income tax according to the US-France tax treaty, it is still reported on the French tax declaration, and the CSM is levied on it.
In summary, people who pay the CSM are generally those who have little to no employment income and significant passive income. Some examples might be early retirees not yet drawing a pension, but living off investment income, or business owners who do not pay themselves a salary out of their business.
When do you Pay for PUMA?
Americans resident in France are not notified of their status as beneficiaries of PUMA, nor that they may even have to pay for it. When they file their French income tax declaration they are flagged 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 2023, you will be covered from that moment, but your first official notification will be when you receive a bill for 2023 PUMA coverage at the end of November 2024. It will be pro-rated for the number of months you are resident in France in 2023.
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 to travel.
Is the CSM Tax Deductible?
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 US return.
Registering with the Sécu
As mentioned above, although PUMA is considered automatic, you are not told about it. You have to apply for a medical insurance account (ouverture des droits) at your local social security office (Caisse Primaire d’Assurance Maladie, or CPAM) before you can claim reimbursements or subscribe to complementary or mutuelle coverage.
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 you either! The Sécu only learns it has a newly affiliated member when that person files the request for ouverture des droits at the CPAM.
The approval can take time, 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.
Private Medical Insurance
In France, private health insurance cannot substitute for the national health system coverage However, French Social Security covers only moderate amounts of most people’s total healthcare spend, so most French residents have optional complementary coverage called a mutuelle.
If you are an American citizen legally resident in France, you should consider whether you want to have 1st euro (non-deductible) private insurance or whether you prefer just the complementary, mutuelle coverage. There are pluses and minuses to both options.
If you are considering the insurance plan offered through AARO, you can subscribe to the 1st euro plan even if you are covered by PUMA. If you choose 1st euro coverage, there are several “pluses”: You would have a much higher reimbursement rate than the Sécu's, and you would probably not need a complementary mutuelle.
You would not need to deal with the Sécu (in French, and bureaucratic), and you would have one reimbursing organization, greatly simplifying the reimbursement process. In addition, you may be covered for care when traveling outside France, including to the U.S. The AARO plan is portable for people who change their country of residence. When there are issues, you can discuss in English.
On the negative side, having a 1st euro private insurance, such as AARO’s plan, means that you will receive, in effect, partially redundant coverage, and you may have to pay the CSM in addition to the AARO plan premium.
Alternatively, you could opt for complementary coverage in AARO’s plan, in which case the Sécu pays in the first instance, and the AARO coverage acts as the mutuelle coverage. We invite you to compare the complementary coverage in the AARO plan, which has high reimbursement rates at competitive rates, to other mutuelles.
Whether you are required to pay the CSM or not, we reiterate that most residents in France prefer to have coverage to reimburse more than just the modest limits imposed by the Sécu.
This information is provided as a service to help inform and educate AARO members and other U.S. citizens. This information is not intended, and should not be construed, as recommendations, or as legal or professional advice from AARO. AARO is not responsible for any action taken based on the information provided.