Americans Helping Americans Abroad

Americans who reside abroad may have complex relationships with the two major US “entitlement” programs, Social Security retirement benefits and Medicare.

An employment history in the US and one or more other countries may create eligibility for pensions in one or more of these countries. This is complicated by the fact that only a couple dozen countries have bilateral agreements with the US that may permit reciprocal recognition of employment in both countries to decide whether a pension has been earned.

The US pensions also provide for spouse, dependent and survivor benefits, but these vary according to the citizenship and/or US residence periods of non-American family members.

The taxation, or not, of US pension income may depend upon bilateral agreements as well.

US Social Security pension amounts reflect average lifetime US earnings and are calculated without knowing the existence of the foreign earnings. Since the pension amounts are not a fixed percentage of these earnings, but instead are progressive, US law currently requires a reduction in the US pension (the Windfall Elimination Provision) to offset this computation anomaly.

With rare and precise exceptions, Medicare provides no health coverage outside the US, but anybody with 10 years of contributions to Medicare may receive Part A (hospital costs, excluding doctors) while in the US, without premium charges. Part B can be purchased, but enrolling after age 65 incurs a permanent 10% penalty per year of delay except in some cases of accepted employment-related coverage abroad.

AARO's mission is to inform members of the conditions for accessing Social Security and Medicare and to lobby for appropriate changes to that access for Americans living abroad or who return to the US.

Update on PUMA, from Jean Taquet

This piece was written by Jean Taquet, whose work focuses on helping Americans cope with French administration, and the logistics of moving to and living in France. 

I would like to thank the Association of Americans Resident Overseas (AARO) for its help on this issue. They are on the forefront of this, and as far as I know are the only organization actively helping members deal with the problem and possibly lobbying in favor of a change. In particular, I would like to thank Eric Fenster, the AARO member who helped me draft this section.

We had feared that the new system would result in adverse situations after being implemented for about two years without collecting premiums for the coverage offered. In fact, the situation is even worse than I had expected. I would like to highlight some of the worst examples I know of (and I am not sure I have identified all of them).

1 – The 2016 premium came due after all.
In almost all situations, especially in the private sector, people expect to have to pay health insurance premiums on time. For over a year, the impression was given that the premiums for 2016 would not be collected. I was one of the few doubting that this would be true once the administration got its act together. Sure enough, it was announced that January 15 was the deadline to pay the 2016 premium. But this came as a surprise to many.

2 – People have been charged for coverage they do not have.
Since December 2017, foreigners who declare their foreign income in France while being properly covered by a private health insurance policy have received bills from URSSAF for 2016 coverage that they have never had. The reason is that URSSAF, instead of checking the database of the caisses primaires d'assurance maladie (CPAM) to find out who was covered by the old couverture maladie universelle (CMU, which PUMa replaced), got its information from the tax office and never checked if people were covered by the public system.

People who received the URSSAF bill had subscribed in good faith to private medical insurance, and no public authority had given any notice of an obligation to join the public system. Indeed, for nearly two years no one was even able to answer questions from those who had heard about PUMa.

When I learned from my AARO connection that many Americans had received the bill, we began to help them contest it on the grounds that it charged for a health coverage system in which they were not enrolled, even though French legislation stated that payment liability did not begin until the date of enrollment.

3 – People are not being charged for coverage when they need it.
This might sound like good news but it can have very adverse consequences. URSSAF was supposed to charge 8% of the global taxable net income for the year, payable per quarter. It took considerable work to figure out that some income, mainly retirement income, is exempt from this 8% premium calculation. For many foreigners who have retired in France, most if not all of their taxable income is retirement income. So they received a letter stating that they owed nothing.

The problem is that the prefecture insists all foreigners have comprehensive coverage from either the public system or a reputable company and also pay for health coverage. So foreigners who were covered by the CMU and now PUMa must show that.

First, they have sufficient assets or income from a foreign source and that the annual net income exceeds minimum wage (14,000€).

Second, that in the case of being covered by the public system, the income used for calculating the 8% premium exceeds 9,654 euros. If the income on which the calculation is based is less, the foreigner pays nothing for the health coverage.

In the past, the prefecture has always interpreted the absence premium payments, as indicating insufficient income, as they then expect a minimum income of 14,000 euros for the same period. In such situations, the prefecture systematically denies renewal of the carte de séjour based on insufficient funds entitling the foreigner to free coverage. It was somewhat logical to expect foreigners to pay for their coverage. Today, though, many foreigners have an income far exceeding this amount and yet the new way URSSAF calculates the premium results in their coverage being free of charge. The main reason is that pensions are not used in URSSAF’s cotisation subsidiaire maladie (CMS) calculation, i.e., the name of the premium paid for the public coverage.

I have no idea how the prefectures will address this issue. If they do not get new guidelines, I fear the worst, i.e., refusal to renew cartes de séjour. I really feel that one part of the administration is not keeping another part informed, and the refusal to renew the “visiteur” immigration status will come as a very nasty surprise. One can hope that properly documenting the way the CMS is calculated should force prefectures to reconsider their procedures in view of this radical change.

4 – Some people previously covered by CMU never declared their income to France.
Holders of a carte de séjour visiteur can have the card renewed without showing a French income tax statement. I advise my clients nevertheless to show the two first pages of their last #1040 to the prefecture just to prove that they had made an income declaration. But whether these people have complied with French fiscal law is irrelevant here. 

Because URSSAF got only tax information from the French tax office and not CPAM, such people never got a letter and were never charged, but they continue to be covered, as CPAM does not verify whether the insured is paying into the system.

How long will this situation last? What are the likely consequences regarding the premiums owed and not paid? I ask the same question about the fact that there was no filing in France even though the person was clearly a French tax resident.

I fear the worst, as URSSAF can easily and rightfully consider this as tax cheating. In this specific instance, to help understand the gravity of the situation, I would compare URSSAF to the American Social Security.

PUMa (Protection universelle maladie)


The comments that follow 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  below prove to be inaccurate or incomplete.

Update 17 January 2018: Please see the bottom of this article for practical guidelines and a letter with suggested legal arguments to contest the obligation to pay.

In December 2015, France passed the budget law for 2016 and included a provision that made people with legal and stable residence in the country eligible for the health care system even if they have no connection with the labor market. This is PUMa (Protection universelle maladie).

In mid-November 2017, based upon information received from the French tax authorities, Urssaf sent a letter to people it believed to be covered under PUMa, notifying them that they would shortly receive a bill for the 2016 premiums (cotisation subsidiaire). The 2016 cotisation was calculated on the basis of revenue received in 2016 and declared to tax authorities in 2017. A little more than a month later, the bill itself was sent, with a due date 30 days later (January 19).

There are three opportunities to react to this assessment:

  • The November letter invited questions by telephone (0810 594 267) or e-mail (This email address is being protected from spambots. You need JavaScript enabled to view it.). People with a certain amount of revenue from professional activity or with “replacement” revenue (such as retirement pensions) are exempt from the cotisation, and the November letter suggested that those people bring those types of revenue, of which Urssaf may not have been aware, to Urssaf's attention so as to assert the exemption. You can still ask questions by telephone or e-mail.
  • During the 30 days prior to the due date, it is possible to contest the amount of the cotisation. Doing so suspends the due date. Urssaf examines the complaint and if a new or revised bill is sent there are again 30 days to pay. No late penalties are incurred.
  • There is a normal procedure for contesting. It has to be invoked within two months of the date of the bill. This involves appealing to the Commission de recours amiable (CRA). If satisfaction is not obtained, the next step is the Tribunal des Affaires de Sécurité Sociale (TASS). Late penalty fees may run during these appeals, unlike the second option.

The formal implementation of the cotisation subsidiaire of the PUMa is described in an interministerial circular, N° DSS/5B/2017/322,  from the director of the French Social Security and dated November 15, 2017. It is recommended that you download this document. The provision for contesting during the 30 days prior to the due date is on page 9. That's where you will find that this action suspends the due date, and that condition should be cited in your appeal.

Whatever position you may take on the legitimacy of the cotisation subsidiaire, you should be sure to verify the accuracy of the bill. This may require professional help. The circular mentioned above describes what is included in the calculation. On page 5 are the expected treatments if you are a couple (marriage, PACS and, according to certain texts, concubinage). If you were not susceptible to the cotisation for all of 2016, correct account should be taken for pro-rating the amount billed.

The conditions and the calculation of the cotisation should respect international agreements, including the US-France tax treaty.

If you want to challenge the legitimacy of the application of PUMa, per se, this is new territory; there is no precedent. While France has not previously opened access to medical insurance on the basis of residence alone, the goal of universal coverage is anchored in the constitution, along with the concept of solidarity, which implies both obligation and contribution according to means. It has been necessary to concoct a new form of payment, not related to either work or taxation.

These factors should be kept in mind when analyzing the behavior of the French administration. AARO cannot offer professional advice, but some elements of the history of PUMa and of its implementation to date can be presented. From these you may decide to develop your own arguments and present them to Urssaf, using the mechanisms and timing described above, or to other parts of the French administration.

Did URSSAF bill precociously?

PUMA (Protection universelle maladie) permits people resident in France on a regular (legal) and stable basis (résidence régulière et stable), but not in the workforce, to affiliate with the general regime of Social security and to have their medical expenses reimbursed (prise en charge des frais). Residence cannot be established until three months of uninterrupted presence. People in this situation may be subject to a premium (cotisation subsidiaire).

The PUMa law was passed on December 21, 2015, was promulgated on December 31, 2015 and took effect on January 1, 2016. Urssaf appears to be billing as of that date for people already resident in France.

A decree to define régulière was not issued until February 24, 2017. (Décret n° 2017-240 du 24 février 2017)

Note that PUMa applies to other than foreigners, but the status of legality for foreigners depends upon their residence permit (titre de séjour). It was therefore necessary to know which titres de séjour conferred the quality of résidence régulière for PUMa applicants who were foreigners. The decree containing the list of qualifying titres was not published until May 10, 2017. (JORF n°0110 du 11 mai 2017 texte n° 138 Arrêté du 10 mai 2017 fixant la liste des titres de séjour prévu au I de l'article R. 111-3 du code de la sécurité sociale )

This suggests an argument with respect to Urssaf that no foreigner was in a position to request affiliation with the Sécu so as to benefit from PUMa until May 10, 2017. Until that date, no CPAM could know which titres de séjour confirmed résidence régulière and thereby conferred eligibility for PUMa.

The circular N° DSS/5B/2017/322 specifies clearly (page 3) that liability for the cotisation subsidiaire begins as of the date of affiliation with the régime général. Urssaf billed inappropriately on the assumption that affiliation occurred as early as the first day of the law. This assumption was implied in the transmission from fiscal authorities to Urssaf of financial data that contained no information about affiliation. Yet the decree of February 24, 2017 states, “II.-La condition de régularité du séjour des personnes est appréciée au jour de la demande présentée pour bénéficier des dispositions . . .” Not assumptions made by the fisc or Urssaf or other administrative organs. Not before the person goes to the CPAM and applies.

No information or guidance by authorities was ever given to the eventual redevables, but even the most conscientious among them, who happened to read the Journal Officiel on December 31, 2015, could not have known until May 10, 2017 what constituted proof of résidence régulière for foreigners and have affiliated in consequence.

Is PUMa obligatory?

Since the passage of the law creating PUMa, this access to medical insurance based upon residence alone has been presented as a right (droit) that could be exercised by affiliating with the Sécu. Since the announcement of the billing for the cotisation subsidiaire, callers to Urssaf have been told that PUMa is obligatory, while many people who phoned Ameli/Sécu or visited CPAM offices have been told it is optional.

It is certain that access to the Sécu via work is obligatory and automatic. This was stated in Article L311-2 of the Social security code in 1985 but that article has not been updated to include obligatory affiliation based upon residence.

PUMa is the completion of the CMU, to finally make the right to medical insurance universal, but the CMU required an application and annual renewals. With the advent of PUMa,  some legal language was “softened.” For example, in a decree published in the JO of May 5, 2017: "L’article R. 243-43-2 est ainsi modifié: a) Au premier alinéa du I, les mots: « auprès duquel le cotisant est tenu de souscrire ses déclarations ou est tenu de s’affilier » sont remplacés par les mots: « dont il relève". . .»"

"Tenu de" has been removed. "Relever de" translates as “the jurisdiction of.” Thus this can be read to mean a new regime will not be created for those who opt to affiliate on the basis of residence, but they will be assigned to one of the existing obligatory regimes; namely, the general one.

This same spirit is found in the Article R111-3, the rule created by the February 24, 2017 decree: “Peuvent bénéficier . . . ou être affiliées à un régime obligatoire de sécurité sociale. . . les personnes qui  . . . sont en situation régulière au regard de la législation sur le séjour des étrangers en France.”

“May” is not the same as “must.”

We can also refer again to page 3 of the circular N° DSS/5B/2017/322, which controls the application of the cotisation subsidiaire: “La cotisation est due à compter de la date d’affiliation au régime général . . .”

It does not say the date of enactment of the law or the date when three months of residence have been accomplished, but the date of affiliation. Affiliation is a deliberate action that involves going to a CPAM and depositing a demande d'affiliation along with necessary documents. The affiliation is only valid once approved. There is no provision that Urssaf or any other agency can affiliate a person by fiat or that they claim to have done so.

Obligations are accompanied by enforcement, but there seem no signs anybody has been advised to affiliate, ordered to affiliate or sanctioned for not doing so. They have just been sent bills as if they had. But affiliation has a quid pro quo: medical expenses are reimbursed in exchange for premiums. Yet the people “affiliated” had no proof of that status, no way during the last two years to claim reimbursement.

There is another side. People have not refused to insure; they have not exposed the public to assuming their health costs, but have subscribed to private insurance. It is fundamental in France that private insurance can complement mandatory insurance, but cannot substitute for it. The answer is for the authorities to explicitly make PUMa obligatory.

Fairness and hardship

The law creating PUMa was passed on December 21, 2015. it was promulgated on Saturday, December 31, 2015, entering into force the following day, a Sunday.

Urssaf is billing as of that date for people already resident. Most of those people, and others who arrived in France after January 1, 2016, took out comprehensive medical insurance in the private sector.

Under French law, such policies are subject to tacit renewal unless notice to cancel is given two months before their annual expiration date.

If people were made subject to the cotisation subsidiaire as of January 1, they would presumably be condemned to pay a duplicative premium for their private insurance policy for an entire year.

According to their age, this could amount to many thousands of euros.

A similar problem would occur for a person arriving in France beginning January 1, 2016 who wanted comprehensive insurance prior to eligibility for PUMa (as opposed to, say, the minimal travel coverage required to obtain a long stay visa). It would be difficult or impossible to find such a policy for just three months.

Almost nobody has even heard of PUMa in the two years since its enactment. The first news for  most was a bill, and this came after a second year of “coverage” was ending, with that bill to come.

Along with a total information blackout and contradictory information, there hasn't been a single element of transition to permit planning or compliance and to avoid double-billing for health coverage.

The pension question

In various texts of the law, rules and decrees, it is stated that people with retirement pensions are exonerated from the cotisation subsidiaire. The best place to quote is Urssaf's own words: “Personnes exonérées de la cotisation subsidiaire maladie ont exonérées de cette cotisation :

What may have been intended was a French pension, because contributions for health coverage are already associated with such pensions, but neither here nor elsewhere do the texts say that.

It isn't that the lawmakers forgot about foreign pensions. Article 160-6 of the Social security code excludes from PUMa eligibility people whose foreign pensions include payment for health coverage (France doesn't want to pick up what other countries already cover based upon years of contributions.) US Social Security retirement benefits do not cover health care; Medicare is separate and does not reimburse expenses incurred abroad anyway. If you are on US Social Security, you might claim the law is what it says until it is changed and that you are thus exonerated.

In any case, PUMA is subservient to international accords and US retirement benefits, not taxable, should not be included in the cotisation calculation. Social charges on US pensions are also non-taxable and the cotisation is simply a substitute for social charges.

Instruction for AARO members who have received an "Appel de Cotisation" from URSSAF on PUMa and who wish to contest to payment due on 19 January.

  1. A letter should be sent to URSSAF containing your name, address and the account and social security numbers stated on the Appel de Cotisation.
  2. You should sign the letter and send it Recommendée avec Avis de Réception no later than the payment due date, normally19 January.
  3. You must decide whether to make the payment and request a refund or not make the payment. 
  4. If you contest the payment before the due date as set forth above, you should not be penalized.
  5. This letter (click to view) presents legal arguments that can be used to contest the obligation to pay.

From John C. Fredenberger, Avocat a la cour

Contact the Social Security Administration: help for overseas Americans

Sometimes it's hard being an overseas American!

One of those times is when you want to contact the Social Security Administration for help in obtaining a Social Security number, creating or managing a personal Social Security account, changing your information on file with the SSA, etc.

Two of the most common questions we receive about Social Security are how to obtain a SS number and how to create an online account to manage personal and payment information.

It is important to know that without a valid US address, you cannot create an online "My Social Security Account". This is due to official guidelines that cannot, at this time, be changed. A personal account like this is not, however, essential to conducting business with the Social Security Administration.

If you already have an account, you can manage it from overseas, and if you do not have one, Federal Benefits Units are there to help!

They can not only answer your questions but also carry out the operations that you are unable to perform in the absence of your own "My Social Security Account".

We are delighted to report that the Baltimore office of the SSA has provided us with contact information for every office around the world, listing the cities and regions served by those offices.

You therefore have what you need to find the right office tasked with helping you. Be sure to look at the entire list of "countries served by FBUs" and then to find the email address for the office serving your city/country.

Questions? Write to This email address is being protected from spambots. You need JavaScript enabled to view it. or This email address is being protected from spambots. You need JavaScript enabled to view it. and we will do our very best to answer!

Download the PowerPoint: Federal Benefits Units Worldwide.pptx

Changes to Social Security Claiming Strategies (revised January 2017)

The Budget Act of 2015 made changes to Social Security claiming strategies involving "restricted applications" or taking spouse benefits only while letting one's own benefits grow.

1) Before, a married person between 62 and full retirement age (FTA) who claimed spouse benefits was also deemed to have applied for all benefits to which he/she was entitled, while those who had reached FTA could take spouse benefits only (restricted application).

Under the changed rule, even people who apply at their FTA and above will be deemed to have applied for all benefits to which they are entitled. The only way to let benefits grow (until age 70) will be to delay starting them entirely.

The change applies to all those who turned 62 after December 31, 2015.

2) A second previous provision allowed the “primary earner” of a couple, in which both partners had reached FTA, to apply for benefits and suspend them. This gave the other partner access to spouse benefits while letting the primary earner's benefits continue to grow (up to age 70). 

This so-called file-and-suspend option expired April 29, 2016.  Couples already using file-and-suspend were grandfathered.

The above information should not be considered as advice and individuals should consult with Social Security or professional advisers.

Published: 2 April 2016 (revised January 2017)

AARO Social Security Seminar

On October 14, 2014, AARO hosted a seminar on U.S. Social Security, organized by longstanding AARO Social Security Chair Tom Rose and prepared by a panel from the American Embassy: Hanna Maija Haramo-Defranchi, Operations Supervisor; Pierre Sacrispeyre, Claims Representative; Mary Puse, Service Representative; and Sheela Saint Ange, Claims Representative.  The four are with the Federal Benefits Unit in Paris, part of the Frankfurt region which, with London, Manila, Mexico City, Rome and San Jose, is overseen by the Office of International Operations (Baltimore).  The panel, coordinated by long-term AARO Social Security Chair Tom Rose, covered a number of issues important to overseas citizens:

MySocial Security online provides an easy way to apply for benefits when you reach retirement age.  It:

  • estimates retirement and disability benefits
  • estimates family benefits if you die
  • provides an earnings record
  • gives estimated Social Security and Medicare taxes paid
  • provides a printable version of your Social Security Statement

While it is a new and user-friendly service, it may not be available to all AARO members because users must be 18 and have:

  • a valid E-mail address;
  • a Social Security number; and
  • a valid U.S. mailing address (including DPO/APO)

They also discussed the “right” age to retire in order to plan for optimum benefits in individual situations.  As in most countries, it has become necessary to work longer to receive full benefits (those born in 1960 or later reach full U.S. retirement age at 67).

For example, if the claimant was born between '43 and '54 (eligible for full retirement at 66)  and retires at:

  • age 62 he/she will receive 75% benefits
  • age 66 – 100% benefits
  • age 70 -  132% benefits

i.e. you will receive a higher monthly payment if you work past full retirement age.

Many do not realize they can work and still receive benefits (if they retire under the “full retirement” age, they must work less than 45 h/month; if at or after “full retirement age”, there is no limit)

While the panel frequently stressed the fact that they stand ready to help in person at the embassy, they also reminded us it is easy to apply online:

Medicare generally does not cover health services received outside the United States. Part A becomes available to you, however, if you return to the United States.  No monthly premium is withheld from your benefit payment for this protection.

If you want Part B, however, you must enroll. If you do, Social Security will normally withhold a monthly premium from your payment.

Because Medicare benefits are available only in the United States, it may not be to your advantage to sign up and pay the premium for medical insurance if you will be out of the United States for a long period of time.

The panel cautioned, however that when you do sign up, you will pay a 10 percent higher premium for each 12-month period you could have been enrolled but were not.  (AARO advocates that this “penalty” be eliminated for those who have been enrolled in foreign complementary health plans.)  AARO has an opinion in our Social Security files from Eileen Terry, former Director of Federal Benefits for Western Europe, that enrollment in a complementary health plan (e.g.: a “mutuelle” in France) qualifies as a private insurance program offered by an employer and thus prevents imposition of the 10% penalty.  However, AARO has not yet received confirmation of the application of this exemption to a real case.

Social Security Retirement estimator

This is a convenient, secure, and quick financial planning tool.  It provides immediate and accurate benefit estimates, letting you create “What if” scenarios based on different ages and earnings.

It can be accessed at

WEP or Windfall Elimination Provision

If you work for a federal, state, or local government agency, a nonprofit organization or in another country, you may be eligible for a pension based on earnings not covered by Social Security.  Such a pension can adversely affect the amount of your U.S. Social Security benefit.  The Social Security Administration does not know whether you are eligible for such a pension, and the benefit estimates you have received may not have been adjusted for such a possibility.

There are online WEP calculators to help you estimate your Social Security benefit at

Social Security and taxes

About 1/3 of the people who get Social Security pay income taxes on their benefits.

To learn your situation, visit the Benefit Planner for “Income Taxes and Your Social Security Benefits” at:

Alien Tax withholding applies to beneficiaries outside the U.S. who are NOT U.S. citizens or U.S. permanent residents.

There is a Nonresident Alien Tax Screening Tool at:

Residents of the following Tax Treaty Countries are not subject to Alien Tax Withholding:

—  Ireland

—  Israel

—  Italy

—  Japan

—  Romania

—  Switzerland

—  United Kingdom

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