27 December 2008

Health Insurance in France

Here's the story of our health insurance coverage since we arrived in France in 2003.

To get a visa from the French consular services in America, applicants are required to show that they have medical insurance for the first year they plan to spend in France. We found insurance with an American company that satisfied the requirement. For me, at age 54, it cost $125 to $150 a month. For Walt, who is younger, it was a little less. My annual premium went up by about 10% each year.

It was never clear to me that the private insurance policy from an American company would ever really cover me in an emergency in France. I guess I just didn't trust it. I felt like I was pouring money down a bottomless well. Now $1500 or even $2000 a year isn't that expensive for coverage, but it would be nice to feel convinced that you would really be covered if you needed it.

The American policy didn't cover prescription medications, doctor visits, or dental bills. It was major-medical coverage only, exclusively for emergency hospitalization. To be covered, you had to give the company at least 48 hours advance notice that you were going to be hospitalized. And you had to go to one of just a few company-certified hospitals in France, one of which was the American Hospital in Neuilly-sur-Seine, just outside Paris. I think the hospital in Tours was a certified facility too. But not Blois.

I'm not sure what was supposed to happen if you had an accident or other unforeseen emergency that required hospital care.

Anyway, we paid for private insurance for three years. During those years, we were being assessed a special tax on unearned income (interest on bank accounts, etc.) as part of our annual French income taxes. The documentation about the tax said that it was a special assessment of 10% on interest and dividends, and that the money thus raised went to helping reduce the deficit run by the French national health insurance system.

In the fall of 2005, I called the French tax service's toll-free line to talk to a customer service representative. I explained my situation and said I didn't think I should be paying the special tax, called the Contribution Sociale, because I wasn't covered by French national health insurance. The answer was: Sorry, every taxpayer in France has to pay 10% of his unearned income, whether he has national health coverage or not.

That didn't seem fair to me, but we had no choice but to go ahead and pay again. That inspired Walt to start reading the French national health service's web site. It didn't take him long to discover that every French resident — legal aliens like us included — is entitled to basic coverage under a plan called the CMU — Couverture Médicale Universelle.

We read the requirements and put in applications in late 2005. The documents the health service, which is called the CPAM (pronounced [say-pahm], it's the Caisse Primaire d'Assurance Maladie), needed from us were not that different from the ones we send in annually for the renewal of our residency permits. Walt did have to get a new birth certificate from the county in New York State where he was born, because the one he had didn't list his parents' names and vital statistics on it. Mine did.

Within a couple of months we got our health insurance cards and we were covered at 70%.

That 70% coverage included all doctor visits, dental care, and prescription medications. It also included hospitalization, of course, which we haven't needed (knock on wood). When I had a colonoscopy back in September, it covered 70% of two 28€ fees for consultations with specialists, and then it covered 100% of the cost of the actual colonoscopy, under a French program to encourage people over 50 years of age to take advantage of regular screening for colon cancer.

Coverage at 70% might not seem like much, but remember that it costs just 22 euros to see a doctor in France, or 28 euros for certain specialists. Prescription medications cost considerably less than in the U.S., and dental care is similarly inexpensive. When I broke a filling, for example, I paid the dentist something like 45 euros to have it repaired. I assumed that was my portion of the bill and that the health service was picking up the rest of the bill. But no, I got 70% of the 45 euros back!

The private American insurance covered nothing. It promised coverage in certain situations. And did I mention that I kept a $5,000 deductible on my policy to keep the price down?

Coverage under the French system is not actually free, though it is universal.We have looked into the rules. The French health insurance system requires you to pay 8% of your income above the first 8,000 euros (that's more than $10,000) per year. So say you have annual income of 16,000 euros. You would end up paying 8% of the "extra" 8,000 euros for health insurance. That would come to 640 euros a year, if my arithmetic is right.

If your income is a lot higher, it would probably be less expensive to contract with a private insurance company for medical coverage. Consult with a French company, however, not an American one, because the coverage in France will be better, I'm sure. If you pay the national service 800 euros on every 10,000 euros of income, that can add up pretty quickly.

What happened to us recently is that the national health service noticed that Walt and I live at the same address. Over the past 9 months, we got letter after letter asking for more and more documents before we finally understood what was going on. We made an appointment with a representative at the CPAM office in Blois, where we learned that we are required to be covered under just one French social security number, not two.

Everybody has been very nice about it all. The only problem is that they assumed we ought to know how the system works. But we didn't know. So now Walt is giving up his French social security number and they are going to put him on mine. In these situations, it is good to be able to speak French, that's for sure.

After thinking about it, I can understand why people in the same household are required to have joint coverage. Imagine two people who live together and who have 8,000 euros each in annual income. They would pay nothing into the system. But under joint coverage, their combined income would show up as 16,000 euros. They would pay 640 euros into the system for coverage. That seems reasonable. Minimizing the number of people who pay nothing in is a way of keeping the system afloat.

In the process of re-enrolling as a family, we've been advised by two health service representatives that we should apply for what they call complementary coverage in addition to the basic insurance. Then we would be covered at 100%, not just 70%. To get the complementary coverage, we have to wait for tax documents (1099s, etc.) from the U.S. for 2008. The application process is not complicated and we'll send everything to the CPAM as soon as we can in 2009, after we receive the IRS documents we need.

For us, the important thing is to have coverage in case of a medical emergency — an accident or a major illness. Coverage at 70% would be much better than no coverage at all, and 100% coverage would be fantastic. Coverage on prescription meds, doctor visits, and dental care is just icing on the cake.


  1. Thanks Ken for that in-depth answer!

    A couple of questions:

    1. Is the 8% for health insurance in addition to the 10%tax that you pay (so you pay a total of 18%)?

    2. Does France tax your social security and pension income?

    I have experienced the French health system up-close and personal (unfortunately) and can only say good things about it.
    There are several excellent hospitals in Paris (in addition to the American in Neuilly-sur-Seine), and the many doctors that treated me, were both knowledgeable and caring.

    I've also had very prompt home visits from a specialist, and, when I was checked into the hospital for an emergency surgery, my primary doctor showed up to check on me. It was in the middle of the night, quite a distance from his residence, so unless he got paid for this visit by the insurance, I am still baffled. I know I had not paid him...

  2. Thanks much for this informative post. It's potentially useful--if I can get the anchor to move, the knowledge will come in handy.

  3. Isabella, I don't really know the answers to your questions. Right now I'm assuming my social security and pension income will be taxable as income in France, but I don't know at what rate.

    And I also assume that yes, I will have to pay 10% of my interest income as the Contribution Sociale and 8% of it to the CPAM for medical insurance. The pension income will not be taxed the 10% for the Contribution Sociale, I hope.

    Carolyn, good luck with the anchor.


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