French Healthcare

Please note that taxation and property are complex subjects and you should not take or refrain from taking any step without full independent advice on the particular facts of your case. The content of this article is of a general nature and no liability is accepted in connection with it.

Many of those who take the plunge and move to France have either reached French retirement age (60) or are close to it and living on a UK private pension. One of their principal concerns is whether they will be able to get healthcare treatment in France, should they need it. Indeed, one of their main reasons for going may be the availability of top-quality healthcare with the absence of waiting lists if required.

That said, healthcare is one of the principal reasons for moving to France in the first place ! According to the WHO, in 2000, France had the best healthcare system in the world, on which it spends more than it spends on defence (!). Perhaps some of the below helps to explain why.

Unlike in the UK, the French system is not free at the point of delivery. Rather, every patient must pay for his treatment and is later refunded to a certain extent. Some treatment is totally refunded, other less so (see below). Therefore, for the expatriate, it is not so much a matter of having to pay as how to get this refund.

In France, every medical treatment has a recommended price. Those who adhere to this are called 'conventionne', those who do not -non-conventionnee. The latter can charge what they like but the former can include 'private' establishments. However, rather like notaries, even those who follow the fixed prices can on occasion charge extra, if, for example, there are complications, but such extra charges must be 'tactful and reasonable'. It's obviously best to establish what they are likely to be in advance, if you can.

There are three main ways that a UK national can use the French healthcare system without paying outright. All are through European Union reciprocity. The onus for requesting the form most suitable to you (for example, pensioners should certainly get hold of an E121) is on you, and you should request it with plenty of notice.

The relevant forms are:

* E111 : this covers emergencies for short-term ("temporary") visitors to another member state and is not a substitute for proper travel insurance;
* E106: this is a certificate of entitlement to certain benefits which a UK national can use in France because he would be entitled to them in the UK - this should be used by those who are retired (i.e. will not be working in France) but have not yet reached UK retirement age. Entitlements under it last for a maximum of two years and in many cases only one year, and then you must pay contributions in France until and unless you are eligible for an E121;
* E121: this entitles UK pensioners (i.e. having reached UK retirement age and in receipt of a UK state pension - you will be asked for proof) officially resident in France to the same healthcare treatment to which they were entitled in the UK, to the extent that the French system provides it (e.g. may not include nursing help). It can also cover those on long-term incapacity benefit and those receiving severe disablement allowance. It covers you for the rest of your life or until you leave France.

Since January 2000 anyone resident in France for three months or more has been obliged to affiliate to the French system, and is thus entitled to basic health treatment (CMU), but must contribute some 8% of taxable income over 6,505 euro (2003 figure) per household, payable quarterly. These contributions are known as the CSG and the CRDS.

Those holding an E106 or E121 are not required to contribute but are still refunded for medical treatment as a Frenchman would be. Also, if one half of a couple is covered by the E121 the other is automatically covered whether or not they would be entitled to an E121 in their own right (and they can request an E121 from the UK authorities). This includes both married couples and those in "concubinage notoire" - i.e. common law couples.

Those who move to France holding no "E" form should in theory pay into the French system from their arrival. This can create problems as year x's payments are determined by reference to year x-1's income, which in the case of high-flying executives in their last year before retirement, can be a large sum.It is best to register with your local healthcare provider (CPAM) as soon as you arrive in France, or shortly after. You will usually require proof of residence to do so. Under the loi Sarkozy of 2003, the "carte de sejour" is no longer compulsory, but it is still possible to obtain one and it can be extremely useful in oiling the wheels of the French state. If you do not have one, another proof of residence may be acceptable (e.g. a utility bill). Please note that once you register, so as to be able to take advantage of the French health system, it will be very difficult if not impossible to argue that you are not tax resident, so it is best to think everything through in advance.

You should show your CPAM any of the above "E" forms which might exempt you from paying contributions in France. You do not need to register with a particular doctor; you just go wherever you want.

The most important fact to remember is that the French system usually only refunds around 70% of medical costs. (Only a few serious illnesses such as cancer are covered to 100%.) It is therefore imperative to obtain private insurance for the remainder. Of course, you can decide whether to have comprehensive cover or merely for more serious illnesses. For example, if a doctor's appointment costs 20 euro you might be happy to fund 30%, or 6 euro, from your own pocket. You might be less happy to cover 30% of an operation which costs 20,000 euro (not including one's food in hospital, ambulance fees, private room etc. none of which are reimbursable). The best policy, if you can afford it, is one that pays out the full difference between the state's contribution and your bill without limitation or exception.

This complementary insurance can be obtained in the UK as well as in France. The advantage of the UK is that it is set up in English and help is usually available in English if you should come to make a claim. On the other hand, the French insurer has greater insight into its country's system due to its proximity. If you are eligible for cover by the French system, it is in fact illegal to provide or to buy comprehensive medical insurance but some coverage from a "mutuelle" - i.e. the complementary coverage - is essential.

The fundamental principle is that you, as a UK national resident in France, are "only" entitled to whatever the equivalent Frenchman would be entitled to. You must therefore be well prepared for the particular facets of the French system. Also be aware that you may not simply be able to return to the UK for NHS treatment at any point although there is no reason why you cannot in principle retain your UK private insurance.

Finally, if you move to France and are not yet entitled to a UK state pension, think about making voluntary NI contributions to the UK system (usually, but not necessarily, from taxed income). The state pension itself may be nothing to write home about, but with it comes the right, via the E121, to free French healthcare, when the time comes.

Sykes Anderson LLP advises on all aspects of French and UK tax. Please contact us at Saul Brownstein or on 020 7398 4700.

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French Healthcare
Please note that taxation and property are complex subjects and you should not take or refrain from taking any step without full independent advice on the particular facts of your...

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