Our expert partners in France, Charles Hamer, offer their independent expertise to make sure you know how to access healthcare in France.
PUMA – Protection Universelle Maladie – is a new law that came into effect at the start of 2016, stating that all residents of France should get free healthcare, whatever their age, prior medical history and record of paying into the French social security system.
If you are covered by an S1 from the UK or you are employed or self-employed, there is no practical impact. If, however, you were previously covered by the CMU (Couverture Maladie Universelle), if you have started a business just to access state healthcare via a system called Auto-Entrepreneur, or if you are under pension age and still planning to move to France, then you need to know about PUMA.
PUMA is a default and compulsory national insurance scheme.
What is PUMA?
PUMA is a default and compulsory national insurance scheme, designed to give everyone who works or lives in France access to medical treatment just as comprehensive as for those who have S1 or A1 certificates.
It applies if you have ‘stable residency’ in France, which is defined as your family or main home being in France, where you have lived continuously for three months initially and then for at least six months each year thereafter.
You must pay into the scheme unless (in the relevant assessment year) you are either:
- Entitled to French healthcare because you have an S1, A1 or EHIC
- Contributing to an existing French national insurance scheme (Regime Général des Salariés) or one of the schemes applicable when your salary exceeds €9,655 or taxable profits of at least €3,860
- Receiving a French basic state pension or Régime Complémentaire pension
- Not working, but your spouse/civil partner is earning above €9,655, or generating profits above €3,860 from a France-based professional activity.
- Not working, along with your spouse/civil partner and your taxable (‘reference’) income is less than €9,655
- Under 16 or between 16 and 18 and in full time education
If contributions apply, the rate for 2016 is 8% of taxable (or ‘reference’) income above €9,611.
Taxable income is assessed by the local tax office via the Avis d’Impot, as being received in the current year.
Practical Application of PUMA
Although you will be able to receive healthcare immediately, your contributions are paid a year in arrears (because your taxable income won’t be known until the year after it is earned).
By referencing incomes in this way, PUMA makes accessing healthcare easier compared to the previous arrangement, known as CMU, for those newly arriving in France, because:
- Contributions are a function of financial status after the move to France.
- In the past you had to apply to the CPAM (Caisse Primaire d’Assurance Maladie) to have your CMU claim assessed. The CPAM was not always co-operative, leading to huge delays between application and final acceptance. Under PUMA your application should be automatically accepted on presentation of suitable ID and proof of residence.
- For adults, PUMA applies to each individual, whereas under the previous system one adult could be dependent on another (personne ayant droit). There are, however, some transitional arrangements.
- Application is made by form 735 CNAMTS (or S3705 for dependent children). This can be obtained from our office or by visiting the following link to the Ameli.fr website: https://www.ameli.fr/sites/default/files/formualires/168/736.cnamts.pdf
- Relevant income includes investment income and gains plus a nominal value for a benefit that derives from a non-income-producing asset, such as a holiday home.
PUMA will often prove to be a better strategy than the present tendency for new arrivals to access healthcare by adopting the Auto-Entrepreneur route.
Anomalies and Uncertainties.
As with any new legislation, the practical application may vary when it comes to niche areas, for example:
Low professional earnings: the rules are as yet unclear on what happens where your work requires you to pay French national insurance but your earnings are below the PUMA thresholds.
The treatment of pensions from the UK: since PUMA is compulsory, but only covers healthcare, the question arises as to whether contributions can be levied against UK/EEA sourced personal and company pensions. Unlike schemes such as Auto-Entrepreneur, PUMA does not confer any entitlement to a future French state pension.
Depending on your personal circumstances – such as how long until you receive a state pension, how long you intend to stay in France, your reliance on professional income to make ends meet, your level of unearned income and the extent to which you can fund your income by drawings from your capital – PUMA will often prove to be a better strategy than the present tendency for new arrivals to access healthcare by adopting the Auto-Entrepreneur route.