Health insurance – who pays for what?

This information is relevant for people coming from a European country with an S1 or S2 form, formerly called E121, E106 or E109, or, more occasionally, an E112, and who wish to live in France.

New names for the European health forms

  • S1 (formerly the E121) is for those who have reached retirement age in their country of origin, and will be covered in France as long as they stay in France.
  • S1 (formerly the E106) is for those who have paid into the health system of their country for a certain time, but have not yet reached retirement age. The health office will provide this form, which enables people to obtain cover in the French system up to a maximum of two years.
  • S1 (formerly the E109) is for those who still work in their country, but live in France (or their family does). This means that they still pay into the health system of their country, but will receive health cover in the country where they live. This form is obtained upon special request.
  • S2 (formerly the E112) is a complementary form which adds to one of the three previous forms in case the person has a preexisting medical condition.

Unmarried couples

What can unmarried partners do, one registered with CPAM, the other having no right to an S form yet? They should go and see the mayor of their place of residence and ask for a certificat de concubinage (proof that they live as a couple). Thanks to this document, delivered simply and for free, the second person can be registered as dependent and can be covered by the E form and the top-up health policy too if they wish.

With these E-forms, you can go to the local CPAM office, in your préfecture or sous-préfecture town, and obtain registration.

Registering for health cover

To do this, you will need to submit:

  • a copy of your passport
  • a copy of your birth certificate
  • a copy of your marriage certificate or certificat de concubinage, if applicable
  • proof of address (electricity, telephone or water bill)
  • bank RIB (identification number of a French bank account)

NB: Before the last change of rules of the CPAM, even with no Eform, you could register and obtain cover by paying a contribution based on your income. This is no longer possible.

Who pays?

CPAM will reimburse medical costs, and will turn to the healthcare office of the country of origin of the person to obtain refund.

For visitors on a short stay in France with an EHIC (European health insurance card), rules are different.

Why, what and how about CPAM?

CPAM stands for Caisse Primaire d’Assurance Maladie. The French government created the Social Security system after World War II, in 1946. Then, anyone living in France was covered for any health cost.

As years went by, society changed, medical care improved, people lived longer, and medical costs increased tremendously up to a point when the French Social Security realised they could no longer pay 100% of the costs.

This is when CPAM started to set up reference prices which were only partly refunded (80% for hospitalisation, 70% for visits to the GP, specialists, radiologist, dentist, 55% or 35% for medication, and nil for medication that is not on their list).

Reference prices are regularly reviewed, but in many cases, for example for glasses or false teeth (prothèses dentaires), the reference price is far below the real cost to the patient, so the refund by CPAM is low.

The same applies if you want to have a private room at the clinic or hospital. Some doctors, specialists or clinics also charge more than the reference price.

Top-up cover

This is why it is a good idea to take out a top-up health cover. The basic top-up cover will refund you the difference between the reference price and what the CPAM refunds. You can also take out 125%, 150% or even 200% cover – in which case, you receive 25, 50 or 100% of the reference price, on top of the reference price.

In France, there are no excesses, whether on the CPAM cover or on the topup cover. Every time you need treatment, you receive a refund.

CPAM will always take you on board under the conditions described above, even if you are disabled or have a pre-existing health condition. Many top-up insurance companies will also give you cover without asking you to fill in a questionnaire, except for the highest cover (200% and above).

Did you know…. ?

A law called Loi Évin states that insurance companies cannot cancel their top-up cover, if it has been running for more than two years. The only valid reason for cancellation by the company would be non-payment of the premium.

Some companies even give the Loi Évin guarantee from the day of subscription, without waiting for the second anniversary of the policy.

If a client’s condition deteriorates, and needs higher medical costs, insurance companies in France are not allowed to make specific premium increases linked with the number of claims, and can only apply standard increases on all their health policies. But they are allowed to add increases linked to the age of the client (for instance at 65, then at 70 etc…).

Unlike in some countries, French top-up insurance companies are not allowed to ask their clients to declare a change in their health, in case this is used as a reason to cancel the policy or dramatically increase the premium.

This article originally appeared in the September 24 – 30, 2010, edition of French Week.

The information provided here is for general guidance. The exact details of your policy will define your legal and contractual obligations. What is written there will take precedence over what is written here.

Ces informations sont données à titre indicatif. Pour connaître précisément vos obligations légales ou contractuelles en relation avec votre contrat d’assurance, veuillez vous référer aux conditions générales et particulières de votre contrat.