Americans Helping Americans Abroad

PUMA (protection universelle maladie) reimburses medical costs to people who have no to relatively low earnings from employment or professional activity. It comes into effect automatically after three months' legal residence in France. (Social Security Code Art. L. 160-1.) Although automatic, you still must apply for a medical insurance account (ouverture des droits) at your local social security office (CPAM).

Exceptions to PUMA

Expatriate workers who are detached by their U.S. employers to work in France (for up to 5 years) or the self-employed (for up to 2 years) are ineligible for PUMA. During those periods, they will need to purchase private insurance.

Paying for PUMA

As quid pro quo, people covered under PUMA contribute to the costs of care (Art. L.380-2). The premium is called the cotisation subsidiaire maladie (CSM). It applies to people who do not make a sufficient contribution based upon work or professional activity. Instead, the CSM is levied against their worldwide investment income, minus a deductible.

French tax authorities examine tax declarations to detect those who qualify for PUMA coverage, and who fit the criteria for earnings and investment income that subject them to the CSM. They send those names to Urssaf, the social security collection agency, which bills at the end of November in the year following each year of coverage.

If you are erroneously said to be liable for the CSM, or if you are liable but the calculation of the CSM is incorrect, the bill from Urssaf will explain how to contest it. You must pay the total or arrange payments or contest within 30 days. Note that the 30 days run through the December holiday season, so you should anticipate this if you plan travel.

A Surprise for Some Americans in France

Residents in France are not notified of their status as beneficiaries of PUMA. Neither is the Sécurité sociale (CPAMs)! The Sécu only learns it has a newly affiliated member when that person files a request for "affiliation” (ouverture des droits) at a local CPAM. The approval can take up to four to six months. Once it is approved, the CPAM will issue an attestation de droits that permits application for a Carte Vitale.

Because of the absence of information, the initial Urssaf bills mailed late last year, for coverage in 2016, came as a complete surprise to people who had already paid premiums for private insurance during 2016.

The same thing will happen at the end of November 2018 when more recent arrivals will receive bills for 2017 for health insurance, they didn't know they had. This is complicated by the fact that not all prefectures seem aware of PUMA, and may still be asking for proof of medical insurance from people who are already automatically covered by the French national system.

French Government Offers Some Relief

In response to challenges to the CSM the government is therefore making changes that give some relief, effective January 1, but not retroactive. These will be of interest to those already paying and to newcomers.

CriterionBeforeAs of January 1 (due Nov 2020)
Professional income Seuil: 10% of PASS, about €4000 Seuil: 20% of PASS, about €8000
World capital income Abatement: 25% of PASS, about €10,000 Abatement: 50% of PASS, about €20,000
Payment rate 8% of amount over €10,000 6.5% of amount over €20,000
Ceiling None, pay on all passive income 8x PASS, pay on up to about €320,000

The PASS is the earnings ceiling for social security contributions, about €40,000/year, inflation-adjusted.
There is also a digressive calculation for people with 0 to €8000 professional income, not treated here.

The changes mean more people will be liable for the CSM because they need earnings of €8000 to be exonerated, but fewer people will be liable because only capital income above €20,000 will be “taxed.”

People who receive any pension are supposed to be exonerated from the CSM and, so far, that seems to be respected. In other words, the exoneration does not apply only to French pensions, but to U.S. Social Security and other pensions as well.

There are also conditions not detailed here for couples (married, PACSed) for exoneration of both when at least one is eligible for exoneration. When both partners work, there are conditions for how revenue is partitioned for purposes of the calculation.

People under the PUMA who also have 1st euro private insurance are, in effect, paying for redundant coverage and could consider the advantages and disadvantages of switching to complementary private insurance.

This article is contributed by Eric Fenster


The comments above 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.