Healthcare Coverage for Americans Resident in France
France has one of the world’s best healthcare systems, funded by a mix of public and private contributions.
Under French law, health coverage is universal and obligatory. Contributions to healthcare costs are determined as a function of income and means.
What is PUMa? Who is Covered by PUMa?
PUMa (protection universelle maladie) became law on January 1, 2016. This ensures that all legal residents in France have medical insurance provided by the French government, even if they are not in the labor market. According to the Code of Social Security (Code de la Sécurite Sociale, or CSS), one is covered automatically by the French Sécurité Sociale (Sécu) after three months' legal residence in France. (CSS Art. L. 160-1).
Exceptions to PUMa
There are a few categories of Americans resident in France who are not covered by PUMa. Expatriate workers who are sent to work in France by their U.S. employers are ineligible for PUMa for up to 5 years. People self-employed in the U.S. who come to work in France are ineligible for up to 2 years. During those periods, these people will need to purchase private insurance, unless provided by their employers.
Certain people already covered for health costs are also ineligible, including employees and retirees of international organizations, diplomats, and people with pensions from other EU countries. (CSS Art. L. 160-6).
Paying for PUMa
The French government determines a resident’s level of contribution to PUMa in different ways, taking into account one’s income and means. Most Americans who are employed in France pay into the Sécu via deductions from salaries, or contributions made by independent workers.
Until recently, many American residents who did not earn income taxable in France did not pay for public healthcare coverage. This was changed by law on Dec 16, 2025 (Article 53 article L. 160-1-1). As of 2026, many Americans residing in France on a regular basis, who do not engage in professional activity there, will need to make a financial contribution for their public healthcare. If these people do not pay the contribution, their public healthcare rights will be suspended. The terms and conditions, including the amount of the contribution, will be determined by decree, typically in the next 6 months.
Some American residents covered by PUMa have already been charged a contribution to the costs of their care called the cotisation subsidiaire maladie (CSM). To explain who might be charged the CSM, it is easier to start by listing who is exempt from the CSM.
People who have annual earnings from employment or professional activity greater than a modest level, set at €9612 for 2026 (equal to 20% of the PASS, or Plafond Annuel de la Sécurité Sociale, an amount revised annually) are considered to have contributed sufficiently to the national health system via payroll deductions paid by them and their employers, or by direct charges. They do not have to pay the CSM.
This category also includes married or PACSed individuals (partners recognized legally) whose income is not sufficient, but whose partners earn sufficient income; and minors. So if either you or your partner declare more than €9612 of income to the French authorities in 2026, or your combined declared income exceeds that amount, then neither of you will be charged the CSM.
Residents receiving French or EU retirement pensions, invalidity pensions, and unemployment are exempt from the CSM. If one partner of a marriage or a PAC is exonerated because of a pension, neither is subject to the CSM. To our knowledge, this exoneration has also been applied to U.S. Social Security pensioners. However, we cannot confirm this last point absolutely, or assert that the applicable law, regulations or interpretation will not change.
Therefore, residents who do not correspond to any of the categories listed above may have to contribute to the costs of their care via the CSM. In these cases, the CSM of approximately 6.5% is levied against an individual’s worldwide passive income over a threshold equal to 50% of the PASS (the 2026 threshold is €24,030), and up to a ceiling of 8xPASS, or €384,480 in 2026. Note that in the case of a couple, the threshold is doubled to €48,060.
Though US source passive income is exempt from French income tax according to the U.S.-France tax treaty, it is still reported on the French tax declaration, and the CSM is levied on it.
In summary, people who pay the CSM are generally those who have little to no employment income and significant passive income. Some examples might be early retirees not yet drawing a pension, but living off investment income, or business owners who do not pay themselves a salary out of their business.
There is much ambiguity concerning who is charged CSM. Sometimes people are billed when they shouldn’t need to pay, and other times people do not receive a bill even though they seem to be required to pay the CSM. There seems to be confusion within the Urssaf, and perhaps different regional offices apply different rules. If you do believe you should not be assessed CSM, yet you receive a bill, you can contest the bill with the Urssaf.
It seems that if you are required to pay the CSM, then you will not be assessed the newly-voted fee for the public health system. But again, none of this is yet clear.
When do you pay for PUMa?
Americans resident in France are not notified of their status as beneficiaries of PUMa, nor that they may even have to pay for it. When they file their French income tax declaration they are flagged by the French tax authorities (the “fisc”). The fisc examines tax declarations to measure the criteria of earnings and investment income that subject the resident to the CSM. The names of those who must pay the CSM are sent to Urssaf, the social security collection agency. Urssaf sends a bill for the CSM at the end of November in the year following each year of coverage. In other words, if you attained three months of legal residency in 2025, you were covered from that moment, but your first official notification will be when you receive a bill for 2025 PUMa coverage at the end of November 2026. It will be pro-rated for the number of months you were resident in France in 2025.
You must pay the total or arrange payments in three equal portions or contest the bill within 30 days. Note that the 30 days run through the December holiday season, so you should anticipate this if you plan to travel.
Is the CSM Tax Deductible in the U.S.?
France's Constitutional Council has ruled that the CSM is not a “tax” (impôt de toute nature), but a quid pro quo. Therefore, ask your tax adviser if it is deductible as a foreign tax credit on your U.S. return.
Registering with the Sécu
As mentioned above, although PUMa is considered automatic, you are not told about it. You have to apply for a medical insurance account (ouverture des droits) at your local Sécu office (Caisse Primaire d’Assurance Maladie, or CPAM) before you can claim reimbursements or subscribe to complementary or mutuelle coverage.
You are not alone in not being told you have national medical coverage. The Sécu, which manages the health system, does not know you either! The Sécu only learns it has a newly affiliated member when that person files the request for ouverture des droits at the CPAM.
The approval can take time, depending upon the workload of the département where you live. In the meantime, if you need health care you must ask the provider for a feuille de soins, which shows what was done medically and how much you paid. You can later submit these documents to the CPAM for reimbursement.
When your application is approved, the Sécu will issue an attestation de droits that tells any medical provider of your enrolled status. You will be able to apply for a health card, the Carte Vitale, and for complementary insurance. You will receive a permanent social security number.
Private Medical Insurance in France
In France, the Social Security covers only moderate amounts of most people’s total healthcare spend, so most French residents have optional complementary coverage called a mutuelle, which provides coverage on top of the costs covered by the French Social Security. A good analogy of this is found in the U.S.: Medicare recipients purchase insurance to supplement their Medicare coverage.
If you are an American citizen legally resident in France, you have several options. You can purchase a private health plan to cover all of your healthcare insurance needs (we call this a “First Euro” plan). Or you can purchase supplemental insurance to top up what is paid by the French Social Security. Or you can just get by with the reimbursements paid by the Sécu, and not have any other coverage but pay out of pocket. There are advantages and disadvantages to each option.
AARO’s First Euro Plan Offers Advantages
If you are considering the insurance plan offered through AARO, you can subscribe to the First Euro plan even if you are also covered by the Sécu. If you choose 1st euro coverage, there are several advantages.
- You will have a much higher maximum reimbursement level than that of the Sécu
- You will not need a complementary mutuelle
- You will not need to deal with the Sécu (in French, and bureaucratic). When there are questions or issues, you can discuss them in English with MSH.
- You will have one reimbursing organization, greatly simplifying the reimbursement process.
- You will be covered for most care when traveling outside France, including to the U.S., and will not be subject only to the limitation of what the Sécu will reimburse.
- If you relocate from France to another foreign country in the future, you can continue to be covered by the AARO plan.
- You can be covered from your first date of relocation to France – no need to wait 3 months for Sécu.
On the negative side, having a 1st euro private insurance, such as AARO’s plan, means that you will receive, in effect, partially redundant coverage, and you may have to pay the CSM in addition to the AARO plan premium.
Or Consider AARO’s Supplemental Coverage
Alternatively, you could opt for complementary coverage in AARO’s plan, in which case the Sécu pays in the first instance, and the AARO coverage acts as the mutuelle coverage. We invite you to compare the complementary coverage in the AARO plan, which has higher reimbursement rates at competitive rates, to other mutuelles. See the Annual Premium Table.
Some benefits of the AARO supplemental plan compared to most mutuelles include:
- Communication can be done in English
- Higher reimbursement levels than most mutuelles
- Worldwide coverage for emergencies, including repatriation
- Worldwide medical network with >1 million medical partners
- 2nd opinion from MSH’s own doctors
- Teleconsultations in English 24/7, including prescriptions
- Third and subsequent children are free
Whether you are required to pay the CSM or not, we reiterate that most residents in France prefer to have private medical coverage to reimburse more than just the modest limits imposed by the Sécu.
Want More Information?
Please go to the Plan Summary page or consult the Features & Benefits of the AARO Health Plan.
If you have questions about AARO’s plans, please contact the MSH Enrollment Team at +33 1 44 20 48 77, or email them at
Disclaimer: This information is provided as a service to help inform and educate AARO members and other U.S. citizens. This information is not intended, and should not be construed, as recommendations, or as legal or professional advice from AARO. AARO is not responsible for any action taken based on the information provided.
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