The Basic Healthcare System in France

November 1, 2007

The French state medical insurance system is officially classified by the World Health Organisation as the number one NHS among over 191 examined. It offers all who join a level of care in both public and private medical establishments that is not equalled anywhere else. It is available to everyone from the poorest to the wealthiest in the land.
 
It is particularly important to note that the system, without question or reservation, accepts applicants crippled from birth, suffering from long-term chronic conditions or serious diseases like cancer and gives them preferential treatment.
 

Entitlement in France under the French state medical insurance system differs widely from that in other EU states. The following outline applies whatever your age or however you are affiliated to the system. For example, by working in France, by retiring early with entitlement to temporary health form E106, by having a UK state retirement pension or other UK benefit giving entitlement to health form E121 or under the provisions of the CMU (France’s universal health cover law)
 
All reimbursements are based on an official price list called the Tarif de Convention.
 
Reimbursements as a percentage of the Tarif de Convention are:
 
                        • Visits to doctors            70%
                        • Pharmacy costs            35% to 65%
                        • Specialists’ fees            70%
                        • Routine dental costs     70%
                        • Hospitalisation costs, depending on the illness, vary from 80% to 100%
 
However, daily food charges, telephone calls and private rooms are not covered.
 
The above percentages need explanation as the system is complex and varies with different medical conditions. The following are important classifications and qualify for reimbursement of 100% of the Tarif de Convention:
 
            a) A list of 30 serious diseases that includes, for instance, cancer, heart disease,
            insulin-dependent diabetes etc.
            b) Surgery superior to KC 50. (KC 50 is a very low level.)
            c) Certain other serious diseases, for example, any illness classified by the attending doctors as             long-lasting. A stroke is an example. In the case of hospitalisation exceeding 30 days the condition is automatically classified as long-lasting.
 
When the illness falls outside the above three classifications the state pays hospital costs only up to 80% of the Tarif de Convention. This limitation can result in a costly shortfall. In addition, while related outpatient treatment and medication is reimbursed 100% of the Tarif for items a) and c) above, this does not apply in the case of item b), surgical operations.
 
It should not be taken for granted that an illness classified or otherwise will be covered 100%. You should ask your doctor to register your condition with the CPAM (Caisse Primaire d’Assurance Maladie) who, if you are accepted as 100%, will send you a letter of confirmation and explanation. If you have a serious condition registered for 100% cover, treatment for that condition is normally given without extra charges. Make sure you update your Carte Vitale accordingly at the special points provided at your local CPAM and hospitals.
 
NB. Practitioners are allowed to charge more than the Tarif de Convention. The surplus, or dépassement, is paid by the patient. The gap between cost and reimbursement is substantial and can be very expensive. To be safe, everyone in France affiliated to the state system should have a top-up insurance as well.
The choice of a top-up insurance policy, or mutuelle, is important. Most are based on a percentage of the Tarif de Convention. The price you pay depends on the percentage level you choose. It should be noted that 100% is not nearly enough. It means that the reimbursement is capped at 100% of the Tarif. This may be enough to cover routine visits to the doctor and normal pharmacy costs but as soon as you suffer from a more serious condition and need specialist treatment and possibly hospitalisation the cost of treatment is always more than the Tarif and at the 100% level you have to pay the excess yourself. The level of cover you require depends very much on the area in which you live and you should take advice on this point.
 
The system is complicated and many people coming to France find it difficult to understand. Here are some examples that may help. The deduction of €1 in the following illustrations is non-reimbursable by either CPAM or the insurer and represents patient participation brought in with the reforms of 2004.
 

Routine visit to a doctor

Tarif de Convention = €21. CPAM pays 70% = €14.70 less €1 = €13.70.
At the 100% level of guarantee the mutuelle insurance will reimburse the unpaid balance up to €20, the patient participation of €1 not being reimbursable by law.
 
If the doctor in the above example had charged €40 the patient would therefore pay €26.30.
 

Visit to a specialist

Tarif de Convention = €28 CPAM pays 70% = €19.60 less €1 = €18.60.
 
Specialists invariably charge more than the Tarif of €28 for a consultation. The charge, depending on the practitioner and the condition, is seldom lower than €35 and can be as much as €100 or even more. At the 100% level of guarantee nothing in excess of the Tarif less the €1 will be reimbursed by the mutuelle insurance.
 
At the 100% level of guarantee the insurer will reimburse the unpaid balance up to €27. If the specialist had charged €100 the patient would pay €81.40. For the insurer to have covered the complete difference less the non-refundable €1 the level of guarantee would need to be a much higher percentage of the Tarif.
 
Bear in mind that tarifs will depend on whether your doctor is your registered GP or not. The same applies for the specialists.
 
Hospitalisation is the same. In a recent settlement where orthopedic surgery was involved, the surgeon, reputed to be one of the best in France, charged extra fees amounting to 396% of the Tarif. In this case there was no limit on the guarantees, the insurer’s claims office paid the entire difference directly to the hospital. The patient never saw the bill.
 
We hope the above examples help you to understand the French system. It is not a complete cover system like the UK NHS and this is one of the ways that the excellent service is financed.
 

Issued by:

EXCLUSIVE HEALTHCARE SA
 
Help and Information Lines
France 0870 449 283 & 0870 449 175
UK 0121 288 2363
Sales +33 (0) 494 403 145

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