France - Health System

Learning how the health system works in a country is paramount to any expatriate, to avoid bad suprises or to be caught unaware and unprepared in an emergency. The subject, understandably, may well occupy pages and pages, but the scope here is simply to give key basic information and alert to the importance of obtaining reliable health related information from pertinent institutions rather than running the risks associated with wrong assumptions.

We encourage you to contribute your own experience or suggestions using the 'Add Comment' button at the end of the document.

National health system
Mutuelle
Prescription
Primary care physician
Who should you consult and when?
When can you by-pass the primary care physician?
Chronic long term illness
Emergency
In-patient services and hospital admissions
Pharmacies
Alternative medicine
Glossary

National Health System

The French national health system is highly developed and computerised. It is managed by the Caisse Primaire d'Assurance Maladie (CPAM), which has an office in each department. The French health care system offers a wide range of facilities, both out-patient and in-patient, public and private, from which to choose.

The French social security system covers only a portion of your medical expenses, and below is a generic guideline to the reimbursement percentage. Remember that the percentage of reimbursement is based upon set goverment fees for each service, treatment or product, rather than the real disbursement you may incur. Following is a list of percentages per categories of medical care:

- hospital fees: 80 %
- medical fees (surgery): 70%
- pharmacy fees: 35 à 65 %
- nurse, physiotherapist fees: 60 %
- dentist fees: 70 %
- optician fees: 65 %

The Sécurité Sociale will only reimburse patients a certain amount of what you paid, whatever is not covered by the Sécurité Sociale is paid by you and/or by a complementary insurance fund (mutuelle), if you have one.
Social Security insurance is compulsory for every working person in France. Your employer is in principle responsible for making the application for social security affiliation (immatriculation) for you, but you may need to remind your HR department or take the initiative yourself.

In this case, you should go to the nearest social security office (Caisse Primaire d’Assurance Maladie or CPAM) and they will give you the necessary forms to be completed by your employer. For a list of all departments click here.
To find out where the one you belong to is located, you can consult the website Assurance Maladie en Ligne (Health Insurance online). The departments are identified in the list by the first two digits of the postal code of your postal address. You can also call, if you speak French, the council of your town.

In order to obtain your number of sécurité sociale and your carte vitale (a card similar in size and shape to a credit card with a microchip) you need to fill out a form called la demande d'immatriculation d'un travailleur. You also need  these documents:

• your resident card
• the E111 or E106 (for European) form, or private medical insurance
• your birth certificate
• relevé d'identité bancaire (RIB): a form you can cut out from any bank statement of your french bank; it contains all the information on your bank account to allow direct deposit of your reimbursement to your bank account .

Once you are affiliated or enrolled, you will receive a carte vitale with your Social Security (National Insurance) number and be assigned to a specific office or centre, usually in the commune or arrondissement or department (suburb) near where you live. They process all matters concerning your account. The carte vitale system is fully computerised.

The social security number and the carte vitale will enable you to be reimbursed for any health costs incurred by you, your spouse and children under 16 or under 20 if they are students.
Once you have become “personally insured” by your employer you are eligible for the following benefits:

• Reimbursement of medical costs and expenses incurred by illness or accident;
• Compensation for work-related illness or accident;
• Daily indemnities for lost pay due to illness, accident or maternity leave.

A fixed sum is automatically deducted from your salary to cover your contribution to social security insurance.
It is very important that when you arrive in France, you find out from your employer what sort of coverage you have and how you should make a claim when you visit any of the medical services (doctor, dentist, opthalmologist, etc.).

If you are covered by the French social security system and you go to the doctor or buy medicine on a prescription you will be asked for your carte vitale and you will  pay your portion for the service directly. Not all doctors are affiliated to the computerised carte vitale system, in this case, you will be given a Feuille de Soins (Health Insurance claim form) stamped by the doctor to fill in your insurance information and send off to your local social security office (CPAM).

The insured person should fill in the personal details and the social security number of his/her carte vitale, add  the personal details of the patient, if different from the insured person, and sign the form. The amount to be reimbursed will be paid directly to your bank account if you have previously given your bank details and you have selected the option:

• virement a un compte postal, bancaire ou de caisse d'epargne (wire transfer to postal account, bank account or credit union account),
•  if not, select autre mode de paiement (other method of payment).

Mutuelle

Mutuelles are additional private health insurances normally provided by employer that cover the remainder part of the medical expense not covered by the social security... but it gets trickier than that.

Let's make an example: you spend at the dentist 500 for a crown, the social security reimburses you 80% of their own list of fees, which places the value of the crown at 200. So let's say the reimbursement is 50% of 200, you will receive 100 in reimbursement. Depending on the contract of the mutuelle (some are more generous than others or have different rates on different medical expenses) the reimbursement you receive from them can total 400 (or 400% of the mutuelle reimbursement), therefore covering the entire amount.

In order to be reimbursed, it is necessary to follow the procedure for submitting your claim to social security first, which will pass the information on the reimbursement they have issued to you, directly to the mutuelle, which in turn will, based on this amount, calculate its reimbursement on it. Depending on which mutuelle coverage you have, this amount could cover the total cost of medical expense or only a portion of the remainder not reimbursed by the social security. Quite often the mutuelle will request from you the original copy of the medical expense you incurred, so always ask the doctor for two originals and always keep a photocopy of any claim you sent out, for your records.

Prescriptions

If you get a prescription (ordonnance) you must take this along to the pharmacy. Normally the doctor will give you the 'ordonnance' in two copies, the copy which has 'duplicata' stamped on it is for you to keep, the original is left with the pharmacist. Hand over your carte vitale when paying. The date and details of your medication will be printed on the prescription and the information automatically forwarded to your Social Security Office and your Mutuelle.

You may sometimes still use the Feuille de Soins. In this case the pharmacist will transfer the colour coded price labels (vignettes) from the packets of medicine you purchase, onto your Feuille de Soins. You should then send the Feuille de Soins, properly filled in, off to your local social security centre (CPAM). The amount reimbursed will be sent to your bank account and you will receive a statement from the CPAM which you should send to your Mutuelle to recover any remaining amounts for which you are insured.

Medical expenses are not reimbursed 100 % by the social security system. As a general rule costs are apportioned as follows:

• Pharmaceutical products are normally reimbursed at 70 % for items with a white sticker (vignette), 40 % for items with a blue sticker and 100 % for items with a cross indicated on the sticker. Costs of medication are surprisingly cheap compared to other countries
• Hospitalisation fees (for treatment in a public or private establishment which is conventionné, which means it has an agreement in place with the national health system) is usually reimbursed at 80 %
• Dispensary treatment by a doctor or nurse is usually reimbursed at 75%, with lab tests being reimbursed at 70 % and auxiliary medical fees at 65 %.

If you wish for additional insurance for reimbursement of medical costs above and beyond those provided by the French social security system you will need to take out a complementary insurance policy, known as Mutuelle.

ATTENTION: Check the delay from joining to starting to recover medical expenses. Many insurances give immediate cover ,but you may wait or a period of three to six months before you can claim for reimbursement. Your company usually has a mutuelle to recommend, depending on the type of contract you have with them. Once you are in the system, details of your medical visits will be automatically signalled to your mutuelle via the carte vitale system.
However there are still occasions where you will have to make the claim using a feuille de soins which you fill in and send off to your social security centre. Once credited to your bank account the information received by the social security centre should be transmitted directly to your mutuelle and their portion will be credited in due course.

If your company does not cover you under the French social security system (for example if you are not employed as a salarié or local employee, but are a detaché), you can still claim back your medical fees but will need to take out the correct insurance before you leave your home country.

If you come from a European Community country and are covered by the El 11 form (for a private trip to France) or E101/106 forms (for a professional stay in France) you should send a copy of this form to the International relations department in the Social security Caisse Primaire d’Assurance Maladie reponsible for your area. You will then receive reimbursement for a certain percentage of your medical costs (although it will not be 100 %).

Primary Care Physician

Until recently, the French Social Security (Sécurité Sociale website, only in French) has been based on the principle of free choice of medical treatment. The insured person chooses his doctor, dentist etc., and when visiting the General Practitioner pays any fees directly, the balance being processed with their carte vitale. The amount of reimbursement for medical expenses represents a percentage of the standardised fees set by the social security administration.

The system has been changed recently to help bring Health Service costs under control. The change consists on the need on the part of the insured person to elect a primary care physician who will treat the insured and will coordinate any further treatment by referral to specialists etc. by filling out a form. To see the form click here.
Caught a cold? Got a nagging pain? Suffering chronic illness or seasonal allergies and need to see a doctor? If you are covered by French Social Security and are aged over 16, you should go and see your primary care physician.

You can still decide not to choose a primary care physician and go to any doctor you wish to see, but you are penalised by receiving a lower percentage of reimbursement, as well as incurring higher expenses from 'out-of-network' doctors.

All medical care received, advice given and all procedures carried out by the primary care physician with whom you are registered, will be refunded at the standard rate. If you do not register with a primary care physician, refunds will be less because doctors are then allowed to apply higher fees, where the total amount is not covered by Social Security.

The aim is also to ensure, that you will get the best care available from a doctor who knows you. Your primary care physician is the doctor who usually treats you and who knows you best. This doctor is your primary contact: the one you should turn to first, whenever you have a health problem.

If necessary, your doctor will advise clinical investigations, refer you to a another physician (a consultant doctor), to a hospital or another healthcare professional (physiotherapist, nurse, etc.). The primary healthcare physician is responsible for your entire 'healthcare pathway'.

Your primary care physician centralises all information relating to your medical care and keeps your medical records updated (laboratory test results, diagnoses, treatments, etc.), something useful for when you are moving out of the country and need a copy of your medical file.

This enables you local doctor to be kept up to date concerning your health and be able to recommend the most appropriate investigations and treatment.

Your primary care physician helps cut down pointless visits and investigations and spares you from taking medication that may be incompatible if advised by one doctor without the knowledge of the other prescribing other medicines.

Personal preventative medical care

Since your doctor knows you well, he can prevent medical problems from arising in the first place (through regular checks on immunisations, regular screening, advice on stopping smoking, dieting, etc.) and by giving you individual preventative advices and procedures based on your life style, your family history (e.g. high cholesterol. diabetes, etc.).

How to choose a primary care physician?

There are no specific rules governing the choice of your primary care physician: any doctor can act as your primary care physician, you can select a general practitioner as well as a specialist,  if they agree. The form you have to fill in, in fact, must have the signature of your chosen physician.
Having factored in all the various aspects, like the possibility of communicating in your own language or the fact that you feel comfortable and at ease, in your best interest, choose a doctor that is close to you.
You are free to choose a doctor whose practice is near where you live, work or near your childrens’ school. You can choose a doctor working in a group practice, in a hospital or in a health centre.

Once you have made your choice, you should let your local sickness benefits office (CPAM) know as soon as possible. You will be provided with a Form number S3704 (Déclaration de choix du médecin traitant).  If you have not received this form, it is available from your local sickness benefits office or off the Internet at www.ameli.fr (under "Forms" ). To see the form click here. You can also phone for it to be sent to you (you will be required to speak french, of course).

The form must be signed by you and your chosen primary care physician.

Who should you consult and when?

Firstly your primary health physician. You should consult your primary care physician for all routine medical care. If necessary, further medical investigations can be advised or you can be referred to another doctor (a “consultant doctor"), a hospital or another health professional (physiotherapist, nurse…).
If necessary: the "consultant doctor". Your primary care physician can refer you to a specialist or consultant doctor (orthopaedist, cardiologist, dermatologist…) and if  he/she thinks that your health condition requires several visits with the same consultant doctor, you need not see him before each visit.
Where the consultant doctor is involved both doctors agree on a treatment plan. With your consent, your consultant doctor keeps your primary care physician aware of his diagnosis and provides all the information needed to ensure proper coordination of your medical care (diagnosis, treatment advised, result of tests, surgical reports…).

All visits to the "consultant doctor" are refunded on a standard basis.

When can you by-pass the primary care physician?

There are various situations that entitle you to refer directly to a specialist or another general practitioner without incurring the reduced reimbursement.

• Emergency: If you need emergency treatment, direct access to a doctor other than your primary care provider is allowed without this affecting the amount of your refund. The treating doctor has to specify on your feuille de soins that you were unable to see your primary care physician because you were in need of emergency treatment.
• Unavailability or away from home: If your primary care physician (or the substitute doctor) is unavailable or if you are away from home, you can see another doctor without this affecting the amount of your refund (provided that you do have a primary care physician). The doctor has to specify on your feuille de soins the reason which prevented you from seeing you primary care physician. With your agreement and to ensure proper co-ordination of your care, all information relating to your health condition will be forwarded to your primary care physician.
• Specialist doctors: gynaecologists, opthalmologist and psychiatrists are specialist doctors you can consult without a referral from your primary care physician and without this affecting the amount of your refund (provided that you do have a primary care physician). With your agreement and to ensure proper coordination of your care, these doctors will forward all information relating to your health condition to your primary care physician.
• Dental surgeons: They are not covered by the primary care provider scheme. You can consult them directly and have the standard refund. Basic dental care is covered at about 75% of costs established by French social security. Prosthetic treatment requires prior approval from your Caisse (CPAM). Reimbursement varies greatly according to the type of work that is done. The dentist should give you, in writing, a description of the treatment as well as an estimate of the cost. The French social security may not reimburse you for all X-rays a dentist considers necessary for treatment.
• Young patients (under 16): Patients under 16 do not have to register with a primary care physician. They already enjoy co-ordinated medical care through the health book (carnet de santé) completed by the paediatrician or the family doctor. They can see a paediatrician, a GP or a specialist without referral. Medical care is reimbursed applying the usual rate (70% or 100%).

From 16 years of age, all individuals have to register with a primary care physician, if not the Social Security Refund will be reduced. For individuals aged between 16 and 18, a parent's (or the parent having legal custody or the tutor) signature is required.

If you are over 16 and your parents are divorced you have to register with one primary care physician only. If you need treatment while away from your primary care physician, you are allowed to see the nearest doctor without this affecting the amount of your refund. The doctor should specify on your feuille de soins that you were unable to see your primary care physician.

The choice of physician is indicated, using Form S3704 ('Déclaration de choix du médecin traitant'). To see the form click here. You can also phone and ask to be sent a form.

Chronic long term illness

If you suffer from chronic long term illness (ALD, ailments de long duree), your doctor has to draw up a care protocol including all care necessary to ensure proper follow-up of your chronic long term illness (referral to a specialist, treatment, investigations…).

Under the care protocol, all procedures and investigations necessary to manage and control chronic long term illness, are entitled to 100% reimbursement, up to Social Security reimbursement level.

Only the procedures included in the care protocol are fully reimbursed up to Social Security reimbursement basis. You have to submit your care protocol each time you visit a health professional (doctor, chemist, nurse…) or in case of hospital admission.

If your care protocol provides for several visits with the same 'consultant doctor', you need not see your primary care physician before each visit.
The care protocol has to be signed by your doctor and by yourself, in agreement with the medical advisor from your sickness benefit office (CPAM).

In-patient services and hospital admissions

It is normally your personal physician who arranges admission to a hospital. You are not restricted to the arrondissement where you live when choosing a hospital, so you can select another hospital in another part of town which could be better equipped to handle your problems.
In the case that you do not have a personal physician, a general practitioner or specialist attached to an out-patient service at a hospital (public or private) can also arrange for admission should it prove necessary.
Hospitals in France are largely state-financed run by Public Assistance  (Assistance Publique-AP), a government unit that administers hospitals.  Public hospitals, which are often the best equipped, are obliged to accept all patients regardless of their ability to pay.
In the French health care system there are not very many full-service private hospitals, the few that exist may have staff who speak a foreign language or the hospital itself has been created to attend to a specific group or nationality (like the American Hospital in Paris).

Pharmacies

Pharmacies in France are recognised by the green cross symbol. When the symbol is illuminated the pharmacy is open. Pharmacists in France tend to have the responsibility of recommending medication and treatments. Pharmacists must verify the doctor’s prescription and make sure that the patient understands the usage of the drug.
Pharmacists sell many drugs over-the-counter including vitamins and mineral supplements, herbal mixtures and homoeopathy preparations without a doctor’s prescription. They sell baby foods, dietary products and cosmetic items etc.
It is also important to know that pharmacists can always be depended on as a source of health care information. They can even tell you if a mushroom you have picked is poisonous or not. They can provide names of doctors, nurses etc. in the area as well as the addresses of laboratories, x-ray facilities and medical supply houses for the purchase or rental of specialised equipment. They have followed a long and rigorous training and are a great source of information. However, they are not doctors, so in case of doubt always consult your physician. In every pharmacy there is a trained pharmacist present at all times.

FINDING AN ENGLISH SPEAKING DOCTOR OR DENTIST
There are various ways to find a GP (gënéralist) or dentist who speaks English. Many do and it is easiest to ask your relocation agent, local international voluntary clubs and societies, your local church or Consular Office and expatriate neighbours or Paguro listing which is a collection of information gathered from expatriates as well as using Paguro Forum.

Emergencies

In general firemen arrive before the police on emergency calls.
If you are injured and need only minor medical attention, go to the Emergency Department of any major hospital. They operate a 24-hour service.
When you are telephoning for an emergency service you must have the following information ready at hand:

• Your name and address including floor and the entrance code if applicable;
• your telephone number;
• patient’s name and age.
• Give details of the nature of the accident or illness and present condition and details of any treatment that has been given.

If you do not speak French and have nobody around who can make the call, talk slowly, clearly and as simply as possible in English.

Life threatening Emergencies: call 15, this is the SAMU (Service d’Aide Médicale d’Urgence) phone number. If you wish to know more abou the emergency system you might enjoy reading about it on the SAMU website (text in English, available also in German)

Dental emergencies: SOS Dentiste. Each city or department has a specific phone number for dentists on call during week-end and holidays. 

Alternative medicine

On-call care by doctors specialised in homoeopathy and/or acupuncture Alternative medicine in France is known as la médecine douce (the gentle medicine). For further information about alternative medicine go to:

www.medecines-douces.com/index.html
Acupuncture and homoeopathy are recognised by French social security and are therefore reimbursed under applicable rules. You should be aware though that even in this area there are constant changes and you should always ensure what is reimbursable before you undertake a treatment.

Glossary

Chronic long term illnesss (ALD affections de longue durée): severe or chronic ailments for which the
Social Security covers 100% of all medical expenses. There is a list of some 30 chronic long term illnesses, including diabetes, hypertension, AIDS, cancer, genetic diseases...

Consultant doctor: a doctor who provides medical treatment upon request of the primary care physician under a "coordinated healthcare pathway". Works in cooperation with the primary care physician. Occasionally, can give general medical advice. Most of the time, the doctor is a specialist.

Coordinated healthcare pathway: a medical care approach where the primary care physician is responsible for coordinating medical care and referring the patient to a "consultant doctor" if necessary. Medical expenses are then reimbursed at the standard rate.

Treatment plan: all procedures and investigations scheduled by the primary care physician upon proposal of the consultant doctor for a specific individual and health condition.