Expats in France: Health Insurance (La Sécurité Sociale) and Doctors in France
Health insurance in France is called la Sécurité Sociale, la Sécu or l'Assurance Maladie. The main website for it is ameli.fr. For a general overview of French health insurance and health in general, you can download the Livret de Sante Bilingue PDF in English and in French.
"In France, everyone is entitled to health insurance to cover the cost of medical care. It is preferable to apply for it before becoming ill. The first step is to apply for “basic” public health insurance, which can be extended by paying for private supplementary insurance ("mutuelle"). For people with a low income, supplementary insurance is available free of charge and is known as supplementary universal medical cover (CMU-Complémentaire). Those without a residency permit and on a low income must apply for State medical aid (AME).
CMU-Complémentaire and AME, which can be granted quickly if necessary, make it possible for individuals to receive care without paying, at the doctor’s office, dentist’s office, hospital, laboratory or pharmacy. Those with neither money nor health insurance can only go to the PASS centres (all-day treatment centres) (PASS) under the public hospital system for the basic care required in all situations. Lastly, there exist specialised public healthcare services, which are free to everyone. The only requirement is to choose your regular doctor from whom you wish to receive care. If necessary, interpreters can be called upon."
I have no experience with CMU, AME or PASS, so this page does not deal with them. It does, however, attempt to explain sécurité sociale in France, as well as the mutuelle system, and provide anecdotes of my experiences with health insurance and doctors in France.
You will most likely receive your health insurance (Sécu) through the CPAM (Caisse Primaire de l'Assurance Maladie); however, if you work for the ministère de l'Education Nationale, la Recherche, la Culture ou Jeunesse et Sports, you will most likely be covered by the MGEN (Mutuelle Générale de l'Education Nationale). La Sécu generally reimburses 60-70% of doctor consultation and prescription costs. If you want the other 30-40% to be reimbursed, you will need to join a mutuelle (see below), which normally costs around 30 € a month.
The percentages can be misleading though, because Sécu reimburses a certain percentage of their index (base de remboursement) for consultations. Doctor consultations usually cost 22 €, but if you go to a specialist, s/he can charge more. The Sécu's index is 23 € for specialists, so regardless of how much you actually paid for the consulation, you will only be reimbursed at most 70% of 23 € by la Sécu.
If you have a spouse/partner and/or children in France with you, they can be covered through your Sécu. "En France, tous les salariés, français ou étrangers, bénéficient du système national de couverture sociale pour les frais de santé consécutifs aux maladies et accidents : la Sécurité sociale. Un chercheur étranger qui dispose d’un contrat de travail bénéficie donc d’une assurance maladie et accident du travail, de même que son conjoint et ses enfants."
If you are PACSed or married to a French citizen, you can just ask your local CPAM to add you to your partner's coverage as a dependent. For workers, if your employer does not help you get signed up with Sécu, then just go to your local CPAM and fill out the paperwork yourself. You will probably need your birth certificate, a certified translation in French, and a RIB from your bank (for the reimbursements).
* I use Sécu to refer to health insurance in general, whether you belong to CPAM or MGEN.
Social Security #: If you are a new arrival in France, you might receive a temporary Social Security number and it may or may not have letters in it. If it does have letters, it is definitely temporary. Real SS#'s begin with this formula:
First set of numbers: 1 for men; 2 for women
Second set: year you were born in
Third set: month you were born in
Fourth set: 99 for foreigners (département you were born in if you're French)
The ASSEDIC can also help you get a SS# if you're starting work or starting to look for work for the first time in France, but depending on the (in)competence of your local ASSEDIC, you might be better off talking directly to the Sécu.
You must know your SS# in order to be reimbursed. It should be listed on your first bulletin de paie (paystub). You can also ask the CPAM or MGEN for the number if you need it right away (i.e. if you needed to see a doctor before you received your first paystub). You should also receive an attestation de droits which states your SS# and the fact that you are covered by Sécu.
Carte Vitale: This green card contains all of your health insurance information and you should present it to the doctor and pharmacy each time. You will still have to the pay the consultation fee for seeing a doctor, but you will be reimbursed later. You can just write a check or pay cash, but note that most offices do not accept debit cards or credit cards. Regular doctors usually do not have a receptionist and so you pay them directly, while specialists generally have you stop at the receptionist on the way out to pay. Depending on if you have a mutuelle, you may or may not have to pay for prescriptions when you go to a pharmacy.
If you do not have your Carte Vitale (it can take a long time to receive if you've just arrived in France), then you will need to have the doctor and/or pharmacist give you a feuille de soins, which you will fill out and mail back to the CPAM or MGEN. You will still be reimbursed, but it will take a little longer. Some medications have a little sticker on the box that you need to transfer to the feuille de soins in order to be reimbursed. If you have thrown away the box, you can try to ask at the pharmacy for a new sticker.
Your Sécu will start coverage the day you start work, so even if you do not receive your SS# or Carte Vitale for a while, you are still covered and will be reimbursed. If you do not know your SS#, you should go to your local CPAM or MGEN and ask for their help. Some départements do not give temporary workers a Carte Vitale, so you may never actually receive it and you will always need to use the feuille de soins; but you should still receive a SS# so you can be reimbursed.
I received two Carte Vitales in the mail about two months after I applied for la Sécu, both with the same number (no letters), but it did not follow the formula above. Later in December, I was asked to return those cards and I received a letter from MGEN with my real SS#, which was also the same number that I found on my first paycheck that I received after Christmas. I did not, however, receive my actual Carte Vitale until March.
New Carte Vitales include an ID photo, so you may need to do extra paperwork after you apply at CPAM/MGEN in order to get your card since you have to send in the ID photo.
Carte d'Europeenne d'Assurance Maladie: This card can be used in all EU Countries (except France, of course) as well as Switzerland, Liechenstein, Norway and Iceland if you need to see a doctor when traveling. You may or may not have to pay up front, but make sure to keep all bills and feuille de soins in case you will be reimbursed later. This card is valid for one year and it replaces the old E111 forms. You can ask for it through CPAM or MGEN. (I ordered mine through MGEN's website.)
There are many mutuelles you can choose from, such as Mutuelle Existence, Groupama, Assurance Mutuelle des Fonctionnaires, MAAF, AXA Assurance Santé , AGF, MACIF, as well as MGEN which is slightly confusing. You can have your Sécu through MGEN and NOT belong to their mutuelle, or belong to a different mutuelle, if you like. For example, I am covered by MGEN for Sécu because I worked for l'Education Nationale as a language assistant, but I have Mutuelle Existence for about 35 € a month instead of MGEN's mutuelle. (MGEN's mutuelle is not very good for single people with no children.) Try doing a google.fr search for either mutuelle or assurance complémentaire santé.
Basically, a mutuelle reimburses what la Sécu does not reimburse and it is also useful for helping to pay hospital fees if something serious should happen, as la Sécu will only cover 80% of hospital fees. You should look at their websites to what they actually reimburse, especially if you plan on getting new glasses or getting dentistry work done while in France.
Mutuelles are partnered with certain dentists or opticians, so if you go to their partners, you will most likely be fully covered for reimbursement. If you go to dentists or opticians that are not partnered with your mutuelle, you may not be reimbursed as much. Usually these partners automatically deduct the reimbursed part from your final bill so that you will actually pay a smaller amount right then and not be reimbursed at all.
Some mutuelles have requirements to join. For the MGEN (tout court) mutuelle, you have to work in education/culture as an employee of the state. For the MGEN Filia, you have to have been the dependent of someone with the MGEN or the MGEN Filia, or a member of the MAIF. Some employers require that their employees on CDI belong to the company's chosen mutuelle, which doesn't give you much choice, but often offers better prices.
One last thing to keep in mind when you are looking for a mutuelle is to check if the benefits start right away, or if you must wait a few months before you can take advantage of them. Some mutuelles do not allow expensive procedures in the first few months because they want to avoid people signing up with them, getting the procedures and then dropping the policy before paying very much into the mutuelle.
Carte Tiers Payant: You may receive a Carte Tiers Payant that you need to give to the pharmacy and opticians when you fill prescriptions. It includes the percentages that the mutuelle will cover, i.e. if it says 100%, that means it will cover the rest after la Sécu has covered a certain percentage (30% if la Sécu covered 70%). Some mutuelles do not have a separate Carte Tiers Payant, but include the information on a membership card.
As of January 1, 2006, if you do not have a primary physician declared (médecin traitant), you are reimbursed at a lower percentage (usually 60% instead of 70%). You simply fill out this form and have the doctor sign it, and then send it back to CPAM or MGEN to declare your primary physician.
Regular doctor consultations are now generally 22 € and you will be reimbursed 15,40 € by la Sécu . If you are on vacation or need to see a doctor in an emergency, you can go to another doctor that is not your primary physician and you will still be reimbursed the same. This also applies if your primary physician is on vacation and cannot see you.
For ophthalmologists and gynecologists, you generally pay more (though they can decide the final price - I've paid anywhere from 28 € to 48€) and you will be reimbursed 60-70% of la Sécu's index of 23 € whether or not your primary physician referred you to them. (It is possible to go directly to specialists without needing a referral.)
In general, dental procedures and optical prescriptions are barely covered at all by la Sécu, so it helps to have a mutuelle if you plan on going to these doctors while you are in France. However, if you will only be in France for a few months, it might not be worth it to pay the extra 30 € a month.
Finding a regular doctor is rather easy as you can just call any office in your area and make an appointment. Specialists, on the other hand, usually have longer waiting lists and you could have to wait 3 to 6 months to get an appointment (especially for eye doctors!) and many do not take on new patients.
Regular doctor: I was very sick with the flu my first winter in France, but my doctor's appointment was actually rather painless. I did not have to wait long and did not have to fill out any paperwork at all. There was no nurse or assistants - just the doctor - and first she had me explain what was wrong and then she examined me (mostly basic things, like checking blood pressure) on the table, which was just behind her desk. In 15 minutes, I was finished and on my way to a pharmacy to fill my prescriptions. The consultation cost 21 € (this was back in 2007 before prices increased) and I was reimbursed 60% by la Sécu because I hadn't declared a primary physician yet. The 4 prescriptions I filled cost no more than 20 € total.
Ophthalmologist & Optician: The two times I've been to my eye doctor, the appointment went by very quickly. He just looked at my eyes and had me say a few letters or numbers that were on the wall. There were no other tests involved. These two doctors are in completely separate offices though, contrary to the US. First you go to the ophthalmologist for the consultation and s/he will give you the prescription(s). Then you go to an optician where you turn in the prescription and choose your frames, etc. You can also buy contact solution at an optician because it is not normally sold in regular grocery stores or supermarkets, though sometimes you can find it at pharmacies.
These consultations cost me 48 €, of which I was reimbursed 70% of the 23 € index by la Sécu. My first year, I paid 130 € for glasses + 15 months of contacts (the original total was 268 €). My mutuelle covers contacts up to 140 € every year, so they were technically free. But neither la Sécu nor my mutuelle cover frames or lenses very much, so glasses seem expensive to me, compared to what I paid in the US for them. My second year, I paid nothing for 12 months of contacts because the total was under 140 €.
Dentist: French dentists seem to care more about fixing problems with your teeth instead of preventing them. My dentist appointment lasted about 15 minutes, and the dentist simply scraped the tartar off my teeth (which actually hurt quite a bit because he used a drill-like machine instead of hand-held instruments) and told me to use Sensodyne. Otherwise, my teeth were perfect according to him. No x-rays, no fluoride, no flossing. No dental hygienist either; just the dentist. They will most likely recommend not coming back for another year and only if you have problems with your teeth. Between la Sécu and my mutuelle, I was reimbursed 100% of the consultation fee.
Even if you do have a mutuelle, serious dental work is not very well reimbursed in France. Most mutuelles cap off at 800 € or 1,000 € a year, so if you need crowns or bridges, you may have to pay a lot. Getting wisdom teeth removed is not very expensive, but French dentists are not allowed to use anything stronger than novacaine, so you will not be asleep for the procedure.
Gynecologist: Again there was no annoying paperwork or nurse or waiting, just me and the doctor. There is absolutely nothing to cover up with, so get used to being naked. Yearly exams generally took only 5 minutes, but the price for the consultation varied a lot. I have no idea why, but I paid 28 € (yearly exam + pap smear), then 35 € (just for a new prescription!), then 32 € (yearly exam, but no pap smear)... In addition, I had to pay 27.50 € to the medical lab to analyse the pap smear (le frottis). I was always reimbursed 60% of the 23 € index by la Sécu.
Click below on the prescriptions (for a lumbar support belt and contact lens) for a larger picture
Pharmacies in Frace all have a big green cross above the door. There should be at least one pharmacy that is open 24 hours for emergencies, but it probably changes everyday, so you might need to call the police to find out which one it is. Beware that you cannot fill prescriptions at parapharmacies. These sell over-the-counter medecine and other toiletries though.
If you have a mutuelle, you most likely won't need to pay anything for prescriptions. For example, the last time I filled a prescription, it cost 5.09 € but Sécu covered 3.31 € and my mutuelle covered 1.78 € so I paid nothing at the pharmacy. You may need to keep the prescription if you are going to receive a year's worth of medication. Usually the pharmacy will only give you 3 months worth at a time and you have to go back until the year is up.
Thanks to Rebecca for additional information!