France: Healthcare, Insurance, and Expatriate Coverage

In this iPMI Global Regional article we look at the French healthcare system, following news that Bupa Global, will open an office there and partner with ExpaTPA.

We explore Ian Youngman's recent report, The Future of International Private Medical Insurance (iPMI) and look at key aspects of the French healthcare system, focusing on its structure, financing, insurance options, and regulatory environment.

1. Overview of the French Healthcare System:

• High Quality and Universal Access: French healthcare is "often extolled as one of [the] world's best." The system aims for universal health protection, ensuring "every individual who lives or works in France benefits from the total or partial reimbursement of medical costs, whether or not they contributed to social security."
• Public and Private Mix: Healthcare provision involves a mix of public, non-profit private, and private for-profit facilities. There are "3,089 facilities, including 1,389 state-owned, 691 run by private non-profits, and 1,009- including 479 clinics- with private owners." Public hospitals account for "about 65% of hospital care."
• Centralized Strategy, Regional Implementation: The central government defines the national health strategy and finances healthcare facilities. "Population health and health care are delegated to regional health agencies that represent the government."
• Statutory Health Insurance (SHI): "Statutory Health Insurance provides health coverage for all residents." Hospitals are largely funded by SHI (80%), with additional funding from voluntary insurance and direct patient payments.

2. Healthcare Coverage and Reimbursement:

• Upfront Payment and Reimbursement: Patients typically pay upfront for medical services and are then reimbursed a percentage of the cost. "People who go to the doctor or hospital in France or have an x-ray or some other kind of test, normally pay up front." Reimbursement is facilitated by the "carte vitale" system.
• State Coverage Percentage: The state typically covers "70% to 85% of the total," with higher coverage for serious conditions.
• "Tarif de Convention" and "Dépassements d’honoraires": Doctors can charge more than the base rates set by the state ("tarif de convention"), resulting in "dépassements d’honoraires." This means the base state reimbursement may not cover the total cost.
• "Mutuelles" (Top-Up Insurance): Due to the gaps in state coverage (co-payments, co-insurance, extra billing), most people obtain supplemental private health insurance, called "mutuelles," to cover the remaining costs. "In 2020, 96% of the population of mainland France had top-up cover according to France’s public finance auditor the Cour des comptes."
• 100% Santé: "100% Health regulation (100% Santé), provides free eye care, dentures and hearing aids without co-payment."
• PUMA (Protection Universelle Maladie): The French healthcare system "offers access to healthcare for all French nationals and all children under 16." PUMA also applies to residents of Guadeloupe, French Guiana, Martinique, La Réunion, Saint-Barthélemy and Saint Martin.

3. Compulsory Health Insurance:

• Employers' Obligation: "All employers in France must provide health insurance for all employees." Employers are mandated to cover at least 50% of employee healthcare costs.
• ANI Law: "Group policies were initially only offered by institutions de prévoyance, but since they became obligatory for employers under the French ANI law in 2016, mutuelles and standard insurance firms now provide them as well."
• Minimum Cover Requirements: Mandatory plans must cover at least "The minimum social security fee (ticket modérateur) for medical visits," "The minimum daily hospital fee (forfait journalier)," "Dental fees," and "Optical fees."
• Exemptions: The law does not apply to those who work in the public sector, are a job seeker, student, self-employed or a pensioner.

4. Healthcare for Expatriates and Digital Nomads:

• PUMA for Expats: "The Protection Universelle Maladie (PUMA) system grants expats in France access to the country’s health insurance plan with less stringent requirements and conditions. Expats are covered if they’ve lived in France for three months on a consecutive basis and remain legal residents regardless of changing circumstances and financial stability."
• Digital Nomad Visas: France offers digital nomad visas for stays exceeding 90 days, but there are restrictions, particularly for work within France.
• IPMI Requirement for Digital Nomads: "Digital nomads must have IPMI as a requirement is repatriation cover."
• CFE (Caisse des Français de l’Etranger): "State body CFE offers insurance to expatriated employees and individuals, and their families. CFE can ensure that there is no benefit loss for French expatriates on assignments abroad, when they leave or come back to France."

5. Healthcare Regulation:

• Ministry of Health: The Ministry of Health enforces healthcare laws and regulations.
• Key Regulatory Bodies: Regional Health Agencies (ARS): Control hospitals and healthcare professionals' work.
• Regional Prefects: Oversee local application of national health policy.
• Health Insurance Funds (CPAMs): Audit prescribers' activities for suspected fraud.
• HAS: Certifies healthcare facilities and professionals and performs quality controls.
• Public Health Code (CSP): "The main legislation governing healthcare is codified in the CSP. This contains both statute law and regulatory provisions governing the professions and the healthcare facilities that are entitled to deliver healthcare."
• Insurance Regulation: "All insurers are regulated by the provisions of the Insurance Code and subject to the control of the state and under the permanent supervision of the French insurance supervisory and regulatory authority (ACPR)."

6. Market Dynamics and Trends:

• Growth in Private Health Insurance: "The French Protection & complementary Health insurance market grew by 5% to reach €25 billion in 2019."
• Service Differentiation: Insurance companies are developing "new and differentiated ad- hoc services, such as telemedicine, prevention or processes digitalisation" in response to standardization of contracts.
• Covid-19 Impact: The French health insurance sector proved resilient to the effects of the coronavirus pandemic.
• Government Intervention: "The pandemic has intensified the role of the government in the French health insurance market"
• Key Players: The document lists many leading local and international health insurers, brokers, and agents operating in France.

7. Mutuelles:

• Non-profit Organizations: "France’s mutuelles are non-profit organisations, which have been in operation in the country for at least 150 years. Their main purpose is to ensure social welfare but not just through additional health cover, also in terms of pensions, disability benefits and other forms of cover."
• Covers Remaining Costs: What a mutuelle does is cover, either partly or completely, the deficit or the part of the cost not covered by the state. So, a mutuelle is top-up health cover and one of the easiest ways of getting 100% health cover.

Key Takeaways:

• France has a highly regarded universal healthcare system with a mix of public and private provision.
• While the state covers a significant portion of healthcare costs, supplemental private insurance ("mutuelles") is very common to cover remaining expenses.
• Compulsory health insurance for employees is mandated, with employers required to contribute at least 50% of the cost.
• The regulatory environment is robust, with several agencies involved in oversight and enforcement.
• The private health insurance market is growing and evolving, with insurers offering differentiated services.

To read the full report, The Future of International Private Medical Insurance (iPMI), click here.

Related Reading: Bupa Global Expands iPMI into France with ExpaTPA Partnership