Health Insurance for Expats in France

Overview

France consistently ranks among the world's best healthcare systems. The World Health Organization famously ranked it #1 globally for overall healthcare quality. For expats, this means access to excellent care—but navigating the system requires understanding how public coverage, private insurance, and visa requirements work together.

The path to French healthcare typically follows this pattern: private insurance for your visa application, then transition to France's public system (PUMA) after 3 months of residency, supplemented by a "mutuelle" (top-up insurance) to cover the portions the state doesn't reimburse.

French Healthcare System

France operates a two-tier healthcare system: public insurance through the Sécurité Sociale, supplemented by private "mutuelle" insurance for costs the state doesn't cover.

How French Healthcare Works

The French system uses a reimbursement model. You pay for care upfront (or your provider bills directly), then the Sécurité Sociale reimburses approximately 70% of approved costs. The remaining 30% plus any excess fees are either paid out-of-pocket or covered by your mutuelle.

• Sécurité Sociale: Covers ~70% of standard medical costs
• Mutuelle: Private top-up insurance covering the remaining ~30%
• Carte Vitale: Your green health insurance card for accessing coverage
• Médecin traitant: Assigned primary care doctor who coordinates your care

Quality of Care

France offers exceptional medical care with modern facilities throughout the country. You'll find English-speaking doctors in major cities like Paris, Lyon, and Marseille. Wait times are generally shorter than the UK's NHS, and you have significant freedom to choose specialists.

Key Differences from US Healthcare

• Universal coverage means no denial for pre-existing conditions
• Prices are regulated—no surprise medical bills
• Prescriptions are heavily subsidized
• The system emphasizes prevention and primary care

PUMA (Universal Health Coverage)

Since 2016, France's Protection Universelle Maladie (PUMA) guarantees healthcare access to all legal residents. This replaced the older CMU system and makes it easier for expats to join the French system.

Eligibility Requirements

• Legal residence in France (valid visa or residence permit)
• Living in France at least 3 consecutive months
• France is your primary residence (183+ days per year)
• Not covered by another EU country's social security

Who Cannot Access PUMA Immediately

• US expat workers: If sent by a US employer, you're ineligible for up to 5 years under the US-France totalization agreement
• US self-employed: If self-employed in the US and working in France, ineligible for up to 2 years
• First 3 months: All new residents must wait 3 months before applying

PUMA Enrollment Process

1. Wait 3 months after arriving in France with a valid long-stay visa
2. Submit "Demande d'ouverture des droits à l'assurance maladie" form to your local CPAM office
3. Processing takes 3-6 months—total wait of ~6-9 months from arrival
4. Receive your attestation de droits (proof of rights)
5. Apply for your Carte Vitale (green insurance card)
6. Choose a médecin traitant (primary care doctor)
7. Sign up for a mutuelle (recommended)

The PUMa Tax (CSM)

The Cotisation Subsidiaire Maladie (CSM), often called the "PUMa tax," is an additional healthcare contribution that may apply to expats with investment income but little professional income in France.

Who Pays the CSM?

You may be liable for CSM if both conditions apply:

• Your professional income in France is below €9,420/year (20% of 2025 PASS)
• Your capital/investment income exceeds €23,550/year (50% of 2025 PASS)

CSM Calculation

• Rate: 6.5% of investment income above the €23,550 threshold
• Cap: Maximum €376,800 in 2025 (8x PASS)
• Exemption: First €23,550 of investment income is not taxed

Good News for American Retirees

Despite the technical rules, French tax authorities have generally not applied the CSM to American retirees with US retirement account income, pensions, or Social Security. They've been grouped with other retirees under reciprocal agreements. However, this practice could change, so consult a French tax advisor.

Visa Requirements

France doesn't have a dedicated retirement visa. Most non-working expats apply for the VLS-TS Visiteur (Long-Stay Visitor Visa), which allows you to live in France without working.

VLS-TS Visiteur Visa Requirements

• Income: ~€1,450/month for individuals, ~€2,100/month for couples (approximately SMIC level)
• Health insurance: Private insurance valid for entire stay (travel insurance not accepted)
• Accommodation: Proof of housing in France
• No employment: You cannot work on this visa

Insurance Requirements for Visa

Your health insurance for the visa application must:

• Cover minimum €30,000 in medical expenses
• Include hospitalization and emergency care
• Cover medical evacuation and repatriation
• Be valid for your entire intended stay
• Come with a "visa letter" from the insurer confirming coverage

Visa Timeline

• Application: Submit no more than 3 months before planned arrival
• Processing: Typically 2-4 weeks
• Fee: €99 application fee
• Validation: Must validate online within 3 months of arrival (€200 fee)
• Duration: Usually issued for 12 months, renewable annually
• Medical exam: Required as part of validation process

Recommended Plans

Your insurance needs depend on where you are in your France journey: visa application, waiting for PUMA enrollment, or long-term residence with PUMA + mutuelle.

For Visa Applications & Pre-PUMA Period

Cigna Global is excellent for expats who want comprehensive coverage during the transition period. They offer Silver, Gold, and Platinum tiers with 24/7 English support. The American Hospital of Paris is in their direct-billing network, making it ideal for English-speaking expats.

Allianz Care offers high-deductible options that can reduce premiums by up to 60%. As an EU-based insurer, French consulates are familiar with their documentation. Good choice for budget-conscious expats who want solid coverage.

BUPA Global stands out for mental health coverage (full parity with physical health) and favorable handling of pre-existing conditions. Premium pricing but comprehensive coverage with up to 30% no-claims discount.

IMG Global offers the most affordable international option for France. Their 50% deductible waiver outside the US means a €5,000 deductible becomes €2,500 effective in France. Best for budget-conscious, healthy expats during the pre-PUMA period.

After PUMA Enrollment: Mutuelles

Once enrolled in PUMA, most expats switch from international insurance to a French mutuelle. These top-up policies cover the ~30% that Sécurité Sociale doesn't reimburse, plus additional benefits like dental, vision, and private rooms.

Popular mutuelle providers include Harmonie Mutuelle, MGEN, Alan (modern digital-first option), and April International. Costs range from €30-150/month depending on coverage level.

Transition Strategy

Smart expats plan their insurance in phases:

1. Months 1-3: International private insurance (required for visa)
2. Months 3-9: Continue private insurance while PUMA application processes
3. Month 9+: Once Carte Vitale received, switch to PUMA + mutuelle

Expected Costs

Healthcare in France is affordable compared to the US, though you'll have costs at each stage of your journey.

Visa & Pre-PUMA Period

• Visa-compliant international insurance: €90-350/month depending on age and coverage
• Visa application fee: €99
• Visa validation fee: €200

PUMA + Mutuelle (After Enrollment)

• PUMA: Free for most expats (see CSM section for exceptions)
• Basic mutuelle: €30-50/month
• Comprehensive mutuelle: €80-150/month

CSM Tax (If Applicable)

• Rate: 6.5% of investment income above €23,550
• Example: €50,000 investment income = ~€1,719/year CSM
• Most American retirees: Currently not charged (verify with tax advisor)

Out-of-Pocket Costs

Even with PUMA and a mutuelle, you may have small co-pays:

• GP visit: €1-2 co-pay (€25 total, ~70% reimbursed)
• Specialist visit: €25-50 (varies by sector)
• Prescriptions: Heavily subsidized, often only €1-5 co-pay
• Hospital stay: €20/day co-pay (covered by most mutuelles)

Common Questions

Can I access PUMA immediately when I arrive?

No. You must be a legal resident for at least 3 months before applying. Then processing takes 3-6 months. Plan for 6-9 months of private insurance before your Carte Vitale arrives.

Is my US health insurance valid in France?

Generally no. US insurance typically only covers emergencies abroad, not routine care. More importantly, US policies don't meet French visa requirements. You need an international policy that's specifically valid in France with the coverage minimums the consulate requires.

Can I skip the mutuelle after I have PUMA?

Technically yes, but it's not recommended. Without a mutuelle, you'd pay ~30% of all medical costs out-of-pocket plus any excess fees. A basic mutuelle (€30-50/month) provides much better value than paying these costs directly.

What happens if I spend more than 6 months outside France?

PUMA requires you to live in France at least 183 days per year. If you spend more than 6 months abroad, you risk losing PUMA eligibility and may need to re-apply when you return.

Will my visa application be rejected if I have pre-existing conditions?

This can be challenging. Some international insurers exclude or limit pre-existing conditions, which may not satisfy visa requirements. Look for guaranteed-issue policies or those with pre-existing condition waivers. ACS and some Cigna Global plans may be more flexible.

Do I need separate dental and vision insurance?

PUMA provides limited dental and vision coverage. Most mutuelles include better dental and vision benefits. If you need significant dental work, consider a higher-tier mutuelle or timing the work for after your mutuelle is active.

What's the difference between CMU and PUMA?

CMU (Couverture Maladie Universelle) was the old system for non-employed residents, replaced by PUMA in 2016. PUMA simplified enrollment and made coverage automatic for all legal residents regardless of employment status.