This comprehensive guide explains how French medical insurance works and how to get the best reimbursement for your medical expenses in France.
- How does healthcare work in France?
- French medical insurance for expats
- Assurance Maladie reimbursements
- Medical expenses not reimbursed by Assurance Maladie
- Coordinated health care roadmap
- French medical insurance for children under 16
- What is Ameli?
- Primary doctor
- Coverage of a doctor’s visit
- Cost of a doctor’s visit
- Medical insurance for women in France
- Other medical costs
- What is Mutuelle Santé?
- How to pay for a doctor’s visit?
- Pharmacy coverage and costs
- Hospitals and clinics in France
- ALD France healthcare (long-term illness)
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If you are already familiar with French medical insurance, jump directly to How to get a carte Vitale in 3 steps to register into the French healthcare system.
French medical insurance – How does it work?
Assurance Maladie is the branch of Sécurité Sociale that covers illnesses and accidents in the workplace. This branch reimburses a portion of the medical expenses of its assurés (insured).
CPAM (Caisse Primaire d’Assurance Maladie) is the department office that administers Assurance Maladie. For all inquiries, CPAM is your middleman for Assurance Maladie.
French medical insurance for expats
Anyone working legally in France is systematically enrolled in the French Social Security system, regardless of their citizenship. Your employer is the one who is supposed to handle the application for you.
If you are not working, you qualify for PUMA after living in France for 3 months. PUMA is a right to health coverage for anyone residing in France for over 3 months. You do not need to be working to benefit from PUMA but your residency has to be stable (it’s not intended for people on vacation). If you’re on a long-stay visitor visa, make sure you read French VLS-TS visitor visa because Puma might not apply in this case.
One of the requirements of a long-stay visa for France is to purchase private health insurance for the duration of your visa. Read Travel Insurance for French Visa to find the right insurance.
Assurance Maladie reimbursements
French medical insurance is based on three essential concepts that you need to be familiar with to understand Assurance Maladie reimbursements.
- tarif de convention (official fee) and base de remboursement (reimbursement basis)
- taux de remboursement (reimbursement rate)
- dépassements d’honoraires (amount above official fee)
Tarif de convention (official fees) and base de remboursement (reimbursement basis)
Medical professionals and Assurance Maladie set an official fee for each medical procedure. This fee is called tarif de convention or tarif de référence. Assurance Maladie uses tarif de convention as a basis to calculate a patient’s reimbursements.
When used as a basis for reimbursement calculation, tarif de convention is called base de remboursement or tarif de base. Even though their designation is different, tarif de convention and base de remboursement refer to the same concept.
Tarif de convention for a doctor’s visit in secteur 1 is set to €26.50, which means that you can’t be charged more than this amount.
Taux de remboursement (reimbursement rate)
Taux de remboursement is the percentage that Assurance Maladie applies to base de remboursement. For instance, for a doctor’s visit in secteur 1, Assurance Maladie applies a 70% taux de remboursement, which means that Assurance Maladie reimburses you €17.55 out of €26.50.
Dépassement d’honoraires (amount above official fees)
Dépassement d’honoraires is the amount charged to you (by the doctor, the lab…) that is above tarif de convention. Assurance Maladie does not reimburse any dépassements d’honoraires but a top-up insurance or mutuelle santé will cover some of the extra fees.
Medical expenses not reimbursed by Assurance Maladie
Assurance Maladie does not reimburse the following expenses.
Ticket modérateur (coinsurance)
Ticket modérateur is the difference between tarif de convention and Assurance Maladie’s reimbursement.
Under certain circumstances, you can be exonerated from paying ticket modérateur. In that case, Assurance Maladie reimburses 100% of tarif de convention.
Women in the last 4 months of their pregnancy as well as people with ALD (long-term illnesses) are exempted from paying ticket modérateur.
€24 forfait (copayment)
For some medical procedures that cost over €120, you pay a flat fee of €24 instead of paying ticket modérateur. People who already benefit from 100% Assurance Maladie coverage do not have to pay a flat fee.
Assurance Maladie reimburses 100% of tarif de convention for emergency transportation services, MRIs and X-rays.
€1 Participation forfaitaire (Flat fee contribution)
Participation forfaitaire is a €1 flat fee that is at your charge every time you see a physician or get some tests done (blood tests, X-rays…). It cannot exceed €50 per patient for the entire year and it cannot exceed €4 per day for one physician.
No participation forfaitaire is charged for patients under 18 or pregnant women.
Franchise médicale is a sum that is deducted from your reimbursements by Assurance Maladie. It applies to:
- non prescribed medication- €0.5 per medication box
- paramedical procedures – €0.5 per procedure
- transportation – €2 per medical transportation
Franchise médicale cannot exceed €50 per patient per year.
Participation forfaitaire and franchise médicale do not apply to children under 18, C2S (Complémentaire Santé Solidaire) and AME (Aide Médicale de l’État) beneficiaries or women in their last three months of pregnancy.
Parcours de soins coordonnés
A major ingredient of French medical insurance is Parcours de soins coordonnés (coordinated health care roadmap). In that schema, médecin traitant (primary doctor) is the doctor coordinating all medical care for a patient. In order to receive the highest reimbursement amount from Assurance Maladie, you need to follow parcours de soins coordonnés, which consists of three rules.
- Declare a doctor as your médecin traitant
- Visit your médecin traitant in priority
- Ask for a referral from your médecin traitant before seeing a specialist
You don’t need a referral to visit the following specialists and qualify for the 70% rate coverage.
- OB-gyn, gynecologist
- psychiatrist (if you are between 16 and 25)
Dental care is not part of parcours de soins coordonnés. You do not need a referral to see a dentist.
French medical insurance for children under 16
Children under 16 do not have to follow parcours de soins coordonnés to get the highest reimbursements from Assurance Maladie. They can see any doctor and go directly to any specialist.
Each child has a right to 20 doctor’s visits that are totally covered by Assurance Maladie. These wellness visits can be done at a primary doctor, a pediatrician or a health center. Children under 6 can go to a PMI (Protection Maternelle et Infantile) center.
What is Ameli?
Ameli (Assurance Maladie online) is France health insurance website. Once you are assuré (affiliated with Assurance Maladie), create an Ameli account to get access to all of your reimbursements. Ameli is not only valuable to access and manage your information. It also has all the resources you need for medical insurance in France. On Ameli you can easily:
- order your carte Vitale
- get an Attestation de droits (health insurance certificate)
- order a Carte Européenne d’Assurance Maladie (CEAM) to travel within Europe
- declare an accident
- request a mediator’s help
- send any request or inquiry to CPAM via a secure email system
Médecin traitant (Primary doctor)
To follow parcours de soins coordonnés and get the maximum reimbursements, your first step is to declare a médecin traitant.
Declaring a médecin traitant
As soon as you get your permanent social security number, you should pick a médecin traitant (primary doctor). You médecin traitant can either be a médecin généraliste (general practitioner) or a spécialiste (specialist). Some doctors refuse to be your médecin traitant because they have too many patients already. Be patient (!) and try finding one until you succeed.
During a visit, the doctor can use your carte Vitale to register as your médecin traitant. If you do not have a carte Vitale, fill out the Déclaration de choix du médecin traitant form and mail it to your local CPAM with your doctor’s signature.
To know what to expect when you go to the doctor in France, read Going to the doctor in France.
When you cannot find a médecin traitant
Send a request for help to a CPAM médiateur (mediator) if you cannot find a doctor who accepts to be your médecin traitant. From your Ameli‘s account, under Mes démarches, select Demander l’aide du médiateur.
If you do not have an Ameli’s account yet, fill out Difficulté d’accès à un médecin traitant and send it to your CPAM médiateur (mediator). Write down Monsieur le médiateur as the recipient on the enveloppe and use your local CPAM’s address. For information on creating an account on Ameli, read How To Get A Carte Vitale.
Switch médecin traitant
Under French medical insurance, you are free to switch médecin traitant at any time. You do not need to inform your previous médecin traitant nor give any reason for the change. The procedure is the same as when you pick your very first médecin traitant.
There is no automatic transfer of your medical records. Ask your medical file to your previous doctor if you don’t want to start from scratch.
How much is covered for a doctor’s visit?
Assurance Maladie reimburses your doctor’s visit better when you are inside parcours de soins coordonnés.
Inside parcours de soins coordonnés
Assurance Maladie reimburses 70% of tarif de convention for a doctor’s visit when you follow parcours de soins coordonnés.
Outside parcours de soins coordonnés
Assurance Maladie reimburses only 30% of tarif de convention for a doctor’s visit when you do not follow parcours de soins coordonnés. You are outside parcours de soins coordonnés if you have not declared a médecin traitant or if you see a doctor other than your médecin traitant without a referral.
There are some exceptions to the rule and you are still reimbursed at the 70% rate in the following situations:
- your médecin traitant is not available and you see his replacement or another doctor at his office
- you have an emergency when you are away from home (in France) and you need to see a doctor
Cost of a doctor’s consultation in France
Consultation with your médecin traitant (Primary doctor)
How much you are paying for a doctor’s visit and how much Assurance Maladie reimburses you is based on the secteur (category) of the doctor and if you are inside parcours de soins coordonnés. Doctors in France can be:
- conventionnés de secteur 1
- conventionnés de secteur 2
- non conventionnés or secteur 3
Docteurs conventionnés de secteur 1
Doctors in secteur 1 charge tarif de convention (€26.50). Assurance Maladie reimburses €17.55 (70% of €26.50 minus €1 participation forfaitaire).
Docteurs conventionnés de secteur 2
Doctors in secteur 2 set their own fees within reasonable limits. Dptam is a network of doctors in secteur 2 who have signed an Optam contract (Option Pratique Tarifaire Maîtrisée) with Assurance Maladie to keep their fees reasonably low. In exchange, Assurance Maladie reimburses the same amount as for a visit to a doctor in secteur 1.
For secteur 2 doctors outside Optam, Assurance Maladie reimburses €15.10 (70% of €23 minus €1 participation forfaitaire).
Docteurs non conventionnés or secteur 3
Doctors non conventionnés set their own fees. Assurance Maladie reimburses €0.61 (this is not a typo) for a visit to a GP and €1.22 for a specialist.
Cost of a doctor’s visit in France
Check a doctor’s honoraires (fees) on Ameli’s annuaire (physician phonebook) before booking an appointment.
The following table details the cost of a consultation with your médecin traitant conventionné de secteur 1.
|Doctor’s visit (secteur 1)||€26.50|
|Assurance Maladie (70%)||€17.55|
|Ticket modérateur (30%)||€7.95|
|At your charge (if you do not have a mutuelle)||€8.95|
A consultation with the same doctor will cost you more if you are outside parcours de soins coordonnés.
|Doctor’s visit (secteur 1)||€26.50|
|Assurance Maladie (30%)||€6.95|
|Ticket modérateur (70%)||€18.55|
|At your charge (if you do not have a mutuelle)||€19.55|
Consultation with a specialist
The cost of a visit with a specialist varies based on:
- the specialists’s category. A visit with a specialist who is conventionné secteur 1 costs less than a visit with a specialist in secteur 2.
- the medical specialty. For instance, a visit with a psychiatrist in secteur 1 costs €51.70 whereas a visit with a cardiologist in secteur 1 costs €52.50.
Assurance Maladie covers 70% of tarif de convention for a specialist’s consultation when you have a referral from your médecin traitant. Outside parcours de soins coordonnés, Assurance Maladie reimburses only 30% of tarif de convention.
Téléconsultation (Online consultation)
Téléconsultations (online consultations) usually follow the same rules of reimbursements as in-person visits.
For an exhaustive list of reimbursements from Assurance Maladie for a doctor’s consultation, read Vos Remboursements on Ameli website.
Medical insurance for women in France
Starting January 1, 2022, Assurance Maladie covers 100% of birth control for women under 25. It covers one visit a year to your gynecologist or midwife, your birth control method and lab tests related to birth control.
For women older than 25, Assurance Maladie reimburses 70% of gynecologist’s visits and you don’t need a referral from your primary doctor.
Starting July 1, 2022, a ob-gyn visit will be mandatory for post-partum care, between the fourth and the eighth week after the birth of your child. This mandatory visit will be totally covered by Assurance Maladie.
Other medical costs
Assurance Maladie applies various rates for each medical treatment and procedure (lab work, prescription drugs, hospital fees..). Check out les Taux de remboursement de l’Assurance Maladie for an exhaustive list of Assurance Maladie coverage.
What is mutuelle santé?
Complémentaire santé or mutuelle santé is a supplemental health insurance that covers some of the medical expenses not covered or badly covered by Assurance Maladie. You should get a mutuelle only after you’re enrolled in the French health care system because a mutuelle complements reimbursements from Assurance Maladie.
Read 4 Reasons to get a Mutuelle Santé to understand why a mutuelle is worth it.
How do you pay for a doctor’s visit in France?
Most of the time, you pay the total amount to your doctor at the end of the visit. Bring your checkbook because some doctors do not have a (functioning) payment card machine.
If you have a carte Vitale, you will automatically get a reimbursement from Assurance Maladie on your bank account within a week. Most doctors and specialists in France accept carte Vitale (I have yet to find one who does not). If you do not have a carte Vitale (or you forgot to bring it), the doctor gives you a feuille de soins that you have to mail to your local CPAM to get reimbursed.
Tiers-payant (third-party payment)
Tiers-payant means that you only pay the ticket modérateur portion of a medical bill, not the Assurance Maladie part. This is highly convenient because you do not have to pay upfront.
How much do you pay at the pharmacy in France?
Always hand out your carte Vitale and your mutuelle’s card (if you have one) to the pharmacist. You can pay tiers-payant for certain prescription drugs.
It is not unusual not to pay a cent if your mutuelle does tiers-payant. I clearly remember the first time it happened to me after I moved back to France. My credit card in hand, I was waiting when the pharmacist told me with a smile “C’est tout bon” (it’s all good). I was in shock.
To learn how French pharmacies are different from American pharmacies, read Pharmacies in France.
Hospitals and clinics in France
When you need to get a medical procedure done, you can choose a hôpital (hospital) or a clinique privée (private clinic). Ask your médecin traitant for his recommendation. If you pick a private establishment, make sure it is conventionné. In France, the quality of treatments is the same whether you go to a hospital or a clinic.
For each day you spend at the hospital, you are charged a forfait journalier (daily flat fee). French government has set forfait journalier to €20 in a hospital or clinic. Assurance Maladie does not cover forfait journalier. You are exonerated from paying forfait journalier in certain situations like during the last months of pregnancy or to deliver your baby.
In French public hospitals and clinics conventionnées, Assurance Maladie covers 80% of tarifs de convention. Dépassements d’honoraires are not covered by Assurance Maladie, nor are extras like getting an individual room.
ALD France healthcare
An ALD (Affectation de longue durée) is a long-term illness that requires medical treatment for longer than six months. In terms of cost, an ALD can be exonérante or non exonérante.
You don’t have to pay ticket modérateur if your ALD is exonérante. ALD 30 is the name of the list of the 30 ALD exonérantes. Your doctor will prepare a demande de prise en charge à 100% (based on basic rates) so you don’t have to pay for your ALD’s treatments. Your médecin traitant will also write a protocole de soins.
Protocole de soins is a document that proves that you qualify for 100% coverage from Assurance Maladie. It also contains the list of specialists that you can consult regarding your ALD without needing a referral. You should show your protocole de soins to every specialist you see.
If your ALD is not in the ALD 30 list, you might still be exonerated from paying ticket modérateur if you are having a severe form of a pathology. You can also be exonerated if you cumulate several diseases, causing debilitating effects. In any case, you should discuss it with your médecin traitant.
ALDs non exonérantes
ALD non exonérantes are diseases responsible for a sick leave longer than 6 months or a need for continuous treatment. You still have to pay ticket modérateur. Assurance Maladie covers the same percentage as for others illnesses.
I hope this guide answered any question you had about French medical insurance. Once you are ready to register with Assurance Maladie, read Apply for carte Vitale in 3 steps .