Health Cover - Plus Ça Change...?

Thursday 01 September 2011

The recent Circular on health cover for early retirees may well be obtuse, but despite the cryptic language the rules really have changed.

Pr.o. alt='search this word'>r.o./a>r to the summer break we broke the news that the EU Commission had forced France to change the rules on granting early retirees access into the health system.

The new regulations are contained in a Circular issued in early July by the French health and social security authorities.

The Circulaire Nº DSS/DACI/2011/225 is a classic piece of French obscurification, leading a number.o. alt='search this word'>r.o./a>f you who have read it to write to us seeking clarification on your.o. alt='search this word'>r.o./a>wn position.

The lack of clarity has not been helped by reports elsewhere, stating that, despite the initial euphoria, there has been ‘no change’ in the rules.

In order to try and shed more light we wrote to the EU, who provided us with the following statement:

'Habitually Resident'

As the EU statement confirms, the formal legal position is actually a very clear.o. alt='search this word'>r.o./a>ne.

If an early retiree from within the EU is 'habitually resident' in France then they are entitled to be treated in the same way as a French national. This implies an equal right to access the health system.

In order to be considered ‘habitually resident’ you must be resident in France for at least three months, with health insurance cover and the minimum level of income.

Health insurance cover provided via an E106/S1 would meet the first criteria. At the expiry of the E106/S1 (up to 2 years) you would have obtained the status of being ‘habitually resident’, and so would be entitled to access the health system, subject to the test of minimum income.

Indeed, you need continuing health cover in order to remain legally resident.

All of this is actually stated in the new Circular, despite the convoluted manner in which it is expressed, particularly the so-called 'case by case' examination of all applications.

Thus, the guarantee of continuing health cover for those who are 'habitually resident' in France is confirmed in the Circular, where it states: 'l’application des règles européennes de coordination permettant d’assurer à une partie des per.o. alt='search this word'>r.o./a>nnes ayant établi leur résidence en France de bénéficier d’une continuité de leurs droits en matière de maladie-maternité, acquis dans un autre Etat membre, par le bénéfice des prestations de l’assurance maladie française.'

It goes on to say: 'Si l’intéressé «n'a droit à aucun autre titre aux prestations en nature d'un régime d'assurance maladie et maternité», français ou européen, l’article L.380-1 et l’article L.861-1 du code de la sécurité sociale ouvrent l’accès à la Couverture Maladie Universelle (CMU) et complémentaire (CMU-C) aux per.o. alt='search this word'>r.o./a>nnes qui justifient d’une «résidence stable et régulière en France».'

Local Interpretation

Now we have no doubt that despite what the Circular may say, some early retirees who meet the criteria will continue to be refused entry into the system by their local health authority, the Caisse Primaire de l'Assurance Maladie (CPAM).

The capricious nature of local public officialdom is an indelible feature of life in France.

Ever since the original Circular.o. alt='search this word'>r.o./a>f November 2007, which ostensibly excluded early retirees from the health system, there has been wide variation in the way the Circular has been interpreted by local health authorities.

Despite the many reports of health authorities taking an inflexible and narrow approach, there have also been a large number.o. alt='search this word'>r.o./a>f CPAMs who have simply ignored the Circular and carried on in the same old way, granting entry to early retirees at the expiry of their E106/S1.

So we fully expect that the same lack of consistency in policy implementation will continue and some of you will be denied access into the system, despite the fact that you may be eligible.

The current uneven application of policy is inevitable, particularly when the guidance from the centre is not spelt out clearly.

Appeal Procedure

If you are unreasonably refused access into the system, what should you do?

Do not accept the decision as irrevocable is what you must do.

You need to challenge it, for there is a reasonable chance you will be successful, and only by determined action against local intransigence will this issue ever be put to rest.

Your local CPAM are required by law to justify their decision to you, which they must do so in writing. You should not be put off by a verbal refusal from a local official. Insist on a letter.o. alt='search this word'>r.o./a>f explanation.

If they are not prepared to give you a letter explaining their reasons, then you should make a written complaint to the Conciliateur of the CPAM. The CPAM will have their contact details, which is normally the local CPAM office. Send the letter by recorded delivery.

If you do have a letter.o. alt='search this word'>r.o./a>f refusal, you have an automatic right of appeal to a local board, called the Commission de Recours Amiable (CRA).

The appeal procedure is very simple. A recorded delivery letter must be sent to the CRA within two months of the (written) decision you contest. You are not required to attend a hearing. The absence of a response from the CRA with one month implies a rejection of your appeal.

If the CRA do reject your appeal, then within two months you can take the matter to the social security and health tribunal - the Tribunal des affaires de sécurité sociale(TASS).

If you are refused health cover, you should also make a complaint to the EU Commission, which you can do at EU Citizens Complaints. We urge you to make use of this complaints procedure.

We would be most interested to continue to hear from you on this issue, as it is of fundamental importance to many who seek to relocate to France and, indeed, to many who are currently resident. E Mail: editor@french-property.com

Early Retirees Access to Health System Confirmed

Tuesday 12 July 2011

A new circular confirms early retirees from Europe have access to the French health system, although not always on an automatic basis.

The guidance* states that, subject to sufficient resources and existing health insurance cover, inactive early retirees can be admitted to the Couverture Maladie Universelle (CMU) on a ‘case by case’ basis.

The November 2007 circular, which barred early retirees from access to the health system unless they had five years legal residence, has now been withdrawn.

Right of Residence

It is clear from the new guidance that the French authorities have been obliged to withdraw the earlier circular due to non-compliance with EU rules on the right of free movement of per.o. alt='search this word'>r.o./a>ns within Europe.

A residence permit (carte de séjour) is not required to reside in another Member country so any EU national is entitled to relocate to France, provided they have sufficient resources and that they hold health insurance.

Indeed, after 5 years legal residence there is an automatic right of permanent residence, irrespective of these two qualifying criteria.

The minimum level of resources to be ‘sufficient’ in order to be legally resident is stated in the circular to be the equivalent of the Revenu de Solidarité Active (RSA) minimum income support level.

The level of the RSA per month depends on household size, as follows:

The health insurance requirement would be met by either possession of an 'E' form (such as E106/S1), or through a comprehensive private health insurance policy.

Private Health Insurance

Nevertheless, this right of admission is less automatic for existing early retirees in France whose current insurance is provided by a private health insurer.

The same hurdle also arises for future early retirees who are insured privately. Some early retirees have no alternative to private health insurance as they do not have enough national insurance contributions to obtain an E106/S1.

The circular states that unless this private cover has been lost, or is otherwise unattainable, they could well be refused access to the CMU.

It states:

‘Sous réserve d'un examen au cas par cas des cir.o. alt='search this word'>r.o./a>nstances dans lesquelles la couverture maladie nécessaire pour résider régulièrement en France a été perdue, les per.o. alt='search this word'>r.o./a>nnes qui démontrent avoir établi leur résidence habituelle et stable sur le territoire et disposent de ressources « suffisantes » peuvent se voir accorder le bénéfice de la CMU…’

The circular gives examples of those cases where access to the CMU may be granted to those with private health insurance:

• A reduction in income making it impossible to continue with private insurance;
• The cost of the private insurance becoming too onerous by the necessity to receive treatment for the insured or a member.o. alt='search this word'>r.o./a>f their family;
• Loss of cover due to loss of employment, death of spouse or partner, or divorce;
• Other unspecified reasons outside of the control of the applicant that led them to lose their current private health insurance.

It is clear from the tone of the circular that the authorities are obsessed about 'health tourism', so the circumstances of each applicant will be examined in detail.

As reasonable as this may seem, there is likely to be concern about the lack of clarity on the admission criteria into the CMU for those with private health insurance. At what point does private health insurance become ‘too onerous’? Without a cost to income threshold figure being stated there are likely to be widespread differences in the application of the law.

The local health authorities in France will almost certainly demand greater clarity from the government, for they are obliged under the guidance to provide anyone who is refused access to the CMU a written statement of the reason(s) for refusal of their application.

Low Income Households

The circular does, however, confirm the right of early retirees on low income to free health insurance through the CMU-C, a right that also applies to self-employed per.o. alt='search this word'>r.o./a>ns who meet the income criteria.

If you meet the low income criteria (currently €11,656 pa for two people), the circular states you can obtain access to the Couverture Maladie Universelle Complémentaire.

It was abuse by expats of the CMU-C that led the French authorities to tighten the regulations in 2007.

So it is not surprising, therefore, that the circular makes it clear that all applicants for both the CMU and the CMU-C will be required to satisfy the authorities on the level of their income.

In the case of the CMU this will be to determine the level of their contribution, while in the case of the CMU-C to assess their eligibility for free health cover.

It can be anticipated that anyone seeking access to the CMU-C, in particular, will have their income and lifestyle thoroughly examined.

The circular infers that low income alone would not necessarily grant access to the CMU-C if the applicant possessed a valuable home or.o. alt='search this word'>r.o./a>ther wealth.

This article was featured in our Newsletter dated 12/07/2011 David Yeates, Editor at www.french-property.com/news

rong>This is the paragraph concerning the PRIVATE COVER nessesities from the 2011rong>

rong>1.3. - Lorsque l’intéressé atteste de la possession d'une couverture maladie privée, contractée en France ou à l'étrangerrong>.

Dans ce cas, il convient de vérifier que le panier de soins est rong>« comparable »rong> aux prestations en nature offertes par l'assurance maladie maternité française (article R. 121-4 du CESEDA).

Le critère essentiel à examiner est qu'il rong>ne doit rong>rong>pas rong>y avoir de rong>catégories rong>rong>de soinsrong>, de produits ou de rong>prestations excluesrong> de la couverture contractée par les intéressés alors que rong>l'assurance maladie française les couvre.rong>

Par contrerong> rong>rong>peuvent exister de petites différences rong>sur les conditions de prise en charge ou de remboursement (par exemple, âge limite de prise en charge d’un traitement contre la stérilité) voire quelques exclusions mineures et non significatives globalement (par exemple, absence de prise en charge des cures thermales). Les rong>tarifs de prise en charge ou les taux de remboursement n’ont pas non plus à être identiquesrong>, il faut donc rassurer et informer les intéressés sur la notion de couverture maladie « complète ».

Il faut comprendre que rong>« comparable » ne signifiant pas « identique »rong>, les CPAM apprécieront avec tolérance de légères différences, le principe étant de protéger les per.o. alt='search this word'>r.o./a>nnes elles-mêmes dans la mesure où leurs soins de santé doivent pouvoir être pris en charge par le contrat souscrit et éviter ainsi de créerrong>une charge pour les finances publiques françaises.rong>

Expats in French Health Cover Lottery

Tuesday 15 June 2010

Our recent exclusive on the EU investigation of French health rules provoked an interesting reaction from both readers and health insurance professionals.

One of the widely made comments concerned the difficulties faced by those with a pre-existing medical condition, both amongst those hoping to relocate to France and already resident.

Chris from Worcester wrote to us advising that he is planning to relocate to France, but due a recent stomach operation was concerned that he might not be able to find private health insurance.

‘When we do relocate we will have a modest income, so we cannot afford to pay large sums each year for health insurance,’ he stated.

Some of you had also applied for to get private health insurance, and had been turned down.

Adrian Metcalfe stated that he suffers from high blood pressure, for which he is undertaking medical treatment to keep it under control, but that was enough for the private insurer to whom he made application to turn down his request for health cover.

‘The result is that we fear we may actually have to return to the UK, as there is no way we can stay in France without having some form of health cover.’
However, it does seem all is not lost for those with a pre-existing medical condition.

rong>Tony Mason of Soficas insurance brokers in Bordeauxrong> states that for those with a medical condition there is a route of entry into the French system.

'If someone makes an application to us for insurance, and we refuse due to a pre-existing medical condition, we will provide the applicant with a letter that they can use to make application for entry into the CMU', he stated.

'Under the rules of entry, those who are resident in France through an E form, can make application to join the CMU when their cover expires, provided they have been refused private health insurance.

''Indeed, we have numerous applicants who have taken precisely this route and they have been successful.

''The only downside is that it is unlikely in the future you would be able to obtain a mortgage or secured credit in France, as your application for life insurance would probably be refused', he stated.

Strictly speaking, admission to the Couverture Maladie Universelle (CMU) because of the refusal of private health insurance only applies to those who developed a medical condition after they relocated to France, although it is clear the local health authorities are not necessarily applying this interpretation of the rules.

Given the unclear position, Peter.o. alt='search this word'>r.o./a>wen of Expathealthdirect.co.uk says people need to act with caution: 'If you are affiliated via E106 and during this per.o. alt='search this word'>r.o./a>d you have an illness and subsequent claims relating to this condition were excluded by a private insurer, then on expiry of the E106 it is possible, even probable, affiliation via the CMU would be granted, as a CPAM would judge this an accident de vie.'

'But', he continued, 'it is less certain if affiliation via CMU would be extended on expiry of E106 if you arrive in France with a pre-existing condition. A CPAM office could well argue this is no accident de vie at all, and may (harshly) judge this as somebody engaged in medical tourism, which the new rules intended to extinguish.'

In his view: 'Individual CPAM offices have always varied in their interpretation of regulations; it is a fact of life. As a result I would never advise a client that once an E106 has expired, affiliation via CMU would be automatically extended because of a pre-existing condition being excluded by a private insurer.'

Lack of Consistency in Rules

The differences in intrepretation of the rules was also commented on by a number.o. alt='search this word'>r.o./a>f readers.

Thus, several months ago we heard from Jane Stewart in the Dor.o. alt='search this word'>r.o./a>gne who told us that she was unable to obtain private health insurance as a result of an illness developed in France, but she received a blank refusal from her local CPAM for health cover.

At the time, we advised her to appeal against that decision, as is her right.

Following our article, she wrote to us last week to say: 'My application did not even go to the appeal panel, as the local CPAM director simply decided to sign off the application for me to be admitted to the Couverture Maladie Universelle (CMU)!'

A similar picture emerged from a conversation with ron Wright of Exclusive Healthcare who pointed out to us that, in his experience several expats he had come across had actually been admitted to the CMU, even though they did not qualify under the rules of the French government circular.o. alt='search this word'>r.o./a>f 23 November, 2007.

‘I know of three cases in three different health authority areas where the local CPAM have decided to admit them into the CMU, purely on the basis that they had been resident in France for more than 3 months in a stable and regular manner and had no other health cover', he stated.

‘There seems not rhythm or reason why this should have happened, and it all seems a bit of a post-code lottery. CPAMs seem to be making up their.o. alt='search this word'>r.o./a>wn rules, with some taking a hard line and others willing to admit you.'

David Yeates, Editor at www.french-property.com/news