Created in 1999, the Universal Sickness Coverage (CMU) allowed coverage of health expenses for people not covered by any compulsory health insurance scheme. This right was subject to the payment of a certain amount of fees or the fulfillment of a certain number of working hours during each reference period. As of January 1, 2016, the CMU was replaced by Universal Illness Protection (PUMA). This guarantees the coverage of health expenses (previously called “benefits in kind”) without interruption of rights in case of change of circumstances (professional, family or residence) to any person who:
Exercise a professional activity, or reside in a stable and regular way in France (including Guadeloupe, French Guiana, Martinique, La Réunion, San Bartolomé and San Martín) for at least 3 months. To be entitled to daily subsidies in case of sick leave less than 6 months, the insured must have worked for 150 hours in the course of the 3 months preceding the leave (or have paid on a salary at least equal to 1,015 times the SMIC (Interprofessional Minimum Salary for Growth) schedule during the 6 months prior to the absence from work).
Above 6 months of sick leave, the insured must have worked at least 600 hours in the course of the previous 12 months or have paid a salary at least equal to 2,030 times the SMIC schedule, before the sick leave. A minimum duration of one year is also required. People who do not work also have a coverage of their health expenses as long as they can justify a stable and regular residence in France from a minimum of 3 months. Depending on their income, said persons must or must not pay the specific PUMa quotation established at 8%.
They must pay this annual contribution, people:
That they do not receive income from work or that their income obtained from work activities carried out in France is less than 10% of the annual limit of Social Security (that is, less than € 3 973 in 2018); And whose returns on capital or assets (real estate income, capital income, goodwill, etc.) are greater than 25% of the annual limit of Social Security (9 933 € in 2018). Quotation calculations are different depending on whether the returns are less than 5% of the annual Social Security limit or if they are between 5% and 10% of this amount. In addition, the contribution is pro rata if the insured belongs only part of the year to the PUMa regime.
The health insurance covers the medical expenses (reimbursement of health care) of the insured and their minor beneficiaries and the economic benefits (daily sickness benefits in case of temporary incapacity for work) for the insured. The expenses for health care cover medical and paramedical expenses and pharmacy, equipment and hospitalization expenses. Both the holder and his beneficiaries who are not registered in any social security scheme can benefit from these benefits.
With the introduction of the Universal Protection of Illness (PUMA) on January 1, 2016, the notion of rightful claimant for the elderly disappears, although the latter lack professional activity. Only minors are still considered beneficiaries, and cease to be, at most, on September 30 of the year in which they turn 18, regardless of whether or not they continue their studies in certain educational establishments, and as long as they do not exercise any professional activity. However, minors who are over 16 years old can apply for personal insurance.
a) Assistance without hospitalization
As soon as he turns 16, each patient must choose a general practitioner to guide him on his medical journey. The role of the general practitioner is to keep the medical file updated, prescribe complementary medical examinations or guide the patient towards a hospital service or another health professional (massage therapist, physiotherapist, nurse …). The role of general practitioner can be performed by both a general practitioner and a specialist. To change your family doctor, just make a new statement to the Sickness Insurance Fund. The reimbursement of the medical acts carried out or recommended by the general practitioner will be reimbursed applying the ordinary type, since the interested party is within the compulsory sanitary route. On the other hand, if the patient did not declare a family doctor or if he is going to consult a specialist directly, the reimbursement will be lower and the part of his expenses will be higher than if he had complied with the sanitary route.
The patient can directly consult a doctor other than the general practitioner in certain cases: medical emergency, absence of the attending physician or his replacement, or away from home ,. Likewise, gynecologists, ophthalmologists and psychiatrists can be consulted directly without going through the family doctor. In all cases, the doctor consulted will mention the corresponding situation in the attendance leaflet. In principle, a certain part of the expenses is left to the insured: it is the “moderator ticket” (which can be abolished in some cases, especially for pregnant women of 6 months and long-term conditions). A consultation with the doctor within the framework of the mandatory sanitary route is reimbursed at 70%. The amount charged to the patient will be higher if the patient is out of the mandatory sanitary route.
Assistance with hospitalization
The Social Security assumes a part of the hospitalization expenses of the insured or its beneficiaries. Specifically, it finances the hospital benefits: medical and surgical fees that correspond to the care provided during hospitalization, medications, exams, interventions, etc. The health insurance does not finance certain supplements for conveniences, such as the private room, the telephone or the television, etc- In case of hospitalization in a public center or in a private arranged clinic, social security assumes 80% of hospitalization expenses. The insured must pay 20% of the hospitalization expenses, plus a daily fixed fee of € 20 for each day of hospitalization.