The French Social Security System I - HEALTH, MATERNITY, PATERNITY, DISABILITY AND DEATH BRANCH

Transcription

1 systèmes nationaux de sécurité sociale > France > Version anglaise The French Social Security System I - HEALTH, MATERNITY, PATERNITY, DISABILITY AND DEATH BRANCH 2016 A - HEALTH, MATERNITY AND PATERNITY INSURANCE Health, maternity and paternity insurance benefits are provided in Metropolitan France by the local Health Insurance Funds (Caisses Primaires d'assurance Maladie/ CPAM) and in the Overseas Departments by the General Social Security Funds (CGSS). As from January 1st, 2016, a universal healthcare system (Puma) covers healthcare costs (formerly called "benefits in kind") for all individuals who: are working, or have been residing in France (including Guadeloupe, French Guiana, Martinique, Reunion Island, Saint Barthelemy and Saint Martin) on a stable and ongoing basis for at least 3 months. To qualify for healthcare coverage before that date, a claimant was required either to have paid a certain amount in contributions or to have worked a certain number of hours within a given reference period. When Puma was rolled out, the Universal Healthcare Coverage program (Couverture maladie universelle/ CMU) ended. CMU was created in 1999 for persons with no entitlement to any compulsory health insurance scheme. To qualify for cash benefits (daily benefits when on medical leave), the claimant must have worked at least 150 hours in the 3-month period preceding the period of sick leave (or paid contributions on earnings amounting to at least 1,015 times the hourly SMIC in the previous 6-month period). To continue receiving cash benefits after 6 months on sick leave, the claimant must have worked at least 600 hours in the previous 12-month period or have paid contributions on at least 2,030 times the hourly SMIC prior to going on medical leave. The claimant must also have been registered with the health insurance scheme for at least one year. Persons who are not employed are also entitled to healthcare coverage if they have been residing in France (including Guadeloupe, French Guiana, Reunion Island, Saint Barthelemy, and Saint Martin) on a stable and ongoing basis for at least 3 months. Their income will determine whether they owe Puma contributions. The health insurance system covers health expenses (reimbursement of healthcare costs) for insured persons and their dependants, and cash benefits (daily sickness benefits for temporary incapacity for work) for insured persons. 1. Healthcare expenses Scope of application: Healthcare expenses cover medical and paramedical expenses as well as medicine, orthopedic appliances, and hospital costs.. Insured persons are entitled to such health benefits both for themselves and for beneficiaries not covered by any social security scheme. Under the new Universal Healthcare Coverage system (Protection Universelle Maladie/ PUMA), which was rolled out on January 1st, 2016, adults can no longer be considered beneficiaries, even if they are "Carte Vitale" not employed. Only minors continue to be considered beneficiaries up to September 30th of the year in The carte Vitale is a card with an embedded which they reach the age of 18, whether or not they are enrolled in certain educational programs, and microchip that certifies entitlement to health provided that they are not employed. insurance. It is issued to all persons aged 16 and over and contains all of the administrative However, minors over the age of 16 can apply to be insured in their own right. information the patient's health insurance fund needs in order to reimburse their healthcare Scope of coverage: expenses. Depending on personal circumstances, it also contains the information needed to use the a) Physician and outpatient care third-party payment system (meaning that the All patients over 16 years of age must choose a treating doctor ("médecin traitant") who will refer them patient does not pay amounts upfront that will later to the appropriate practitioners and hospitals and is responsible for updating their personal medical be reimbursed either by the health insurance record. This so-called "coordinated care pathway" system does not apply to children. The treating system or by his/her supplementary insurance, doctor may be either a general practitioner or a specialist and must agree to act as the patient's treating which kicks in once the patient has been doctor. Patients can change their treating doctor by making a new statement to their Health Insurance reimbursed by the national system. Fund. Parents can apply for a separate carte Vitale for children ages 12 and up. The treating doctor maintains the patient's medical record and prescribes further medical investigations and referrals to hospital services or other health-care professionals (physiotherapists, nurses, etc.). All medical procedures carried out or recommended by the treating doctor are refunded at the normal rate, given that the patient is following the coordinated care

2 pathway. If however the patient has not registered with a treating doctor or consults a specialist doctor directly, they are considered as acting outside the care pathway system and will be refunded at a lower rate than that which would apply if they had seen a treating doctor first. The patient may see a doctor other than the treating doctor in the event of a medical emergency, the absence of the treating doctor or his locum, or if the patient is far from home. Gynecologists, ophthalmologists and psychiatrists may be consulted without referral from a treating doctor. In such cases the practitioner will indicate the "special circumstances" applying on the medical claim form ("feuille de soins"). The patient is generally required to bear part of the medical cost ("ticket modérateur"). In special cases however, such as for women more than 6 months pregnant or long-term illnesses,, the patient is exempted from the co-payment. A doctor's appointment within the healthcare pathway system is reimbursed at a rate of 70%. The patient's out-of-pocket payment will be higher if the healthcare pathway system is not followed. The patient also bears various other costs, in addition to the co-payment: a flat-rate charge for extensive procedures, a 1 charge for visiting a doctor and for examinations and tests and a flat charge for medicines, paramedical procedures and travel for medical purposes. The flat-rate charge for extensive procedures is 18 and applies to medical or surgical procedures costing upwards of 120. This charge applies whether the procedure is performed in a doctor's surgery or a hospital. Certain procedures are exempted from this charge as well as persons who, for health reasons, have 100% statutory health insurance coverage [See b) Treatment that includes hospitalization]. Since 1st January 2005, all patients have been required to pay a 1 charge for a visit to or procedure performed by a doctor, as well as for X-ray examinations and laboratory tests. Such charges may not exceed 4 per practitioner or laboratory per day, or 50 per calendar year. As of 1st January 2008, a new flat charge applies to medicines, non-hospital procedures performed by allied health professionals and travel expenses for medical purposes. This new charge is 0.5 per item of medicine and paramedical procedure and 2 per journey, and is capped at 50 per year for all procedures, 2 per day for paramedical procedures and 4 per day for travel. Minors under 18 years of age, women who are more than 6 months pregnant and those covered by the supplementary CMU program are exempted from paying these different charges. To ensure that the amounts refunded to patients correspond with actual expenditure (including the co-payment) and that the Funds are not required to reimburse medical expenses without controls, the health insurance organizations have entered into national agreements with doctors and allied health professionals. Under this system there are three "secteurs" within which practitioners may choose to work, and which apply different rates of reimbursement: Secteur 1 doctors adhere fully to the national agreement and charge the official rates negotiated with the health insurance system. Secteur 2 doctors set their fees freely. Practitioners may also charge higher rates for patients who are not referred by or registered with a treating doctor. Medicines Medicines are supplied on prescription. The social security system covers a portion of the cost of medicines included in the positive list of reimbursable pharmaceutical products. Certain medicines are reimbursed on the basis of a reference price determined according to the price of the lowest-priced generic equivalent. Reimbursement rates vary between 100% and 15% depending on the recognized "medical service rendered". Provided that the patient shows his/her "carte Vitale" and accepts generics where available, the pharmacist can use the "third-party payment" system, meaning that the patient does not pay the full charge upfront and is only responsible for the portion of the fees that are not covered by the national health insurance system. More information is available on the ameli b) In-patient care The French social security system contributes to hospital costs incurred by insured persons and their dependants. The system covers all hospital services, including fees for medical and surgical procedures performed during the patient's stay in hospital, medication, examinations, etc. It does not cover the cost of non-medical extras such as a private room, telephone, television, etc. In the case of hospital stays in public hospitals or private clinics operating within the social security framework, hospital costs are covered at a rate of 80%. Patients are required to pay 20% of their hospital expenses, plus an 18 daily fee. In some cases or for certain insured individuals (after the 31st day in the hospital), patients receive 100% coverage: pregnant women needing hospitalization from the 4th month of pregnancy onwards, hospitalization resulting from an industrial accident or illness, hospitalization for a long-term illness those with complementary CMU or State Medical Aid (Aide Médicale d'etat/ AME) coverage, etc. In these situations, they are still required to pay the 18 flat fee (or in a psychiatric ward) as well as the 18 flat-rate charge for extensive procedures (costing 120 or more). This flat-rate charge is payable only once during any hospital stay even if several such procedures are performed. However, some patients may be exempted from paying either or both of these two charges (those with CMU-Coverage, patients with a long-term illness, a work-related illness, or an occupational accident injury, and pregnant women from the 6th month of pregnancy).

3 The 18 flat-rate charge for extensive procedures costing upwards of 120, is payable only once during any hospital stay even if several such procedures are performed. Note: Some hospitals or clinics impose excess charges which are not covered by the social security health insurance system. For more information about rates charged and reimbursement rates, please visit the "Annuaire santé" to locate a facility in line with your needs. When the insured is admitted to hospital, an application for coverage is submitted to the relevant Fund. The direct settlement system then applies. The Fund pays the amounts owed directly to the health care institution while the insured is responsible only for the co-payment, the daily fee and the flat-rate charge for extensive procedures. c) Transportation expenses Transportation expenses for medical services can be covered if they have been prescribed. A prescription is necessary in order to be reimbursed for the following: Transportation in connection with a hospitalization, regardless of length, Transportation in connection with a long-term illness (LTI) if the person's state of health does not allow him/her to travel independently, Transportation in connection with an industrial accident or illness, Ambulance transportation when the person's state of health requires him/her to lie flat, Transportation in connection with statutory verifications (appointment for a medical verification, with a medical evaluator, or with an accredited prosthesis supplier. Even with a doctor's prescription, the following types of transportation require prior authorization from their Health insurance fund's medical team: Long-distance transportation, or more than 150 km one way, Frequent transportation (at least 4 trips of over 50 km one way over a 2-month period for the same treatment, Transportation for children and adolescents enrolled in early-intervention medicalsocial centers (centres d'action médico-sociale précoce/camsp) and medicalpsycho-pedagogical centers (centres médico-psycho-pédagogiques/ CMPP). Commercial airline or boat transportation. Transportation expenses are generally reimbursed at a rate of 65%. The patient bears the remaining 35%, plus the minimum charge of 2 per journey up to a maximum 4 in any one day and 50 euros per year. More information is available on the Ameli. Supplementary health insurance programs for people on low incomes To cover healthcare expenses that are not covered by the compulsory scheme, insured persons who do not have group supplementary insurance through their employment have the possibility of taking out supplementary insurance with a mutual fund, provident fund or insurance company. Persons on low incomes are entitled to supplementary Universal Health Insurance Coverage ("CMU-C"), which covers all costs. Recipients pay no upfront costs and are also exempted from the 1 charge and the 0.5 flat charge. People whose income slightly exceeds the ceiling for entitlement to CMU-C can apply for a grant to contribute toward the cost of a mutual or private insurance plan. The amount of this grant varies based on the beneficiary's age. More information is available on the "ameli". 2 - CASH BENEFITS (cash sickness benefits) a) Daily cash benefits In the event of incapacity for work, a sick note must be obtained from a doctor. Daily cash benefits are payable as from the 4th day of absence from work. The daily benefit is equal to 50% of the daily wage of the last 3 months up to a limit of 1/91.25 of the quarterly wage subject to a ceiling of 1.8 times the and twothirds of the daily wage as from the 31st day of sick leave if the insured person has 3 or more dependent children, up to a limit of 1/ of 1.8 times the annual SMIC (with maximum amounts - as of 1st January of per day and respectively). For long-term illnesses, the daily benefit can be paid for a maximum period of three years from beginning to end date for each illness. For all other illnesses, the maximum number of daily benefit payments over a 3-year period is 360. b) Daily compassionate care leave allowance This allowance is paid to persons who have been granted compassionate leave to look after a gravely ill family member (ascendant, descendant, sibling) or trusted person ("personne de confiance"), or who have used their compassionate leave to cut back to part-time work for that purpose. If the recipient stops work completely the allowance is payable for 21 days at a rate of per day. If the recipient reduces the number of hours worked to part time, it is payable for 42 days at half the full-time rate, or (rates have not changed since April 2014). For more information, visit the Ameli. - MATERNITY AND PATERNITY INSURANCE

4 Maternity and paternity insurance benefits are provided in Metropolitan France by the local Health Insurance Funds (CPAM) and in the Overseas Departments by the General Social Security Funds (CGSS). Maternity and paternity insurance covers pregnancy and delivery-related costs as well as cash benefits during the mother's pre- and post-natal leave, the mother's and/or father's adoption leave and the father's paternity leave. 1 Maternity-related healthcare Coverage is provided to women who are insured, and to the spouses, daughters or daughters-in-law of insured males. The claimant must notify their local Health Insurance Fund as soon as possible, and submit to various compulsory pre- and post-natal medical examinations. Entitlement to benefits, determined at the estimated date of conception (or if there was no entitlement at that date, at the date of prenatal leave) is governed by the same conditions as applicable for health insurance. All compulsory pre-natal examinations (compulsory prenatal appointments, birth preparation classes, and complementary laboratory tests), are covered at a rate of 100%. Moreover, between the first day of the sixth month of pregnancy and the twelfth day following birth, all medical expenses are covered at a rate of 100%, whether or not they are pregnancy-related. The mother is also exempted from the 1 charge and the flat charge for medicines, paramedical services and travel. 2 - Cash benefits Cash benefits are provided when the concerned person stops working. In addition to maternity cash benefits paid to women during pre- and post-natal leave, paternity leave benefits are paid to fathers. For adoptions, daily benefits may be shared between both parents. To qualify for these benefits, the insured person must have paid the requisite amounts in contributions or worked the requisite number of hours, and must also have been registered with the social security system at least 10 months prior to the expected date of delivery or the child's date of arrival in the household. Mothers are required to take a minimum 8 weeks' maternity leave, but are entitled to a total 16 weeks' leave (usually 6 weeks prior to the expected date of delivery and 10 weeks after). 2 additional weeks prior to delivery may be awarded in the case of a pregnancy with complications. With a doctor's recommendation, the mother may also take part of the prenatal leave after giving birth. For a third child, leave is extended to 26 weeks (8 pre-natal and 18 post-natal). Mothers expecting twins or triplets (or more) are entitled to 12 weeks' and 24 weeks' pre-natal leave respectively, and 22 weeks of post-natal benefits. In the case of premature births (more than 6 weeks before the expected date of delivery) the maternity leave period is increased by the number of days intervening between the date of delivery and the date 6 weeks before the expected date of birth. The paternity leave period is 11 consecutive days for the birth of 1 child, or 18 consecutive days in the case of a multiple birth. Finally, adoption leave is 10 weeks, or 22 weeks for the adoption of more than one child. If the adopted child is at least the 3rd child in the household, the leave period is extended to 18 weeks. If the father and the mother are eligible to benefit payments during their parental leave and if the parental leave is shared by the parents, the period of leave is extended to 11 days, or 18 days if more than one child is adopted. The amount of the daily maternity, adoption or paternity benefit payment is equal to the average daily wage of the 3-month period preceding pre-natal leave up to the quarterly social security ceiling ( 9,654 in 2016), after deduction of the employee's share of statutory social contributions and taxes (flat rate of 21%). As of 1st January 2016, the daily payment cannot be lower than 9.26) and cannot exceed B - DISABILITY INSURANCE Payer : Disability pensions are awarded by: the local health insurance funds (caisses primaires d'assurance maladie/ CPAM) ; the Ile-de-France region health insurance fund (caisse régionale d'assurance maladie d'île-de-france CRAMIF), for the Paris region the general social security funds (caisses générales de sécurité sociale/cgss) for the overseas Departments the social security fund (caisse de sécurité sociale/ CSS) in Mayotte. Disability insurance is an outgrowth of sickness insurance and is intended to compensate disabled persons for the loss of earnings resulting from a decrease in their ability to work or earn a living. 1 - Disability pension Disability insurance is an outgrowth of sickness insurance and is intended to compensate disabled persons for the loss of earnings resulting from a decreased ability to work or earn a living. A disability pension is awarded to an insured individual whose disability was not caused by an industrial accident or illness and who: has not reached statutory retirement age (between the ages of 60 and 62 depending on birth year);

5 is suffering from a condition that prevents them from earning - in any gainful activity a wage equal to at least 1/3 of the wage normally paid for the job in which they were employed before stopping work or prior to the recognition of their disability status; had been insured for at least 12 months at the time s/he stopped working and either worked for at least 600* hours, or paid contributions on a salary equivalent to 2,030 times the hourly minimum wage (SMIC) over the same period. *800 hours if the insured stopped working or the disability was recognized prior to February 1, Pension calculation There are three categories of pension, depending on the degree of inability to work: The 1st category applies to disabled persons who are still able to perform some form of gainful activity. The pension is calculated according to the following formula: SAM* (salaire annuel moyen: Average Annual Earnings) x 30%.. The maximum monthly amount is equal to 30% of the social security ceiling ( ). The 2nd category applies to disabled persons who are unable to perform any form of gainful activity. The calculation is the same as for the first category of pensions, except for the percentage applied to the average annual earnings (SAM* x 50% ) The maximum monthly amount is equal to 50% of the social security ceiling ( 1,609). The 3rd category applies to disabled persons who belong to the second category but need the constant attendance of another person to perform activities of daily living. The amount of the basic pension is then increased by 40% and cannot be lower than an annual minimum amount which is re-evaluated on April 1st of each year. The maximum monthly amount of the third category disability pension is 2, ( 1, ,103.08). *The SAM represents the earnings accrued and credited to the insured person's old-age account during their ten highest-earning years, adjusted and divided by ten (if there were ten years) Minimum: the disability pension, whatever the category, cannot be lower than a guaranteed minimum amount ( per month). Recipients of disability pensions are entitled to health/maternity benefits for themselves and their dependants, with no co-payment ("ticket modérateur", i.e. portion of the medical cost borne by the patient and designed to moderate demand). They must however pay the flat charges on medical procedures, paramedical procedures, medicines and transport but are exempted of the 18 charge on major medical procedures. If the recipient does not work, the disability pension is automatically converted into an old-age pension at the legal minimum retirement age (between 60 and 62, depending on the year of birth). If they do work, they must apply for their retirement pension. Disability pension payments stop automatically when the recipient reaches the age at which a full pension is payable, regardless of the total period of insurance (between 65 and 67), or before then if the recipient stops working. 2 - Widow's or widower's disability pension The widow's or widower's disability pension is paid by the local Health Insurance Fund, the Regional Health Insurance Fund for Ile de France (in the case of the Paris region) or the General Social Security Fund (in the case of the Overseas Departments). It is payable to the surviving spouse of a person who had been in receipt of, or who had been entitled to receive, a disability pension or an old-age pension. To qualify, the surviving spouse must be under 55 years of age and suffer from a permanent disability reducing their ability to work or earn a living by at least two thirds. The amount of the pension is equal to 54% of the pension that was paid, or would have been paid, to the deceased spouse. A 10% increase is granted to recipients who have had at least 3 dependent children. More information is available on the Ameli. C - DEATH INSURANCE The death grant is paid to the relatives of the deceased person by the local Health Insurance Fund (in the case of Metropolitan France) or the General Social Security Fund (in the case of the Overseas Departments). In terms of entitlement, priority is given to those persons who at the time of death were effective, total and permanent dependants of the insured person. If the deceased person has several dependants, the order of priority regarding payment of dependants is as follows: a surviving spouse who was neither legally or voluntarily separated from the insured person at the time of death, or a partner with whom the deceased had entered into a civil union (PACS), the legitimate, illegitimate, adopted and foster children of the deceased, the ascendants of the deceased. For entitlement to a survivor's pension, it must be established that during the three month period prior to their death, the deceased was either: in salaried employment;; entitled to continued benefits; engaged in an activity equivalent to employed work; a disability pensioner; in receipt of industrial injury benefits with a disability percentage at or above 66.66%.

6 For all deaths occurring from 1st January 2015, the death grant is a lump sum that increases annually. As of 1st January 2016, this lump sum was More information is available on the Ameli. Centre des Liaisons Européennes et Internationales de Sécurité Sociale 11 rue de la tour des Dames Paris cedex 09 Tél. : +33(0) Fax : +33(0)