Dor.o. alt='search this word'>r.o./a>gne Makes Concession on Health Cover

Friday 01 June 2012

The health authority in the Dor.o. alt='search this word'>r.o./a>gne has agreed to admit early retirees with a long term illness into the health system.

According to Tony Mason of health insurance brokers Soficas those with what is known as an 'Affection de Longue Durée (ALD)'* pr.o. alt='search this word'>r.o./a>r to losing their health cover rights under an S1/E106 will now be able to obtain cover under the Couverture Maladie Universelle (CMU).

‘It still remains a little unclear to me why the CPAM have changed their position’ he says,‘but in large measure I think it is genuinely because, until we made them aware, they simply had no idea of the scale of the difficulties being faced by a large number.o. alt='search this word'>r.o./a>f early retirees, who simply had no medical cover.’

The enlightenment of officials to the problem began several months ago when Tony attended a meeting of around 70 British expatriates in Perigeux organised by Angela Martyn, the President of the North Eastern Dor.o. alt='search this word'>r.o./a>gne Women's Association. He arranged for local CPAM officials to be present.

At the time, the health officials denied that there was a problem of access into the health system.

''So as if to prove the point' say Tony, 'I opened the matter up to a show of hands in the room, when around one-third of those present stated that they had been refused health cover by the CPAM.

The look of disbelief on the faces of the officials was only matched by my own astonishment that they should appear to be so blindingly oblivious to what was taking place in their department.

At the end of the meeting officials confided to me that they clearly needed to undertake some internal consultation, and the outcome now appears to be the change in policy administration.''

Tony advises that those in the department of Dor.o. alt='search this word'>r.o./a>gne with a pre-existing long-term illness should contact him to discuss whether they might be eligible to obtain access to join the CMU.

Those who develop an Affection de Longue Durée (ALD) after they come to France already have a right of access into the health system under ‘accident de vie’ provisions, on a case by case basis.

The position of those early retirees who do not have a long-term illness remains unchanged, although we would suggest you discuss your circumstances with Tony to see what can be done. You can contact him at tony@soficas.fr.

The same applies to those living in other areas of France, where the position of many local CPAMs remains intransigent, although not in all cases.

We are finding that a number.o. alt='search this word'>r.o./a>f health authorities are conceding when pressured, while others are recommending that early retirees secure a residence permit, on the basis of which the health authority would then be able to grant them access into the system. We covered this point in our last Newsletter.

We await further news from the European Commission who are pressing the French government for a relaxation in the rules and infringement proceedings remain in force. It remains to be seen how matters might develop with a new government in place in the country.

*Affections de Longue Durée (ALD)

The list of those illnesses (in French) classified an ALD provided from the French health service website is show below. It currently excludes high-blood pressure, removed from the list last year, but this may by under review by the new government.

• Accident vasculaire cérébral invalidant
• Insuffisances médullaires et autres cytopénies chroniques
• Artér.o. alt='search this word'>r.o./a>pathies chroniques avec manifestations ischémiques
• Bilharziose compliquée
• Insuffisance cardiaque grave, troubles du rythme graves, cardiopathies valvulaires graves, cardiopathies congénitales graves
• Maladies chroniques actives du foie et cirr.o. alt='search this word'>r.o./a>ses
• Déficit immunitaire primitif grave nécessitant un traitement prolongé, infection par le virus de l'immuno-déficience humaine (VIH)
• Diabète de type 1 et diabète de type 2
• Formes graves des affections neurologiques et musculaires (dont myopathie), épilepsie grave
• Hémoglobinopathies, hémolyses, chroniques constitutionnelles et acquises sévères
• Hémophilies et affections constitutionnelles de l'hémostase graves
• Maladie coronaire
• Insuffisance respiratoire chronique grave
• Maladie d'Alzheimer et autres démences
  
• Maladie de Parkinson
• Maladies métaboliques héréditaires nécessitant un traitement prolongé spécialisé
• Mucoviscidose
• Néphropathie chronique grave et syndrome néphrotique primitif
• Paraplégie
• Vascularites, lupus érythémateux systémique, sclérodermie systémique
• Polyarthrite rhumatoïde évolutive
• Affections psychiatriques de longue durée
• Rectocolite hémorragique et maladie de Crohn évolutives
• Sclérose en plaques
• Scoliose idiopathique structurale évolutive (dont l'angle est égal ou supérieur à 25 degrés) jusqu'à maturation rachidienne
• Spondylarthrite grave
• Suites de transplantation d'organe
• Tuberculose active, lèpre
• Tumeur maligne, affection maligne du tissu lymphatique ou hématopoïétique

The statement does at least give some glimmer.o. alt='search this word'>r.o./a>f hope, and it may well be that further progress will be made after the forthcoming French presidential elections in May.

      rong>i. Appeal
rong>      rong>ii. Change of Circumstances
rong>      rong>iii. Residence Permit
rong>      rong>iv. Auto-Entrepreneur
rong>      rong>v. Aide Médicale de l’Etatrong>

i. Appeal

If you are refused health cover by your local Caisse Primaire d'Assurance Maladie (CPAM) you should make a formal appeal against the decision to the local appeal panel, the Commission de Recours Amiable (CRA).

iii. Residence Permit

iv. Auto-Entrepreneur

v. AME

Five Year Rule

This article was featured in our Newsletter dated 01/05/2012   David Yeates, Editor at www.french-property.com/news

EU Questions France over Health Cover Refusals

Wednesday 04 January 2012

The EU is stepping up pressure on France over reports that expats are still being refused health cover.

Complain, Complain, Complain

This article was featured in our Newsletter dated 04/01/2012 David Yeates, Editor at www.french-property.com/news

Health Cover and Residence Permits

Wednesday 05 October   2011

In order to try and get into the French health system, it seems some of you are applying for a residence permit, but it is a game of chance.

Over the past few weeks we have received dozens of e mails from readers relating your experiences of trying to get into the French health system.

Some of you have relayed very distressing chronicles to us, including some living in France without any health cover at all, while there are others who are paying a very substantial proportion of their income in private health insurance contributions.

We are grateful to you for telling us of your experiences, for they are invaluable to us in trying to get a full understanding of just what is happening.

As we anticipated in our last Newsletter, a very variable picture has emerged across the country in the application of the new Circular N°DSS/DACI/2011/225 concerning the admission of inactive early retirees into the system.

While some local health authorities are now admitting early retirees, some continue to rigidly apply the five year residence rule.

The European Commission has been alerted to the continuing problems being faced by many of you, and they have expressed to us their concern that some local health authorities have continued to fail to implement European legislation.

A spokesman told us that, ‘The Commission is monitoring carefully how this new Circular is applied in practice by the French authorities and is in contact with the French authorities on this issue. We are, of course, surprised by reports that the French health authorities have said the new Circular doesn't change anything, which, if confirmed, would be a source of concern.’

It is important that the EU is provided with the evidence that some health authorities in France continue to ignore EU regulations. So if you are being refused access into the health system, then we urge you to make a formal complaint to the European Commission, which you can do so at EU Citizen Complaints.

Appeal Procedures

One thing that is becoming clear is that intransigent local health authorities (CPAMs) are sometimes yielding when pushed hard by those who are aware of their rights and the procedures.

Accordingly, it is important you do not give up on your application if you are rebuffed by a local official.

You need to make use of the appeal procedure we outlined in our last Newsletter, and if necessary take the matter to the local tribunal.

We recommend you quote European Regulation (EC) No 883/2004 of 29 April 2004, which grants a right of equal treatment to EU residents who are legally resident in another Member State. Elements of the new Circular quoted in our last Newsletter would also be useful to include in your appeal letter.

Residence Permits

A small number.o. alt='search this word'>r.o./a>f you have also written to us about the provisions in the Circular which grant access into the health system for those who hold a residence permit, a carte de séjour.

Your mails on this point seem to be prompted by advice you have received from the English speaking CPAM help-line that this is the approach to take.

Although EU residents no longer need a residence permit to live in France, there is a provision in Circular N°DSS/DACI/2011/225 that grants those who hold a particular type of residence permit an automatic right of access into the health system.

Thus, the Circular states: ‘Les citoyens de l’Union bénéficiant de la qualité de résident permanent, appréciée par les préfectures et matérialisée par la détention d’une carte de séjour portant la mention « CE-séjour permanent-toutes activités professionnelles », ne sont plus soumis aux conditions exigées des inactifs (ressources suffisantes et assurance maladie complète) visées à l’article L.121-1 du CESEDA. Ils peuvent être affiliés à la CMU et, le cas échéant, complémentaire (CMU-C), dans les conditions de droit commun.’

What this means is that an EU resident who has a residence permit that indicates they have business/employment in France does not have to comply with either the requirement of existing health cover.o. alt='search this word'>r.o./a>r minimum income in order to be entitled to access the Couverture Maladie Universelle (CMU).

Now, of course, if you run a registered business in France then you are automatically affiliated to the health system, and a carte de séjour is not obligatory, although it is available on request.

However, there is anecdotal evidence from you that some préfectures are prepared to issue such a carte de séjour without the need to prove the creation of a business or salaried employment.

In short, what seems to be being said is such a permit grants the right to start a business or take employment for those that may have the intention to do so.

We do not believe that this broader interpretation was ever the scope of such residence permits, but it is clearly a game of chance, and all we can say is that if you have exhausted all other.o. alt='search this word'>r.o./a>ptions, this is one option that may well be worth pursuing.

If all you are being offered is a carte de séjour ‘non-actif’, then it is unlikely that this would take you much further, although it would of course confirm that you were legally resident in France.

In order to obtain a residence permit you need to make application to your local préfecture, the main governmental office that is located in each department of France. You will need to provide a range of documentation, whose list may vary, but you would be well advised to go along with your passport, utility bills, income tax notice, taxe d’habitation, marriage and birth certificates.

We would be most interested to continue to hear from you on this issue. You can contact us by mail at: editor@french-property.com

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

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