“You really should take out la mutuelle,” the receptionist at my health insurance provider insisted, trying to convince me to sign up for extra health insurance coverage.
She pulled out a reimbursement form and gestured to it. “Look at this–this guy would’ve paid 700 euros for his hospital visit if he hadn’t had la mutuelle.“
I smiled politely and said thanks, but no thanks. I laughed and thought to myself: I’m American–you can’t scare me with high healthcare costs!
It was wry humor that was unfortunately true. Last year, I paid $360 out-of-pocket for a two-mile (3km) ambulance ride in Boston where I received zero treatment; it was basically just a 10-minute taxi ride. The pre-insurance bill was $1800. My friend called the paramedics since I had peeled my finger with a veggie peeler, and we weren’t sure if it needed stitches. I was luckily fine, and only received a tetanus booster, antibiotic ointment, gauze, and 3 Tylenol pills at the emergency room. That bill was $200 after insurance.
Fortunately, I haven’t had to go to the ER in France (so far), but if I did, I wouldn’t have to worry as much about the cost: ambulances are FREE in France. FREE. Because of universal healthcare, it’s generally way cheaper to take care of yourself.
Since it’s France though, there are also a lot more rules and administrative steps that might be confusing to an American expat. Here’s what I’ve learned this year about French healthcare, so hopefully you can navigate the system more smoothly!
Overview of American Healthcare
For any non-American readers, I want to first explain the American healthcare system. We don’t have universal healthcare, but it’s the hot button topic of the 2020 election. As it currently stands, 87 million Americans are uninsured or underinsured. Most Americans get insurance by working a full-time job, where both the employer and employee contribute to the cost of insurance. Only after retirement (age 65) can you benefit from state-granted health insurance.
This can be extremely limiting in several ways. For one, it stifles entrepreneurship and non-traditional careers; since private insurance is so expensive, many people with business ideas don’t pursue them. This is because they need a full-time job to be insured themselves, and they also would need to pay high premiums for their employees’ insurance, if they were to start a business. It also prevents people from retiring early; if they wish to do so, they and their families might be uninsured.
Healthcare costs in the US are expensive beyond the cost of insurance, though. Basically every insurance company has “deductibles,” which are set amounts you must meet before your benefits kick in. For instance, I have a $250 physical therapy deductible, meaning that I have the pay the full amount until I meet $250 worth of treatment. This deductible amount is actually considered “very low,” according to my PT (even though it seems like a lot of money to me!). Also, emergency care is crazy expensive, as you know from my ambulance story.
The worst part is that I’m one of the “lucky” ones, as my insurance is considered “good,” and my family has the means to pay these bills. I can’t imagine how difficult it must be for people with bad insurance, let alone no insurance at all (which is why we need Medicare for All!).
Overview of French Healthcare
La sécurité sociale (la sécu) and la mutuelle
France has a universal healthcare system. The first two terms you need to know are la sécurité sociale (la sécu) and la mutuelle. La sécu is the state-provided health insurance guaranteed to all residents in France. It covers about 70% of your medical costs* (I’ll go into detail on the asterisk later), and your contribution is automatically deducted from your paycheck. I actually don’t know how much was taken from my paycheck, but the monthly cost is 10€/month on average.
La mutuelle is the extra insurance many people take out to cover the remaining 30%. The cost of la mutuelle varies in function with your salary–the more you make, the more it costs. As an English lectrice (university teaching assistant), I made around the minimum wage of 1200€/month, and la mutuelle would’ve cost me 26€/month.
To receive the benefits of la sécu, you need to enroll with a health insurance provider. I chose MGEN, which is apparently the largest provider in France. I made an appointment and brought all necessary documents. I remember needing a copy of my work contract, bank information, and a copy of my passport. At some point, you will also be required to send in a copy of your translated birth certificate. When you make your appointment, be sure to ask what exactly you should bring.
It is relatively cheap to see the doctor in France. Without insurance, the set rate for a general practitioner is 25 euros. With la sécu, you get back 16,50€ (your health insurance provider takes a 1€ fee from your 70% of 25€).
Note, however, that you MUST declare a primary care physician to get back 16,50€, otherwise you only get 6,50€. Ask for a déclaration du médecin traitant when you sign up for la sécu. Fill it out, ask the doctor of your choice to sign it, and turn it in as soon as possible.
Other Medical Specialists: Dentists, Eye Doctors, Physical Therapists
Other medical specialists also have set rates, and they are generally more affordable than they are in the US. La sécu may not cover these visits super well, however, so be sure to ask your insurance provider. According to my friend Diane, an American expat in France, a cleaning costs 50 euros before the 70% reimbursement. I can’t offer any insight from my experience, as I didn’t go to the dentist or eye doctor in France since I just got those appointments done on trips back to the States.
Also know that there may be unusual rules to make appointments with medical specialists. I was told that to see a physical therapist, I first had to see my general practitioner to get a referral. It seemed like too much work (and money) to have to visit two doctors when I just wanted to see one, so I never went. I later learned that there’s a similar policy in the US for certain states, but I’ve always lived in direct access states, which allow you to self-refer to a PT.
EDIT (July 2019): I did end up going to see a physical therapist for my ankle issue, and each 30 minute session was 20€ before la sécu, and 10€ after. This is significantly better than US rates of around $125 per 30 minute session, not to mention insurance deductibles (mine was $200). X-rays, ultrasounds (used frequently for tendon issues), and bone scans were also much cheaper, coming out to around 13€ after la sécu. It does take longer to get a bone scan or MRI appointment in France, however–usually a few weeks. That said, I was able to get my X-ray and ultrasound appointments within the same day, or next couple days.
I have a whole post dedicated to physical therapy in France, so check that out if you want more info on referrals, costs, and my experience.
Prescription medicine is VERY cheap in France compared to the U.S. (around 3€ per medication before insurance). That said, you also aren’t well-reimbursed for prescriptions with la sécu. For about 10€ worth of prescriptions, I usually got only 3€ back. Each prescription comes with a code that indicates the percentage you can expect to be reimbursed:
For women, I also want to note that reproductive care is more affordable in France. According to this article, birth control is 2-15€ for a month’s supply. Plan B is also much cheaper, costing around 7€ instead of the $30+ in the U.S.
You’ll notice that there are pharmacies everywhere in France–sometimes within 100m of each other! This makes getting prescription or over-the-counter medication a lot more convenient.
Note, however, that non-prescription medication is a lot more expensive than prescription meds. I’ve paid almost 30€ for an aloe gel and herbal supplement a pharmacist suggested for my itching symptoms, 6€ for 14 ibuprofen pills (yikes!), and 10€ for a pack of probiotics that ended up giving me side effects. I would not buy any extra over-the-counter medications that a pharmacist suggests. When in doubt, just visit your doctor to get recommendations, as it will likely be cheaper after reimbursements than just going to the pharmacy for suggestions. Pharmacists in France are actually known for being sales-y, so don’t buy into their gimmicks!
Carte Vitale / Reimbursement
Getting reimbursed is really easy, if you have a carte vitale. This is basically a health insurance card that you can swipe at the doctor’s office and pharmacy to get your insurance discounts either automatically, or later deposited to your bank account. For prescriptions and X-Rays, you get the discount up front. For doctor’s and PT appointments, you pay full price, and then get reimbursed to your bank account.
I received a letter from MGEN about the card two months after enrolling in la sécu. The letter asked me to mail in a copy of my translated birth certificate, residency permit, copy of my passport, and an ID photo so I could get my carte vitale. While they ask for a certified translation, I did my own, and it was accepted. You should, however, get an apostille in your home state before leaving to authenticate your birth certificate. An apostille is basically a piece of paper that declares that your official document is real. After sending in all this information, I got a second letter three months later, asking me to confirm my personal details by mail for my card.
Unfortunately, administrative processes take forever in France, so I only got my card 8 months after arriving. Since I didn’t have a carte vitale for most of the year, I had to instead get a feuille de soins (photos 2 and 5) that I physically gave to MGEN so they could reimburse me through direct deposit. For prescription reimbursement, you need to attach a copy of the prescription to the feuille de soins (see below photo). The whole reimbursement process generally took one month.
Should I enroll in la mutuelle ?
Staff at health insurance companies will pressure you endlessly to buy extra coverage, la mutuelle. They’ll claim that basically everyone enrolls in it and that it’s very risky to not.
None of the five TAs in my year bought this extra health insurance because we didn’t think it was worth it. Most of us had insurance from our home countries that also applied abroad. I did the math and saw that I’d pay around 260€ total during my stay. I figured that I’d have to get pretty sick for this extra investment to “pay off.”
I estimate that I’ve spent 120€ out-of-pocket on doctor’s visits and medicine during 9 months in France, with 60€ being over-the-counter meds that wouldn’t have been covered anyways. If I had taken out la mutuelle, I would’ve gotten all my doctor’s visits and prescriptions covered (the remaining 60€ out-of-pocket), but I also would’ve paid 260€ for the extra insurance. So my net cost would’ve been 200€ + 60€ over-the-counter meds = 260€. This would’ve been 140€ more than the 120€ I spent without la mutuelle.
Of course, it is a gamble to decline la mutuelle (what happens if you actually do have a medical emergency? I could still have some crazy issue in the next couple months, for instance). Since I have U.S. health insurance that works abroad, it’s a little less of a worry for me. If you aren’t covered by American insurance though, it might be a better idea to consider la mutuelle, especially if you plan to see the dentist or optometrist in France.
EDIT (July 2019): By the end of my stay in France, I had spent 210€ out-of-pocket on healthcare. This means that I only “saved” 50€ by deciding not to take out la mutuelle. The bottom line is that you will likely save at least 100€ if you don’t have any major health issues, nor need to see a PT, dentist, or eye doctor. Again, health issues are unpredictable though, so it is a risk. If it gives you a peace of mind to buy extra insurance, that’s plenty good a reason to do so.
I hope this gives you a better sense of how healthcare works in France! If you have any questions, feel free to leave them in the comments.