Expat Health Insurance in France 2026: PUMa, Mutuelle and Private Cover for Americans and Britons

Written by Steffan Grund · Insurance specialist (Versicherungsfachmann BWV) · Updated October 27, 2026Facts checked: October 27, 2026

Key facts: health insurance for expats in France (2026)

Sources: ameli.fr (Assurance Maladie, September–October 2026), service-public.fr (PUMa, checked 13 May 2026; C2S, 1 July 2026), Urssaf, CLEISS, GOV.UK, TLScontact UK guidance.

What are the three layers of health cover in France?

Health cover in France has three layers: PUMa pays a set share of most bills, a mutuelle can pay much of the rest, and international insurance pays on its own terms, also before PUMa starts and outside France. The French system is built so that public insurance never pays 100% of an ordinary bill. The part left to you is called the reste à charge, and the French market for top-up policies, the mutuelles, exists to cover it. International insurance sits outside that system: it does not care whether you have a Carte Vitale, and it is the only layer that can cover you from the day you arrive.

Who needs what depends mainly on your stage. Before the visa and in the first three months, you need cover that pays the whole bill, which means private insurance or a UK S1. After PUMa starts, the question becomes how much of the remaining share you want to carry yourself. The expat health insurance guide explains how long-term international plans work in general; this page applies it to France.

What health insurance do you need for a French long-stay visa?

You need medical cover for the whole stay: service-public.fr lists "health insurance covering the length of your stay" as a condition of the visitor residence card, and France-Visas asks visitors to prove their medical cover. The most explicit rules come from the UK application guidance (TLScontact, May 2021): long-stay visitors need private health insurance covering the full visa, up to one year; Schengen travel insurance is not accepted, because it only applies to stays of up to 90 days; and retirees drawing a UK State Pension may show a valid S1 instead.

No official page we read sets a minimum sum or a required wording for long-stay visitor insurance, and the US consulate has not published its own insurance rule on the pages we could read. In practice, ask for a certificate in English or French that names you, the start and end dates, France as covered, and the main benefits (hospital, doctors, repatriation). We make no claim that the consulate accepts any particular insurer, including Care Expat World; the consulate decides. The full visa process, the income rule and the fees are on our France retirement visa guide.

A timing detail for long-term plans: Care Expat World always starts on the 1st of a month, at most four months ahead, and not before you cross the border. Plan the start date to match your arrival, and keep in mind that the minimum term is 12 months, longer than the three-month PUMa wait.

How does PUMa work for expats, and when does it start?

PUMa starts after three months of stable, regular residence for people who do not work in France, and it stays open as long as you live in France at least six months a year. It is not a separate insurance policy but your membership of the Assurance Maladie, the French public health insurer, run locally by your CPAM. On ameli.fr, the Assurance Maladie describes the principle simply: anyone who works or lives in France in a stable and regular way is entitled to have their health costs covered.

1. Wait three months. Count from your arrival. Keep proof: your validated VLS-TS, lease, utility bills.
2. Apply to the CPAM. Use the form "Demander l'ouverture des droits à l'Assurance maladie" with your residence document, ID and proof of address. UK State Pensioners register their S1 instead.
3. Get a social security number. People born abroad first receive a temporary number, then a definitive one.
4. Order the Carte Vitale. With the definitive number, order it in your ameli account with a scanned photo and ID; about two weeks online, and it is free. Until then, use your attestation de droits.
5. Declare a médecin traitant. Choose a GP and declare them; without this you are outside the coordinated care pathway and refunds drop.

The médecin traitant step is easy to miss and expensive to skip. Ameli.fr shows the effect on a €30 GP visit: inside the pathway PUMa refunds €19; outside it, only €8.40. Specialists you see on your GP's referral are also refunded at the full 70%, while some specialists can be seen directly (gynaecologists, ophthalmologists, and psychiatrists for patients under 26). If you are called to the OFII medical exam after validating your visa, attend it: it is part of the residence process, not of PUMa.

How much does French public insurance reimburse?

PUMa reimburses 70% of the official tariff for doctors, 80% for hospital care and between 15% and 100% for medicines, always on the official tariff rather than on the price you were charged. That last point matters. The percentage is applied to the base de remboursement, the official tariff, not to the fee on your receipt. If a doctor in sector 2 charges more, the extra (the dépassement d'honoraires) is yours or your mutuelle's.

Some situations lift the hospital rate to 100%: stays longer than 30 days (from day 31), a recognised long-term illness (ALD) for the related care, pregnancy-related stays, work accidents and people on the Complémentaire santé solidaire. Even then, the daily hospital charge and comfort extras such as a private room, television and telephone stay outside public cover. In a private clinic that has no agreement with the Assurance Maladie, you pay the full bill upfront and receive 80% of the official tariff, which can leave a large gap.

What is the reste à charge, and which flat fees does no insurance refund?

The reste à charge is everything PUMa does not pay: the remaining 30% or 20% (the ticket modérateur), doctors' extra fees, the daily hospital charge, comfort extras and a set of small flat fees that the law keeps back from your refunds. A mutuelle can refund most of these, but under the standard "responsible" contracts it does not refund the €2 participation or the franchises, because they are meant to stay with the patient.

The flat fees look small, and individually they are. Their annual caps make them predictable: in a heavy year, the doctor-visit fee and all franchises together are capped at €140 per person. The real risk sits elsewhere, in the 20% of a long hospital bill, in extra fees from sector-2 surgeons and in a private room, which is why people who skip a mutuelle often keep some other protection against large bills. Children under 18, people on the Complémentaire santé solidaire and pregnant women from the sixth month are exempt from the flat fees.

Do you need a mutuelle as an expat in France?

You do not legally need a mutuelle; it is an optional French top-up that pays some or all of what PUMa leaves, but only once you are in PUMa. GOV.UK describes it to British residents as top-up insurance that "will cover all or part of your medical costs not covered by the state". On a €30 GP visit with your médecin traitant, PUMa refunds €19; a mutuelle that pays the ticket modérateur adds €9, leaving you with the €2 flat fee. Without it, you pay €11.

Three things to know before you buy one. First, a mutuelle is not a substitute for PUMa or for visa insurance: it tops up refunds, so in your first three months there is nothing for it to top up. Second, contracts vary widely in how much they pay for sector-2 extra fees, dental crowns, glasses and the daily hospital charge; compare how much of the official tariff (the base de remboursement, "BR") each contract pays rather than the brand. Third, we found no official price list for mutuelles, so this page gives no price; ask several insurers for quotes once you have your social security number. If your income is low, the public Complémentaire santé solidaire below may replace a mutuelle at little or no cost.

Can low-income expats get the Complémentaire santé solidaire?

Yes: foreign residents with a valid residence permit who have lived in France for more than three months can get the Complémentaire santé solidaire (C2S) if their income is under the ceiling. It is a public top-up that replaces a mutuelle: your costs are paid in full up to the official tariffs, doctors may not charge you extra fees, the daily hospital charge is covered, you pay no franchises or €2 fees, and you do not advance money at the doctor's if you follow the care pathway.

Ceilings and charges from ameli.fr (31 March 2026) and service-public.fr (checked 1 July 2026). Age counts on 1 January of the year the right is granted; the charge is never more than one euro a day per person. Higher ceilings apply to larger households.

For visitor-visa holders who meet the income rule, the C2S is out of reach: the visa itself asks for resources of at least €1,477.93 a month (€17,735.19 a year), which is above the paid-C2S ceiling for a single person. It matters for couples living on one modest pension, or if your income falls later.

Do expats pay for PUMa in 2026?

Not yet as a fixed premium: the 2026 Social Security Financing Law creates a contribution for non-working PUMa members, but the decree that sets its amount had not been published on the official pages we read on 27 October 2026. Service-public.fr (checked 13 May 2026) says the contribution targets residents who are covered on the basis of stable, regular residence, have no professional activity and pay no CSG, CRDS or health contribution under an international convention. That description may fit a US retiree living on US income. UK State Pensioners with a registered S1 have their French care funded by the NHS through the S1, so they are likely outside it; check once the decree is out.

A separate charge already exists: the cotisation subsidiaire maladie (CSM), collected by Urssaf. It applies only if all three conditions are met: you are covered by PUMa, your French work income is below €9,420 (2025 figure, 20% of the social security ceiling), and your capital and property income is between €23,550 and €376,800. The rate is 6.5% on capital income above the €23,550 allowance, billed in the fourth quarter on the previous year's tax return.

The pension exemption is good news for retirees, but Urssaf does not say whether a foreign pension counts, so if you live mainly on rental income or investments, ask Urssaf before you budget. These French charges are separate from income tax; for tax residence and pensions, see the tax section of the France retirement visa guide.

Health insurance for Americans vs Britons in France: what is different?

The main difference is the S1: British State Pensioners can bring UK-funded cover to France, while Americans have no equivalent and rely on private insurance until PUMa starts. CLEISS, the French liaison body for social security, states that the 1987 US–France social security agreement contains no provision for health care paid on the basis of a US pension. Medicare pays outside the United States only in narrow cases, so it is not residence cover in France.

For Americans, the question is what to do about Medicare. Medicare does not pay in France, but Part B can matter if you plan treatment back in the US; ask Medicare about premiums and late-enrolment penalties before you decide. For Britons, the S1 is the step change: registered at your CPAM, GOV.UK says you usually receive a temporary French social security number within one to three months and then healthcare "on the same basis as a French citizen", which still means paying the same share of costs as other residents.

When does private international cover still make sense in France?

International cover is optional once you are in PUMa: French public insurance with a mutuelle pays most of the cost of care in France at official tariffs. It earns its place in three situations. The waiting period: without an S1, nothing public pays in your first three months, and the visa asks for cover anyway. Travel: PUMa is built for care in France; a Zone 1 plan covers you across the world except the USA, China and Singapore, with emergencies in the USA for up to 42 days per trip (never for US citizens, whose home country is the USA). Private care: it lets you choose private hospitals and specialists and pays the bills that French tariffs leave, such as sector-2 fees and a single room.

The trade-offs are real. A long-term plan such as Care Expat World has a 12-month minimum term, so using it only for the three-month wait still costs a year of premiums. Premiums rise with each age band and are reviewed every 1 January. It does not cover US or UK citizens in their home country, and it does not refund French flat fees. If you keep it after PUMa starts, a higher deductible can lower the price: you can downgrade your level or raise your deductible on 1 January without a new health check. The plan has no end date and the insurer cannot cancel it in the ordinary way, which is useful if you later spend long periods outside France. Full terms are on the plan details page.

What does health cover in France cost? 2026 comparison

PUMa has no published premium yet, a mutuelle has no official price, the C2S costs nothing or up to €30 a month, and international cover in our registry starts from €200 a month at 55–59. The table puts the sourced numbers side by side.

What a year of care costs you depends far more on what happens than on the premium. A healthy year with four GP visits and a few prescriptions costs a PUMa member with a mutuelle little more than the flat fees. A five-day hospital stay without a mutuelle costs at least €115 in daily charges alone, plus 20% of the bill (or the €32 flat fee for a heavy act) and any extras: use the estimator above with the figure from your hospital's estimate. For premiums at every age, see what international health insurance costs.

Your first year in France: health cover month by month

Checklist: health cover for your move to France

• Private health insurance certificate for the whole visa period, naming France (or a UK S1 if you draw the State Pension)
• No Schengen travel insurance as your main cover for a long stay
• Insurance start date aligned with your arrival
• Proof of residence from day one: lease, utility bills, validated VLS-TS
• Birth certificate and passport ready for the CPAM file
• CPAM application after 3 months ("Demander l'ouverture des droits à l'Assurance maladie")
• Carte Vitale ordered in your ameli account
• Médecin traitant declared
• Mutuelle quotes compared, or a C2S application if your income is low
• Decision on Medicare Part B (Americans) or the S1 (Britons) written down

Worked example: an American aged 58 and a Briton aged 61

Karen, 58, from Ohio, moves to Montpellier on a visitor visa. She needs private health insurance for the visa and her first three months. She chooses Care Expat World Comfort with a €1,200 deductible: €505 a month, €6,060 for the 12-month minimum term. After three months she applies to the CPAM, receives her number, orders a Carte Vitale and declares a GP as her médecin traitant. Her GP visit now costs her €11 after PUMa's €19. She decides to keep her international plan for trips around Europe and for private care, and on the next 1 January she switches to Basic with a €3,600 deductible at €200 a month, a downgrade that needs no new health check. Her premium moves to the next age band from 1 January of the year she turns 60.

Graham, 61, from Bristol, has not reached UK State Pension age, so he has no S1. His visa needs private health insurance for the full visa period. He takes Basic with a €3,600 deductible at €325 a month (Comfort with a €1,200 deductible would be €655). After three months he joins PUMa. A three-day hospital stay without a heavy act, on a bill of €2,000 from the hospital's estimate, would leave him €400 (20%) plus €69 in daily charges with PUMa alone; with a mutuelle that pays both, close to nothing. When he starts drawing his State Pension he can ask NHS Overseas Healthcare Services for an S1 and register it at his CPAM. On visits to Bristol, his plan does not cover him, because home-country cover applies only to EU or Schengen citizens.

What if you are 65 or older?

At 65 or older, PUMa is still open to you on the same terms, since it has no age limit, and UK State Pensioners can use an S1; what changes is the private layer. Care Expat World only accepts people who start cover by 1 December of the year they turn 64. If you are close to that age and want international cover, the year you apply matters more than the month. For a French resident over 65, the French top-up is a mutuelle on top of PUMa, and the Complémentaire santé solidaire applies if your income is low. The France visa requirements themselves are the same at any age; see the France retirement visa guide.

Expat health insurance in France vs other countries

France stands out because public cover opens to non-working residents after only three months. Elsewhere the public route is narrower or closed to foreign retirees, which makes the private layer more important. All countries below are in Zone 1 of Care Expat World.

Still choosing a country? Our retirement visas by country overview compares the income rules side by side.

France is in Zone 1 (worldwide except the USA, China and Singapore). Trips into the USA are covered for medical emergencies only, for up to 42 days per trip. Your home country is never part of the zone, and the terms give home-country cover only to EU or Schengen citizens, so Americans are not covered in the USA and Britons are not covered in the UK. We make no claim that French consulates or prefectures require or accept this plan. Already 65 or older in the year cover would start? This plan is closed to you; we are preparing a comparison of plans without an entry-age limit. Prices for every age are on the Care Expat World overview.

Plan your move to France

Each of our France guides covers one part of the move:

• France retirement visa guide: requirements, documents and the application steps.
• Healthcare in France for expats: how the public and private systems work for foreigners.

Before you apply, check the age limits on international health insurance, how insurers treat pre-existing conditions, and the options for covering a partner or family. Who qualifies for cover on visits home is explained in international health insurance with home-country cover.

Where these facts come from

• Ameli.fr (Assurance Maladie): summary of reimbursement rates (30 September 2026); consultation tariffs in metropolitan France (2 October 2026); hospital cover (7 October 2026); forfait hospitalier (2 March 2026); participation forfaitaire (29 September 2026); franchises médicales (29 September 2026); flat fee on heavy acts (7 October 2026); ticket modérateur (30 September 2026); Carte Vitale (14 October 2026); Complémentaire santé solidaire beneficiaries (31 March 2026); PUMa principles
• Service-public.fr (DILA): PUMa for people living in France (F34308, checked 13 May 2026); Complémentaire santé solidaire (F10027, checked 1 July 2026); visitor residence card (F302, checked 1 June 2026)
• Urssaf: cotisation subsidiaire maladie for PUMa beneficiaries (2025 figures, read 27 October 2026)
• CLEISS: retiring in France from the United States (US–France agreement of 2 March 1987)
• France-Visas: long-stay visitor visa and visa FAQ (accessed 27 October 2026)
• TLScontact UK: notice on health insurance for long-stay visitor visas (14 May 2021)
• GOV.UK: Healthcare in France (updated 25 July 2022); Living in France (updated 2 October 2026)
• Medicare: fact sheet on coverage outside the United States
• Care Concept: Care Expat World premium table and terms (read 27 October 2026)

Official French pages change often, especially in autumn when the following year's social security budget is debated. The 2026 PUMa contribution amount was not published on the pages we read; the UK insurance notice dates from 2021. Check with your consulate, CPAM and Urssaf before you rely on a figure.