France's PUMA Health Coverage: How the Sécurité Sociale Works for Newcomers

What PUMA is (and what it replaced)

Before 2016, health coverage in France was tied mainly to employment status: workers were covered through their job, others through the CMU (Couverture Maladie Universelle). The 2016 reform replaced that patchwork with the Protection Universelle Maladie, which guarantees a personal, continuous right to coverage for anyone who works or resides in France in a stable and regular manner. "Continuous" is the key word: once affiliated, your rights do not break if you change jobs, lose a job, or move house.

Two affiliation routes exist:

• On the basis of work (critère professionnel). If you work in France — salaried, self-employed, freelancer, student with a job — you are affiliated through your professional activity, from day one. No waiting period.
• On the basis of residence (critère de résidence). If you do not work but live in France legally and stably, you can be affiliated on residence alone.

Note: PUMA is the name of the scheme, not an office. The CPAM (Caisse Primaire d'Assurance Maladie) is the local office that handles applications and manages your file. The Assurance Maladie is the branch of the Sécurité sociale that pays for health care.

The conditions: stable and regular residence

For the residence route, two conditions are cumulative:

1. Regular residence (régularité). Non-EU nationals must hold a valid residence title: titre de séjour, long-stay visa valid as a residence permit, récépissé de demande, etc. EU/EEA citizens do not need a residence permit, but if they are inactive, they may need to show sufficient resources so as not to become an unreasonable burden on the system.
2. Stable residence (stabilité). You must have lived in France for at least 3 months before your rights open, and you must live in France at least 6 months per calendar year to keep them.

The 3-month waiting period does not apply if you start a professional activity in France, or in certain special cases (for example, family reunification or returning French nationals with no coverage). If you are covered under another country's system through a secondment or a European Health Insurance Card during a short stay, PUMA is a different question — check official guidance for your case.

Registering with the CPAM: the steps

The basic process:

1. Complete form Cerfa n° 15763*02 (also called S1106) — the "demande d'ouverture des droits à l'assurance maladie." One form per adult; if you have dependent minor children, fill in the child-attachment form too.
2. Attach the supporting documents listed in the form: typically identity document, proof of regular residence (residence title), proof of address, and proof of presence in France (for example rent receipts or utility bills showing your name and dates, if requested).
3. Send or hand-deliver the file to the CPAM of your place of residence. In Paris (75), documents can be submitted online through the CPAM's document-drop platform; elsewhere, mail or in-person deposit is the norm.
4. Keep copies of everything and a stable postal address with a mailbox in your name — CPAM correspondence goes by mail. If you have no fixed address, an official domiciliation address can be arranged.

Foreign students generally use the dedicated online portal etudiant-etranger.ameli.fr instead of the paper route.

The numéro de sécu and the carte vitale

Once your file is accepted, the CPAM assigns you a numéro de sécurité sociale (numéro de sécu), a 15-digit individual identifier. It is assigned for life. This number unlocks your ameli account (ameli.fr), the online portal where you can track reimbursements, download your attestation de droits (proof of coverage), and report changes of situation.

The carte vitale is the physical chip card that proves your registration and rights. It is issued to everyone aged 16 and over, is free, and contains your administrative details. Presenting it at the doctor's or pharmacy's terminal triggers automatic electronic reimbursement — typically within about a week, with no paper feuille de soins to mail. If you paid without the card, you can still be reimbursed by sending the paper treatment forms by mail to your CPAM.

One practical note: processing times vary. The sécu number can take weeks or even months to arrive, which is the single most common newcomer frustration. It is normal — your coverage rights start from the date your file is complete, and costs incurred after that can be reimbursed once the number is issued. Keep all receipts and feuilles de soins in the meantime.

What is covered — and what is not

The Assurance Maladie reimburses part of your health expenses, not everything. Two figures decide each reimbursement:

• The reimbursement rate (taux de remboursement) — set by the Sécurité sociale, varying by type of care. For example, a GP consultation within the coordinated-care pathway is reimbursed at 70%.
• The reimbursement base (base de remboursement / tarif de convention) — the official tariff for each procedure, e.g. €30 for a standard GP consultation in metropolitan France since December 2024.

So a €30 GP visit is reimbursed at 70% of €30 (€21), minus the €2 fixed participation forfaitaire — leaving €19 paid back to you and the rest at your expense. Medicines are reimbursed at various rates (15%, 30%, 65%, or 100% depending on their medical value), hospital stays at 80%, and so on. Beyond the official tariffs, doctors in "sector 2" can charge dépassements d'honoraires (fees above the tariff), which the public scheme reimburses only partially or not at all. Cosmetic surgery, most alternative medicine, and other items outside the reimbursable list are not covered.

The parcours de soins coordonnés (coordinated-care pathway) matters too: you are expected to declare a médecin traitant (primary doctor) and see specialists through referral. Going off-pathway reduces your reimbursement rate.

The mutuelle: top-up insurance

The part the public scheme does not reimburse — the ticket modérateur (the co-payment), dépassements d'honoraires, and poorly covered areas like dental, optical, and hearing — is where the mutuelle (complémentaire santé) comes in. It is optional for individuals: you can buy one freely from an insurer or mutuelle of your choice. But it is mandatory for employees: since January 2016, every private-sector employer must offer a company mutuelle and pay at least 50% of its cost, and employees must join it unless exempt.

For low-income residents, the Complémentaire Santé Solidaire (CSS) — free or low-cost depending on income — covers the co-payment, the hospital daily fee, and dental/optical care within set ceilings. It replaced the old CMU-C and ACS in 2019.

A word of caution for newcomers affiliated on the residence criterion: if your income or wealth from activity exceeds a threshold, you may owe the cotisation subsidiaire maladie, a subsidiary health contribution paid to URSSAF. Check the official URSSAF page if you have significant income outside salaried work.

What to do in your first months

• Working in France? You are affiliated from your first day of work; ask your employer about the company mutuelle.
• Not working? After 3 months of legal, stable residence, file the S1106 form with your CPAM.
• Get your documents ready early: passport, residence title, proof of address, birth certificate. Keep receipts for any care in the meantime.
• Declare a médecin traitant once affiliated to get the full reimbursement rates.
• Consider a mutuelle — or check your CSS eligibility — so the ticket modérateur does not surprise you.

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