Healthcare Contributions in France for American Retirees (Simple Guide for PUMa)

Many Americans who retire to France are surprised to learn that they may access the French public healthcare system through the Protection Universelle Maladie (PUMa).

However, the rules governing who contributes financially to the system can be confusing. They depend primarily on:

• the type of income you receive,

• whether you work in France,

• and in some cases your residency or visa status.

  
  

Recent policy discussions in France may also introduce a specific healthcare contribution targeting certain non-EU retirees, including some Americans.

This guide explains the current system in simple terms.

1- Step one: access to healthcare in France

If you legally live in France for more than 3 months, you can usually access the French public healthcare system through PUMa. This gives you:

• access to the national healthcare system

• reimbursement of a large portion of medical costs

• the ability to purchase supplementary insurance (mutuelle)

But access does not automatically mean you pay a contribution!

2- The healthcare contribution for people who do not work in France

Individuals who live in France but do not have employment income may be subject to a healthcare contribution called the famous👉 Cotisation Subsidiaire Maladie (CSM). This contribution is designed to ensure that individuals benefiting from the healthcare system participate in its funding even if they are not paying standard payroll contributions.

The CSM generally applies to investment income, such as:

• dividends

• interest

• rental income

• capital gains.

However, pension income is typically excluded from the CSM calculation. This includes U.S. Social Security and most pension income but the treatment of certain retirement account withdrawals (such as IRAs) may depend on how they are classified under French tax rules.”

3- Why some American retirees currently pay no healthcare contribution

Because of the tax treaty between the United States and France, which states that U.S. Social Security benefits are taxable only in the United States and France cannot tax them. At the same time, pensions are excluded from the CSM calculation.

This means some retirees can currently access the French healthcare system without paying a healthcare contribution. This is the technical gap currently being discussed by the French government.

Another important feature of the system is that the CSM is calculated per individual, not per household. Each adult in a couple is assessed separately. This means that how income is allocated between spouses canaffect the total contribution.

4- Healthcare contribution overview for Americans in France

The following table summarizes the most common situations.

Income situation	Access to French healthcare	Healthcare contribution
Working in France	Yes	Standard French social security contributions
Self-employed in France	Yes	Social security contributions
U.S. Social Security only	Yes (via PUMa)	No contribution currently
Pension income only	Yes	Usually no CSM
Investment income (dividends, interest, capital gains)	Yes	CSM may apply
Mixed income (pension + investments)	Yes	CSM applies to investment income

5- Example calculation of the healthcare contribution

The CSM rate is approximately 6.5% on certain investment income above a threshold. Example for a single person:

Item	Amount
Investment income	€100,000
Approximate threshold	€20,000
Taxable base	€80,000
Contribution rate	6.5%

Estimated annual healthcare contribution: €5,200

This contribution provides access to the French healthcare system through PUMa.

6- Potential reform affecting American retirees

French government are currently discussing a new healthcare contribution specifically targeting certain non-EU retirees living in France under a visitor visa. The proposed measure would likely apply to individuals who:

• live in France full-time,

• benefit from the public healthcare system through PUMa,

• and do not contribute through employment or investment income.

In practice, the measure would primarily affect retirees whose only income is U.S. Social Security. The exact structure of the contribution — whether a fixed amount or a percentage of income — has not yet been finalized and published!

Maud MESTRE - Associée gérante MESTRE TAX ADVISOR