ADECRI The French Social Protection System THE FRENCH SOCIAL PROTECTION SYSTEM

Transcription

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2 THE FRENCH SOCIAL PROTECTION SYSTEM 1

3 Copyright ADECRI,

4 The ADECRI was created in 1995 by all of the French Social Security National Organizations, i.e. the National funds of all the basic regimes (employees of industry and commerce, farmers, minors, artisans and retailers), as well as the Groups of national funds and the EN3S (École Nationale Supérieur de Sécurité Sociale). The aim was to provide support, to those countries who wished it, in their development or reform of their own social protection system. This common initiative brings forth answers to questions that could not be addressed or adequately dealt with without a collective approach. Inter-regimes and inter-branch, the ADECRI is the privileged contact for foreign institutions seeking to benefit from the expertise of the French system as a whole. Responsible for revitalizing the resource potential of the 600 national, regional and local organizations composing the French social security system, the ADECRI thus has approximately 80 experts, mainly working in the French social security institutions, participating every year in the development and reform of foreign social security systems. Offering services of a real consulting firm, the ADECRI has positioned itself as a French player in terms of social protection on the world stage and is recognized as such by international institutions, in particular by the European Union and the World Bank. Since 2002, at the request of its foreign partners, the ADECRI has published a booklet that presents the French social protection system as a whole. Updated every 3 years, this booklet, initially translated into English, Russian and Chinese, now exists in Arabic and Spanish in order to be of use to all of the institutions and countries with which the Agency undertakes co-operative activities. This booklet is also downloadable from the Agency s website: 3

5 TABLE OF CONTENTS Introduction: The French System of Social Protection 8 History 8 The French System Today 10 Part 1: Health Care and Health Insurance Systems 12 Introduction 12 I. Medical Services 12 II. Health Insurance Schemes 14 A. Basic Schemes Benefits-in-Kind General Scheme Agricultural Workers Fund Fund for the Self-Employed Cash Benefits General Scheme Maternity Benefits Sickness Benefits Occupational Injury/Illness Benefits Disability Pensions Other Schemes 23 B. Supplementary Schemes 23 C. Universal Medical Coverage (CMU) 24 III. Organisational Aspects 24 Part II: Retirement Pensions 27 I. Private Sector Employees 28 A. Basic Pension Pension Indirect Benefits 31 B. Mandatory Supplementary Schemes Direct Benefits Indirect Benefits 32 C. Non-Mandatory Additional Pensions 32 D. Principles of the Agricultural Sector Employees Pension System 32 4

6 E. Management 32 II. Private Sector, Other Schemes 34 A. Basic Pension Schemes Entrepreneurs and Trades People Professionals 35 B. Supplementary Pension Schemes Entrepreneurs and Trades People Self-Employed Professionals 36 III. Special Schemes: Civil Servants and the Public c Sector Corporations 36 A. Pensions 37 B. Indirect Benefits 37 C. Supplementary Pensions 37 Part III: Family Support Programmes 38 Introduction 38 I. Different Types of Benefits 39 A. Family Income Support Benefits Assistance for Infants Family Allowances that Evolve with Number of Children General Family Allowance Family Supplement Old Age Insurance for Stay at Home Parents Assistance to Single-Parent Families Family Support Allowance Assistance in Collection of Child Support Payments Single Parents Benefits Other Benefits Specific Situations The Handicapped Child: The Special Education Allowance The Sick Child: The Parents Assistance Allowance Schooling Expenses Allowance 43 B. Personal Housing Subsidies 44 C. Social Services Disabled Adult s Allowance Minimum Insertion revenue 46 5

7 II. The Role of the Family Branch s Directorate 47 Part IV: Social Assistance and Supplementary Social Action 48 I. Social Assistance Programmes 48 II. The Minimum Income Policy 49 III. Supplementary Social Action 50 Part V: Unemployment Benefits 52 Introduction 52 I. The Unemployment Benefits 53 A. The Unemployment Benefit Based on Previous Salary 53 B. The Assistance and Personalized Support Services for Employment Seeking 53 C. The Solidarity Scheme (Society s Responsibility) 53 II. Organisational Aspects 54 Part VI: Financing the Different Benefits 56 Introduction 56 I. Financing the Mandatory Benefits 58 A. Principles 58 B. Decision-Making Process 59 C. The Role of the Collection Branch 60 II. Financing the Agricultural Sector Regime 60 III. Financing Non-Mandatory Benefits 61 Appendix 62 6

8 INTRODUCTION: THE FRENCH SYSTEM OF SOCIAL PROTECTION It is not easy to provide an understandable yet accurate description of the French Social Security System. For more than 100 years, numerous social, economic and political factors have had an impact on the development of the French Social Security System. The development of social security protection in neighbouring countries, particularly Germany and the United Kingdom, has also had an effect. Today, the French Social Security System consists of a complex network of schemes, covering virtually the entire population of France and providing a wide variety of benefits. History As was the case for other European countries, the Industrial Revolution during the 19 th century had a profound impact on the development of French society. During a few decades, a growing working class appeared, totally dependent on regular wages for its livelihood. Occupational risks, associated with the development of modern industries, increased. At the same time a growing number of people were displaced, cut off from traditional forms of community support (religious, family or guild associations). They were, therefore, particularly vulnerable at risk of becoming destitute as a result of old age, sickness, occupational injury or unemployment. Traditional tort liability law, when applicable, was ill adapted to helping them. Even when applicable, its implementation was inefficient, and it was poorly adapted to situations where power relations were clearly out of balance. Over the century, mutual aid societies arose, taking the place of the old guilds, which had been abolished in 1791, during the French Revolution 1. Toward the end of the 19 th century and the beginning of the 20 th, a social assistance system was developed. But this system, useful as it was, benefited only a fraction of the population. Based on voluntary contributions from working people, and conceived of as a last resort for people who were destitute as a result of old age, sickness, occupational injury or unemployment, it did not provide adequate protection for the population at large against the economic and social distress caused by the loss of income, for a person who could not work. New institutions that provided more adequate protection slowly evolved. A law passed in 1898 established the principle of an industrial employer s absolute liability in the event of an occupational injury. 1 Mutual aid societies ("sociétés de secours mutuel") were legally recognised in The right to organise them was granted by law in

9 A number of schemes covered certain types of workers (seamen, civil servants, miners, railwaymen), but the first attempt at organising a mandatory old-age pension scheme benefiting all employees proved to be a failure: the first law, passed in 1910, had little, if any, impact. After World War I, the region of Alsace-Lorraine that had been annexed by Germany was reunited with France. Social security programmes developed in Germany under Chancellor Bismarck had been implemented there, and this accelerated their adoption in France. After lengthy debates, an insurance scheme was introduced by law in 1930, protecting employees in commerce and industry against the financial consequences of sickness, maternity, disability, old-age and death. Funding the scheme depended on equal contributions from both the employee and the employer. Family allowances were originally created by certain employers as a way to attract and retain workers, thus increasing employee retention. They were extended to all private sector employees in The effort to assist families was further extended by the Vichy regime. The family allowances of 1932 were extended first to agricultural workers (1936), then to agricultural employers (1938), then to all employees (1939). After World War II, development of a comprehensive social security system was begun. The new scheme was influenced by the Beveridge Report; it promoted a universal system, with a unified scheme that expressed society s responsibility toward all its members. In 1945, the General Scheme ("Régime général") was created, with the mission of rapidly covering the entire population 2. But after a short-lived period of national unity, differences arose, based on competing interests. Contributors benefiting from special schemes were unwilling to lose the advantages they enjoyed by participating in a single scheme. Their schemes were "temporarily" maintained. Independent workers, tradesmen and artisans did not want to be classed together with wage earners and were wary of the potential cost of a comprehensive system. They were granted the right to create their own schemes based on lower levels of coverage. In 1947, a supplementary pension plan was introduced for managerial and professional employees ("cadres") by a national inter-professional collective agreement between trade unions and employees' associations. In 1962 a majority of private-sector employees were covered by a supplementary pension plan, in addition to their basic social security pension plan. During post-war reconstruction, unemployment seemed to be less of a threat than it had been before. For this reason, unemployment insurance was not part 2 Although the General Social Security Scheme ( Régime général ) was implemented, a number of preexisting special schemes continued to exist, as well as a scheme for agricultural workers. 8

10 of the social security plan, but was created much later in 1958, by way of an inter-professional collective agreement 3. As supplements to the social security schemes were being developed and special independent schemes were being maintained or created, the status of the General Scheme (Régime général), as the main provider of social security benefits, was being strengthened. In addition to covering private sector employees, the scheme was extended over the years to cover other categories of the population (for example, students, war widows and orphans, and disabled persons). Successive reforms also allowed people who would otherwise have ceased to be eligible for benefits to remain covered, by applying increasingly liberal requirements for personal contributions. In 1978, the entire population of France became eligible for family benefits, with no condition of employment. Today, the General Scheme s national fund for family support programs (CNAF) provides family benefits to every eligible person legally residing in France. Health Insurance has been constantly extended over the years to new categories of people, with the often repeated goal of attaining total coverage. The Universal Medical Coverage (Couverture médicale universelle: CMU) implemented in 2000 is the final step in this direction. Contribution to a pension plan was made mandatory in 1972, for all working people, and a guaranteed old-age minimum income ( minimum vieillesse ) was established for people who had made little or no contributions. The French System Today Over the years, the French social protection system has evolved into a complex mosaic of benefits, contributory as well as non-contributory, covering various social hazards. Although they were originally very different in terms of management, contributions and coverage, the various schemes have come to be very similar to the General Scheme (Régime général). This trend is noticeable among the different private sector schemes, especially for the health-care benefits. The General Scheme (Régime général), is the main scheme. It generates more than half of the total social security expenditure 4 in France. Its basic pension 3 From the time they were created to today, French supplementary pension plans and the Unemployment Insurance fund have featured a management model with strong involvement on the part of the social partners both for their overall direction and their key decisions. Social Security institutions, on the other hand, despite affirming the principle of democratic management (with boards composed originally of a majority of trade union representatives) have always been under close State supervision. 4 Total expenditures in 2005: billion. See Cour des Comptes (September 2006). 9

11 plan 5 covers private sector employees. Its health insurance scheme 6 covers about 80% of the population. Its family support programs are accessible to all eligible claimants, without requiring employment or personal contributions. Other professional or sector-based schemes, whether basic or supplementary, are also part of the first social protection pillar, which is usually called Social Security 7. The most important of the professional or sector-based schemes are the agricultural scheme, the different civil servants' schemes, and a series of more or less co-ordinated schemes covering self-employed workers 8. The agricultural workers fund (MSA) and the funds connected with it, play the same role as the General Scheme. They are responsible for collecting the withholdings of their members (agricultural employees and employers, rural trade groups and financial organisations) into special funds. They reimburse certain expenses (illness, maternity, disability, occupational injury, family expenses, old-age pensions, etc.), and are also responsible for promoting health and social welfare activity and preventing occupational accidents. On July 1 st 2006, the Independents Social Scheme (RSI) was implemented as a result of the fusion of the Independents Health Care Insurance Scheme (AMPI), the Artisans Old Age Insurance Scheme (AVA) and the Retailers Old Age Insurance Scheme (ORGANIC) 9. The institutions offering voluntary supplementary coverage comprise the second pillar. Unemployment Insurance is separate from Social Security for historical reasons. The social assistance programs deliver subsidies and offer services to identified categories of the population. All these components are part of what in France is called the Social Protection System. Its main features will be described in the different parts of this document. As a whole, the Social Protection System delivers benefits amounting to billion, or 29.6% of the GDP Administered by the Caisse nationale d'assurance vieillesse des travailleurs salariés (CNAVTS). 6 Administered by the Caisse nationale d'assurance maladie des travailleurs salariés (CNAMTS). 7 In France, the term "Sécurité sociale" is often used to refer to the mandatory Health Insurance scheme, which can be misleading. 8 See Appendix 2 for an overview of the different mandatory schemes. 9 See: 10 See Julien BECHTEL et Michel DUÉE, «Les prestations de protection sociale en 2005», DREES, Études et Résultats, n 523, septembre

12 PART I: HEALTH CARE AND HEALTH INSURANCE SYSTEMS Introduction ADECRI Health care expenditures amount to 11.1% of GDP in France for That same year, France allocated billion to its health system, or 3,138 per inhabitant 12. Health care and medical goods account for 12.1% of household consumption. The French system can be described as expensive, but the population strongly supports it 13. In a report released in 2000 that analysed the performance of the health systems of its 191 members, the World Health Organisation (WHO), ranked the French system first in providing the best overall health care 14. I. Medical Services Medical services in France are provided by public institutions (hospitals), private institutions (private hospitals: cliniques) and by private providers (doctors and other medical and paramedical professionals). Medical density is relatively high 15 compared with other European countries, although distribution across the nation is uneven. The growth of the number of practitioners in the different medical and paramedical professions is monitored by a numerus clausus mechanism (system of quotas), which restricts the number of students allowed to enter the different disciplines. Public hospitals account for about three-quarters of the overall number of hospital beds 16, providing 81% of the general medicine beds and 63% of the gynaecology-obstetrics beds. Surgery beds are about evenly divided between private and public hospitals (44% for clinics and 10% for private not for profit hospitals) 17. On the one hand, the number of short-stay hospital beds has decreased over the last 18 years, reflecting the general decrease in the length of stay and the development of alternatives to regular hospitalisation. On the other hand, beds in long-term 11 In 2006, France was ranked third in the Organization for Economic Cooperation Development (OECD) countries. See 12 See Annie FENNINA and Yves GEFFROY, Les comptes nationaux de la santé en 2006, DREES, n 593, septembre Two-thirds of the population are fairly satisfied with the system, which is relatively high compared with public opinion in other European countries: Eurobarometer 1997, cited in The changing Health System in France OECD, See World Health Report 2000 on 15 See OECD, Health Data 2003: in 2003, France had 3.4 doctors per 1000 inhabitants (51% of them specialists) and hospital beds of which 38% for acute care. In 2003, a total of 201,400 doctors were practising in mainland France and 4,307 in the overseas departments.there were 423,400 nurses in 2003, 73% of whom were employed by a public or private hospital. See DREES Données sur la situation sanitaire et sociale en France en 2005, Annexe A au Projet de la loi de financement de la Sécurité Sociale pour See DREES Données sur la situation sanitaire et sociale en France en 2005, Annexe A au Projet de la loi de financement de la Sécurité Sociale pour See DREES Données sur la situation sanitaire et sociale en France en 2005, Annexe A au Projet de la loi de financement de la Sécurité Sociale pour

13 care institutions have increased in recent years, in response to the needs of a growing number of dependant elderly people 18. Public hospitals are funded through budgets set annually by local hospitalisation agencies (Agence régionale de l hospitalisation - ARH). These are responsible for distributing the regional budget among the different institutions. Private hospitals are paid on a fee-for-service basis. A schedule of fees is contracted annually between the ARH and each private hospital. The different ARH are also responsible for monitoring the activity of the medical institutions operating in their region. They do this by setting objectives in the contract signed with each hospital. They also authorise the creation or expansion of medical departments and the acquisition of major pieces of equipment. The prices of reimbursable drugs and other medical goods are set by the government following consultation with experts and providers. The prices of non-reimbursable drugs are set by the pharmaceutical companies. Medical practitioners and allied medical workers are paid on a fee-for-service basis. Fees are part of periodic agreements (conventions) signed by professional associations and the three national health insurance funds (CNAM, MSA and RSI (Health Care Branch)), under the supervision of the State. Official schedules of reimbursement are set according to these agreements, but some of the doctors are allowed to charge more than the official schedules. At the present time, no additional doctors are being granted this privilege and the number of doctors benefiting from it is slowly decreasing 19. Hospital expenses accounts for 47.9% ( 69.9 billion in 2006) of the total health care consumption, 27.3% ( 42.8 billion in 2006) of these expenses are generated by health professionals and 20.4% by prescription drugs. 20 Health expenditures accounted for 11.1% of GDP in 2006 ( billion). France ranks third in the world behind the United States (15.3%) and Switzerland (11.6%) 21, in terms of health expenditures as a percentage of GDP. 18 According to the memo DHOC/O/n. 44 of February 4th 2004 on home-hospitalization, in terms of handling capacity, the closure of 70,000 hospital beds over the past 10 years was accompanied by the creation of 48,000 part-time beds, to which we can add 4,200 spaces for home care. Beds for long term care represented, in 2002, 17.5% of total beds, compared to 10% in See DREES Données sur la situation sanitaire et sociale en France en 2005, Annexe A au Projet de la loi de financement de la Sécurité Sociale pour The Secteur II was created at the beginning of the 1980's. Since 1990 it has been closed to further access. About 25% of doctors belong to Secteur II, but the percentage is higher for specialists than for general practitioners. The portion of the fee that exceeds the official schedule is not reimbursed by the basic Health Insurance scheme or by most of the supplementary schemes. 20 See Annie FENNINA et Yves GEFFROY, «Les comptes nationaux de la santé en 2006», DREES, Études et Résultats n 593, septembre Ibid. 12

14 Since the mid-1970 s, various reforms have been implemented in an attempt to slow the growth of health-care expenditure and reduce the deficit. Earlier plans attempted without success to balance Health Insurance accounts. They increased funds while raising the cost of health care for patients, in order to promote more economic behaviour and to counter the inherent tendency of spending, in a system that gives both patients and professionals a great deal of freedom to spend. Faced with a severe financial crisis in the Social Security system in the 1990s, the authorities promoted a series of reforms in order to ensure the solvency of the system and to allow it to adapt to changing conditions. In 1996, the French constitution was revised, and a series of ordinances were established to allow Parliament to pass a law each year financing the Social Security system. This law contains a National Health Care Spending Objective (ONDAM), detailed in different sections (private hospitals, public hospitals, benefits-in-kind, ambulatory care, etc). This objective is based on revenue estimates and on health priorities defined by a National Health Conference. The ONDAM is not mandatory benefits are paid even if the target is eventually exceeded (as has been the case so far), but resources allocated to the different institutions and agreements contracted with professionals must be consistent with its provisions. It is still early to judge the effectiveness of regulations which, in some cases, have not yet been fully implemented, but a trend towards a reduction in the rate of growth seems to be discernible, with health spending as a percentage of GDP falling slightly between 1995 and Health expenditure remains, nonetheless, a concern for public authorities. II. Health Insurance Schemes The French system of Health Insurance is composed of two tiers. The first tier provides basic coverage through different mandatory schemes, which cover about 75% of household medical expenses. The second tier consists of an optional supplementary coverage provided by mutual (not-for-profit) or private insurers. Health insurance schemes provide benefits in kind, as well as cash benefits, to compensate for the loss of income in certain kinds of situations (illness, disability, maternity, occupational injury/disease). Since 2000, the legislation on the Universal Medical Coverage (CMU) is in place, thus ensuring that any legal resident in France who is not covered by another mandatory health care insurance scheme has access to the health care insurance to cover all medical costs: the basic CMU million low income persons also have access to 100% coverage under a supplementary CMU scheme. See 13

15 After three weeks of debate at the National Assembly and another in the Senate, the legislation reforming healthcare was adopted on July 30 th 2004 and promulgated on August 13 th 2004 (Legislation n ). Key points of the legislative reform for the claimants The 2004 reform has led to many modifications to the services offered to the claimant 23. The Personal Medical File No later than July 1st 2007, each claimant will be the holder of a personal medical file composed of health information obtained during medical visits. This will allow the tracing of health care acts and services. Access to the medical file will be limited to medical acts (for Occupational Health Physicians or for contractual purposes). The level of coverage for the expenses incurred by the claimant will be subordinate to the authorization to access the medical file that he or she will grant the health care professional. The variation of the level of coverage will be defined by the National Union of Health Care Organizations - UNCAM (Union nationale des caisses d assurance maladie) within the limits imposed by a Conseil d Etat decree (s. 3). The Health-Care Protocol for Long-Term Care (ALD) In order to benefit from the partial or total co-payment exoneration, the long term care patient must (except in case of emergency) present the consulting physician with the medical protocol, that he will have signed, as established by the attending physician and the medical expert of the fund (s. 6). Furthermore, the health-care protocol must mention the obligations imposed to the beneficiaries of the ALD, including: To follow the treatments as prescribed jointly by the attending physician and the medical expert; To attend the medical visits and controls as organized by the fund; To abstain from all non-authorized activity and to do the prescribed exercises for re-education or professional reclassification purposes. Treatments Possibly Leading to Improper Use The Health Care system will cover expenses and treatments that might lead to improper use (such as Subitex ) under certain specific conditions. For every 23 For further information on this reform, see Comprendre la reformer de l Assurance Maladie : 14

16 prescription renewal, the patient must provide the physician with the name of the pharmacist responsible for the delivery of the medication. The physician must include the name of the pharmacist on the prescription which must then only be delivered by him in order to ensure coverage (s. 17). The Attending Physician Any claimant or beneficiary of at least 16 years of age must choose a primary physician (generalist or specialist) in order to benefit from the co-payment plan. If the claimant has not made this choice or has directly contacted a specialist in certain areas, the co-payment portion could be increased. This increase will not be applied in cases where a health care protocol is established (for long term care) and in cases of emergency (s. 7). Furthermore, specialized physicians who are directly contacted by patients are authorized to charge increased fees for all consultations (s. 8). However, there are certain specialists, not identified as of the date of publication, who will still fall into the direct-access category (ex.: pediatricians, ophthalmologists, etc.). Increased fees will continue to be the responsibility of the beneficiary of the supplementary CMU who would consult a specialist directly (s. 10). Co-payment In order to render claimants responsible, they are required to financially participate for every act or for each appointment with a physician that is covered by health care insurance (whether in a private practice, a health institution or centre). Also, participation will be required for all biological medical acts. This payment is applicable to claimants that are ill as well as those for workers victims of occupational injury or disease. However, all payments by these claimants will have a ceiling, established by decree, to a maximum number of payment contributions. Furthermore, persons hospitalised (except in cases of emergency hospital care and external consultations), claimants under the age of 16, beneficiaries of the CMU and women covered by maternity benefits will not have to pay this supplement (s. 20). The amount of this participation is to be established by decree and currently stands at 1. To discourage supplementary health care organizations from taking on the financial responsibility for this payment, the benefits related to the non payment of social costs on bonuses or contribution and non payment of taxes 15

17 on insurance agreements will be limited to those contracts that establish both a minimal level of coverage and exclusions to coverage (such as the one related to this payment). This schedule of conditions will be implemented for all applicable contracts as of January 1 st 2006 (s. 57). Assistance for acquiring supplementary health care coverage As of January 1 st 2005, assistance for acquiring supplementary health care coverage is in place for those who, due to their low income, cannot otherwise benefit from it. A tax credit will be available for supplementary individual health care insurance contracts signed with supplementary coverage organizations by those claimants whose resources are within the applicable ceiling for supplementary CMU and the same ceiling increased by 15%. The amount of the tax credit will vary based on the number and the age (the age being evaluated on January 1 st of that year) of the persons in the household. The management of this tax credit is the responsibility of the financial management fund of the supplementary CMU. The funds expenses will be financed by a global take on the health care system. The Health Care Card Carte Vitale The information contained in the health care card (medical acts, delivery of products and services provided) are now accessible to the physician. A picture will be added to the new version of the card (Vitale 2). Also, the legislation has included a provision whereby medical institutions can ask a claimant for proof of identity (s. 21). Sick Leave and Payments of Daily Indemnities The payment of daily indemnities will be suspended when the claimant does not submit himself or herself to the controls established by the Medical Control Service (s. 27). The fund will inform the employer of this suspension. The employer will then have the possibility to suspend supplementary compensation. Furthermore, the daily indemnities beneficiaries obligations (to follow physicians orders, to submit himself or herself to the controls, to respect the hours allocated to leaving the home and to abstain from all non authorized activity) are no longer included in the operational regulations of the CPAM they have now been included in the legislation in order to have more clout. Should these responsibilities and obligations not be respected, the daily indemnities can be withheld, either partially or totally. A legal control, within the purview of the Social Security, can occur in case of recourse, on the amount of the sanction announced and its appropriateness as it relates to the 16

18 infraction by the claimant. The portion of the cash payment to be withheld will be obtained in one or more payments depending on the social situation of the household (s. 29). Also, the renewal of the work stoppage or sick leave will now exist within a framework. The compensation will be conditional on the extension of the work stoppage order by the same physician who initially signed off on it (s. 28). Finally, new assistance possibilities are offered to the claimant to favour his or her return to work (s. 24). A. Basic Schemes There are not as many basic Health Insurance schemes as there are pension plans, but the principle of employment-based coverage still exists. The General Scheme (Régime général) delivers 86.6% 24 of the benefits, and covers private sector employees, public servants (benefits-in-kind), as well as different categories of people who were not originally covered by a scheme (for example, students, war veterans, persons benefiting from certain guaranteed minimum incomes such as certain family allowances). The General Scheme (Régime général) has thus been used over the years as a catch-all scheme, to provide access to medical coverage for the entire population. A variety of small special schemes cover different categories of workers (for example, railway employees, employees of the Paris public transportation system, seamen, and employees at the Banque de France 25 ). Cash benefits for public servants are funded by the State through the general budget. Two other schemes cover other categories of workers: one protects those working in the agricultural sector (MSA 26 ), and the other protects artisans, entrepreneurs, tradesmen and retailers, as well as professional people and lawyers (RSI 27 ). 24 See Eco-Santé France, 2007 (January 2008 version), 25 See chart in appendix, Other Special Schemes. 26 See 27 A national fund (the Social Scheme for Independent Workers - RSI) is responsible for co-ordinating the system. Benefits are paid by an approved insurer, chosen by the insured person from an approved list. Contributions are no longer paid directly to the chosen insurer as of January 1 st 2008, except for professionals. 17

19 1. Benefits-in in-kind ADECRI Coverage provided by mandatory basic schemes varies according to the nature of the expenses. Hospitalisation-related expenses are covered at a rate of 80%. Outpatient care and medical equipment are covered at about 65% and 58% of their cost 28, respectively. As a whole, Social Security schemes cover about 80% of household health expenses. For outpatient care, the patients pay the provider directly, and are subsequently reimbursed. Reimbursement by the Social Security is usually partial; the patient is responsible for a copayment (ticket modérateur), which in some cases is reimbursed by supplementary insurance. Direct payment to doctors from the Health Insurance fund is growing (and already exists in certain types of situations, such as occupational injuries). Local agreements between health insurance funds and pharmacists organisations have also led to an increasing percentage of medical prescriptions being paid directly. 1.1 General Scheme (Régime général) Benefits-in-Kind account for 93.7% (about billion in 2006) of the expenses of the health insurance scheme 29. Conditions of entitlement: employees must meet certain minimum requirements in terms of paid employment in order for them and their families to be covered 30. The reimbursement rates vary according to the services or medical goods provided 31. Rates are set by the official schedules. Coverage can be 100% in certain types of situations See Eco-Santé France 2004, CREDES-DREES. 29 In 2006, total expenditure (sickness, maternity, disability, occupational injury/diseases, and death) was billion, of which: billion was for benefits-in-kind, and 7.3 billion was for cash benefits. 87% of the total was allocated to sickness benefits (both in-kind and cash). See Chiffres et repères de l assurance Maladie 2004, 30 Conditions have become less and less stringent over the years. A contribution to the scheme from employment income amounting to 60 times the minimum hourly wage is enough to cover the contributor and his/her dependants for a period of 4 years. If need be, special rules apply to maintain the coverage beyond that. 31 Examples: prescribed drugs: 35%, 65% or 100%. Physicians: 70% (for both specialists and general practitioners (same rate applies to dentists). Allied medical workers: 60%. Optic lenses: 65%. See for other rates. 32 For example, persons suffering from a recognised long-term illness, disability or occupational injury, pensioners, pregnant women (from the fourth month of pregnancy), and persons benefiting from the CMU. See for more details. 18

20 1.2 Agricultural Workers Fund (MSA) ADECRI The same reimbursement rates and conditions apply for the agricultural sector. The agricultural workers and their dependants covered have the same benefits in terms of sickness coverage as employees covered by the General Scheme. 1.3 Fund for the Self-Employed (RSI) Self-employed workers originally chose to remain outside the General Scheme (Régime général) and to set up their own scheme, with lower contribution rates and less benefits. Although the contribution rates remain inferior, the benefitsin-kind have been progressively adjusted and today are equivalent to those offered to employees 33. Since January 1 st 2001, the reimbursement rates are aligned to those of the employees General Scheme (Régime général). This scheme covers entrepreneurs, tradesmen, artisans and independent professionals. Since January 1 st 2006, the CANAM is an integral part of the RSI (see note 27). 2. Cash Benefits 2.1 General Scheme (Régime général) Cash benefits amount to 7.3% of the total value of all benefits, and compensate the loss of professional income in a certain number of situations. Direct contributors (as opposed to covered family members) compelled to stop working are entitled to cash benefits. The surviving spouse of a deceased contributor is entitled to a death grant in certain circumstances Maternity Benefits Conditions for entitlement: a pregnant woman has to meet certain requirements (in particular a minimum amount of paid employment prior to the leave) in order to be entitled to maternity leave 35. The length of the maternity leave varies based on the number of children expected and the number of children already born. The typical leave (mother of 33 See for more details. 34 Capital décès : equal to the last3 months salary of the deceased contributor. The minimum amount of the death grant is (as of January 1 st 2008). The maximum amount of the death grant is 8, (as of January 1 st 2008). See Décès for more details on the conditions. On the Social Security ceiling mechanism, see Appendix A pregnant woman must have worked at least 200 hours in the three months prior to the beginning of the pregnancy, or prior to the prenatal leave. She must moreover have been contributing for at least ten months to the scheme at the estimated date of the delivery. See for more details. 19

21 two or less children expecting a single child) is 16 weeks, 6 before and 10 after the birth 36. The amount of the maternity benefit depends on the wages. The daily allowance amounts to the average daily wage received in the 12 months prior to the maternity leave with a maximum amount of per diem in Alsace- Moselle and per diem in other French departments (as of January 1 st 2008) 37. Collective bargaining contracts often top up the social security benefit in order to maintain the expectant mother s income during the leave Sickness Benefit Conditions for entitlement: A minimum length of paid employment prior to the leave is required. The amount required varies according to the length of the leave (more or less than 6 months) 38. Sickness benefits are paid from the fourth day of leave in cases of hospitalisation, and on the eighth day in cases of illness or accident 39. The amount of the benefit is 50% of the average daily wage received in the 3 months prior to the leave, with a maximum of about per diem as of January 1 st Collective bargaining agreements may top up the rest Occupational Injury/Illness Benefits Occupational injuries have historically been the first risk covered by collective insurance mechanisms. Today, occupational injury and illness benefits are still organised under a specific body of rules, and constitute their own sub-scheme within the General Scheme s (Régime Général) Health Insurance scheme. Funding comes from employer-only contributions; the following rates are applied: 0,6% of revenues within the annual limit of the Social Security ceiling ( 30, for 2005) 36 Expecting mothers of twin babies are entitled to take 12 weeks prior and 22 weeks after the birth. Expectant mothers having already had more than two children are entitled to take 8 weeks before and 18 weeks after the birth. In any case, it is mandatory to take a minimum of 8 weeks of maternity leave. See for further details. 37 See for further details. 38 Condition of entitlement: professional activity of at least 200 hours during the 3 months prior to the leave or have contributed on a salary at least equal to 1,015 time the amount of the hourly minimum wage (SMIC) over the 6 months prior to the sick leave (less than 6 months), or (more than 6 months) 800 hours during the 12 months prior to the leave (with 200 hours during the 3 first of the 12 months) or have contributed on a salary at least equal to 2,030 times the hourly minimum wage (SMIC) over the 12 months prior to the sick leave, of which at les 1,015 times the amount of the hourly minimum wage (SMIC) over the first 6 months. See 39 See 40 See 20

22 ADECRI + 5.9% of revenues within the limit of 5 times the annual limit of Social Security ceiling ( 150, for 2005) 41. Conditions for entitlement: All employees 42 are protected, without condition of a minimum paid employment prior to the injury. Employment injuries are broadly defined by the law 43. Traffic accidents, if they are work-related, receive the same protection. Occupational illnesses are those itemised on a special list, and are contracted under the conditions described in the list. Benefits: Two types of benefits can be paid. An allowance is paid if the incapacity to work is only temporary. In case of permanent disability, a pension is paid according to the level of disability. Amount: Daily allowances are paid starting the day after the accident (the employee is responsible for the daily wage on the day of the accident). The daily amount is equal to 60% of the daily average wage of the last month for the first 28 days (with a maximum amount of per day as of January 1 st 2005), and 80% from the 29 th day (with a maximum amount of per day as of January 1 st 2005). The maximum daily allowance is higher than the allowance paid for regular sick leave 44. Pensions are based on the average wage of the last 12 months and consist of a percentage of this average depending on the recognised percentage of disability. Pensioners needing constant assistance from a third person receive an additional 40%. Occupational injury and professional illnesses coverage is mandatory for agricultural workers as well as farmers, family helpers and spouses who participate in the work. It guarantees benefits in kind and cash benefits. The Agricultural Workers Fund (MSA) now manages the workers benefits: other categories have the freedom to select the insurer Disability Pensions Conditions for entitlement: To be eligible, a claimant must have suffered a reduction of 2/3 of his capacity to work, be under the age of 60, establish that he has been insured for at least 12 months and show that he has had a minimum amount of paid employment For daily indemnities, artisans and trades people pay an extra due of 0.5% of revenues (within the limit of 5 times the annual ceiling of the Social Security). See 42 Other different categories of people are also protected. See L412-2 and L412-8 Code de la sécurité sociale. 43 See section L411-1 Code de la sécurité sociale. 44 See 45 Evidence must be provided that least 800 hours of work have been performed in the last 12 months (including at least 200 hours in the 3 first months prior to the disability). 21

23 Amount of the pension: The amount is based on the salary history and depends on the level of disability. Contributors able to undertake paid work are entitled to 30% of their average annual wage 46. Maximum monthly pension is about (as of January 1 st 2005) 47. Contributors unable to undertake any paid work are entitled to 50%, with a maximum of about 1,258 per month (as of January 1 st 2005) 48. The pension is increased if the daily assistance of a third person is necessary Other Schemes Benefits available to employees in the agricultural sector are equivalent to those provided by the General Scheme (Régime Général): however, farmers do not benefit from a per diem rate for illness through the health care system. Civil servants are entitled to the benefits-in-kind provided by the General Scheme (Régime Général). Cash benefits are special 50 and are financed through the general budget. Cash benefits paid by the Fund for the Self- Employed (RSI) have been modified in 2002 and are becoming closer to those provided to private-sector employees 51. B. Supplementary Schemes An estimated 91% of persons living in France have supplementary Health Insurance 52. Slightly fewer than half the persons covered by a supplementary plan have individual contracts. In more than 50% of the cases, supplementary coverage is a job-related benefit subscribed to on a group basis 53. Three kinds of institutions provide supplementary coverage: mutual insurers (not-for-profit: mutuelles) which cover 7.4% 54 of the total health expenditure; private insurers (3.2%) and Provident Institutions (institutions de prévoyance: 2.4%) 55. Supplementary schemes may provide both cash and in-kind benefits. 46 Average annual wage of their 10 best years. 47 See 48 See 49 See 50 Sickness leave: 12 months maximum of which 3 with full wage. Employment injury: full wage if the injury can be linked to the position occupied. The family of a deceased civil servant is entitled to a lump sum equivalent to a year of wage (1/3 for the survivor spouse, 2/3 for children under 21 years of age). See le statut du fonctionnaire for additional information. 51 See for more details. 52 But only about 78% of the unemployed are covered. See CREDES, Santé soins et protection sociale en See above. 54 See DREES Les comptes nationaux de la santé en 2006, Etudes et résultats, n 593, septembre % of people are covered by a mutual insurer, 20% by a private insurer and 15% by a Provident Institution, see CREDES above. 22

24 C. Universal Medical Coverage - Couverture médicale universelle (CMU) Universal Medical Coverage, which replaces the health care assistance provided by local authorities (départements), has been available since January It covers all people legally residing in France who would not otherwise have medical coverage, or who experience administrative difficulties in accessing basic coverage due to their particularly precarious situation. As of December 31 st 2005, 1.7 million persons were covered under this scheme based on residential criteria, of which 300,000 in overseas departments (DOM). With 17% of the population, the basic rate of coverage of the CMU is still higher in overseas departments (by 2%). At the same time, the supplementary CMU covered 4.1 million beneficiaries in mainland France and approximately 600,000 people in the overseas departments 56. In 2003, 0.97 billion were allocated to the supplementary coverage. Persons benefiting from the CMU are exempt from the co-payment (ticket modérateur), and do not have to pay fees up front (health professionals and institutions are directly paid by the health insurance funds 57 ). They can freely choose their provider for the supplementary coverage. III. Organisational Aspects The organisation of both the health care and the Heath Insurance system is complex. There is a basic mandatory public pillar with, in most cases, supplementary coverage. The system features a mix of public care (public hospitals 58 ) and private care (cliniques, office-based doctors, allied medical staff). The French health system delivers high-quality care. It gives patients the ability to choose freely among medical professionals, for both general practitioners and specialists. Treatment is usually provided without the patient having to be placed on a waiting list. Health professionals enjoy a large amount of freedom in prescribing therapies. Control Pursuant to the 2004 legislative reform, new rules have been implemented for health care professionals as they must now follow more stringent rules as established by the Executive Health Authority (Haute autorité de santé) or by another method established by decree. Those who do not respect this regulation risk sanctions (s. 14). 56 See See also: DRESS Études et résultats «Les bénéficiaires de la CMU au 31 décembre 2005» published in August The annual ceiling of resources allowed to benefit from the supplementary CMU is on January 1 st 2007 in the amount of 7,272 for a single person, 10,908 for two people, 13,090 for three people, 15,271for four people and 2,908 for each additional person. Amount increased by 10.8% exist for persons living in overseas departments (Martinique, Guadeloupe, Guyanne and Réunion). See Within the limit of the official fee schedules. 58 The staff working in public hospitals has a public servant status. 23