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3. Protection Universelle Maladie (PUMA)

3.2. How Much do You Pay?

The PUMA charge is called the Cotisation Subsidiaire Maladie (CSM) .

The charge has been the subject of legal controversy, which we have covered in several health articles:

As we stated above, the formula was changed significantly for 2019 onwards, substantially reducing the number of households liable, but it remains a complex formula, leaving many households exempt, granting them free affiliation. We question whether such arrangements are sustainable.

3.2.1. Who is Liable?

One of the most notable characteristics of the charge is that it is applied on an individual basis, not per household, contrary to many other taxes and charges.

Nevertheless, exemptions apply to the whole household where one of them meets the conditions for exemption.

To be liable for the charge three conditions apply:

That you have no professional activity (business or salaried), or that you have a professional activity, but your income from this activity is below above a minimum threshold;
That in the second case you also have capital income (revenus de patrimoine) above the exemption threshold;
That you are not in receipt of a pension or unemployment benefit.

The law states the income that is liable is:

Cette cotisation est assise sur le montant des revenus fonciers, de capitaux mobiliers, des plus-values de cession à titre onéreux de biens ou de droits de toute nature, des bénéfices industriels et commerciaux non professionnels et des bénéfices des professions non commerciales non professionnels...

In short, the charge is aimed at those who live on their capital income, but who are not of pensionable age. Note that revenus de patrimoine includes capital gains.

In relation to pension income, the regulations make no distinction between State retired pensions and early retirement pensions/annuities. They merely reiterate the clause set out in Article L380-2 of the Code de la sécurité sociale, which states individuals are only liable if:

'Elles n'ont perçu ni pension de retraite, ni rente, ni aucun montant d'allocation de chômage au cours de l'année considérée. Il en est de même, lorsqu'elles sont mariées ou liées à un partenaire par un pacte civil de solidarité, pour l'autre membre du couple.'

This clause means that a couple would be exempt if only one of them was in receipt of a pension.

In guidance published by the social security agency URSSAF, they make a distinction between French pensions and foreign pensions, stating that whilst pensions from the EEA exempt the person, those from outside of the EEA are not automatically exempt. Only those non-Europeans whose health cover is met by their home country would they be exempt:

'Pour les pensions de retraite servies par un Etat hors Union européenne ou la Suisse, la perception de cette pension permettra d’exonérer la personne uniquement si la prise en charge de ses frais de santé, ainsi que ceux des membres de sa famille qui résident avec elles, est supportée définitivement par le régime étranger qui sert la pension de retraite.'

The legal basis for this statement is not entirely clear as the legislation makes no distinction between the country of origin of the pension and could well be subject to legal challenge. For most of those on a retirement pension, the question is, however, an academic one, for they are covered by an S1 via their home country. In addition, all the circumstantial evidence we have seen suggests that in practice, no distinction is being made between foreign and French pensions.

The official guidance on the issue also states that those in receipt of an invalidity pension would also be exempt, as would their partner.

The position of early retirees on a pension remains open to some interpretation, but it seems that the law is being interpreted widely and that anyone with a pension is being exempted from the charge. Whether that remains the case is questionable, as such pensions in France are normally referred to as a pension de préretraite, a term that is not used in the legislation.

Those who obtain health cover in France via an S1 certificate of exemption, who are insured for health from their home country are exempt. This mainly affects EEA nationals on a State retirement pension, but it also includes anyone else who holds a S1 certificate;

On the income tests the law states exempt households are:

Economically inactive individuals with capital income less than a minimum threshold, being 50% of the plafond annuel de la sécurité sociale which in 2024 is €23,184 pa;
Business owners and salaried employees with a professional income higher than 20% of the plafond annuel de la sécurité sociale which in 2024 is €9,273 a year;

The formula (Décret n° 2019-349 du 23 avril 2019) means that only those with a professional activity earning below €9,273 pa and capital income higher than €23,184 would be liable for the charge.

The two income tests are cumulative, but even if you were liable under these tests, you would be exempt if you were on a pension or an S1.

For those with professional income the charge rate reduces progressively with an increase in professional income.

In the case of a married couple or those in a civil partnership, the charge will not apply to either of them where one of them has income from a professional activity above the threshold.

This same rule applies in relation to those couples where at least one of them is in receipt of a pension, when they are both them exempt from the charge.

An upper limit to the capital income that gives rise to the charge is also applies, equivalent to €370,004 (2024). So income over this amount will be exempt from the charge.

The position of those who are covered for health through a private health insurance policy is not stated in the regulations, but many expatriates with such policies have received a demand for payment of the health charge. Once again, the issue needs some legal clarity. There are a number of cases pending in the courts. URSSAF state that those with a private health policy are not exempt from the charge.

Contrary to widespread belief, there is no specific social charge for health cover on pension (or other) income. This charge, called the Cotisation d’assurance maladie (CAM), is only payable on the pension income of those in receipt of a French pension living abroad who benefit from French health cover, as well as those in the Alsace-Moselle pension scheme. It is also payable by certain ex employees of specialist pension schemes, eg ex railway workers.

The CAM also needs to be distinguished from the Cotisation Subsidiaire Maladie (CSM), under PUMA.

(There are slightly different rules that apply to frontier workers/business owners with Switzerland.)

3.2.2. Eligible Income

For those with no professional activity, the only income on which the CSM is payable is income from capital sources, called revenus de patrimoine. That is to say, investment income, rental income and capital gains.

If your income from such sources is below the minimum threshold above you are also exempt from the charge.

Only those with a low income-earning professional activity (as above) would have this income taken into consideration in the calculation on a progressive basis.

A married couple or those in a civil partnership each benefit from the above exemption threshold. They would need to have revenus de patrimoine of around €41,000 before they were liable, but if they were in receipt of a pension, they would remain exempt.

If the level of your revenus de patrimoine in the form of rental income was such that it your were required to become a professional landlord (LMP) you would not pay the CSM, although you would pay social security contributions.

For the purposes of determining the amount payable the authorities can also take into consideration your lifestyle (train de vie), an assessment that will particularly affect those households living on their capital resources. Details of this process have yet to be published.

In your first year in France, without any previous tax returns having been made, the authorities will assess your contribution level on the basis of your tax return and income in your previous country of residence. If your income has reduced significantly since this time (often the case) then you need to make clear this is the case and provide appropriate and clear evidence. The charge is applied on a pro-rata basis for those not in PUMA for a full year.

3.2.3 Calculation

The insurance contribution rate is 6.5% of net eligible income although disgressive reducing to 0% when professional income is above €11,592 (2024).

With the abolition of 'dependant' status (ayants droits) under PUMA, those liable for the CSM will be assessed on the basis of their own eligible income, plus half of the joint revenus de patrimoine they earn with their spouse/civil partner.

As the regulations state: 'La cotisation subsidiaire est individuelle : elle est due par chaque assuré à titre personnel sur ses revenus du capital.'

3.2.4 Payment of the Charge

The charge is levied in November each year, payable in arrears. So the payment for 2024 is due in November 2025.

It is payable either in one single payment or in three equal payments over 90 days for each payment, but only on request. If payment is not made within 30 days of the demand, there is a 5% penalty plus 0.4% interest for each month of non-payment.

Although the regulations are not explicit on the point, there is no reason for not supposing that the PUMA charge is a deductible expense for the purposes of determining liability to income tax and social charges. We would be interested to hear from your own experience ([email protected]).

3.2.5. Challenging the Assessment

If you wish to contest the imposition then you need to write to URSSAF with your documentary evidence.

If they are unwilling to accept your challenge you are entitled to appeal to the Commission de Recours Amiable (CRA) in the agency, which you need to do so within two months of receipt of the bill, and ultimately appeal to a local court, the Tribunal des Affaires de Sécurité Sociale (TASS).