Health Insurance in France: Puma, the Carte Vitale and Your Mutuelle

This guide is for internationals who have just moved to France and need to understand state health cover and top-up insurance. After reading it, you will be able to follow the steps to join the protection universelle maladie (universal health protection) and understand how an employer’s mutuelle and the complémentaire santé solidaire fit in.

• What Puma is
• Who qualifies: the residence conditions
• The three-month waiting period and how to apply
• The carte Vitale
• Top-up cover and the employer’s mutuelle
• The complémentaire santé solidaire
• FAQ

What Puma is

The protection universelle maladie, or Puma, covers health costs through the Assurance maladie (state health insurance). According to Service Public’s page on Puma, anyone who works or lives in France on a stable and regular basis has this right personally and continuously. People stay in the same scheme when their situation changes, for example after losing a job or separating from a partner.

Adults are insured in their own right and can no longer be an ayant droit (dependant). This means an adult without a job does not need to be attached to anyone. Each adult can receive reimbursements into their own bank account and hold their own Ameli account (the online Assurance maladie account). Children are dependants attached to a parent. They can apply for their own cover from the age of 16 and stop being dependants in the year they turn 18.

Who qualifies: the residence conditions

Two conditions apply, and both must be met: residence must be regular (lawful) and stable. Nationals of the European Economic Area and Switzerland need only an identity card or passport to show regular residence. Other nationals need a titre de séjour (residence permit) or another residence document. Residence permits are a matter for the prefecture. Questions about an individual’s status go to the prefecture or a migration advice service.

The three-month waiting period and how to apply

Someone who works in France is affiliated straight away once their application is accepted. Otherwise there is a three-month wait after arrival, which means living in France without interruption for more than three months. Rights then stay open while the person lives in France for at least six months of the year. Some people have no wait: refugees, people returning from an international volunteering placement abroad, and people receiving the allocation adulte handicapé (AAH, adult disability allowance) or the allocation supplémentaire d’invalidité (Asi, supplementary invalidity allowance).

The application starts with the form Demander l’ouverture des droits à l’Assurance maladie (application to open health insurance rights). Joining is compulsory. Deliberately refusing to join is punishable by six months’ imprisonment and a €15,000 fine, or one of the two. Puma can be withdrawn if the conditions stop being met, and a move abroad must be declared on the form Déclaration de transfert de résidence hors de France.

A change is on the way. The 2026 social security financing law, dated 30 December 2025, provides for a financial contribution from some Puma beneficiaries: those who live in France on a stable and regular basis, have no professional activity, and pay neither the CSG nor the CRDS (social contributions) nor the health insurance contribution due under an international agreement. The amount will be set by a decree, which had not yet been published.

The carte Vitale

The carte Vitale is the health insurance card linked to a person’s Assurance maladie file. The official pages used for this guide do not say how it is issued, what documents it requires or how long it takes. The Assurance maladie decides these points, and the office that manages the person’s file answers questions about the card.

Top-up cover and the employer’s mutuelle

The Assurance maladie does not pay all health costs. The share it leaves, the part complémentaire, is paid by the patient unless they hold a complémentaire santé (top-up health insurance), usually called a mutuelle.

Service Public’s page on company mutuelles explains that an employee can decline an employer’s collective scheme only in certain cases, including:

• existing cover, including as a dependant, under another compulsory company scheme, a Madelin group contract, the Alsace-Moselle local scheme, CAMIEG (the electricity and gas industries’ scheme) or a scheme for public-sector staff
• an individual contract, in which case the exemption lasts only until that contract expires
• the complémentaire santé solidaire, for as long as the employee receives it
• a scheme set up by unilateral employer decision with an employee contribution, in which case the refusal must be made in writing when the scheme is set up or changed
• cases allowed by the collective agreement or employer decision that created the scheme, which the employer must then accept

The request is generally made at hiring or when the scheme is set up. Where the employee has other cover or the C2S, it can also be made on the date that cover starts. Some employees who opt out can receive the versement santé, an employer contribution towards an individual policy. That policy must be a “responsible” contract, meaning it meets the legal coverage rules. Most exemptions apply to health costs only. Questions about these rules go to the DDETS (departmental employment, labour and solidarity office).

The complémentaire santé solidaire

The complémentaire santé solidaire (C2S) replaced the former CMU-C. It pays the complementary share for people on low incomes, so health costs are reimbursed in full within Social Security tariffs. According to Service Public’s page on the C2S, it is free or carries a contribution depending on income. Holders pay no dépassements d’honoraires (fees above the standard rate), no franchise médicale (fixed patient deduction) and no €2 flat contribution. They also get tiers payant (no upfront payment) when they see their médecin traitant (registered GP) before going to a specialist.

These are the annual income ceilings in the general case, as shown when the page was checked on 1 July 2026:

• 1 person: free up to €10,421; with a contribution between €10,421 and €14,069
• 2 people: free up to €15,632; with a contribution up to €21,103
• 3 people: free up to €18,758; with a contribution up to €25,324
• 4 people: free up to €21,885; with a contribution up to €29,544
• each additional person: €4,169 (free) or €5,628 (with a contribution)

Income is assessed over a 12-month period, running from the 13th to the 2nd calendar month before the month of application. A fixed housing amount is added to the income of people who receive housing aid, are housed free of charge or own their home. People receiving the RSA (revenu de solidarité active, minimum income) get free C2S automatically unless they decline it. Foreign nationals need a valid residence permit and more than three months of uninterrupted residence, unless another listed situation applies, such as working in France for more than three months. People without lawful residence can apply for the aide médicale de l’État (AME, state medical aid) instead.

FAQ

Is there always a three-month wait before cover starts?

No. People who work in France are affiliated straight away once their application is accepted. Others wait three months after arrival, except refugees, people returning from international volunteering placements, and people receiving AAH or Asi.

Can an adult partner be covered as a dependant?

No. Since Puma was introduced, every adult is insured in their own right. Only children are attached to a parent, and they can apply for their own cover from the age of 16.

Can an employee refuse the company mutuelle?

Only in the cases set by the rules or allowed by the document that created the scheme, such as existing cover elsewhere or receiving the C2S. Most exemptions apply to health costs only.

Is the complémentaire santé solidaire free?

It depends on income. In the general case, a person living alone gets it free if their income is up to €10,421 a year. Between €10,421 and €14,069, they pay a contribution.

Sources: service-public.fr · service-public.fr · service-public.fr

Last verified: 20 October 2026 against the pages linked above. Rules and fees change; the responsible authority always has the final word.

This is general information, not legal or immigration advice. For your own situation, ask the prefecture of your département, a recognised migration advice service or a lawyer (avocat).