Health-maternity insurance

III. Health-maternity insurance - France's social security scheme for self-employed workers

A. Health care

As from January 2016, France's universal health care system ("Protection universelle maladie"/ Puma) provides health-maternity coverage to all persons working in France or residing in France on a stable and ongoing basis. Workers' adult family members (spouse and/or children) can now be insured in their own right. If not employed, the worker's spouse, de facto partner, or civil union ("Pacs") partner can remain a member of his/her former health insurance scheme (the general or other scheme) or choose RSI without any break in coverage.

Self-employed workers' health care expenses are covered under the same conditions and using the same reimbursement rates that apply to salaried workers under the general scheme:

Prestations

Prise en charge par le RSI

Doctor's fees (within the coordinated healthcare pathway through your primary-care physician ["médecin traitant"])* 70%

70%

Doctor's fees (outside the coordinated healthcare pathway) 30%

30%

Auxiliary health workers' fees 60%

60%

Medical analyses 60%

60%

Medications 100%, 65%, 30%, or 15% depending on the recognized ("medical service rendered")

 

Care and hospitalizations in connection with a long-term illness 100%

100%

Hospitalization = for 30 days or less

80%

Hospitalization from the 31st day and beyond

100%

Hospital stays that include an extensive procedure with a fee of 120 € or more

100%. The 18 € hospital charge is paid by the insured.

*If you declare a primary-care physician ("médecin traitant"), you will be reimbursed at a higher rate. RSI reimburses 70% of a 25 € doctor's appointment, or 16.50 €, if you have a primary-care physician, versus 6.50 € if you do not.

You will receive your reimbursement from one of RSI's approved organizations. That is where you will need to send your medical expense claim forms ("feuilles de soins").

An approved organization ("organisme conventionné") is a mutual fund or a group of insurance companies that have signed an agreement with RSI to manage the scheme's compulsory health care benefits. Whichever approved organization you chose when you created your business, your reimbursement rates will be the same.

B. Daily medical leave benefits

Craftspeople, shopkeepers, and manufacturers receive daily (cash) benefits if they are prescribed medical leave as the result of an illness or accident.

Private-practice professionals do not pay compulsory contributions for daily benefits, which mean they are ineligible for these.

The RSI-approved organization which the worker has chosen is in charge of paying these benefits.

1. Eligibility requirements

To be eligible to receive daily benefits, you must meet the following requirements:

  • You must have been a member of RSI's health insurance scheme for at least 1 year,
  • Be up-to-date with all of your health insurance contributions,
  • And produce a prescription for full-time medical leave.

If you were previously a member of another compulsory health insurance scheme, either through employment or a period on unemployment benefits, your period of membership in that scheme can be taken into account provided that you transitioned directly from one scheme to the other with no break in coverage.

Pages 1 and 2 of the medical leave prescription your doctor has issued you must be sent to your RSI fund's medical department within 48 hours of the prescription.

2. Rates

Daily benefits are paid at a rate of 1/730th of your average annual earned income over the past 3 calendar years, up to a maximum of the annual Social Security ceiling (39,228 € in 2017). If your average annual income is 3,806.80 € or more, your daily benefits, which are proportional to your income, will come to between 5.14 € and 53.74 € per day. If your income is below that level, daily benefits will not be paid.

According to these calculation methods, members paying a minimum contribution will receive daily benefits at a rate of approximately 21 €.

Sample calculations

  • Average annual earned income for the previous 3 years: 2,500 €.
    2,500 < 3,806.80 €
    Daily benefits are not paid.
  • Average annual earned income for the previous 3 years: 8,000 €. 
    8,000 € x 1/730 = 10.96 €
    Daily benefits are paid at a rate of 10.96 €.
  • Average annual earned income for the previous 3 years: 42,000 €. 
    42,000 € x 1/730 = 57.53 €
    Daily benefits are paid at the maximum rate of 53.74 €.

3. Length of entitlement

How long you will receive daily benefits depends on the type of medical leave you have been prescribed:

Long-term illness ("Affection de longue durée"/ALD) or long-term care ("soins de longue durée"/SLD)

A long-term illness ("affection de longue durée"/ALD) is a serious and/or chronic illness which is covered by France's health care system at a rate of 100% for all necessary treatments.

Long-term care ("soins de longue durée"/SLD) is in connection with an illness requiring ongoing care and/or medical leave for a period of more than 6 months.

As under France's general scheme, if you are prescribed medical leave under one of these two categories, you will be eligible to receive daily benefits for up to 3 years provided that the leave was medically justified.

Other situations

If you are prescribed medical leave that is not connected to a long-term condition (illness, accident, etc.), you will be eligible for 360 days of benefits over a period of 3 years, as under the general scheme.

C. Maternity – Paternity

Craftspeople, shopkeepers, and private-practice professionals who are members of RSI in their own right are eligible for maternity benefits if they are up-to-date with the payment of their compulsory health and maternity contributions.

1. Coverage of care and exams

Your care will be covered by the RSI-approved organization you chose when you created your business, according to the following reimbursement rates:

Type of care

Reimbursement rate

Mandatory pre- and post-natal exams

100%

All exams and care performed or provided from the 6th month of pregnancy up to 12 days after the actual date of delivery

100%

Expenses in connection with pregnancy, delivery, and post-delivery care, such as: fetal caryotype and amniocentesis, glucose readings, and post-natal physical therapy

100%

Hospitalization (all expenses: fees and accommodations)

100%

Physical exam for the father-to-be

100%

Care or hospitalization of the child over the 30 days following birth

100%

Compulsory medical follow-up exams for the child up to his/her 6th birthday

100%

Other care (not covered by maternity insurance) for the mother or child, provided by a doctor or midwife (as a practitioner)

70%

Other care (not covered by maternity insurance) for the mother or child, provided by an auxiliary health worker (nurse or physical therapist)

60%

2. Cash benefits

Company directors can receive two different pregnancy-related benefits from RSI at the same time.

The lump-sum mothers' rest benefit ("allocation forfaitaire de repos maternel")

This benefit is intended to compensate for a decreased work load. If your income is above 3,806.80 €, it comes to 3,269 € for a pregnancy or 1,634.50 € for an adoption and is paid in 2 installments:

  • Half of the amount at the end of the 7th month of pregnancy,
  • Half of the amount following delivery.

The lump-sum daily benefit for time off work

This is paid to women who stop working for 44 consecutive days, 14 of which must immediately precede the expected date of delivery. Their medical leave can be extended by one or two periods of 15 consecutive days.

If your income is above 3,806.80 €, this benefit comes to 2,364.56 € for the first 44 days off work, then 806.10 € per additional period of 15 days.

Your medical leave can be extended under certain circumstances (pregnancy-related difficulties, pathological pregnancy, premature birth, twin birth, adoption, or hospitalization).

Those with contributing spouse ("conjoint collaborateur") status are also entitled to maternity benefits. For more information on maternity insurance for company directors and contributing spouses, please refer to RSI's brochure.

3. Paternity leave

Company directors or contributing spouses are eligible for paid paternity leave from RSI.

Paternity or adoption leave is granted to the father as well as, where applicable, to the spouse, de facto partner, or civil union ("pacs") partner if he is an RSI member.

Rates and length of entitlement

Leave must begin within 4 months of the child's birth.

Company directors receive daily benefits at a flat rate of 53.74 € per day. These can be paid for:

  • Up to 11 consecutive days for a single birth or adoption, or 591.14 € total.
  • Up to 18 consecutive days for a multiple birth or adoption, or 967.32 € total.

These amounts are awarded if annual income exceeds 3,806.80 €.

As of January 1st, 2016, if a company director's earned income comes to less than 3,806.80 €, his/her benefits are reduced to 10% of the usual amounts.

For contributing spouses, the "replacement" benefit ("indemnité de remplacement") is paid at a rate of 52.87 € per day. It is paid for the same amount of time as to fathers who are company directors.

Information Provided by:

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