Three months in France, and the state health system opens its doors. Here's how to walk through them.

PUMa — protection universelle maladie — covers anyone living in France in a stable, regular way. That includes American and Canadian retirees on visitor visas. No age limit, no medical exam, no pre-existing-condition exclusions. The process is paperwork-heavy but predictable, and one funding rule catches early retirees by surprise.

Who qualifies

PUMa has two entry doors: working in France, or residing in France in a "stable and regular" way. For non-working residents — visitor-visa retirees included — "stable" means your real home is in France, shown by 3 months of continuous residence; "regular" means lawful status, shown by your validated visa or residence card. After joining, coverage continues as long as you live in France at least 6 months a year.

The application, step by step

1. Wait out the 3 months from arrival, and collect proof you were here: lease, utility bills, bank statements.
2. Complete the application form (demande d'ouverture des droits à l'assurance maladie — Cerfa form via ameli.fr) for each adult.
3. Assemble the file: passport, validated visa or residence card, birth certificate (a certified French translation is commonly required — order apostilled copies before you leave North America), proof of address, marriage certificate if applying as a couple, bank RIB.
4. Submit to your local CPAM (caisse primaire d'assurance maladie) by post or in person.
5. Receive a temporary social security number, then a permanent one. Reimbursements can start here, on paper forms (feuilles de soins).
6. Order your carte Vitale once the permanent number arrives. From then on, reimbursements are automatic within days.
7. Declare a médecin traitant (regular GP). Without one, reimbursement on most care drops from 70% to 30%.

What the state pays — and what you pay

Sector-2 doctors — common in Paris, Lyon, and the Riviera — legally charge above the official tariff. The state still reimburses on the tariff; the excess is yours unless your mutuelle covers it. When choosing a mutuelle, that "dépassements d'honoraires" line is the one to read.

The PUMa contribution: the rule that surprises early retirees

PUMa is funded through social contributions, and URSSAF applies a specific one — the cotisation subsidiaire maladie (CSM), informally the "PUMa tax" — to residents who live off capital rather than work or pensions. For 2026:

• It applies if your household's professional income is below €9,612 (20% of the social security ceiling) and you draw no retirement or unemployment pension.
• The charge is 6.5% of capital and investment income (dividends, interest, rents, gains) above €24,030 (50% of the ceiling), on a base capped at €384,480.
• Pension recipients are exempt. If you receive US Social Security, CPP/OAS, or an occupational pension, you should generally escape the CSM — but URSSAF's handling of foreign pensions has varied in practice. Keep award letters and payment evidence, and expect to show them if assessed.
• Who it really hits: the 55-year-old who retired early and lives off a brokerage account until pensions start. If that's you, model the 6.5% before you move.

What it means in dollars

A couple in their 60s with pensions, a standard mutuelle at ~€120 each, and typical use of GPs, specialists, and prescriptions spends roughly €250–350/month (≈$285–400) on healthcare all-in — mutuelle premiums included, with catastrophic risk essentially capped by the state system. Compare that with a US couple on Medicare with Medigap, Part B and D premiums, and deductibles. It's one of the largest line-item savings in a France move. (Estimate; your mutuelle choice moves it.)

Before PUMa: the insurance bridge

Your visitor visa required private insurance covering the full stay including hospitalisation and repatriation. That policy is your bridge: months 0–3 you're not yet eligible; months 3–9 you're likely waiting on CPAM. Buy the visa policy with that whole first year in mind, not the minimum the consulate accepts. US Medicare does not cover you in France; most people keep premium-free Part A and drop or suspend the rest — take advice before cancelling anything. Canadians: provincial plans (OHIP, RAMQ etc.) end after your departure grace period; don't count on them.