You are British, you have retired early or you live on savings, rental income and investments, and you have settled in France after Brexit. You do not receive a United Kingdom State Pension yet, you do not work in France, and nobody has given you an S1 healthcare form. Then the worry arrives: a letter from the caisse primaire d’assurance maladie, the CPAM, the local health insurance fund that handles affiliation for most residents, tells you that your application for French healthcare is refused, or a hospital asks you to pay the full bill, or the Urssaf, the body that collects social contributions, sends a demand for a yearly levy you never heard of. For a British household that planned carefully for the move, this moment feels alarming. Medical cover was supposed to be a detail. It is now the file that blocks everything else, from registering with a doctor to planning an operation.

This guide answers the exact questions British early retirees ask after Brexit: can a person with no job and no S1 still join the French health system, what does three months of residence really mean for a newcomer, how much does the yearly cotisation subsidiaire maladie, the CSM, the subsidiary sickness contribution paid by inactive residents with capital income, actually cost, and what can you do when the CPAM says no or the Urssaf sends the wrong figure. It is written entirely in English, with United Kingdom spelling, for a British reader, and every French term is explained the first time it appears. The protection universelle maladie, known as PUMA, is the universal health protection that gives any person who works or who resides in France in a stable and lawful way a right to reimbursement of health costs. The carte Vitale is the green plastic health card used to claim reimbursement at the doctor and the pharmacy. The commission de recours amiable, the CRA, is the internal appeals board inside each social security fund that must be contacted before going to court. The plafond annuel de la sécurité sociale, the PASS, is the yearly social security ceiling used to calculate thresholds and caps. The complémentaire santé solidaire is the means-tested top-up cover that pays most of what the basic scheme leaves behind. With those definitions fixed, the legal position can be stated plainly: an inactive British resident who lives in France lawfully can join PUMA even without an S1, but must prove stable residence, may have to pay the CSM levy on capital income, and must challenge any refusal or wrong bill within strict time limits with documents.

I. No S1 and no job in France: can a British early retiree still join the French health system after Brexit?

The short answer is yes, provided residence in France is stable and lawful. The long answer is where British files succeed or fail, because the CPAM examines exactly those two words, stable and lawful, and the meaning of each changed for British citizens on the day the United Kingdom left the European Union. Before Brexit, a British citizen could rely on European coordination rules almost without thinking about them. Since Brexit, a British newcomer is a third-country national, a citizen of a country outside the European Union, and must hold a French residence document for any stay longer than three months while also showing that France is genuinely home. The S1 form, the document by which the United Kingdom pays for the healthcare of some of its pensioners and posted workers abroad, helps those who have one, but it was never the only route. PUMA exists precisely for people who have no professional activity in France and no S1, including early retirees living on savings.

A. We moved to France with savings but no S1: does PUMA cover a British inactive resident?

PUMA covers any person who works in France or, where the person carries on no professional activity, who resides in France in a stable and lawful manner. The statute says this in one sentence that every British early retiree should know: Article L160-1 of the Social Security Code provides that “Toute personne travaillant ou, lorsqu’elle n’exerce pas d’activité professionnelle, résidant en France de manière stable et régulière bénéficie, en cas de maladie ou de maternité, de la prise en charge de ses frais de santé dans les conditions fixées au présent livre.” In plain English, a person with no job who lives in France in a stable and lawful way receives coverage of health costs for illness and maternity under the conditions set by the Code. The words stable and lawful are then defined elsewhere, and the CPAM applies them line by line.

Lawful residence, the séjour régulier, means holding the right residence document. Since Brexit, Article L411-1 of the Code on the Entry and Residence of Foreigners and the Right of Asylum states that “tout étranger âgé de plus de dix-huit ans qui souhaite séjourner en France pour une durée supérieure à trois mois doit être titulaire de l’un des documents de séjour suivants”, namely a long-stay visa, a temporary residence card, a multi-year card, a resident card, or one of the other listed permits. For a British adult, that means in practice a long-stay visa endorsed for residence, then a carte de séjour, the residence card, or for those who were already living in France before the end of the transition period, a Withdrawal Agreement residence card. A British visitor who stays under ninety days on a passport stamp, without a visa or card, does not meet the lawful-residence condition for PUMA, even if the person rents a house and pays French bills. That visitor relies instead on a United Kingdom-issued Global Health Insurance Card, the GHIC, or the older European Health Insurance Card, the EHIC, for medically necessary care during a temporary stay, a route described in our companion guide on GHIC and EHIC refusals in France. The early retiree who has moved permanently, holds a visa or residence card, and lives in France year-round sits on the other side of that line and falls inside PUMA.

Stable residence, the résidence stable, is assessed under Article L111-2-3 of the Social Security Code, which sends the detail to regulation, and under Article R111-2 of the same Code, which states that “sont considérées comme résidant en France de manière stable les personnes qui ont leur foyer ou le lieu de leur séjour principal sur le territoire métropolitain”, with further detail for overseas territories. In ordinary language, the fund looks for the home base, the foyer, the place where the person normally lives on a permanent basis, or the principal place of stay. The same article adds a sentence British applicants should quote back whenever a file goes wrong: “La résidence en France peut être prouvée par tout moyen.” Residence in France can be proved by any means. No single document is legally required, and the CPAM cannot lawfully demand one specific paper as the only acceptable proof.

What PUMA then pays for is broad. Article L160-8 of the Social Security Code lists general and specialist medicine, dental care and dentures, pharmacy, laboratory tests, hospitalisation and treatment in care and rehabilitation establishments, transport costs for care, preventive acts and vaccinations, and several other categories. The basic scheme does not reimburse everything at one hundred per cent, which is why most residents add a mutuelle, a private top-up insurer, or, where income is low, apply for the complémentaire santé solidaire under Article L861-1 of the Social Security Code, the means-tested complementary protection granted where household resources sit below a ceiling set by decree, or with a financial contribution where they sit between that ceiling and the same ceiling increased by thirty-five per cent. For the early retiree with comfortable capital income, the top-up will usually be a private policy; for the household whose income dropped after the move, the solidarity top-up is worth checking, because the CPAM examines household resources and composition under that article.

Two distinctions matter for British readers at this stage. First, the pensioner with an S1 follows a different administrative path, registration of the British S1 at the CPAM so that the United Kingdom reimburses France, and that route is explained in our guide on S1 healthcare and recovery of costs paid before registration. The early retiree with no S1 follows the PUMA residence path described here, and should not let a CPAM desk insist that an S1 is compulsory for every British applicant. It is not. Second, the British student follows the student affiliation path with its own work and residence paperwork, described in our guide on British students, visas, work and post-study stay. The inactive adult, the personne sans activité, follows neither of those paths and must build a PUMA file on residence alone.

Practical preparation makes the difference. File the PUMA application, the demande d’ouverture des droits à l’assurance maladie, the request to open health insurance rights, with the CPAM of the place of residence as soon as the household is installed, using the official form and keeping a dated copy of everything sent. Attach the passport, the long-stay visa or residence card for each adult, proof of address in the applicant’s name such as a lease or utility bill, and, where available, the birth certificate and a certified translation. The United Kingdom guidance on healthcare for United Kingdom nationals living in France confirms that residents without an S1 must register with the French system and that the United Kingdom will not pay their costs, so the PUMA application is the correct step, not a request to London. Keep private health insurance running until the CPAM confirms affiliation and the numéro de sécurité sociale, the social security number, arrives, because medical costs incurred before affiliation are recovered only within strict limits and on proof. Anyone who deliberately refuses to take steps towards compulsory affiliation risks a criminal penalty stated on the official public service page, so the file should be opened early and chased in writing rather than left to drift.

B. CPAM says we have not lived here three months: how do British newcomers prove stable residence?

The three-month objection is the most common refusal British newcomers meet, and it is also the most misunderstood. French regulation does require, in most cases, a period of uninterrupted presence before affiliation, but the rule is narrower than many CPAM letters suggest, and the courts read it strictly against the fund. The leading decision is a published ruling of the Second Civil Chamber of the Court of Cassation, the Cour de cassation, the supreme court for civil and social security matters, which states that “les personnes qui demandent à bénéficier de la prise en charge des frais de santé en application des dispositions de l’article L. 160-5 peuvent produire un justificatif démontrant qu’elle résident en France de manière ininterrompue depuis plus de trois mois ou qu’elles relèvent de l’une des catégories qu’il énumère limitativement.” In other words, applicants show either continuous residence for more than three months or membership of one of the exhaustively listed exempt categories. Read the full ruling under its exact reference Court of Cassation, Second Civil Chamber, 3 June 2021, appeal No. 20-10.687, published in the Bulletin, and note the solution, rejection of the appeal, which confirms that the three-month rule and its limited exemptions apply to everyone without distinction of nationality.

For a British household that arrived in, say, September, this means the CPAM will normally ask for proof of presence since June or earlier before opening rights, and a refusal dated October for a family that arrived in September can be perfectly lawful on that ground alone. The error to avoid is treating that refusal as final. The correct response is to calendar the date on which three months of continuous presence is reached, keep every proof of presence from day one, and reapply or complete the file at that point rather than abandoning the claim. Presence is proved by any means, and British newcomers should build a bundle that a judge would accept: dated lease or purchase deed, electricity, gas, water and internet contracts and bills, home insurance certificate, bank statements showing daily spending in France, school enrolment certificates for children, and travel records showing entries into France and absence of long trips back to Britain. Where passports are no longer stamped systematically, ferry and airline bookings, toll receipts and fuel receipts help fill the gap. A short trip back to Britain does not always break continuity, but a file that shows the family spent most of the last three months outside France invites a refusal that will be hard to overturn.

Lawful residence interacts with the three-month question. A British citizen who entered visa-free for a short stay and then applies for PUMA from inside France without a long-stay visa or residence card will normally be refused on the regularity ground regardless of physical presence, because the file shows no document authorising a stay longer than three months. The remedy is immigration advice before the health file: the correct long-stay visa applied for from the British country of residence, then validation on arrival and application for the residence card in the prefecture, the préfecture, the state authority that issues residence documents. A British spouse of a French citizen follows the private and family life card path described in our guide on the vie privée et familiale card after Brexit. A British retiree with independent means typically holds a long-stay visitor visa with a financial undertaking not to work, then a corresponding card. Whatever the card, a legible copy goes into the CPAM bundle, and any renewal receipt, the récépissé, the official receipt issued while a renewal is examined, goes in too, because it proves continued lawful stay while the new card is prepared.

Children and dependants follow the affiliation of the household once the parents are affiliated, and the CPAM examines school certificates and family records for them rather than separate three-month bundles. Keep copies of everything, send the application by a method that proves the date, and reply to any request for further documents within the stated time. Where the CPAM remains silent for a long period, chase in writing and keep the chase letters, because delay itself can later support a claim for reimbursement of costs necessarily paid in the meantime, and because limitation periods for appeals run from notification of an express decision.

II. How much will French healthcare cost an inactive Briton and how do you fight a wrong bill or refusal?

Joining PUMA is only half the file. The other half is money: the yearly CSM levy that many inactive British residents must pay, the top-up cover that controls what a hospital stay really costs, and the appeal routes when a figure or a refusal is wrong. British early retirees often discover the CSM levy with surprise, because the United Kingdom has no equivalent charge on savings income for access to the National Health Service. In France the logic is different. Workers contribute through payroll charges. Pensioners with an S1 are covered through the British reimbursement. Inactive residents with capital income contribute through the CSM levy, collected by the Urssaf on the basis of tax data. Understanding who pays, how the sum is calculated, and how to challenge it turns an alarming demand into a manageable file.

A. Urssaf asks us to pay the CSM levy on our savings income: who really pays and how is it calculated?

The statute casts the net in deliberately wide terms. Article L380-2 of the Social Security Code opens with the sentence “Les personnes mentionnées à l’article L. 160-1 sont redevables d’une cotisation annuelle lorsqu’elles remplissent les conditions suivantes”, then sets two cumulative conditions: professional income in France below a threshold fixed by decree, for both spouses or civil partners where applicable, and no retirement, invalidity, annuity or unemployment income during the year considered, again for both members of the couple where applicable. The contribution base is then defined as rental income from property, income from movable capital, capital gains on disposals of property or rights of any kind, non-professional industrial and commercial profits and non-professional non-commercial profits, calculated under the procedures of paragraph IV of Article 1417 of the General Tax Code, plus, where not already counted, all means of subsistence and lifestyle elements available to the beneficiary anywhere in the world. In practice, a British couple living in France on dividends from a United Kingdom company, interest, rental income from a British buy-to-let and occasional capital gains, with no French salary and no pension yet in payment, sits squarely inside the charge, while a neighbour of the same age who already draws a French or British pension in payment sits outside it, because pension receipt excludes the levy.

The calculation follows a regulation whose formula should be quoted exactly, because Urssaf bills that depart from it can be challenged. The decree states: “Montant de la cotisation = 6,5 % × (A-0,5 × PASS) × [1-R/ (0,2 × PASS)]”, where A is the capital income base capped at eight times the yearly ceiling, PASS is that ceiling, and R is professional income. The official text is Article D380-1 of the Social Security Code. An allowance, the abattement, the fixed reduction subtracted from the base before applying the rate, and a cap on the base, both fixed by decree, complete the picture, and the levy is collected in the year following the year examined, on the basis of income tax data sent by the tax administration to the collection bodies. Take a simplified illustration with round figures to show the mechanics rather than any individual’s bill: with a yearly ceiling of about forty-seven thousand euros, twice-ten per cent of that ceiling sets the professional income threshold near five thousand euros, half the ceiling near twenty-four thousand euros, and a household with sixty thousand euros of French-law capital base and no professional income would apply six and a half per cent to roughly thirty-six thousand euros, subject to the allowance and cap in force for that year. The real bill always depends on the exact ceiling, allowance, cap and household composition for the year, so the illustration never replaces the line-by-line check of the demand against the tax notice, the avis d’impôt, the yearly tax assessment notice.

The courts have examined this levy twice at the highest level in early 2025, and both rulings help British payers understand what can and cannot be challenged. In the first, the Court of Cassation recalled the constitutional reservation in these terms: “la seule absence de plafonnement d’une cotisation dont les modalités de détermination de l’assiette ainsi que le taux sont fixés par voie réglementaire n’est pas, en elle-même, constitutive d’une rupture caractérisée de l’égalité devant les charges publiques. Toutefois, il appartient au pouvoir réglementaire de fixer ce taux et ces modalités de façon à ce que la cotisation n’entraîne pas de rupture caractérisée de l’égalité devant les charges publiques”. The passage comes from Court of Cassation, Second Civil Chamber, 27 February 2025, appeal No. 22-21.800, published in the Bulletin, which rejected the payer’s claim after noting that the Council of State, the Conseil d’État, the supreme administrative court, had already held that the calculation rules did not create a characterised breach of equality before public charges. The same court added a procedural reminder worth quoting because British litigants often raise the wrong challenge in the wrong court: “il n’appartient qu’à la juridiction administrative de porter une appréciation sur la légalité d’un acte administratif.” Only the administrative court may rule on the lawfulness of an administrative act, subject to narrow exceptions, so a challenge to the decree itself belongs before the administrative judge, while the dispute about an individual Urssaf bill belongs before the social security courts. In the second ruling, the court annulled an appeal judgment on a CSM assessment, holding in its operative part: “CASSE ET ANNULE, sauf en ce qu’il déclare l’appel recevable et rectifie l’erreur matérielle affectant le jugement déféré en ce qu’il a retenu au titre du RFR la somme de 25 890,25 euros au lieu de 25 890 093,25 euros”. The reference is Court of Cassation, Second Civil Chamber, 27 February 2025, appeal No. 23-15.218. The lesson for a British payer is concrete: arithmetic errors in the taxable reference income, the revenu fiscal de référence, wrong household composition, double counting of income already excluded, or misidentification of the year examined are all winnable points on the individual bill, while a bare complaint that the levy is unfair in principle will fail.

Three practical checks therefore come before any payment of a surprising bill. First, confirm the year: the levy collected this year relates to last year’s income and last year’s family and pension position, so a household where a pension started in the year examined may already be outside the charge. Second, confirm the base line by line against the tax notice, because British-source dividends, interest, rental income and gains are included through the French-law categories, but professional income, pensions and unrelated items must not inflate the base. Third, confirm the rate, allowance and cap for that exact year, because the 2019 reform capped the levy and the figures move with the ceiling. Where the bill looks wrong, write to the Urssaf at once asking for the detailed calculation, the year examined, the base items and the text applied, and keep the letter. Where the bill looks right, pay within the stated time or seek a payment plan, the échéancier, the agreed schedule for paying in instalments, because surcharges and enforced recovery make a correct bill more expensive when it is ignored.

Former workers keep a safety net worth knowing. Article L161-8 of the Social Security Code maintains cash benefits for persons who stop meeting the activity conditions for affiliation while they continue to meet the residence conditions, for a period fixed by decree, and the official public service page on what PUMA is and who it covers explains the continuity of rights in plain language alongside the Urssaf page for PUMA beneficiaries and the CSM levy. A British employee who resigns in France to retire early does not lose everything overnight, but the maintenance covers defined benefits for a defined period and never replaces the PUMA affiliation file or the CSM analysis for capital income.

B. CPAM refused our healthcare or Urssaf sent a wrong CSM bill: how do we challenge it within the deadline?

Every refusal or bill states a remedy and a time limit, and British applicants lose more files to missed deadlines than to bad law. The distinction to hold onto is between the two defendants. The CPAM decides affiliation, opening of rights, and reimbursement. The Urssaf decides the CSM levy. Each has its own internal appeal board, and the courts behind them differ, so the letter must go to the right body with the right reference number, the numéro de sécurité sociale or the Urssaf account number, and a copy of the contested decision.

Against a CPAM refusal of PUMA affiliation or reimbursement, the first step is the CRA of that fund. Article R142-1 of the Social Security Code provides that “Les réclamations relevant de l’article L. 142-4 formées contre les décisions prises par les organismes de sécurité sociale et de mutualité sociale agricole de salariés ou de non-salariés sont soumises à une commission de recours amiable composée et constituée au sein du conseil, du conseil d’administration ou de l’instance régionale de chaque organisme.” The same article fixes the time limit in a sentence to calendar immediately: “Cette commission doit être saisie dans le délai de deux mois à compter de la notification de la décision contre laquelle les intéressés entendent former une réclamation.” The board must be contacted within two months of notification of the decision challenged. The broader rule behind that step is Article L142-4 of the Social Security Code, under which contentious appeals in the listed matters are preceded by this prior internal appeal under conditions set by decree. A letter sent on the last day of the second month still counts if proof of sending is kept, but a letter sent in the third month is late, and lateness ends the case whatever the merits. The CRA letter should identify the decision by date and reference, state precisely what is asked, opening of rights from a given date or reimbursement of specified bills, and attach the residence bundle in numbered pages: visa or card, proofs of continuous presence, birth certificates, tax notices, and the medical bills with proof of payment where reimbursement is claimed. Ask expressly for a written, reasoned decision, the décision motivée, the decision that states the legal and factual reasons, because an unreasoned refusal is harder to defend and easier to challenge at the next stage.

Where the CRA rejects the claim expressly or by silence, the file moves to the court. Since the 2019 reform, disputes about affiliation and benefits go to the specially designated chamber of the judicial court, the tribunal judiciaire, the ordinary civil and criminal court, sitting in its social protection litigation formation, with appeal to the court of appeal and then, on points of law, to the Court of Cassation. The claim must be filed within the time stated in the CRA decision, with the CRA decision attached, and the judge will examine exactly the two conditions discussed above, lawful stay and stable residence on the relevant date, plus the three-month evidence where applicable. British claimants in Paris and the surrounding region file at the Paris judicial court, whose social chamber handles a heavy volume of affiliation disputes, and should allow for longer waiting times while keeping interim private cover. Readers elsewhere in the Paris region and the Ile-de-France, the administrative region around the capital, deal with the CPAM of their department of residence and the corresponding Urssaf office, but the legal test is national and identical: the fund for Hauts-de-Seine applies the same articles as the fund for Dordogne. Mention Paris and Ile-de-France in correspondence only through the correct fund address and the correct court heading, because a letter sent to the wrong fund loses weeks.

Against a wrong CSM bill, the parallel route runs to the Urssaf’s own internal board first, then to the same social courts for the individual assessment, while any attack on the decree itself belongs to the administrative courts under the separation rule quoted above. The letter to the Urssaf should demand the full calculation sheet and then plead the concrete errors in order: wrong year examined, pension or unemployment income wrongly ignored for exclusion, professional income wrongly stated, capital base inflated by items outside the statutory categories, allowance or cap for the wrong year, or household composition wrongly assessed for a married couple or civil partnership. Attach the tax notice for the year examined, proof of pension start dates, payslips where professional income is disputed, and the family record book, the livret de famille, the official booklet recording marriage and children, where composition is disputed. Never simply refuse to pay without filing the appeal, because enforced recovery continues while the file sleeps. Where the sum is correct but heavy, request a payment schedule in the same letter and pay what is admitted, so the dispute narrows to the contested balance and surcharges stop accumulating on the agreed part.

Conclusion

A British early retiree without an S1 is not left without healthcare in France, but nothing in the file happens automatically. Lawful stay through the correct visa or residence card comes first, because without it PUMA cannot open. Proof of a stable home in France comes second, because the fund examines presence with the three-month rule and accepts proof by any means, and the household that keeps dated evidence from arrival day wins the argument that the unprepared household loses. The CSM levy comes third, because capital income that funds the early retirement also funds the contribution, calculated at six and a half per cent on the base above half the yearly ceiling with allowance and cap, collected a year in arrears, and reviewed line by line against the tax notice before payment. Challenge comes fourth, because CPAM refusals go to the internal appeals board within two months and then to the social courts, while Urssaf bills go through the parallel internal route with concrete arithmetic pleas, and the decree itself belongs to the administrative judge. The two published Court of Cassation rulings of February 2025 confirm that the levy in its capped form survives principled attack but that individual assessments remain fully reviewable for error. Build the bundle early, keep private cover until the social security number arrives, calendar every deadline from notification, and put every request and every reply in writing. The household that does that work turns a frightening refusal letter into an ordinary administrative file. The household that waits for the fund to correct itself watches deadlines expire while hospital bills accumulate.

Need a quick opinion on your case.

Settled in France without an S1 and facing a CPAM refusal or a surprising Urssaf bill for the CSM levy. Our firm offers a telephone consultation within 48 hours with a lawyer of the firm to review your residence documents, your proof of presence, your tax notice and the contested decision. Call +33 6 46 60 58 22 or write to us through our contact page with a copy of your visa or residence card, your last tax notice and the CPAM or Urssaf letter.