Healthcare Reimbursement in South Africa: Who Reimburses What Depending on Your Situation

The French embassy in South Africa reminds us: the French state does not pay healthcare costs in case of hospitalisation, care or medical repatriation abroad. There is no bilateral social security agreement between France and South Africa: CLEISS does not list it among France’s agreements. There is therefore no coordination between schemes: no European card, no totalisation of periods, no cross-coverage.

Four players may step in depending on status: the South African medical scheme, the French scheme kept in place (secondment), the CFE and international health insurance. The right cover is chosen before departure, according to the visa, the employer and the budget. The notions of reimbursement base and out-of-pocket cost help compare offers. How the care networks work is described on the page healthcare in South Africa.

The local-contract employee comes under the South African system. UIF unemployment insurance, funded by 1% of salary and 1% from the employer, does not cover health. Health cover depends on the contract: some medical schemes are restricted to an employer, a sector or an administration, others are open to all (Council for Medical Schemes). Failing that, the employee turns to the public sector or chooses an open scheme. For their work visa, the Department of Home Affairs (DHA) asks for a medical report, not membership of a scheme. See the glossary entry on the local contract.

The seconded employee of a French employer stays enrolled in the compulsory French scheme, with contributions paid in France, for 3 years renewable once; the host country may also require its own contributions. They send their paid invoices to their fund with form S 3125c “care received abroad”; cover corresponds to equivalent benefits in France, and supplementary insurance is recommended when local costs are high. Accompanying dependants have the same rights (CLEISS). See seconded or expat and the glossary entry on the seconded worker.

The self-employed person or digital nomad has no employer to enrol them. The Remote Work Visa list of documents mentions no medical insurance, but cover for hospitalisation, outpatient care and evacuation remains the most complete solution. Three routes exist: an open medical scheme, the CFE or international insurance; see digital nomad insurance and the guide to digital nomad visas.

The student holding a study visa, like the participant in an exchange programme, presents to the DHA proof of cover with a medical scheme registered under South African law: standard travel insurance does not replace this requirement. Under 30, the CFE offers its youth plan from €57 a month, to compare with the options of a scheme. See student insurance abroad.

The retiree does not fall under the S1 form, valid in the European Union: South Africa is not among the countries with an agreement. CLEISS indicates three routes in a country with no agreement: voluntary CFE membership, the local scheme and private insurance. The retired person visa requires proof of medical cover (DHA), and the CFE retirees’ plan starts at €147 a month depending on the country, age and household composition. During temporary stays in France, they are covered if their pension is based on at least 15 years of insurance in France; their spouse takes out insurance before travelling. See retiree health insurance abroad and the page on retiring in South Africa.

The spouse and children follow the holder’s visa: the DHA provides that the spouse and dependent children of a retiree receive an appropriate visa. A medical scheme covers the beneficiaries registered on the contract, the CFE like international insurers offer family contracts, with maternity and paediatrics depending on the contract. See expat family insurance and the guide to children’s health cover abroad.

The CFE is a voluntary social protection body. In France, it reimburses with direct billing in public and private hospitals; abroad, it reimburses according to the country of care, through rates or flat amounts applied to actual expenses. When the South African price exceeds the base used, the difference remains at the member’s expense: the guide to CFE reimbursements details this mechanism.

• Plans: the main plan (age 30 and over) from €87 a month, the youth plan (under 30) from €57 a month, the retirees’ plan from €147 a month. They cover GP consultations, medicines, tests, hospitalisation, maternity, dental care, emergency transport and vaccines.
• Waiting period: immediate cover if enrolment takes place before departure or within three months of moving abroad; beyond that, a three-month wait before age 45 and six months from age 45.
• Maternity: conception must come after enrolment.

On returning to France, the CFE indicates that there is no waiting period. Regaining rights with the Assurance Maladie (the French national health insurance) requires working in France or living there in a stable and regular way for more than three months; a CFE member benefits from free continuation of rights for the first three months (Assurance Maladie). See the guide to reducing the waiting period and the page on returning to France.

International health insurance at the first euro reimburses actual costs within its ceilings, after any deductible, waiting periods and exclusions of the contract. It gives access to private establishments with direct billing when the contract provides for it. Contracts are compared on the annual ceiling, the coverage zone, evacuation and the handling of prior medical history; see the guide to the coverage zone and the page on the medical questionnaire and prior medical history.

The French tourist stays 90 days at most without a visa (DIRCO). The French embassy recommends taking out assistance insurance covering medical costs and medical repatriation before the trip; bank cards often offer this protection for stays of less than 90 days, depending on the contract conditions, with ceilings to check. See long-stay travel insurance.

• Consultation: at a private practice, the medical scheme reimburses according to the option chosen, sometimes with a patient co-payment outside the scheme’s provider network; reimbursed by the CFE on its country scale; actual costs for a first-euro contract.
• Hospitalisation: the prescribed minimum benefits (PMB) cover emergencies and 271 conditions; French scheme for the seconded employee; CFE with direct billing in France; international contract with direct billing.
• Medicines: the single exit price regulates the price in the private sector; for chronic diseases listed under PMB, the medical scheme covers medicines, consultations and tests linked to the condition; reimbursed according to CFE scales or the ceilings of an international contract.
• Dental: included at the CFE according to its scales and in most international contracts, with an annual ceiling; medical schemes include dental care in their routine benefits depending on the option.
• Optical: glasses and lenses fall mostly under international contracts and scheme options, with limits per period; to be read carefully in the guide to benefits.
• Maternity: the CFE requires conception after enrolment; a medical scheme applies waiting periods of 3 months for the general wait and 12 months for a pre-existing condition, except PMBs; international contracts generally apply a waiting period to maternity.

The reimbursement guide and the page on expat health insurance give benchmarks; Expavy helps you weigh these options against your situation.