Healthcare Reimbursement in Guadeloupe: Who Reimburses What Depending on Your Situation

Guadeloupe is an overseas department and region where laws and regulations apply as of right (Article 73 of the Constitution). Title V of Book VII of the Social Security Code specifies that its provisions apply to Guadeloupe for all beneficiaries of general social security legislation (Article L751-1). CLEISS indicates that, in the overseas departments, benefits are paid by the CGSS and not by the CPAM, and that the stable and lawful residence condition expressly refers to Guadeloupe. No international coordination formality is therefore needed for a stay within French territory alone.

Reimbursement rests on three tiers: the general scheme reimburses on the basis of its rates; the co-payment (ticket modérateur), the hospital daily charge and extra-billing fall to supplementary health cover; the Complémentaire Santé Solidaire, free or paid depending on income, covers modest incomes. The out-of-pocket cost therefore depends as much on the supplementary cover as on the compulsory scheme. How care is organised is described in the guide healthcare system in Guadeloupe.

The local employee does not have to show a minimum period of activity: carrying out a professional activity is enough to open their rights (Assurance Maladie). They benefit from reimbursement of care at the general scheme rates, from daily allowances in case of sick leave and from benefits linked to maternity and work accidents, according to national rules. Contributions are collected locally: the CGSS carry out the collection mission in the overseas departments (CGSS of Guadeloupe).

The employee sent by their mainland employer works in France: they come under the general scheme from the start of their activity, with no secondment or international coordination form, since Guadeloupe is part of the national territory and the question of a social security agreement does not arise. The public service only reminds you to report the change of address to your fund and your employer.

The State civil servant transferred to Guadeloupe keeps their status; the public service specifies that a public employee may depend on a specific health cover body. The sources consulted do not name this body for Guadeloupe: it should be confirmed with your administration and the CGSS at the time of the transfer.

The self-employed person is covered from the start of their activity (Assurance Maladie). Reimbursement follows the general scheme rates; contribution terms and entitlement to daily allowances should be confirmed with the CGSS and the Urssaf (the social security contributions collection body; Urssaf appointments on 39 57, according to the CGSS of Guadeloupe).

The retiree is covered on the basis of their stable and lawful residence in France: CLEISS cites residence of at least 3 months for a person with no occupation, and the Assurance Maladie indicates that, in case of inspection, you must be able to show 6 months of residence over the last 12 months. They send Cerfa form S1106 to the CGSS if their rights do not open automatically. Beneficiaries of the FSV or of the solidarity allowance for the elderly benefit from higher rates: 80% for medical fees, dental and optical, and 100% for transport (Assurance Maladie table). The guide retiring in Guadeloupe details pensions and taxation.

The person with no occupation comes under the same residence criterion. CLEISS specifies that the opening of rights is not automatic where there is no occupation, cover based solely on residence, or arrival in France: form S1106 must then be filled in and sent to the body of the place of residence.

The student: according to the public service, they do not change scheme on first enrolment in higher education and generally remain on their parents’ scheme; they become an independent insured person at 18, and can ask to be insured in their own right from age 16. They can supplement their reimbursements with a student mutual insurer, their parents’ or another body, and apply for the Complémentaire Santé Solidaire if their resources are low. A student who is a national of the European Economic Area or Switzerland remains affiliated to the scheme of their country of origin and can apply for a European Health Insurance Card; a student of another nationality is covered by universal health coverage (PUMa) and registers on the etudiant-etranger.ameli.fr website. For studies abroad from Guadeloupe, the page student insurance abroad presents the solutions.

The spouse keeps their own rights if they are insured in their own right, on an activity or residence criterion. Minor children can be dependants; this status ends at the latest on 30 September of the year they turn 18, and a minor can be insured in their own right from age 16; the Vitale card can be issued from age 12 at the parents’ request (CLEISS).

The mainland resident on a short stay keeps their home fund and the same scheme: Guadeloupe comes under the same social security legislation as mainland France. The sources consulted do not describe a practical rule specific to people insured with another fund who are passing through (Vitale card, third-party payment): it is prudent to ask your fund before departure and to plan for assistance for evacuations. CLEISS also notes that the European coordination regulations apply in Guadeloupe, an outermost region; for a foreign visitor, cover depends on their own scheme, to be confirmed with their fund and the CGSS.

A trip outside France from Guadeloupe: in Europe, an insured person of the French scheme living in Guadeloupe can obtain a European Health Insurance Card from the CGSS, to be requested at least 15 days before departure; it covers only care that becomes necessary during the stay. Outside Europe, only urgent and unforeseen medical care can possibly be reimbursed on return, after payment on the spot, with form S3125 or from the ameli account, on the basis of flat-rate French tariffs and with no daily allowances; the medical adviser assesses urgency and a refusal cannot be contested. The Assurance Maladie recommends an assistance or insurance policy, notably for countries where costs are very high. See the page on repatriation and assistance.

Returning to mainland France means informing the CGSS and requesting the opening of rights with the fund of the new place of residence: CLEISS specifies that this opening is not automatic on a significant change of situation and that Cerfa form S1106 must then be filled in. No waiting period is mentioned in the sources consulted for this change of residence within the national territory.

The Caisse des Français de l’Étranger covers French people living abroad, with a main offer, a youth offer and a retiree offer. As long as a French citizen lives in Guadeloupe, they come under the general scheme; membership only becomes useful if they leave France. The CFE guide details the scales and waiting periods.

The Complémentaire Santé Solidaire is free or paid depending on income. For Guadeloupe, French Guiana, Martinique and Réunion, the public service publishes annual ceilings higher than those of mainland France: for a single person, €11,599 for free cover and €11,599 to €15,659 with a contribution; for two people, €17,398 and €17,398 to €23,488; for three, €20,878 and €20,878 to €28,185. It covers the supplementary share within the limit of social security tariffs, removes extra-billing, the hospital daily charge, the deductible and the flat-rate contribution, and opens third-party payment if the care pathway is followed. The fund’s decision comes at the latest 2 months after the application; with no reply, the application is deemed accepted. The procedure is done via the ameli account or with Cerfa form no. 12504.

First-euro private insurance is not needed for basic reimbursement, but supplementary cover funds the co-payment, the hospital daily charge and extra-billing, and an assistance policy covers travel outside France and evacuations that exceed the compulsory scheme.

• Consultation: sector 1 general practitioner at €36, reimbursed 70% i.e. €23.20 after the €2 flat-rate contribution; outside the pathway, €12.60; sector 1 specialist at €31.80, reimbursed €20.26 within the pathway (Assurance Maladie). Surcharges and extra-billing are not included in these examples.
• Hospitalisation: 80% in a public hospital or approved clinic; the remainder (20% co-payment, hospital daily charge of €23 a day or €17 in psychiatry, comfort supplements, extra-billing) is borne by the insured person. Reimbursement rises to 100% in certain cases: a procedure with coefficient 60 or more (or a tariff of €120 or more), a stay of more than 30 consecutive days from the 31st day, a long-term condition, a work accident or occupational illness. The hospital daily charge is not due notably for pregnant women during the last 4 months of pregnancy, for delivery and in the 12 days that follow, and for recipients of the Complémentaire Santé Solidaire.
• Medicines: 65% for major or important medical benefit, 30% for moderate benefit, 15% for low benefit, 100% for irreplaceable and particularly expensive medicines; €1 deductible per box.
• Dental: 60% of the base tariff for the dental surgeon; the “100% Santé” offer reimburses with no out-of-pocket cost certain crowns, certain bridges and removable resin prostheses, with a so-called responsible supplementary cover contract, the dentist having to provide a quote.
• Optical: 60% for prescription glasses; the “100% Santé” offer with no out-of-pocket cost covers class A lenses and frames at €30 at most; renewal every 2 years from age 16, except in special cases.
• Maternity: the compulsory examinations of pregnancy follow-up are covered at 100% from the declaration of pregnancy, to be made before the end of the 3rd month; from the first day of the 6th month to the 12th day after delivery, all reimbursable costs are reimbursed at 100%. The first two ultrasounds are reimbursed at 70%, the third at 100%. A preventive oral examination is free from the 4th month to 6 months after delivery.
• Health-related travel: transport subject to prior approval equivalent to a medical prescription; companion’s costs under conditions; the transport reimbursement rate is 55% under the general scheme (Assurance Maladie).