Expat insurance and health insurance in Guam

Guam has no universal health insurance fund comparable to French Sécurité sociale. The system combines the US federal programmes (Medicare for those aged 65 and over, Medicaid for low-income households), Guam's Medicaid administered by the Department of Public Health and Social Services (DPHSS), and employer or individual insurance, which is supervised by the Guam Department of Insurance, attached to the Department of Revenue and Taxation. CMS specifies that Guam residents cannot use the federal Marketplace. According to the MACPAC commission, the federal contribution rate for Guam's Medicaid is permanently set at 83%, and Guam extended its Medicaid to low-income adults on 1 January 2014 (Medicaid.gov).

France Diplomatie describes for the United States an excellent medical infrastructure but at a very high cost, and recommends as essential an assistance contract or insurance covering all medical costs, including surgery and hospitalisation, as well as medical repatriation: these costs can under no circumstances be covered by the embassy. Guam Memorial Hospital, in Tamuning, describes itself as the island's only public hospital. See the page healthcare system in Guam.

• Stay of 90 days or less: ESTA authorisation, to be requested at least 72 hours before departure, valid for 2 years, with an electronic or biometric passport. It allows neither professional activity, paid or unpaid, nor study, and does not constitute a right of entry (France Diplomatie, United States section). The France Diplomatie page does not mention Guam: before booking, confirm the applicable procedure with US Customs and Border Protection (CBP).
• Guam and Northern Mariana Islands visa waiver programme: admission for 45 days at most, limited to Guam or the Mariana Islands, with form I-736 (DHS). This programme is separate from the ESTA programme and its eligible nationalities are set by federal regulation (8 CFR 212.1): France is not on the list read.
• Stay of more than 90 days, work, internship or study: visa, with a medical examination for long-stay visas. Overstaying the authorised period leads to removal and, generally, an entry ban of several years (France Diplomatie).
• Travel insurance: an assistance contract or insurance covering all medical costs and medical repatriation is deemed essential by France Diplomatie; admission to hospital is subject to a financial guarantee.
• Local affiliation: no general health insurance obligation for a visitor was found in the sources consulted; employer insurance, an individual contract, Medicare or Guam's Medicaid apply depending on status.
• Student: no EHIC (outside the European Union); Assurance Maladie (French health insurance) recommends an assistance contract or insurance, notably for the United States, and CFE membership remains possible. See student insurance abroad.
• Seconded employee : continuation of the French scheme under conditions, form SE 404-02 for 5 years with no extension (CLEISS); the CFE and an assistance contract remain recommended in addition.
• Retiree: the 1987 agreement contains no provision allowing reimbursement of care received in the United States under a French pension; the CFE or private insurance takes over (CLEISS).

No individual fine for lacking insurance is mentioned in the sources consulted, but the high cost of care and the financial guarantee required at admission make the financial risk significant for an uninsured expat.

Coordination between France and Guam runs through the France-US social security agreement, signed on 2 March 1987 (administrative arrangement of 21 October 1987) and entered into force on 1 July 1988. According to CLEISS, its territorial scope includes, on the US side, the federated states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam and American Samoa. It coordinates disability, old age and survivors' benefits.

• Sickness and maternity: no coordination provision; no S1 form, no EHIC. Planned care remains at the person's own expense unless their fund exceptionally authorises it; during a temporary stay, only urgent and unforeseen care can possibly be reimbursed on return (Assurance Maladie).
• Secondment: form SE 404-02 covers 5 years for an initial secondment, with no extension (CLEISS summary table). The seconded employee keeps French health insurance and sends their paid invoices with form S 3125c.
• Expatriation: an employee working on site is in principle subject to the legislation of the country of work; their dependants who stayed in France should enquire with their CPAM and their CAF.
• Retiree: health contribution of 3.2% (basic pension) and 4.2% (supplementary pension) that can be withheld as long as they remain attached to a French scheme; no CSG, CRDS or Casa if tax residence is no longer in France (CLEISS).

Tax treaty. The consolidated text of the treaty of 31 August 1994 defines, in its article 3, the term "United States" as the United States of America, without Puerto Rico, the Virgin Islands, Guam or any other territory or possession. The residence and tax-allocation rules provided for the United States therefore cannot be taken for granted in Guam. The IRS specifies that Guam has its own tax system, based on the same laws and rates as those of the United States, that bona fide residents of Guam file their return with Guam on their worldwide income, and that a mutual agreement procedure exists between the United States and Guam for cases of double taxation (publication 570).

1. Before departure: notify French agencies of your departure (health insurance fund, CAF, France Travail, pension funds); hand back your carte Vitale and EHIC if you are expatriating.
2. For any stay, including a short one: take out an assistance contract or insurance covering all medical costs and medical repatriation, essential according to France Diplomatie.
3. Apply for ESTA at least 72 hours before departure with an electronic or biometric passport, or for a visa for a stay of more than 90 days, an activity or study; confirm the procedure applicable to Guam with CBP.
4. Check the France Diplomatie alert and the notices from Guam Homeland Security (GHS/OCD) before departure, especially during typhoon season.
5. Seconded employee: request form SE 404-02 through the employer; self-employed: Urssaf (international mobility department).
6. Long-term settlement: choose local insurance (employer, individual contract, Guam Medicaid or Medicare depending on the conditions) and, if needed, the CFE before departure or within three months.
7. Taxation: have your situation validated with the French tax administration, the Guam Department of Revenue and Taxation and the IRS, as the tax treaty does not include Guam in the definition of the United States.
8. Retiree: arrange the CFE (retiree plan) or private insurance, then look into Medicare from age 65.
9. Register on the roll of French nationals living abroad with the French Consulate General in San Francisco, whose district includes Guam (free, valid for 5 years).