Healthcare Reimbursement in Guatemala: Who Reimburses What, Depending on Your Situation

CLEISS publishes sheets for the countries bound to France by a social security agreement: Guatemala does not appear among them. The two countries therefore do not coordinate their schemes: no card giving access to care in both countries, no totalisation of insurance periods, no cross-coverage. ameli.fr (the Assurance Maladie website) reminds readers that a worker expatriated outside the European Union necessarily comes under the scheme of the country of work, which reimburses their medical costs, and that a specific contract, with repatriation insurance, can be useful.

Four players can come into play: the Guatemalan scheme (IGSS for employees, public network), the French scheme kept in place (secondment outside an agreement), the CFE and international health insurance. The notions of reimbursement base and out-of-pocket cost help you compare; the local organisation is described on the page on the healthcare system in Guatemala.

Employee on a local contract. The employer affiliates them to the IGSS, compulsory from three workers; the employee is treated in the institute’s units after four contributions in the last six months, and receives two thirds of their daily wage in the event of incapacity. Their beneficiaries are their wife or female partner and their children under seven. See the notion of a local contract.

Seconded employee. In a country without an agreement, the seconded employee remains affiliated to the French scheme for three years, renewable once. They are covered up to the benefits they would have received for the same care in France: they send their fund the paid invoices with form S 3125c, their dependants who accompany them follow the same procedure and those who stayed in France turn to the affiliation fund. A sick-leave certificate must be declared within 48 hours. See seconded worker.

Self-employed. They take out the CFE, which covers sickness-maternity for a self-employed person, or international insurance. Voluntary IGSS affiliation requires having already been affiliated and does not include medical care.

Retiree. The S1 form, reserved for residents of the European Union, the EEA, Switzerland and the United Kingdom, does not apply. The retiree chooses between the CFE and international insurance. During a temporary stay in France, they are reimbursed for their care if they draw a pension from a basic scheme based on at least 15 years of insurance and have no activity; the spouse who accompanies them is not covered (CLEISS).

Student. In the absence of an agreement, CLEISS indicates that, for a stay of under six months, the French fund may reimburse unforeseen care on a flat-rate basis, on an optional basis and after the costs have been advanced. Beyond six months, a student over 20 is no longer covered by French health insurance and takes out cover locally, with the CFE or a private insurer. See student insurance abroad.

Spouse and children. They are IGSS beneficiaries (wife and children under 7) if the holder is an affiliated employee, remain under the French scheme if they accompany a seconded worker, or have their own contract. See expat family insurance.

Tourist (under three months). No visa is required, but France Diplomatie considers essential a contract covering care, hospitalisation and repatriation, since the embassy does not cover these costs.

The CFE offers its main offer (aged 30 and over), its youth offer (under 30) and a retiree offer, each with a contribution that depends on age and the plan chosen, with no health questionnaire. Cover is immediate if you join before departure or within three months of settling; otherwise the waiting period is three months before age 44 and six months beyond age 45. Abroad, reimbursement depends on the country of care and the procedure, with a rate or a flat amount applied to the actual expense; maternity requires conception after joining. See CFE contributions.

First-euro insurance reimburses actual costs within the contract’s ceilings, with direct payment to the establishment possible, which avoids the payment guarantee required by private clinics; excesses, waiting periods and exclusions determine the out-of-pocket cost. See first euro.

Return to France. A CFE member with no activity in France keeps their rights for up to three months after returning and affiliates to the CPAM (the local health insurance office) of their place of residence with form S1106; an employee taking up a contract in France has rights from the start. With no agreement with Guatemala, the lifting of the waiting period does not rely on an agreement and is confirmed with the CPAM. See return-to-France insurance.

• Consultation: outpatient consultation in the IGSS units for a member; payable by the patient in the private sector unless covered by a contract; according to the CFE’s country scale.
• Hospitalisation: IGSS network for a member; French scheme for the seconded worker within the limit of French benefits; in the private sector, a payment guarantee is required before treatment, hence the value of direct payment.
• Medicines: according to the list and availability of the local scheme; reimbursed according to the CFE’s scales or the ceilings of an international contract.
• Dental: the extent of IGSS cover is checked with the institute; the CFE and international contracts apply their own ceilings.
• Optical: mainly a matter for international contracts, with ceilings per period to be read in the benefits table; the IGSS provides orthopaedic devices and prostheses on medical indication.
• Maternity: covered by the IGSS sickness, maternity and accident programme for female members; the CFE requires conception after joining; international contracts generally apply a waiting period.

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