Healthcare Reimbursement in French Guiana: Who Reimburses What Depending on Your Situation

Title V of Book VII of the Social Security Code applies in French Guiana (article L751-1), and article L752-1 provides for a general social security fund and a family allowance fund in French Guiana. CLEISS (the French centre for European and international social security liaison) specifies that, in the overseas departments, benefits are paid by the CGSS and not by the CPAM (primary health insurance funds). No international coordination formality is therefore needed for a stay on French territory alone.

Reimbursement rests on three tiers: the general scheme reimburses on the basis of its rates; the ticket modérateur and excess fees fall to supplementary health insurance; the complémentaire santé solidaire, free or payable depending on income, covers modest incomes. The out-of-pocket cost therefore depends as much on the supplementary insurance as on the compulsory scheme. How the healthcare offering is organised is described in the guide health system in French Guiana.

The employee no longer has to prove a minimum activity: carrying on a professional activity is enough to open their rights (ameli). They benefit from reimbursement of care at the general scheme rates, daily allowances in the event of sick leave (3-day waiting period, 50% of the capped basic daily salary, 360 days at most over 3 years) and maternity-related benefits. Supplementary health insurance, group or individual, covers the ticket modérateur and excess fees.

The employee transferred by their employer from the mainland stays on the general scheme; secondment abroad and its forms do not apply to a French territory. They notify their home fund of their change of address and check with the CGSS of French Guiana that their rights have been opened.

The State civil servant comes under the civil servants' compulsory scheme. The sources read do not specify the competent managing body for an employee assigned to French Guiana; it is to be confirmed with their managing department and the CGSS before arrival, as are the file transfer formalities.

The self-employed person is covered from the start of their activity (ameli). Contribution terms specific to the territory are to be confirmed with the CGSS; reimbursement follows the general scheme rates.

The retiree is covered on the basis of stable and lawful residence in France, with proof of 6 months of residence over the last 12 months in the event of a check; they send form Cerfa S1106 to the fund of their place of residence. Beneficiaries of the solidarity allowance for older people or the Old-Age Solidarity Fund allowance benefit from higher rates: 80% for medical, dental and paramedical fees, optical care and appliances, and 100% for transport (Assurance Maladie, the French national health insurance). The basic pension is managed by the CGSS of French Guiana; the guide retiring in French Guiana details the procedures.

The person with no activity is insured in their own right from the age of majority, or from 16 on request (ameli). CLEISS mentions stable and lawful residence for at least 3 months: the CGSS specifies the applicable rule.

The adult student is insured in their own right from the age of majority, or from 16 on request (ameli). The conditions for attachment to a fund when studying in French Guiana, on the mainland or abroad are to be confirmed with the CGSS. For studies abroad, the page student insurance abroad presents cover solutions.

The spouse and adult dependants keep their rights and can ask to be affiliated in their own right on a residence criterion using form S1110 (ameli). Minor children are covered as dependants; the household's Vitale card covers the spouse and children under 25 living under the same roof (CGSS of French Guiana).

The complémentaire santé solidaire is Assurance Maladie aid for people on modest incomes; in French Guiana, the application is filed with the CGSS, one per household. The public service publishes annual income ceilings, revised every year, for a single person in the overseas departments (French Guiana included), one for free cover, the other for the payable option. Income over the 12 months before the application is taken into account. CLEISS reminds that the "100% santé" scheme covers optical care, dental care and hearing aids.

The Caisse des Français de l'Étranger is for French people who live and work abroad (main plan, youth plan and retiree plan, each with a contribution that depends on age and the plan chosen, according to its website). As long as a French citizen lives in French Guiana, they come under the general scheme; membership only becomes useful if they leave France, for example to settle in Suriname or Brazil. The CFE guide details the scales and waiting periods.

Private first-euro insurance is not needed for basic reimbursement, but it can fund excess fees and complement evacuation and assistance. As health prices are 16.5% higher than on the mainland according to the Insee survey (via the IEDOM), it is worth comparing guarantee ceilings.

The French resident of the mainland on a short stay keeps their home fund: French Guiana comes under the same social security legislation. The sources read describe no practical rule specific to insured persons of another fund passing through (use of the Vitale card, third-party payment): it is wise to ask your fund before departure. The medical evacuation pathway described by the CGSS of French Guiana is aimed at patients affiliated to that fund. For a visitor insured in another EU state, CLEISS indicates that the European Health Insurance Card can be used in the overseas territories known as outermost regions; the situation is confirmed with the fund of affiliation and the CGSS.

A trip to Suriname or Brazil is a stay abroad. Outside the EU, EEA, Switzerland and the United Kingdom, only urgent and unforeseen care may possibly be covered on your return: you pay the costs on the spot, keep prescriptions and paid invoices, and file the application from your ameli account or with form S3125. The medical adviser assesses the urgency, reimbursement is on French flat-rate tariffs, a refusal decision cannot be contested and no daily allowance is paid during the stay (ameli). See the country pages Suriname and Brazil and the page repatriation and assistance.

Returning to the mainland means informing the CGSS of French Guiana and having your rights opened or updated with the fund of the new place of residence; the change of address is declared from your ameli account or on 3646. The sources read detail neither the deadlines nor the change of fund: they are to be confirmed with the CGSS. See also the page insurance on return to France.

• Consultation: 70% of the base for doctors' fees within the care pathway; a €2 flat-rate contribution remains payable by the insured person. The flat fee in emergency departments without hospital admission is €23.
• Hospital stay: 80% in principle, with a daily hospital charge of €23; 100% in some cases, such as long-term conditions. Transfer between hospitals is covered at 65% and transport at 55%, under conditions (Assurance Maladie).
• Medicines: 65% for major or important medical benefit, 30% for moderate benefit, 15% for low benefit, with a €1 deductible per box. Preventive malaria treatment is covered for social security members in French Guiana (ARS French Guiana).
• Dental and optical: 60% for dental surgeons, optical care and prostheses; the "100% santé" scheme covers optical care, dental care and hearing aids (CLEISS).
• Maternity: the pregnancy must be declared before the end of the 3rd month and compulsory examinations are covered at 100%; maternity leave ranges from 16 weeks for a first child to 46 weeks for triplets or more, and paternity leave lasts 25 days (CLEISS).
• Medical evacuation and health travel: transport on prior approval serving as a medical prescription; accompanying person's costs under conditions; for scheduled care on the mainland or in the French Antilles, 45% ticket modérateur unless exempt, the cheapest ticket compatible with the state of health, and any supplement for changing the return date payable by the insured person unless a medical reason is certified (CGSS of French Guiana).