Healthcare Reimbursement in the Cook Islands: Who Reimburses What Depending on Your Situation

CLEISS publishes the list of countries linked to France by a bilateral social security agreement: the Cook Islands are not on it, any more than New Zealand. There is therefore no coordination of schemes, no S1 form, no EHIC and no cross-border cover (see the bilateral agreement). France Diplomatie (the French foreign ministry) adds that the embassy covers no medical costs and that an assistance contract covering all costs, including medical repatriation, is essential, failing which access to care may be refused, even in a life-threatening emergency.

On the local side, the Ministry of Health (Te Marae Ora) applies a two-category fee schedule. Category I includes in particular expatriate workers who have lived and paid tax for more than six months, permanent residents and spouses of an islander or permanent resident after six months; category II covers visitors and anyone else. The notions of reimbursement basis and out-of-pocket cost help compare plans. How the system is organised is described in the page healthcare system in the Cook Islands.

The local-contract employee comes under the host country’s social security scheme and is no longer socially insured in France; they hand back their carte Vitale, no longer receive French family benefits and do not see their local periods of activity taken into account for the rate of their French pension (CLEISS). They can contribute voluntarily to the CFE for sickness, maternity and disability. Locally, the fee schedule classes them in category I after six months of residence and tax, on proof of permanent employment with a valid permit; before six months, they come under category II and do not fall within the patient referral policy.

The seconded employee remains affiliated to the French scheme, with contributions paid in France as if they were working there, for 3 years renewable once; they are covered up to the benefits they would have received in France and send their paid invoices with form S 3125c. Any local contributions remain due, accompanying dependants come under the same procedure and those who stayed in France continue to deal with the fund. If care is expensive, top-up health insurance can be taken out (CLEISS; see seconded employee).

The self-employed person benefits from no coordination: they choose between the CFE, a private contract and international insurance. The care schedule describes permanent employment with a permit; the category applicable to a self-employed person should be confirmed with the Ministry of Health’s planning and funding unit.

The retiree receives no certificate before departure. CLEISS indicates that it is for them to check with the host country’s institutions to what extent the local scheme covers their care, and that they can join the CFE voluntarily or take out private insurance. The CFE retirees’ plan is for holders of a pension from the French basic scheme, with no health questionnaire; it covers care received abroad, care in France remaining covered by the compulsory French scheme. Retirees of the general scheme outside the European Union, the European Economic Area and Switzerland come under the CNAREFE for their affiliation and payments. See the guide health insurance for retirees abroad.

The student under 20 or on a stay of less than six months can have their parents’ fund reimburse urgent care on the basis of French flat-rate tariffs, if they attend an institution preparing for an official qualification and return to France at least once in the academic year; beyond 20 years or six months, they must in principle join the host country’s student scheme, or failing that the local general scheme, and Assurance Maladie (French health insurance) suggests a private contract or the CFE (ameli). The local schedule has no category specific to students: category II covers anyone who does not fall under category I, to be confirmed with Te Marae Ora. See student insurance abroad.

The spouse of an expatriate worker who has been resident for more than six months comes under category I of the schedule, like the children; so does the spouse of an islander or permanent resident married for more than six months. On the French side, cover follows the status of the main insured person; see expat family insurance.

The CFE has a youth plan, a main plan and a retirees’ plan, with contributions that depend on age and the plan chosen, according to cfe.fr, the real price depending on the country of residence, age and family situation. Cover is immediate if membership takes place before departure or within three months of settling abroad; beyond that, a waiting period of three or six months, depending on age, applies. Members send their reimbursement claims for care received in France to the Seine-et-Marne primary health insurance fund (CLEISS). In the Cook Islands, the member pays up front according to the category of the local schedule, then is reimbursed according to the terms of their contract.

First-euro insurance from an international insurer reimburses actual costs within the contract ceilings: it is compared on the coverage zone, ceilings, pre-existing medical conditions and above all evacuation, a patient without New Zealand citizenship bearing alone all care costs in New Zealand (Te Marae Ora). See the page health insurance in the Cook Islands.

Outside Europe, for a temporary stay, only urgent and unforeseen medical care can possibly be covered by French health insurance on return. The visitor pays on site and keeps prescriptions, paid invoices and proof of payment; they request reimbursement from their ameli account or with form S3125. A medical adviser judges whether it was an emergency: if approved, reimbursement is made at French flat-rate tariffs, not actual costs, and if refused, no appeal is possible. No daily allowance is paid for a stay outside Europe.

On site, the visitor comes under category II: they pay the full rate at the time of care, for example 40 New Zealand dollars (about €20) for an adult consultation aged 16 to 59 at Rarotonga hospital, and present proof of health insurance at registration. The patient referral policy excludes visitors: travel insurance covering assistance and repatriation is therefore the only safety net, which France Diplomatie deems essential. The conversions on this page are based on the ECB reference rate.

According to service-public.gouv.fr, for a return from a country outside the European Union, French health insurance lapses in principle during expatriation, unless voluntarily maintained. A former CFE member can keep certain benefits for the three months following their return, under conditions. An employee who immediately goes back to work is affiliated from the first hour worked (form S1106 to the primary health insurance fund); with no immediate activity, three consecutive months of residence in France are required before rights to universal health protection open. See the page return to France.

Consultation. At Rarotonga hospital, the schedule gives, for an adult aged 16 to 59, 5 New Zealand dollars in category I and 40 dollars in category II (20 dollars for a child or a person aged 60 and over in category II); a visiting specialist costs 50 dollars in category II, excluding procedures. Hospital stay. A day in a general ward is priced at 100 dollars (about €51) in category II, a day in high dependency care at 1,000 dollars (about €506); category II surgical procedures are classed in six bands from 500 to 3,500 dollars, with surgeon and anaesthetist fees per procedure.

Medicines. No public medicine prices were read in the official sources: the amount should be requested from the Ministry of Health, and the CFE or private insurance reimburses according to the contract. Dental. Public care follows its own schedule (examination at 10 dollars in category I and 25 in category II, extraction of one or two teeth at 30 and 70); dental care is covered by contract (CFE or private insurance), the French scheme examining abroad only the urgent and the unforeseen. Optical. No public optical prices were read in the official sources: the item is covered by contract and should be anticipated before departure. Maternity. Antenatal visits are free for both categories; delivery with hospital stay is free in category I (excluding the child’s health book at 30 dollars) and costs 500 dollars (about €253) in category II. These amounts come from the ministry schedule; later amendments exist and should be confirmed with the ministry.