Expat insurance and health insurance in the U.S. Virgin Islands

The U.S. Virgin Islands have no universal health insurance fund comparable to French Sécurité sociale. The system combines the US federal programmes (Medicare for those aged 65 and over), the territory's Medicaid, called the Medical Assistance Program and run by the Department of Human Services (DHS), and employer or individual insurance falling under the Division of Banking and Insurance. CMS specifies that residents of the territory cannot use the federal Marketplace. According to the MACPAC commission, Medicaid there operates with an annual federal funding cap and a federal contribution rate permanently set at 83%.

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. The territory has three reference facilities, on Saint Thomas, Saint Croix and Saint John; patients from Saint John needing extensive care are transferred by boat to Saint Thomas (Department of Tourism). See the page healthcare system in the U.S. Virgin Islands.

• 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 nor study and does not constitute a right of entry (France Diplomatie). The territory's Department of Tourism indicates that the entry conditions for non-citizens are the same as for entering the United States from any foreign country.
• 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. A sailboat or private aircraft bound for the U.S. Virgin Islands requires a visa, even with a previously approved ESTA.
• 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 insurance obligation was found in the sources consulted for a visitor; employer insurance, an individual contract, Medicare or the territory's Medicaid apply depending on status.
• Student: Assurance Maladie (French health insurance) recommends an assistance or insurance contract, 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 the U.S. Virgin Islands 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.
• Secondment: form SE 404-02 covers 5 years for an initial secondment of an employee, with no extension, and 2 years for a self-employed worker, with an exceptional derogation possible beyond that (CLEISS). The seconded employee keeps French health insurance and sends their paid invoices with form S 3125c.
• Expatriation: an employee working on site falls under US social security legislation; 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 (amendments of 8 December 2004 and 13 January 2009) 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 the U.S. Virgin Islands. The territory has its own tax administration, the Bureau of Internal Revenue (BIR): according to the IRS (publication 570), bona fide residents generally pay income tax only to the territory, on their worldwide income.

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, study or an arrival by sailboat or private aircraft.
4. Seconded employee: request form SE 404-02 through the employer; self-employed: Urssaf (international mobility department).
5. Long-term settlement: choose local insurance (employer, individual contract, Medicare or the territory's Medicaid depending on the conditions) and, if needed, the CFE before departure or within three months.
6. Taxation: have your situation validated with the French tax administration, the BIR and the IRS, as the tax treaty does not include the Virgin Islands in the definition of the United States.
7. Retiree: arrange the CFE (retiree plan) or private insurance, then look into Medicare from age 65.
8. Register on the roll of French nationals living abroad with the French Consulate General in Miami (free, valid for 5 years, recommended).
9. Before the hurricane season (1 June to 30 November): identify the evacuation plan for your place of residence, subscribe to the alerts of the territorial emergency management agency and follow local authorities' instructions.