Healthcare Reimbursement in the U.S. Virgin Islands: Who Reimburses What, Depending on Your Situation

The social security agreement between France and the United States, signed on 2 March 1987 and in force since 1 July 1988, includes the Virgin Islands in its territorial scope. It coordinates disability, old age and survivors. For sickness and maternity, CLEISS specifies that the agreement contains no coordination provision: no S1 form, no European card, no cross-cover (see the bilateral agreement). France Diplomatie (the French foreign ministry) reminds us that the embassy pays no medical costs and that admission to hospital is subject to a financial guarantee.

Several players can therefore step in depending on status: employer insurance or a local individual contract, the French scheme maintained for a seconded employee, the CFE and international health insurance. Medicare and the territory’s Medicaid are added for eligible residents: their conditions are detailed in the page healthcare system in the U.S. Virgin Islands. The notions of reimbursement basis and out-of-pocket cost help to compare offers.

The local-contract employee is subject to US social security legislation as soon as they carry out a professional activity on site, outside secondment. They leave the French scheme for sickness: CLEISS specifies that their dependants who stayed in France have no entitlement to sickness and maternity benefits on the basis of their activity in the United States and should enquire with their CPAM and their CAF about their rights under French law alone. Their care generally goes through the employer’s insurance; declaring the departure to the health insurance fund, the CAF and France Travail avoids having to repay benefits paid in error. See the glossary entry on the local contract.

The seconded employee sent by a French employer can remain on the French scheme under certain conditions, thanks to the 1987 agreement. CLEISS indicates that they keep French health insurance with no additional contribution: they send their paid invoices to their fund with form S 3125c, their dependants who accompany them follow the same procedure, those who stay in France continue to deal with the fund they are affiliated to, and daily allowances are paid by that fund. As costs in the United States can exceed those in France, CLEISS advises checking the top-up health insurance; employers often add an international group contract. See seconded or expatriate and the glossary entry on the seconded employee.

The self-employed person or digital nomad has no employer to affiliate them to a local scheme. A self-employed worker seconded from France receives benefits from the French scheme, but CLEISS reminds us that the agreement provides no coordination for sickness. They choose between an individual contract, the CFE and international insurance; cover for hospitalisation, outpatient care and medical repatriation suits a stay of several years. See digital nomad insurance.

The student depends on the host country. According to Assurance Maladie (French health insurance), a student under 20 or staying less than 6 months pays their urgent medical costs on site; their parents can be reimbursed under three conditions: an institution preparing for an official diploma, a certificate of enrolment and a return to France at least once during the academic year. Beyond 20 years or 6 months, the page refers to the student scheme of the host country. Assurance Maladie recommends an assistance or insurance contract, citing hospitalisation in the United States, and mentions the CFE for a French student; the CFE youth plan is for those under 30. See student insurance abroad.

The retiree receives no reimbursement under the agreement: CLEISS specifies that it contains no provision allowing reimbursement of care received in the United States under a French pension. For cover on site, two routes exist: voluntary CFE membership for a French national, or private insurance. The CFE retirees’ plan is for holders of a French basic scheme pension with no professional activity, with no health questionnaire, and covers care received abroad. A health contribution of 3.2% on the basic pension and 4.2% on the supplementary pension may be withheld when the retiree is attached to a French scheme. See the guide retiree health insurance abroad and the page retiring in the U.S. Virgin Islands.

The spouse and children follow the status of the holder. For a seconded employee, they are reimbursed like them on paid invoices. For a local employee, they generally fall under the employer’s plan. The CFE offers contracts that include dependants, with maternity and paediatrics depending on the contract. See expat family insurance.

The CFE is a voluntary social protection body. The plans have contributions that depend on age and the plan chosen, for the youth plan (under 30), the main plan (over 30, who live and work abroad) and the retirees’ plan, depending on country of residence, age and family composition. Abroad, reimbursement depends on the country where care is received: the CFE applies a rate or a flat amount to the actual expense, and the difference from the price billed remains at the member’s expense. The guide CFE reimbursements details this mechanism.

• Cover: worldwide, including France for the youth and main plans.
• Waiting period: immediate cover if membership takes place before departure or within three months of settling; otherwise three months before age 44 and six months from age 45.
• Maternity: conception must be after membership or after joining as a dependant; daily allowances require 10 consecutive months of membership at the presumed date of delivery.
• Health questionnaire: none, whatever the age.

See also the guide CFE or private insurance and the page CFE top-up.

International health insurance at the first euro reimburses actual costs up to its ceiling, after any deductible, waiting periods and exclusions in the contract. It opens direct payment to facilities, which answers the financial guarantee that France Diplomatie points to on admission. Before taking out a policy, check that the coverage zone includes the United States, the annual ceiling, medical evacuation and the handling of pre-existing conditions (see coverage zone). The page healthcare system in the U.S. Virgin Islands locates the reference facilities on the three islands.

The tourist stays 90 days at most with ESTA. Assurance Maladie specifies that, outside the European Union, care is paid for on site and only urgent and unforeseen medical care can possibly be covered on return: the medical adviser decides, reimbursement is based on French flat-rate tariffs, no appeal is possible in case of refusal and daily allowances are not paid. Planned care is entirely at the person’s own expense, unless their fund exceptionally authorises it, and no reply within two months counts as refusal (CLEISS). Travel or assistance insurance is recommended, particularly for the United States. See long-stay travel insurance.

According to service-public.gouv.fr, a return from a non-European Union country follows three cases. With salaried work in France, affiliation is acquired from the first hour worked: the contract or a payslip accompanies form S1106 sent to the CPAM. With no immediate activity, three consecutive months of residence in France must be shown before rights open, then universal health protection (PUMA) can be requested. A CFE member can, under conditions, keep their benefits for the three months following their return.

For a retiree, the situation depends on the agreement between France and the country of residence: if the agreement opens no right in France and the stable residence conditions are met, PUMA is requested with form S1106. See the guide reducing the waiting period and the page return to France.

• Consultation: the insurer’s network for a local employee; French rules on paid invoices for a seconded employee; rate or flat amount of the country of care at the CFE; actual costs for a first-euro contract.
• Hospitalisation: financial guarantee requested on admission (France Diplomatie); direct payment avoids advancing the funds; the prior authorisation is sometimes required by the contract.
• Medicines: reimbursed according to the list and co-payment provided by the local insurer’s contract; by the CFE according to its country scale; within the ceilings of an international contract.
• Dental and optical: cover often separate and capped in international contracts; to be read in the table of benefits before taking out a policy.
• Maternity: at the CFE, conception must follow membership; international contracts generally apply a waiting period; a seconded employee is reimbursed according to French rules on invoices.

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