Healthcare Reimbursement in North Macedonia: Who Pays for What Depending on Your Situation

North Macedonia is not a member of the European Union: France Diplomatie (the French foreign ministry) recalls that the European health insurance card is not valid there. CLEISS specifies that the general Franco-Yugoslav agreement of 5 January 1950, supplemented by the administrative arrangement of 23 January 1967, has applied between France and North Macedonia since the exchange of letters from Paris (13 December 1995) and Skopje (14 December 1995), which came into force on 14 December 1995. It concerns employees of French or Macedonian nationality and covers all branches except unemployment insurance: sickness-maternity, disability, old age and survivors, work accidents and occupational diseases, family benefits and death.

The agreement opens specific rights depending on the situation, detailed below; outside these cases, it is your status that determines the payer: Macedonian Fund, CFE or international insurance. The notions of reimbursement basis and out-of-pocket cost help with comparisons. How the Fund works is presented in the guide North Macedonian healthcare system.

The employee on a local contract is affiliated to the Fund by their employer, who alone bears the contributions (7.3% of gross salary for sickness-maternity). Care in kind opens from the first day, with a contribution of 10% to 20% of the cost depending on the type of care outside emergencies, and an annual cap set at 70% of the previous year’s average monthly net salary. Care in a non-contracted establishment remains at the patient’s expense: private supplementary cover opens direct access to this sector. See the glossary entry on the local contract.

The posted employee of a company established in France keeps French health insurance with no additional contribution. For care received in North Macedonia, two options are open: send the paid invoices with form S 3125c to the French fund, or send the Macedonian body a request for cover with a copy of the certificate of coverage SE 21-01, which applies Macedonian legislation. The family accompanying them follows the same options; the family who stay in France continue to come under the French fund. Daily allowances are paid by the French fund, with a sick-leave notice sent within 48 hours; family benefits continue to be paid by the CAF (French family benefits fund). CLEISS suggests checking with the supplementary insurer whether the contract needs adapting, as care may cost more than in France. See posted worker or expatriate and the glossary entry on the posted worker.

A self-employed person settled in North Macedonia contributes to the Fund at the same total rate of 31% as the employer, including 7.3% for sickness-maternity. They can also choose the CFE or international insurance, particularly to gain access to private clinics and repatriation. See digital nomad insurance.

The student is not mentioned by the CLEISS page on temporary stays. The Macedonian State programme covers children under 18, or 27 if they are studying, but access for a foreign student should be confirmed with the Fund and the establishment. Before age 30, the CFE offers its youth offer; student insurance contracts complete the picture. See student insurance abroad.

According to CLEISS, a French or Macedonian national who receives a French old-age pension from the employees’ scheme can obtain health cover in North Macedonia if they have no right under Macedonian legislation. No certificate is issued before departure: the retiree contacts the social security fund of their place of residence, which checks that they are not insured locally, then sends form SE 21-34 to the French body that pays their basic pension; that body issues SE 21-35 (right confirmed) or SE 21-36 (refusal). With SE 21-35, the Macedonian fund covers their care and that of dependants living with them, as if they were a pensioner under Macedonian legislation only.

With this form, the retiree’s care during temporary stays in France is covered under French law, with prior agreement of the CPAM (local health insurance office) after a medical check for hospitalisation of more than a month; only the pensioner and their minor children are covered, and a spouse who lives abroad is not, hence the value of private insurance. The CFE also offers a retirees’ offer. See the guide retirees’ health insurance abroad and the page retiring in North Macedonia.

The CFE reimburses abroad on a rate or flat amount specific to the country of care, applied to actual expenses: the fund’s example is a French general practitioner consultation set at €25 and reimbursed at 70%, or €21. In France, it follows the principles of Assurance Maladie with direct payment, for stays of under three months. The contributions depend on age and the plan chosen, for the main offer, the youth offer and the retirees’ offer. No waiting period applies if membership takes place before departure or within three months of settling; after that, it is three months before age 45 and six months from age 45. Maternity requires conception after membership. See CFE reimbursements.

International health insurance on a first-euro basis reimburses actual costs within its ceilings, after any deductible, waiting periods and exclusions. France Diplomatie recalls that medical repatriation costs can be very high and strongly recommends cover taken out in France before the trip.

The French tourist does not benefit from direct cover: CLEISS recalls that form SE 21-04 A, requested from the CPAM before departure, is intended only for Macedonian nationals on a temporary stay during paid leave, French-Macedonian dual nationality being excluded. Other insured people can ask their fund, on return, to reimburse unforeseen care on paid invoices, which CLEISS describes as a possibility and not an obligation; daily allowances are only paid on return, on sick leave issued by a doctor practising in France. See long-stay travel insurance.

On returning to France, a 3-month waiting period applies to a French national with no professional activity before affiliation to the CPAM under the PUMa (universal health cover); a CFE member with no activity benefits free of charge from retention of rights for the 3 months following return (Assurance Maladie). See reducing the waiting period and return to France.

• Consultation: 10% to 20% contribution for a Fund insured person, on referral from the general practitioner for a specialist; reimbursed at the French tariff on invoice or under Macedonian law for the posted worker; at the country scale for the CFE; at actual costs within the ceilings of a first-euro contract.
• Hospitalisation: public hospitals or contracted private establishments for an insured person; CFE direct payment in France; direct cover possible with an international contract.
• Medicines: only listed medicines are reimbursed, with a 5% to 20% contribution; CFE scales; contract ceilings.
• Dental: periodic check-ups and primary prevention only, with 20% at the patient’s expense for the Fund insured person; included at the CFE according to its scales and in most international contracts according to an annual ceiling.
• Optical: mainly under international contracts, with ceilings per period.
• Maternity: 9-month leave at 100% of average salary after six months of contributions for the Fund insured woman; the CFE requires conception after membership; international contracts generally apply a waiting period to maternity.

The reimbursement guide and the page expat health insurance give pointers; Expavy helps compare these options with your situation.