Expat insurance and health insurance in the Northern Mariana Islands

The Northern Mariana 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, Medicaid for low-income households), the territory's Medicaid run by the Commonwealth Medicaid Agency, and employer or individual insurance, whose matters come under the CNMI Department of Commerce. CMS specifies that CNMI residents are not eligible for the federal Marketplace. According to the MACPAC commission, the federal contribution rate for the CNMI's Medicaid is permanently set at 83% by the 2023 appropriations act, and CMS indicates that the CNMI has chosen the option of covering lawfully residing children or pregnant women, including those subject to the five-year waiting period.

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 CDC specifies that emergency care may be limited or may not meet US standards and recommends medical evacuation insurance. Public provision is organised by the Commonwealth Healthcare Corporation (CHCC) in Saipan, Tinian and Rota. See the page healthcare system in the Northern Mariana Islands.

• Stay of 90 days or less: France Diplomatie describes for the United States an 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, paid or unpaid, nor study, and does not constitute a right of entry. The France Diplomatie page does not mention the Northern Mariana Islands: before booking, confirm the applicable procedure with US Customs and Border Protection (CBP).
• Guam and Northern Mariana Islands visa waiver programme: admission for 45 days at most, limited to Guam or the CNMI, with electronic travel authorisation mandatory since 29 November 2024 (8 CFR 212.1). This programme is separate from the visa waiver programme (ESTA); France is not on its list of nationalities.
• Stay of more than 90 days, work, internship or study: visa, with a medical examination for long-stay visas (France Diplomatie). To work in the territory, the specific status is the CW-1 (CNMI-only transitional worker), valid only in the CNMI (USCIS). Overstaying the authorised period leads to removal and, generally, an entry ban of several years.
• 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 health insurance obligation for a visitor was found in the sources consulted; employer insurance, an individual contract, Medicare or the CNMI's Medicaid apply depending on status.
• Student: no EHIC (outside the European Union); Assurance Maladie (French health insurance) recommends an assistance contract or insurance, notably for the United States, and CFE membership remains possible. See student insurance abroad.
• Seconded employee: CLEISS describes for the United States form SE 404-02 (5 years, with no extension), but the territorial scope of the agreement does not name the Northern Mariana Islands. The applicable scheme (agreement or secondment outside an agreement, 3 years renewable once, with dual affiliation) should be confirmed with CLEISS and Urssaf before departure; 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 United States 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. It coordinates disability, old age and survivors' benefits. A point of vigilance specific to this destination: CLEISS describes the territorial scope on the US side as the federated states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam and American Samoa, and the text of the agreement read live on the CLEISS site repeats this list. The Northern Mariana Islands are not named in it, whereas Guam is. Its application to an activity or a residence in the CNMI should therefore be confirmed with CLEISS, the Cnav and the fund of affiliation.

• 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 (Assurance Maladie).
• Secondment: CLEISS describes for the United States form SE 404-02 (5 years for an initial secondment, with no extension), with paid invoices and form S 3125c. For a country with no applicable agreement, CLEISS describes a secondment of 3 years renewable once, with dual affiliation and contributions also due in the country of activity.
• Expatriation: an employee working on site is in principle subject to the legislation of the place of work; 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 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 of the United States. It does not name the Northern Mariana Islands; the residence and tax-allocation rules provided for the United States therefore cannot be taken for granted in the CNMI. On the territorial side, the IRS explains that bona fide residents of the CNMI file their return with the CNMI on their worldwide income and generally have no federal return, apart from self-employment tax, and that a mutual agreement procedure exists between the United States and the CNMI for cases of double taxation (publication 570).

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 or study; confirm the procedure applicable to the Northern Mariana Islands with CBP.
4. Employee: the CNMI employer requests certification from the US Department of Labor then files the CW-1 petition with USCIS; the status is valid only in the CNMI.
5. Seconded employee: ask CLEISS and Urssaf about the applicable scheme (form SE 404-02 or secondment outside an agreement) before departure.
6. Long-term settlement: choose local insurance (employer, individual contract, CNMI Medicaid or Medicare depending on the conditions) and, if needed, the CFE before departure or within three months.
7. Taxation: have your situation validated with the French tax administration, the CNMI Division of Revenue and Taxation and the IRS, as the tax treaty does not name the Northern Mariana Islands in the definition of the United States.
8. Retiree: arrange the CFE (retirees' plan) or private insurance, then look into Medicare from age 65.
9. Find out about typhoon preparedness guidance from CNMI services and the US weather service in Guam, before and during the stay, all year round.
10. Register on the roll of French nationals living abroad with the French Consulate General in San Francisco, responsible for the Pacific islands according to France Diplomatie (free, valid for 5 years); the consulate site's list does not name the Northern Mariana Islands, to be confirmed.