Healthcare Reimbursement in the Northern Mariana 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, coordinates disability, old-age and survivors’ benefits. CLEISS describes its territorial scope on the US side as the federated states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam and American Samoa, and the text of the agreement repeats this list: the Northern Mariana Islands are not named in it. France Diplomatie (the French foreign ministry) for its part indicates that there is no social security agreement covering health insurance between France and the United States: no S1 form, no European card, no cross-border cover (see the bilateral agreement). The embassy covers no medical costs and admission to hospital is subject to a financial guarantee.

Several players can therefore intervene depending on status: employer insurance or an individual contract, the maintained French scheme for a seconded employee, the CFE and international health insurance. Medicare and CNMI Medicaid are added for eligible residents: their conditions are detailed in the page healthcare system in the Northern Mariana Islands. The notions of reimbursement basis and out-of-pocket cost help compare plans.

The local-contract employee comes under the legislation of the place where they work. They leave the French scheme for sickness, and their dependants who stayed in France should enquire with their CPAM and their CAF about their rights under French law alone. Their care generally goes through the employer’s insurance, whose matters come under the CNMI Department of Commerce; notifying the health insurance fund, the CAF and France Travail of the departure avoids repayments of benefits paid in error. See the glossary entry on the local contract.

The seconded employee of a French employer can remain in the French scheme under certain conditions. For the United States, CLEISS describes form SE 404-02 for 5 years, with no extension. As the territorial scope of the agreement does not name the Northern Mariana Islands, the applicable scheme should be confirmed with CLEISS and Urssaf (the French social security contributions collection body); outside an agreement, CLEISS describes a secondment of 3 years renewable once, which maintains French affiliation but leaves the contributions of the country of activity due where its scheme is compulsory. In both cases, CLEISS indicates that the seconded employee keeps French health insurance (with no additional contribution under the agreement, and up to what the French scheme provides for the same care outside an agreement): they send their fund the paid invoices with form S 3125c, their dependants who accompany them follow the same procedure, those who stay in France continue to deal with the fund of affiliation, and daily allowances are paid directly by that fund, the sick note being sent to it within 48 hours. Family benefits cannot be exported. As costs in the United States can exceed those in France, CLEISS advises checking top-up health insurance. See seconded or expatriated and the seconded employee glossary.

The self-employed person or digital nomad has no employer to affiliate them to a local scheme. They choose between an individual contract (information from the CNMI Department of Commerce), the CFE and international insurance; hospital, outpatient and medical repatriation cover suits a stay of several years. See digital nomad insurance.

The student: according to Assurance Maladie (French health insurance), if the student is under 20 or stays less than six months in a country with no social security agreement with France, the parents’ fund can reimburse their urgent medical costs, on three conditions: attending an institution preparing for an official qualification, providing a certificate of enrolment and returning to France at least once during the academic year. Reimbursement is limited to French flat-rate tariffs. Beyond 20 years or six months, Assurance Maladie indicates joining the host country’s student scheme or following its general affiliation procedure if there is none. It recommends an assistance or insurance contract, the United States being among the countries where medical costs are very high, and CFE membership remains possible; the 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 pension from the French basic scheme with no professional activity, with no health questionnaire, and covers care provided 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 health insurance for retirees abroad and the page retiring in the Northern Mariana Islands.

The spouse and children follow the status of the main insured person. For a seconded employee, they are reimbursed like them on paid invoices. For a local employee, they generally come under the employer’s plan; as the spouse of a CW-1 worker (CW-2 status) is not authorised to work, they cannot count on insurance of their own. CMS notes that the CNMI has chosen the option of covering lawfully residing children or pregnant women in its Medicaid, to be confirmed with the Commonwealth Medicaid Agency. The CFE offers contracts including dependants. See expat family insurance.

The CFE is a voluntary social protection body. Its plans have contributions that depend on age and the plan chosen, for the youth plan (under 30), the main plan and the retirees’ plan, depending on the country of residence, age and family composition. Abroad, reimbursement depends on the country where care is received and the type of procedure: the CFE applies a rate or flat amount to actual expenditure, and the gap with the price charged remains the member’s responsibility. The guide CFE reimbursements details this mechanism.

• Cover: care abroad, and stays of less than three months in France for the main plan.
• Waiting period: cover is immediate 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 at least 10 consecutive months of membership of the corresponding plan 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 with first-euro cover reimburses actual costs within the limit of its ceiling, after any deductible, waiting periods and exclusions of the contract. It can open direct payment with facilities, which answers the financial guarantee that France Diplomatie flags at admission. Before taking it out, you should check that the coverage zone includes the Northern Mariana Islands and the United States, the annual ceiling, medical evacuation (recommended by the CDC in the event of serious injury) and the handling of pre-existing conditions (see coverage zone).

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 if refused and daily allowances are not paid. The request is made from the ameli account or with form S3125. An assistance or insurance contract is recommended, particularly for high-cost destinations such as the United States. See long-stay travel insurance.

The return to France. According to service-public.gouv.fr, with employed 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 activity, three consecutive months of residence in France must be shown. A CFE member can, under conditions, keep their benefits for the three months following their return. See return to France and the guide reducing the waiting period.

• Consultation: 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.
• Hospital stay: financial guarantee requested on admission (France Diplomatie); direct payment avoids advancing funds; the prior approval is sometimes required by the contract.
• Medicines: reimbursed according to the list and co-payment set by the local insurer’s contract; by the CFE according to its country scale; within the ceilings of an international contract. A French prescription does not allow you to buy medicines in the United States (France Diplomatie).
• Dental and optical: cover often separate and capped in international contracts; to be read in the table of benefits before taking out a contract.
• Maternity: at the CFE, conception must follow membership; international contracts generally apply a waiting period; a seconded employee is reimbursed under French rules on invoices.

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