Healthcare Reimbursement in New Caledonia: Who Pays What Depending on Your Situation

New Caledonia has a social protection scheme separate from the mainland one, run by the CAFAT. The CLEISS specifies that, as soon as a professional activity is carried out there, New Caledonian legislation applies, unless there is a secondment. Coordination with mainland France rests on decree no. 2002-1371 of 19 November 2002, in force since 1 December 2002, which applies whatever the nationality: it sets the scheme of the place of activity as the rule, with exceptions (seconded workers, flight crew, civil servants), coverage of immediately necessary care during a temporary stay, totalisation of insurance periods and payment of pensions wherever the person lives. It is therefore not a social security agreement between two States. The Assurance Maladie (French public health insurance) website nevertheless places New Caledonia in the list of territories for which provisions exist covering retirees and family members.

The notions of out-of-pocket cost and ticket modérateur (co-payment) help you read the scales. The page on the healthcare system in New Caledonia describes the schemes and hospitals.

An employee on a local contract is declared to the CAFAT by their employer and comes under the RUAMM (the unified health and maternity insurance scheme). Their entitlements are opened for 1, 3 or 6 months (or one year under annualised entitlements) depending on the hours of work or the salary shown; the first month of activity opens no reimbursement, except for apprentices, vocational training trainees and civic service volunteers. An employee coming from mainland France presents form SE 988-02 (certificate of totalisation of insurance periods) with their last six payslips. See the glossary entry on the local contract.

A posted worker sent by a mainland employer remains subject to the French scheme for 2 years, renewable for 2 years, with form SE 988-01 issued by the Urssaf (the French social contributions collector) or by the affiliation fund (CLEISS); the CAFAT asks for SE 988-07 with SE 988-01. Beyond that, or if the conditions are no longer met, the employee comes under the local scheme. The mainland long-term condition (ALD) system does not apply on site: the request for long-term illness status is made by a doctor to the CAFAT medical control. See secondee or expatriate.

A State employee: the CAFAT manages the compulsory health cover of civil servants, with no waiting period, and the coordination decree provides exceptions to the place-of-activity rule for civil servants (CLEISS). The pages read do not detail the affiliation of a State employee assigned on site: it depends on their status and the length of the assignment, and is confirmed with the human resources department and the CAFAT before departure.

A self-employed person is affiliated to the RUAMM with no residence condition as long as they work in the territory, and with no waiting period if their contributions are up to date. Under full integration, all care is reimbursed at RUAMM rates; under partial integration, only care covered at 100% (long-term illness, long-term hospitalisation, medical evacuations) is reimbursed: consultations, for example, remain at their expense. A self-employed person in activity can be neither a dependant nor a voluntary insured person.

A student under 28 who studies in the territory takes out the CAFAT student insurance: the basic contribution is calculated on 50 times the hourly SMG (of the order of CFP 49,000 for a study year), paid in full by the province for scholarship holders and recipients of medical assistance. Entitlements end if studies are interrupted. A student already covered as a dependent child under 21 of an insured person does not need to take it out. The page consulted does not deal specifically with students from mainland France and does not present a compulsory supplementary policy; a student on an unpaid placement or on holiday can use form SE 988-03. See insurance for students abroad.

Spouse and children are dependants of the insured person: spouse, PACS partner (civil partner), cohabiting partner (established cohabitation for at least 12 months), dependent children and grandchildren up to 18, or up to 21 if they continue their studies, and, subject to income conditions, parents. They must have no compulsory cover of their own; entitlements run from receipt of the complete file. A dependant who comes alone to the territory while the insured person stays in mainland France or in an overseas department presents SE 988-05. See expat family insurance.

A retiree receiving a pension from the mainland scheme requests form SE 988-06 from their pension fund: part A is completed by the mainland fund, the CAFAT completes part B, and the pensioner is registered with the dependants who live with them. For retired civil servants and military personnel, the CLEISS says to report the transfer of residence to the pension management centre before departure. During a stay in mainland France, the registered pensioner’s care is reimbursed by the fund that pays the pension, on presentation of the pension certificate; a hospitalisation of more than a month requires prior medical agreement. The non-pensioned spouse is not covered in France, and insurance is advisable. A retired self-employed person of the territory keeps their RUAMM entitlements if they are removed from the business licence register (patentes), are at least 62 and have five years of activity on site. See retiring in New Caledonia.

A visitor from mainland France on a short stay (holiday, assignment, unpaid placement) requests SE 988-03 from their fund before leaving. The CAFAT then reimburses, under New Caledonian legislation, the immediately necessary care during the stay; in case of sick leave, you must inform your fund within 48 hours, and it pays the allowances. For an authorisation of return, of transfer of residence or of appropriate care with the fund’s agreement, the form is SE 988-04. A travel insurance policy covers what the CAFAT does not, notably trips outside the territory.

A CFE member: the Caisse des Français de l’Étranger (CFE), the voluntary health insurance scheme for French people abroad, offers a main offer, a youth offer and a retiree offer, each with a contribution that depends on age and the plan chosen according to its website. The territories appear in the drop-down list of countries of residence, with no particular condition indicated, and both the Assurance Maladie and the CLEISS state that CFE members who live in the territory send the CPAM (local health insurance office) of Seine-et-Marne their claims for care received in France. A resident’s eligibility and the link with the CAFAT remain to be confirmed with the CFE before any membership; it does not replace the compulsory affiliation of an employee or a self-employed person in activity.

Supplementary insurance: the CAFAT states that local mutual insurers receive their members’ claim forms, except for care covered at 100% by the CAFAT (compulsory childhood vaccinations, maternity, long-term illness). A supplementary policy or insurance from the first euro covers all or part of the ticket modérateur and of the services reimbursed at low rates; its limits, deductibles and exclusions determine the out-of-pocket cost.

Medical evacuation is organised by the CAFAT after a request by the doctor and the opinion of a medical committee: guarantees of payment for care and accommodation, accommodation offered or reimbursed up to €60 a day, medical journeys reimbursed on prescription, and the companion’s accommodation, meals and transport costs covered on the same terms. An urgent return for personal reasons remains at the patient’s expense. See repatriation and assistance.

Returning to mainland France: the CAFAT recommends requesting your social security number before departure (assigned within four weeks of filing, as only the CAFAT can issue it) and a coordination agreement, then contacting the primary fund of your place of residence. The Assurance Maladie invites you to contact the fund of your place of residence to recover the full extent of your entitlements. The guides on returning to France and on reducing the waiting period complement this point. The CAFAT also asks you to report a permanent departure, or one of more than six months, for family benefits.

• Consultation: a 10% ticket modérateur applies to medical consultations, paid to the health professional; the other rates appear in the CAFAT leaflet, to be consulted before care.
• Hospital care: reimbursed by the RUAMM; third-party payment is possible in mainland France, in the overseas departments and in French Polynesia, where CAFAT rates apply on the basis of Sécurité sociale tariffs (or of the Polynesian CPS).
• Medicines: pharmacy is part of the medical-surgical benefits, at the leaflet rates; compulsory childhood vaccinations are covered at 100%.
• Dental: dental care is included in the RUAMM medical-surgical benefits; the detailed rates appear in the CAFAT leaflet, which the pages read do not reproduce.
• Optical: the pages read do not detail coverage of glasses and contact lenses; the CAFAT publishes its rates in a leaflet, and no rate is quoted here for lack of a direct reading.
• Maternity: covered at 100% of the CAFAT liability rates, pregnancy follow-up, recognised tests, hospitalisation for childbirth and ten postnatal rehabilitation sessions; other costs (pharmacy, unrecognised tests, childbirth preparation) follow the medical-surgical rates.
• Long-term illness: 32 listed illnesses, related care reimbursed at 100%, with no advance of costs.
• Care abroad: only hospitalisations of at least one night for unforeseen and urgent care are reimbursed, within the limits of CAFAT tariffs and rates.

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