Healthcare Reimbursement in French Polynesia: Who Pays What Depending on Your Situation

French Polynesia is part of the Republic, but its social protection is the Country’s own. Coordination between the mainland and Polynesian schemes rests on decree no. 94-1146 of 26 December 1994, in force since 1 January 1995: it governs secondment, totalisation of insurance periods, care during a stay in the other territory and the situation of dependants and pensioners. The High Commission sums up the mechanism: each body reimburses or advances for its own members, then is reimbursed through the national centre for care abroad. It is not a social security agreement between two States, and the mainland Assurance Maladie (French public health insurance) has no branch on site.

The High Commission’s golden rule is that the insured person is the first to be responsible for their entitlements: an up-to-date certificate of entitlements (valid for one year at most, to be renewed at least a month before it expires, failing which the CPS suspends entitlements without notice), an Ameli account, an up-to-date carte Vitale, an online CPS account. The notions of out-of-pocket cost and of universal health protection (PUMa) shed light on these rules. The page on the healthcare system in French Polynesia describes the schemes.

An employee hired locally, including contract staff recruited on site by a State administration, is declared to the CPS by their employer and comes under the general employees’ scheme. They are reimbursed at 70% of the CPS tariff, and at 100% for hospitalisation, maternity, sick leave of more than 30 days and medical evacuations (CLEISS, the French centre for international social security links). See the glossary entry on the local contract.

A civil servant, military member, magistrate or national contract employee contributes to mainland Sécurité sociale during their stay. To benefit from local third-party payment, they hold a valid certificate of entitlements and a 980 form (the 980-02 is the certificate of affiliation for civil servants, magistrates, military personnel and State workers), then declare themselves to the CPS. For care provided in Polynesia, it is the CPS that reimburses or applies third-party payment according to its rates and scales, then is reimbursed by Sécurité sociale; cover may therefore be lower than in mainland France, and the national health insurance fund covers a gap only if the member is not declared to the CPS at all. There is no referring doctor to declare on Ameli, but during a stay in mainland France you must have “away from usual residence” ticked on the claim form, failing which reimbursement is sharply reduced (€6 instead of €16 for a GP).

A posted employee sent by a company established in mainland France remains subject to their home scheme. The decree provides for continued affiliation of three years at most, extendable once for three years with the agreement of the authorities of the place of secondment; the CLEISS table indicates 3 years then 1 year (form 980-01), and the High Commission mentions a joint extension authorisation: the exact length should be confirmed with the Urssaf (the French social contributions collector). For third-party payment, the employer declares the situation to the Urssaf (Cerfa 11559-03), then the employee requests the 980-01 (and the 980-04 for their dependants) and declares themselves to the CPS on arrival. See secondee or expatriate.

A self-employed person comes under the non-salaried scheme as soon as their declared average gross monthly income reaches CFP 87,346 (CFP 97,346 for a household), after more than 6 months of residence; health insurance is compulsory, with reimbursement generally at 70% of the CPS tariff and at 100% in particular for hospitalisation or sick leave of more than 30 days. Industrial accident cover is voluntary for them (CLEISS).

A resident without activity, for example after a career break or unpaid leave, keeps for one year at most their entitlement to reimbursement under their previous activity, according to the High Commission. After that, depending on their income, they affiliate to the non-salaried scheme or, with no income to declare, to the solidarity scheme, with proof of residence of at least 6 months and a complete file: the new entitlements only take effect after it is received.

A student coming from mainland France requests form 980-04 from the primary fund of their place of residence before arriving, files it with the CPS and asks for their file number to be created with their identity document and bank details; they are then covered like residents, and file their claim forms with the CPS. A student who works comes under the employees’ scheme. An adult dependent child who studies in mainland France requests independent status from the fund of the place of study; an adult child or a student over 18 must have their own cover. See insurance for students abroad.

Spouse and children: a non-working spouse is by default covered neither by Sécurité sociale nor by the CPS on arrival (6 months of residence and a resource ceiling for the solidarity scheme). An exceptional derogation allows an adult dependant to be added for staff attached to the Val-de-Marne primary fund, with Cerfa 14411-01; no other fund opens it. Minor children remain dependants until 18. The CPS also states that a spouse or partner of more than two years can become a dependant under conditions. See expat family insurance.

A retiree requests form 980-06 from their pension fund (the national old-age insurance fund for the general scheme; the Rennes pension management centre via ENSAP messaging for State pensioners since 1 January 2023), then declares themselves to the CPS with the certificate of entitlements, bank details, birth certificate and identity document. Care in mainland France 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, and the non-pensioned spouse is not covered in France (CLEISS). See retiring in French Polynesia.

A visitor from mainland France (holiday, placement, assignment) requests form 980-04 from their fund before leaving: the CPS then covers immediately necessary care under Polynesian legislation, and so does the family listed on the form. They declare themselves to the CPS on arrival; without the form, they advance the costs and are reimbursed by their home fund. In case of sick leave, they inform their fund. The High Commission recommends travel insurance for trips outside Polynesia, including stopovers: see long-stay travel insurance.

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, which states no particular condition for the overseas collectivities. Both the Assurance Maladie and the CLEISS state that CFE members who live in the territory send their claims for care received in France to the CPAM (local health insurance office) of Seine-et-Marne. A resident’s eligibility is confirmed with the CFE, which does not replace the CPS affiliation of a working person.

Supplementary insurance covers all or part of the out-of-pocket cost; the High Commission specifies that the employee sends their mutual insurer their CPS benefit statements (to be printed online) and invoices if needed. Insurance from the first euro reimburses actual costs within its limits, after the contract’s deductible, waiting period and exclusions.

The evasan (medical evacuation) is requested by the treating doctor and authorised by the medical adviser. For a CPS insured person, it covers transport, hospitalisation and accommodation (an approved companion can benefit). For a member of mainland Sécurité sociale, the CPS only advances the return ticket (and the companion’s on dispensation from the chief medical officer) and the transfer from the airport: accommodation, meals, local transport and clothing remain at their expense. The State’s territorial continuity aid can help a companion: it is CFP 111,575 (€935) per traveller for a resident of at least six months under an annual income ceiling of CFP 2,147,971.

Returning to mainland France: the universal health protection system requires proof of activity or of stable and regular residence in France; to reopen your entitlements, you contact the fund of your place of residence (Assurance Maladie). The guides on returning to France and on reducing the waiting period complement this point. For a long-term condition, it must be recognised by both bodies in order to be covered at 100% in Polynesia as in mainland France.

• Consultation: 70% of the CPS tariff for an employee; claim forms to be filed with the CPS within the year. The obligation to declare a referring doctor also applies to members of Sécurité sociale.
• Hospital care: 100% for the CPS insured person; the High Commission notes that CPS reimbursement is sometimes more favourable than that of Sécurité sociale, for example in hospital.
• Medicines: at CPS rates; for long-term illness, 100% for prescriptions related to the condition and 30% for homeopathy and medicines with moderate medical benefit.
• Dental and optical: some services reimbursed in mainland France on the Sécurité sociale basis, such as dental care and optical, are not necessarily reimbursed in the same way on the CPS basis; cover may be lower or non-existent, and Sécurité sociale does not fill the gap for a member declared to the CPS.
• Maternity: covered at 100%; the general scheme’s leave is 16 weeks (6 before and 10 after the expected date), with 7 prenatal consultations, 8 preparation sessions and 3 ultrasound scans at 100% (CLEISS).
• Long-term illness: CPS long-term illness booklet, with 95% for related consultations and 100% for prescriptions and hospitalisation.

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