Expat insurance and health insurance in Puerto Rico

Puerto Rico has no universal health insurance fund comparable to French Sécurité sociale. The system combines three tiers: US federal programmes (Medicare for those aged 65 and over, Medicaid for low-income households), the Plan Vital, the Puerto Rican government's health plan run by the Puerto Rico Health Insurance Administration (ASES), which has about 1.6 million beneficiaries, and private insurance, individual or employment-based, supervised by the Commissioner of Insurance (OCS). CMS specifies that residents of Puerto Rico cannot use the federal Marketplace. Federal Medicaid funding there works with an annual cap and, according to the MACPAC commission, a high federal contribution rate, revised periodically.

France Diplomatie describes the United States as having excellent but very expensive medical infrastructure, and treats as essential an assistance policy 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 Puerto Rico Medical Center (Centro Médico) in San Juan, run by the Medical Services Administration (ASEM), houses the island's only Level I trauma hospital. See the page healthcare system in Puerto Rico.

• Stay of 90 days at most: ESTA authorisation, to be requested at least 72 hours before departure, valid for 2 years, with an electronic or biometric passport. It allows neither work nor study and is not a right of entry (France Diplomatie). US customs include Puerto Rico in the definition of the term "United States" for the visa waiver programme.
• Stay of more than 90 days, work, internship or study: visa, with a medical examination for long-stay visas. Exceeding the authorised length of stay leads to refusal of entry and, as a rule, an entry ban of several years. A sailing boat bound for Puerto Rico or the US Virgin Islands requires a visa.
• Travel insurance: an assistance policy 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 insurance requirement was found in the sources consulted for a visitor; employer insurance, an approved individual policy, Medicare or the Plan Vital apply depending on status.
• Student: no EHIC (outside the European Union); the Assurance Maladie recommends an assistance or insurance policy, in particular for the United States, and joining the CFE remains possible. See student insurance abroad.
• Seconded employee : continuation of the French scheme under conditions, form SE 404-02 for 5 years with no extension (CLEISS); the CFE and an assistance policy 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 on admission make the financial risk significant for an uninsured expat.

Coordination between France and Puerto Rico runs through the France-US social security agreement, signed on 2 March 1987 (administrative arrangement of 21 October 1987) and in force since 1 July 1988. According to CLEISS, its territorial scope includes, on the US side, the Commonwealth of Puerto Rico, alongside the states, the District of Columbia, the Virgin Islands, Guam and American Samoa. It coordinates disability, old-age and survivors' benefits for employed and self-employed workers of French or US nationality.

• Sickness and maternity: no coordination provision; no S1 form, no EHIC. Planned care remains at the individual's expense unless their fund grants an exceptional authorisation; during a temporary stay, only urgent, unplanned care may possibly be reimbursed on return.
• Secondment: form SE 404-02 covers 5 years for an initial secondment of an employee, with no extension, and 2 years for a self-employed worker, with an exceptional derogation possible beyond that (CLEISS). The seconded worker keeps French health insurance and sends their paid invoices with form S 3125c.
• Expatriation: an employee working on site is subject to US legislation; dependants who stay in France check with their CPAM and their CAF.
• Retiree: health contribution of 3.2% (basic pension) and 4.2% (supplementary pension) that can be deducted for as long as they remain attached to a French scheme; no CSG, CRDS or Casa if the tax residence is no longer in France (CLEISS).

Tax treaty. The consolidated text of the treaty of 31 August 1994 (protocols of 8 December 2004 and 13 January 2009) 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. The residence rules and the allocation of taxing rights provided for the United States therefore cannot be taken for granted in Puerto Rico. The island has its own tax administration (Hacienda), and IRS Publication 570 specifies that bona fide residents generally pay Puerto Rican tax on their worldwide income.

1. Before departure: notify French agencies of your departure (health insurance fund, CAF, France Travail, pension funds); return the Carte Vitale and the EHIC if you are expatriating.
2. For any stay, including a short one: take out an assistance policy 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, work or study.
4. Seconded employee: have the employer request form SE 404-02; self-employed: the Urssaf (international mobility department).
5. Long-term move: choose local insurance (employer, individual policy approved by the Commissioner of Insurance, Plan Vital or Medicare depending on conditions) and, if needed, the CFE before departure or within three months.
6. Tax: have your situation validated with the French tax administration, Hacienda and the IRS, as the tax treaty does not include Puerto Rico in the definition of the United States.
7. Retiree: plan for the CFE (retiree offer) or private insurance, then look into Medicare from age 65.
8. Register with the roll of French nationals living abroad at the Consulate General of France in Miami (free, valid for 5 years).
9. Before the hurricane season (1 June to 30 November): identify the evacuation plan for your place of residence and follow the instructions of the local authorities.