Healthcare Reimbursement in Puerto Rico: 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, includes the Commonwealth of Puerto Rico in its territorial scope. It coordinates disability, old-age and survivors’ benefits. For sickness and maternity, CLEISS (the French Centre for European and International Social Security Liaison) specifies that the agreement contains no coordination provision: no S1 form, no European card, no cross-border cover (see the bilateral agreement). France Diplomatie (the French foreign ministry) points out that the embassy covers no medical costs and that admission to hospital is subject to a financial guarantee.

Several players may therefore step in depending on status: employer insurance or an individual local policy, the French scheme maintained for a seconded worker, the CFE and international health insurance. Medicare and the Plan Vital are added for eligible residents: their conditions are detailed in the page healthcare system in Puerto Rico. The notions of reimbursement basis and out-of-pocket cost help to compare offers.

An employee on a local contract is subject to US social security legislation as soon as they carry out a professional activity on site, outside a secondment. They leave the French scheme for sickness: CLEISS specifies that their dependants who stay in France have no right to sickness and maternity benefits based on their US activity and that they check with their CPAM and their CAF about their rights under French law alone. Their care generally goes through the employer’s insurance; declaring the departure to the health insurance fund, the CAF and France Travail avoids the repayment of benefits paid in error. See the glossary entry on the local contract.

A seconded employee sent by a French employer can remain on the French scheme under certain conditions, thanks to the 1987 agreement. CLEISS states that they keep French health insurance with no additional contribution: they send their paid invoices to their fund with form S 3125c, 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 by that fund. As costs in the United States can exceed those in France, CLEISS advises checking the supplementary health insurance; employers often add an international group contract. See seconded or expatriate and the glossary entry on seconded employees.

A freelancer or digital nomad has no employer to enrol them in a local scheme. They choose between an ACA-compliant individual policy approved by the Puerto Rico Commissioner of Insurance, the CFE and international insurance; cover for hospitalisation, outpatient care and medical repatriation suits a stay of several years. See digital nomad insurance.

A student depends on the host country. According to the Assurance Maladie (French national health insurance), in a country with no agreement or whose agreement does not mention students, they generally pay urgent costs up front; their parents may be reimbursed under three conditions: an institution preparing for an official qualification, a certificate of enrolment and a return to France at least once during the academic year. The Assurance Maladie recommends an assistance or insurance policy, in particular for the United States, and joining the CFE remains possible for a French student; the CFE youth offer is for people under 30. See student insurance abroad.

A 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 membership of the CFE for a French national, or private insurance. The CFE retiree offer is for holders of a pension from the French basic scheme with no professional activity, has no health questionnaire, and covers care received abroad. A health contribution of 3.2% on the basic pension and 4.2% on the supplementary pension may be deducted when the retiree is attached to a French scheme, in particular for stays in France. See the guide health insurance for retirees abroad and the page retirement in Puerto Rico.

The spouse and children follow the status of the policyholder. For a seconded worker, they are reimbursed like them on paid invoices. For a local employee, they generally fall under the employer’s plan. The CFE offers contracts including dependants, with maternity and paediatrics depending on the contract. See expat family insurance.

The CFE is a voluntary social protection body. The offers have contributions that depend on age and the plan chosen, for the youth offer (under 30), the main offer (over 30, excluding retirees) and the retiree offer, depending on the country of residence, age and family make-up. Abroad, reimbursement depends on the country where care is received: the CFE applies a rate or flat amount to the actual expense, and the gap with the price billed remains the member’s responsibility. The guide CFE reimbursements details this mechanism.

• Cover: worldwide, including stays of under three consecutive months in France for the youth and main offers.
• Waiting period: immediate cover if joining 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 come after joining or after becoming attached as a dependant; daily allowances require 10 consecutive months of membership 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 cover.

International health insurance with first-euro cover reimburses actual costs up to its ceiling, after any deductible, waiting periods and exclusions in the contract. It provides direct payment to facilities, which answers the financial guarantee that France Diplomatie flags on admission. Before taking it out, check that the coverage area includes the United States, the annual ceiling, medical evacuation and the handling of pre-existing conditions (see coverage area).

The tourist stays 90 days at most with ESTA. The Assurance Maladie specifies that, outside the European Union, care is paid for on site and only urgent, unplanned medical care may 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. Planned care is entirely at the person’s expense, unless their fund grants an exceptional authorisation, and no reply within two months counts as a refusal (CLEISS). Travel or assistance insurance is recommended, particularly for the United States. See long-stay travel insurance.

According to service-public.gouv.fr, a return from a country outside the European Union follows three cases. With employment in France, affiliation is acquired from the first hour worked: the contract or a payslip accompanies form S1106 sent to the CPAM. With no immediate activity, three consecutive months of residence in France must be shown before rights open, after which universal health protection (PUMA) can be requested. A CFE member can, under conditions, keep their benefits during the three months following their return.

For a retiree, the situation depends on the agreement between France and the country of residence: if the agreement opens no right in France and the stable residence conditions are met, PUMA is requested with form S1106. See the guide reducing the waiting period and the page return to France.

• Consultation: the insurer’s network for a local employee; French rules on paid invoices for a seconded worker; rate or flat amount of the country of care at the CFE; actual costs for a first-euro contract.
• Hospitalisation: 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.
• Dental and optical: guarantees often separate and capped in international contracts; read the table of guarantees before taking out a policy.
• Maternity: at the CFE, conception must follow joining; international contracts generally apply a waiting period; a seconded worker is reimbursed under French rules on invoices.

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