Healthcare Reimbursement in the Democratic Republic of the Congo: Who Pays for What Depending on Your Situation

The CLEISS list of social security agreements does not include the DRC, and Assurance Maladie reminds readers that, for a country outside the European Union without an agreement, you should find out about the local system and consider a specific health insurance contract, which may allow a return to France for care. No European card, no totalisation of periods and no cross-coverage are therefore organised between France and the DRC. The French embassy pays no medical costs, and France Diplomatie (the French foreign ministry’s travel advice) judges a contract covering all medical costs, hospitalisation and medical repatriation to be essential: without it, access to care may be refused, even in a life-threatening emergency.

Four parties may be involved: the Congolese CNSS, the French scheme maintained for a seconded employee, the CFE and international health insurance. The notions of reimbursement base and out-of-pocket cost help to compare offers. How care is organised is presented in the guide to the healthcare system in the DRC.

An employee on a local contract is declared by their employer to the CNSS, which pays occupational risk benefits, family benefits (prenatal allowances, maternity daily allowances, family allowances) and old-age, invalidity and survivors’ pensions. Its pages describe no reimbursement of routine care. Employers therefore often supplement the CNSS with a group health contract. See the glossary entry on the local contract.

A seconded employee of a French employer can remain attached to the French scheme for 3 years at most, renewable once, with a 2-year gap before a new secondment in the same country for the same company; formalities are handled with Urssaf (the French social security contributions collector). Care received abroad is covered within the limit of the benefits that would have been paid for the same care in France, and private insurance supplements this cover in countries where care is costly (CLEISS). Industrial accidents are reported to the local health insurance office (caisse primaire) within 48 hours, and family benefits are paid only for children living in France. See seconded or expatriate and the glossary entry on the seconded employee.

A self-employed person or digital nomad has no employer to affiliate them to the CNSS, whose pages do not deal with self-employed workers as a category. No public cover mechanism was read for a non-employed foreign resident: the CFE or international insurance, with hospitalisation and repatriation, is the most complete solution. See digital nomad insurance.

A student has no public scheme identified for foreigners in the sources read. Before age 30, the CFE offers its youth offer (with a contribution that depends on age and the plan chosen); international student insurance taken out before departure is the other option. See student insurance abroad.

A retiree does not come under the S1 form: Assurance retraite (the French pension insurance body) reserves the certificate of entitlement to healthcare for general-scheme retirees living in the European Union or in a country linked to France by an agreement. The CFE offer for retirees has a contribution that depends on age and the plan chosen, with no medical questionnaire. During a stay in France, the Cnarefe (the health insurance centre for retirees living abroad) takes over, subject to 15 years of contributions. See the guide to health insurance for retirees abroad and the page on retirement in the DRC.

The spouse and children of an expatriate come under the social protection rules of the country of expatriation (Assurance Maladie), so in practice the CFE or an insurance that covers them as dependants; the CFE main and youth offers cover dependants. For maternity, the CFE requires conception after joining. See expat family insurance.

The CFE is a voluntary social protection body. In France, it reimburses according to the principles of Assurance Maladie, with direct payment at the hospital; abroad, reimbursement depends on the country of care and the type of treatment, as a rate or flat amount applied to actual expenses. When the local price exceeds the base used, the difference remains payable by the member: the guide to CFE reimbursements details this mechanism. The list of countries where hospital direct payment applies should be checked on the CFE website before departure.

• Offers: the main offer (over 30), the youth offer (under 30) and the retiree offer, each with a contribution that depends on age and the plan chosen; the simulator calculates the exact contribution according to the country, age and family situation.
• Waiting period: none if joining before departure or within three months of settling abroad; otherwise three months before age 44 and six months from age 45. No waiting period on return to France.
• Maternity: conception after joining; for daily allowances, at least 10 consecutive months of membership of the option at the expected date of delivery.
• Employee option: the three-in-one employee pack starts at €12 a month and includes daily allowances of €34.28 to €68.56 a day after a 30-day waiting period, within the limit of 120 days over 12 months.

On return to France, a French national without activity is subject to a three-month waiting period; a CFE member benefits free of charge from a continuation of rights during these three months, then joins the CPAM (the local health insurance office) under universal health coverage. These rules, presented by Assurance Maladie, should be checked with the CFE and the CPAM. See the guide to reducing the waiting period and the page on returning to France.

International health insurance on a first-euro basis reimburses actual costs within its ceilings, after any deductible, waiting periods and exclusions of the contract. As all services are payable in advance in the DRC, direct payment with private facilities is a decisive criterion; contracts are also compared on the annual ceiling, evacuation and the handling of pre-existing medical conditions.

A tourist holds a tourist visa for a stay of less than six months. France Diplomatie recommends checking before departure that you are properly insured: medical costs, hospitalisation and medical repatriation should be guaranteed for the whole length of the stay, and bank card assistance can supplement this arrangement, with ceilings to be checked. See long-stay travel insurance.

• Consultation: to be paid in advance with a private general practitioner or specialist; reimbursed by the CFE on its country scale, at actual cost within the ceilings of a first-euro contract, under French rules for a seconded employee.
• Hospitalisation: private facilities payable in advance; public hospitals are described as very run down by France Diplomatie. The contract must provide for direct payment and evacuation.
• Medicines: to be bought in reliable pharmacies, never on the street; reimbursement depends on the CFE scale or the contract ceilings.
• Dental: dental practices judged reliable exist in Kinshasa; cover is read in the contract’s table of benefits, often with an annual ceiling.
• Optical: glasses and lenses depend mainly on international contracts, with ceilings per period.
• Maternity: the CNSS provides prenatal allowances and maternity daily allowances for the affiliated female worker; the CFE requires conception after joining; international contracts generally apply a maternity waiting period.

The reimbursement guide and the page on expat health insurance give points of reference; Expavy helps to match these options against your situation, and the guide to repatriation and assistance details the evacuation cover.