Healthcare Reimbursement in Saint-Martin (French Side): Who Pays What Depending on Your Situation

Saint-Martin is part of the Republic and title V of book VII of the social security code applies there (Article L751-1). The Guadeloupe CGSS and family allowance fund apply the legislation in Saint-Martin, each in its field (Article L752-1). The CLEISS (the French centre for international social security links) specifies that, in the overseas departments, benefits are paid by the CGSS and not by the CPAM (local health insurance offices), and that the stable and regular residence condition also applies to Saint-Barthélemy and Saint-Martin. No international coordination formality is therefore needed for a stay on French territory alone.

Reimbursement rests on three tiers: the general scheme reimburses on the basis of its rates; the ticket modérateur (co-payment) and extra fees fall to supplementary health insurance; the solidarity supplementary health scheme, free or paying depending on resources, covers modest incomes. The out-of-pocket cost therefore depends as much on the supplementary policy as on the compulsory scheme. The organisation of care provision is described in the guide to the healthcare system in Saint-Martin.

An employee does not have to show a minimum length of activity: carrying out a professional activity is enough to open their entitlements (Assurance Maladie, French public health insurance). They benefit from reimbursement of care at the general scheme's rates, daily allowances in case of sick leave and benefits linked to maternity and industrial accidents, under national rules. A supplementary health policy, group or individual, covers the ticket modérateur and extra fees.

A State civil servant comes under the compulsory civil servants’ scheme. In mainland France, the law of 9 April 1947 entrusted the management of benefits to delegated mutual insurers, notably local mutual sections, which may be ministerial or inter-ministerial (National Assembly information report on the management of the compulsory scheme by certain mutual insurers). The documents consulted do not specify the competent manager for an agent assigned to Saint-Martin: it should be confirmed with their managing department and the CGSS before arrival, as should the file transfer formalities.

A self-employed person is covered from the start of their activity (Assurance Maladie). The contribution arrangements specific to the island are confirmed with the CGSS; reimbursement follows the general scheme’s rates, and entitlements to daily allowances depend on the fund’s conditions.

A retiree is covered by virtue of their stable and regular residence in France, with proof of 6 months of residence in the last 12 months in case of a check; they send form Cerfa S1106 to the fund of their place of residence. Their pension is paid by the schemes they come under; the guide to retiring in Saint-Martin details the steps. People with no professional activity come under the same residence criterion.

An adult student is insured in their own right from the age of majority, or from 16 on request (Assurance Maladie). The Assurance Maladie does not detail a particular rule for Saint-Martin students: the conditions for affiliation and for changing fund in case of studies in mainland France or abroad are confirmed with the CGSS. For studies abroad, the page on insurance for students abroad presents the cover options.

The spouse: in case of marriage, separation or widowhood, the non-working insured person keeps their own entitlements. Only minors keep dependant status; an adult dependant can request affiliation as an insured person on the residence criterion with form S1110. Children remain dependants until they reach adulthood, or until 30 September of the year of their 18th birthday at the latest (CLEISS).

A visitor from mainland France on a short stay keeps their home fund. Saint-Martin comes under the same social security legislation as mainland France; the documents consulted describe no practical rule specific to insured people of another fund passing through (use of the carte Vitale, third-party payment): it is prudent to ask your fund before departure and to plan for assistance covering evacuations. See the page on repatriation and assistance.

A trip to Sint Maarten is a stay abroad. France Diplomatie (the French foreign ministry’s travel advice) specifies that the European health insurance card does not cover the Dutch overseas territories, including Sint Maarten, and recommends cover for medical costs, hospitalisation and medical repatriation. For a stay outside Europe, the Assurance Maladie possibly reimburses only urgent and unforeseen medical care, after advancing the costs and an application with form S3125, on the basis of French flat-rate tariffs and with no daily allowances.

Returning to mainland France means informing the CGSS and requesting the opening of entitlements with the fund of the new place of residence: the CLEISS specifies that this opening is not automatic on a change of situation and that form Cerfa S1106 must then be completed. No waiting period is mentioned in the sources consulted for this change of residence within national territory.

The Caisse des Français de l’Étranger covers expatriates who live and work abroad (a main offer, a youth offer and a retiree offer, each with a contribution that depends on age and the plan chosen, according to the CFE website). As long as a French citizen lives on the French side of Saint-Martin, they come under the general scheme; membership only becomes useful if you leave France, for example a main residence in Sint Maarten. The guide to the CFE details the scales and waiting periods.

The solidarity supplementary health scheme is free or paying depending on resources. The public service publishes annual ceilings for mainland France (€10,421 for a single person where it is free) and for Guyana, Guadeloupe, Martinique and La Réunion (€11,599); Saint-Martin is not mentioned on this page, and the application of the ceilings to the island is confirmed with the CGSS. It removes extra fees, the medical deductible and the advance of costs when the care pathway is followed. Private insurance from the first euro is not needed for basic reimbursement, but it can fund the extra fees and evacuations that exceed the compulsory scheme.

• Consultation: 70% for a GP; a €2 flat-rate contribution remains payable by the insured person (example of a €30 consultation: €21 covered).
• Hospital care: 80% on the reimbursement base; the daily hospital charge is not given in the rates page consulted. Transfer between facilities is covered at 65%, transport costs at 55% (100% for certain recipients).
• Medicines: 65% for major or important medical benefit, 30% for moderate, 15% for low; a €1 medical deductible applies in the example of a box of medicines.
• Dental and optical: 60% for dentists and optical, with a reimbursement base of €2.84 for the frame and €6.25 per single-vision lens; recipients of the solidarity supplementary health scheme benefit from cover with no out-of-pocket cost.
• Maternity: the hospital centre has a level 2b maternity unit; reimbursement follows national maternity rules, to be confirmed with the CGSS.
• Medical trips: transport on prior agreement counting as a medical prescription; companion’s costs under conditions; daily allowances under the usual conditions (Assurance Maladie).