Healthcare Reimbursement in Saint-Pierre and Miquelon: Who Pays What Depending on Your Situation

Saint-Pierre and Miquelon is part of the Republic: no bilateral social security agreement is needed. The CLEISS describes a local scheme similar to the mainland one, run by the CPS, which is gradually being harmonised with it. Coordination with the schemes of mainland France, the overseas departments, Saint-Barthélemy and Saint-Martin is organised by decree no. 2011-512 of 10 May 2011, which applies whatever the nationality. It governs affiliation, secondment, temporary stays, retirees, medical evacuations and the totalisation of insurance periods.

In practice, you choose your doctor freely, the insured person advances the costs and is then reimbursed by the CPS within the limits of its liability tariffs, and extra fees are never reimbursed. The coordinated care pathway requires declaring a referring doctor. The notions of ticket modérateur (co-payment), out-of-pocket cost and reimbursement base help you read a statement. The organisation of care is presented in the guide to the archipelago’s healthcare system.

An employee on a local contract works on site without being posted: they come under the archipelago’s legislation, for themselves and for the family members who live there, according to the CLEISS. They register with the CPS with a local payslip and the certificate from their former fund. Before leaving, form SE 975-02 (totalisation of insurance periods) avoids a waiting period on returning to France. Daily allowances require 150 hours worked in the last three calendar months or contributions on a salary of at least 1,015 times the hourly SMIC (minimum wage) over six months (CPS).

A State civil servant assigned to Saint-Pierre and Miquelon, together with their dependants, is affiliated from the day they take up their duties to the archipelago’s health and maternity insurance scheme for benefits in kind (Article 4 of the decree). The CPS asks for a copy of the transfer order and withholds a specific health contribution of 7.25% of the base (4.80% employer, 2.45% employee).

A posted employee sent by a mainland company remains subject to the French scheme as long as the secondment does not exceed two years, leave included, and they do not replace another posted worker. The employer requests the certificate of liability (SE 975-01) from the CPS. Care is claimed either from the CPS with forms SE 975-01 and SE 975-05 (which then applies its local rules), or from the home fund with paid invoices and form S 3125c. Daily allowances remain paid by the home fund, on sending the sick note within 48 hours. See the posted worker glossary entry.

A self-employed person comes under the CPS like an employee, with identical protection provided their contributions are up to date: 9.00% sickness-maternity on income up to the ceiling, according to the CPS. They are not covered by unemployment insurance. The CPS invites self-employed people with cash-flow difficulties to contact its collection department.

Spouse and children are dependants of the insured person: children under 18 are affiliated as dependants of their parents, an adult is affiliated individually and a non-working spouse follows the main insured person. The supporting documents are the family record book and each child’s school certificate. If the family stays in mainland France while the employee works in the archipelago without being posted, it registers, for lack of cover of its own, with the primary fund of its place of residence with form SE 975-06 issued by the CPS (cover by the main insured person’s affiliation fund, Article 9 of the decree); in case of secondment, it remains attached to the home fund. For family benefits, the claimant must be registered with the CPS and show permanent residence. See also expat family insurance.

A retiree of a French scheme (former employee, self-employed person or civil servant, excluding military pensions) who settles in the archipelago registers with the CPS with form SE 975-07, completed by their pension fund and the CPS, which also allows the dependants living with them to be registered. Benefits in kind are then provided by the CPS under its regulations. If tax residence is no longer in France, no CSG, CRDS or Casa (French social levies) is due; a health insurance contribution is, however, withheld from the pension if the retiree remains attached to a French scheme (3.2% on the basic pension, 4.2% on the supplementary pension and 7.1% for self-employed workers’ pensions, according to the CLEISS). The page on retiring in Saint-Pierre and Miquelon complements this point.

A student remains covered depending on the place of study: the CPS invites you to check the procedure before leaving the archipelago, and offers an information sheet for students returning from abroad. A student from mainland France who settles in the archipelago comes under the stable and regular residence rule. Higher education takes place outside the archipelago, which makes the page on student insurance useful for a course in Canada. The solidarity supplementary health scheme does not apply to the archipelago.

An insured person from mainland France (or from an overseas department, Saint-Martin or Saint-Barthélemy) who stays temporarily in the archipelago can have immediately necessary care covered. Before leaving, they request form SE 975-03 from their fund and present it to the CPS; care is handled under local legislation, family members listed on the form being covered in the same way. If care continues beyond the period indicated, the CPS contacts the home fund for a new certificate. Scheduled care is excluded from this arrangement. Sick leave during the stay is reported to the home fund within 48 hours; it pays the daily allowances.

For scheduled care or paid sick leave, the home fund can authorise the stay with form SE 975-04: the authorisation cannot be refused if the care cannot be provided in mainland France within a reasonable time. A foreign traveller, who is not insured with a French scheme, does not fall within this arrangement: the sources consulted describe no cover for them, and travel insurance with assistance (see travel insurance) covers medical costs and repatriation. The hospital centre publishes a section on hospitalisation costs.

The Caisse des Français de l’Étranger (CFE), the voluntary health insurance scheme for French people abroad, is aimed at expatriates. Its subscription form lists Saint-Pierre and Miquelon among the places of residence, but the sources consulted do not specify the eligibility conditions for a resident of the archipelago, who is otherwise affiliated to the CPS. The decree of 10 May 2011 itself excludes voluntary insurance from its scope. Before any membership, you should obtain a written reply from the CFE and the CPS. The guides on the CFE and on CFE reimbursements detail how this body works in general.

A supplementary health policy covers the ticket modérateur and the hospital charge, which the local health insurance does not reimburse; the policy’s level of cover determines the share of extra fees covered. International health insurance from the first euro reimburses actual costs within its limits, after deductible and waiting periods: it serves mainly to complement family evacuations, stays in Canada or care outside the coordinated pathway. Expavy helps you weigh these options against your situation.

• Consultation: sector 1 GP, 70% of €30, i.e. €21 reimbursed and €9 remaining; sector 2 (free fees), 70% of €23, i.e. €16.10 (CLEISS). No reimbursement of the extra fee.
• Hospital care: hospital charge of €20 a day (€15 in psychiatry) and a €24 contribution for major procedures according to the CLEISS; the CPS has mentioned a charge of €18: the amount should be confirmed with the fund. The CLEISS cites 100% cover for radiodiagnosis, MRI, emergency transport, hospitalisation from the 31st consecutive day and laboratory tests, and exemptions from the flat-rate contribution for long-term conditions (30 illnesses), pregnant women from the 6th month or a newborn in its first 30 days.
• Medicines: 30%, 65% or 100% depending on the medical benefit.
• Dental: care at the CPS health centre (two dentists and a dental technician); the CLEISS cites dental prostheses among the services covered at 100% of the liability tariff; annual preventive appointment programme for insured people aged 3 to 24.
• Optical and hearing aids: the CPS publishes pages on glasses and hearing aids, but the amounts do not appear on the pages consulted; ask the CPS before buying.
• Maternity: 100% of the liability tariff for pregnancy, childbirth and postnatal care, with a pregnancy declaration to the CPS before the end of the 3rd month; 10 months of registration are required for the allowances.
• Medical evacuation: transport, care and residence allowance covered by the CPS after the committee’s opinion; the extra cost of a facility chosen by the insured person is borne by them.

The general guide to reimbursements and the page on returning to France complement these benchmarks.

On return, form SE 975-02 given to the mainland fund allows entitlements to be resumed with no waiting period, thanks to the totalisation of insurance periods (Article 5 of the decree). A resident of the archipelago on a stay in mainland France receives benefits in kind from the institution of the place of stay, reimbursed by the CPS. For a retiree, reimbursement falls first to the fund linked to the scheme that pays the pension; for a hospitalisation of more than a month, prior medical agreement is needed, and the spouse who accompanies them is not covered by this scheme. Travel insurance before the stay is advised by the CLEISS. For private trips to Canada, cover is confirmed with the CPS before departure.