Expat insurance and health insurance in American Samoa

American Samoa has no universal health insurance fund comparable to French Sécurité sociale. The system combines the territory's Medicaid (programme created in 1983, run by the American Samoa Medicaid Agency), Medicare for those aged 65 and over under conditions, and employer or individual insurance, supervised by the territory's Insurance Commissioner. CMS indicates that American Samoa residents cannot use the federal Marketplace. According to the MACPAC commission, the federal contribution rate for the territory's Medicaid is permanently set at 83%, within an annual federal funding ceiling (section 1108 ceiling). Medicaid.gov specifies that the territory does not determine eligibility individually but uses presumptive eligibility based on the share of the population below 400% of the federal poverty level, with nearly 40,000 people considered eligible for Medicaid and CHIP.

France Diplomatie describes for the United States an excellent medical infrastructure but at a very high cost, and deems essential an assistance contract or insurance covering all medical costs as well as medical repatriation. The LBJ Tropical Medical Center, in Faga'alu, presents itself as the territory's only hospital. See the page healthcare system in American Samoa.

• Territory entry permit: the Department of Legal Affairs specifies that American Samoa's entry laws differ from those of the United States and that no one can enter without meeting the requirements of the territory's government (Department of the Interior). A national of a country in the US visa waiver programme applies online for a 30-day visitor permit ($40 non-refundable, passport valid for at least 6 months after departure, return ticket, accommodation booking), at least 72 hours in advance excluding weekends and public holidays; this permit cannot be extended. The territory's page does not mention ESTA, and the France Diplomatie page describes no rule specific to American Samoa.
• Other travellers: 30-day permit requested in person by a sponsor aged at least 21, a US citizen or national ($40), extendable once by 30 days ($50).
• Settling, work: residency petition based on family (form P-12) or on employment (form P-45), to be approved before entering the territory; application fee of $75, identity card of $30 and a bond varying by country of origin, paid after approval.
• Travel insurance: an assistance contract or insurance covering all medical costs and medical repatriation is deemed essential by France Diplomatie for the United States; admission to the emergency department is subject to a financial guarantee.
• Local affiliation: no general health insurance obligation for a visitor was found in the sources consulted; employer insurance, an individual contract, Medicare or the territory's Medicaid apply depending on status.
• Student: no EHIC (outside the European Union); Assurance Maladie (French health insurance) recommends an assistance contract or insurance for the United States, and CFE membership 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, United States line); the CFE and an assistance contract 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 at admission make the financial risk significant for an uninsured expat.

Coordination between France and American Samoa runs through the France-US social security agreement, signed on 2 March 1987 (administrative arrangement of 21 October 1987) and entered into force on 1 July 1988. According to CLEISS, its territorial scope includes, on the US side, the federated states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam and the American Samoa Islands. It coordinates disability, old age and survivors' benefits, with totalisation of periods from six US quarters of insurance.

• Sickness and maternity: no coordination provision; no S1 form, no EHIC. Planned care remains at the person's own expense unless their fund exceptionally authorises it; during a temporary stay, only urgent and unforeseen care can possibly be reimbursed on return (Assurance Maladie).
• Secondment: form SE 404-02 covers 5 years for an initial secondment, with no extension (CLEISS summary table). The seconded employee keeps French health insurance and sends their paid invoices with form S 3125c.
• Expatriation: an employee working on site is in principle subject to the legislation of the country of work; their dependants who stayed in France should enquire with their CPAM and their CAF.
• Retiree: health contribution of 3.2% (basic pension) and 4.2% (supplementary pension) that can be withheld as long as they remain attached to a French scheme; no CSG, CRDS or Casa if tax residence is no longer in France (CLEISS).

Tax treaty. The treaty of 31 August 1994 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 of the United States (treaty text published by the IRS). American Samoa, a US territory, is not named but falls within this general exclusion: the residence and tax-allocation rules provided for the United States therefore cannot be taken for granted for a stay in the territory. The IRS specifies that American Samoa has its own tax system, separate and independent, inspired by the federal code with differences; bona fide residents file a federal return excluding local-source income (form 4563 attached) and turn to the territory's Government Tax Office for territorial tax. A mutual agreement procedure exists between the United States and American Samoa for cases of double taxation (publication 570).

1. Before departure: notify French agencies of your departure (health insurance fund, CAF, France Travail, pension funds); hand back your carte Vitale and EHIC if you are expatriating.
2. For any stay, including a short one: take out an assistance contract or insurance covering all medical costs and medical repatriation, essential according to France Diplomatie.
3. Visitor: apply online for the 30-day permit from the Department of Legal Affairs at least 72 hours before departure (passport valid 6 months after the departure date, return ticket, confirmed accommodation); a person who arrives without a permit may be refused entry.
4. Settling: have the residency petition (family or employment) filed and approved before entering the territory, with the immigration office, reachable on (684) 633-4163 or info@la.as.gov.
5. Consult the notices of the American weather service in Pago Pago before and during the cyclone season, from 1 November to 30 April.
6. Seconded employee: request form SE 404-02 through the employer; self-employed: Urssaf (international mobility department).
7. Long-term settlement: choose local insurance (employer, individual contract, territory's Medicaid or Medicare depending on the conditions) and, if needed, the CFE before departure or within three months.
8. Taxation: have your situation validated with the French tax administration, the territory's Government Tax Office and the IRS, as the tax treaty excludes US territories from the definition of the United States.
9. Retiree: arrange the CFE (retirees' plan) or private insurance, then look into Medicare from age 65.
10. Register on the roll of French nationals living abroad; consular responsibility for American Samoa is to be confirmed with the French Consulate General in San Francisco, whose page mentions the US Pacific territories.