Healthcare Reimbursement in American Samoa: 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 American Samoa Islands in its territorial scope, alongside the states, the District of Columbia, Puerto Rico, the Virgin Islands and Guam. It coordinates disability, old age and survivors. CLEISS specifies that, for retirees, it contains no provision allowing reimbursement of care received in the United States: no S1 form, no European card, no cross-border cover (see the bilateral agreement). France Diplomatie (the French foreign ministry) indicates that admission to the emergency department is subject to a financial guarantee.

Several players can therefore intervene depending on status: employer insurance or an individual contract, the maintained French scheme for a seconded employee, the CFE and international health insurance. Medicare and the territory’s Medicaid are added for eligible residents: their conditions are detailed in the page healthcare system in American Samoa. The notions of reimbursement basis and out-of-pocket cost help compare plans.

The local-contract employee comes, under the agreement’s general rule, under the legislation of the country where they work. They leave the French scheme for sickness, and their dependants who stayed in France should enquire with their CPAM and their CAF about their rights under French law alone. Their care generally goes through the employer’s insurance, whose licence is checked with the territory’s Insurance Commissioner; notifying the health insurance fund, the CAF and France Travail of the departure avoids repayments of benefits paid in error. See the glossary entry on the local contract.

The seconded employee of a French employer can remain in the French scheme under certain conditions, thanks to the 1987 agreement. CLEISS indicates, for the United States, that they keep French health insurance: they send their fund the paid invoices with form S 3125c, their 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 directly by that fund, the sick note being sent to it within 48 hours. Family benefits cannot be exported. As costs in the United States can exceed those in France, CLEISS advises checking top-up health insurance. See seconded or expatriated and the seconded employee glossary.

The self-employed person or digital nomad has no employer to affiliate them to a local scheme. They choose between an individual contract supervised by the territory’s Insurance Commissioner, the CFE and international insurance; hospital, outpatient and medical repatriation cover suits a stay of several years. See digital nomad insurance.

The student: according to Assurance Maladie (French health insurance), if the student is under 20 or stays less than six months in a country with no social security agreement with France, the parents’ fund can reimburse their urgent medical costs, on three conditions: attending an institution preparing for an official qualification, providing a certificate of enrolment and returning to France at least once during the academic year. Reimbursement is limited to French flat-rate tariffs. Assurance Maladie recommends an assistance or insurance contract, medical costs being very high in countries like the United States, and CFE membership remains possible; the youth plan is for those under 30. See student insurance abroad.

The 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 CFE membership for a French national, or private insurance. The CFE retirees’ plan is for holders of a pension from the French basic scheme with no professional activity, with no health questionnaire, and covers only care provided abroad. A health contribution of 3.2% on the basic pension and 4.2% on the supplementary pension may be withheld when the retiree is attached to a French scheme. See the guide health insurance for retirees abroad and the page retiring in American Samoa.

The spouse and children follow the status of the main insured person. For a seconded employee, they are reimbursed like them on paid invoices. For a local employee, they generally come under the employer’s plan. The CFE offers contracts including dependants. See expat family insurance.

The CFE is a voluntary social protection body. The plans have contributions that depend on age and the plan chosen, for the youth plan (under 30), the main plan and the retirees’ plan, depending on the country of residence, age and family composition. The CFE estimator asks for the country of residence from a list: whether American Samoa appears in that list should be confirmed with the CFE before joining. Abroad, reimbursement depends on the country where care is received and the type of procedure: the CFE applies a rate or flat amount to actual expenditure, and the gap with the price charged remains the member’s responsibility. The guide CFE reimbursements details this mechanism.

• Cover: care abroad, and stays of less than three months in France for the main plan.
• Waiting period: cover is immediate if membership 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 be after membership or after joining as a dependant; daily allowances require at least 10 consecutive months of membership of the corresponding plan 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.

International health insurance with first-euro cover reimburses actual costs within the limit of its ceiling, after any deductible, waiting periods and exclusions of the contract. It can open direct payment with facilities, which answers the financial guarantee that France Diplomatie flags at admission. Before taking it out, you should check that the coverage zone includes American Samoa and the United States, the annual ceiling, medical evacuation (the territory having only one hospital) and the handling of pre-existing conditions (see coverage zone).

The tourist stays, in practice, 30 days at most with the territory’s visitor permit. Assurance Maladie specifies that, outside the European Union, care is paid for on site and only urgent and unforeseen medical care can 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. The request is made from the ameli account or with form S3125. An assistance or insurance contract is recommended, particularly in the United States. See long-stay travel insurance.

The return to France. According to service-public.gouv.fr, with employed work in France, affiliation is acquired from the first hour worked: the contract or a payslip accompanies form S1106 sent to the CPAM. With no activity, three consecutive months of residence in France must be shown. A CFE member can, under conditions, keep their benefits for the three months following their return. See return to France and the guide reducing the waiting period.

• Consultation: insurer’s network for a local employee; French rules on paid invoices for a seconded employee; rate or flat amount of the country of care at the CFE; actual costs for a first-euro contract.
• Hospital stay: financial guarantee requested on admission (France Diplomatie); the LBJ Tropical Medical Center publishes its price file online; 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: the territory’s Department of Health presents dental care; cover is often separate and capped in international contracts and is read in the table of benefits before taking out a contract.
• Maternity: at the CFE, conception must follow membership; international contracts generally apply a waiting period; a seconded employee is reimbursed under French rules on invoices.

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