Subsidiary State medical cover (from 1 January 2025): publication of the regulatory text implementing law no. 1.562 of 2 July 2024 (Ministerial Order no. 2024-554 of 10 October 2024)

Ministerial Order no. 2024-554 of 10 October 2024 (JDM no. 8717 of 18 October 2024) implements Law no. 1.562 of 2 July 2024 on subsidiary medical cover (couverture médicale subsidiaire "CMS"): conditions for eligibility, costs covered, minimum contribution to healthcare costs, amount of the annual contribution, formalities and procedures, termination.

Subsidiary medical cover (CMS) from 1st January 2025 is a subsidiary, paying insurance scheme offered by the State to Monegasques and foreign nationals residing in Monaco on a stable and regular basis for at least 5 years, designed to compensate for the lack of cover provided by the private sector, regardless of the beneficiary's means.

NOTE: The CMS referred to here should not be confused with the State medical aid (aide médicale de l'État) that may be awarded to the aforementioned persons, provided that they can prove that their average daily income is below the ceiling of 30 euros per day (see Sovereign Order n° 5.743 of 3 March 2016 relating to State medical aid and the implementing Ministerial Order no. 2016-151 of 3 March 2016).

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IN DETAIL

¤ Conditions for entitlement to subsidiary medical cover (CMS)

The Ministerial Order specifies that the person who terminated the last health insurance contract of which he or she was a beneficiary cannot be considered as "unable to take out an individual health insurance contract with a private insurance company", and therefore be eligible for SMC within the meaning of Law no. 1.562 of 2 July 2024.

The following are considered to be unable to take out an individual health insurance policy with a private insurance company:

• a foreign resident in Monaco for at least 5 years who can prove that he/she has been refused full or partial cover for illness by 3 insurers operating in Monaco;
• a Monegasque who can prove that he has been refused full or partial cover for sickness by 3 insurers operating in his or her place of residence.

These 3 refusals must have occurred within a period of less than or equal to 1 year prior to the date of application.

¤ Expenses that may be reimbursed under the CMS

The Ministerial Order defines the expenses that may be covered and incurred in the event of maternity and illness other than an occupational illness or accident, disability or death for the claimant, by reference to Article 22 of Sovereign Order no. 8.011 of 12 March 2020 relating to the granting of medical benefits to civil servants and employees of the State and the Commune, namely:

1. general and special medical expenses, including surgical operations and those performed by medical auxiliaries;
2. cost of dental treatment and prostheses;
   
3. pharmacy costs
   
4. orthopaedic treatment;
   
5. laboratory analyses and tests;
   
6. costs of hospitalisation and treatment in care and cure establishments;
   
7. costs of stays in convalescent or rest homes;
   
8. accommodation and treatment costs for disabled children or adolescents in medical establishments for special and vocational education, as well as treatment costs for such education outside these establishments;
   
9. transport costs necessitated by the patient's treatment.

This reimbursement is made under the conditions set out in articles 23 to 42 of the aforementioned Sovereign Order and the amount reimbursed may not exceed the costs incurred.

¤ Minimum contribution to healthcare costs

Except in exceptional circumstances, the CMS leaves the beneficiary of benefits to pay a minimum contribution which may not exceed 20% of the basis for reimbursement of healthcare costs.

The Ministerial Order specifies that the minimum contribution towards healthcare costs may, in the light of the beneficiary's situation, be limited or waived by decision of the Director of Social Action and Assistance (Directeur de l’Action et de l’Aide Sociales), taken on the basis of a reasoned opinion from the medical officer (médecin conseil) of the State Medical Benefits Department (Service des Prestations Médicales de l’État).

¤ Amount of the monthly contribution

The CMS is paid on condition that the beneficiary, or where applicable the beneficiary's legal representative, pays a monthly contribution, the amount of which is set at 700 euros by Ministerial Order.

¤ Formalities (application and supporting documents)

The Ministerial Order specifies that the application for the CMS must be made using a form available from the Department of Social Action and Assistance (Direction de l’Action et de l’Aide Sociales), which must be returned to this Department by the applicant or, where a teleservice is available for this purpose, by electronic means with acknowledgement of registration in accordance with Article 52 of Sovereign Order no. 3.413 of 29 August 2011 on various measures relating to relations between the Administration and the citizen.

The application must be accompanied by the supporting documents required to examine the file, and in particular:

1. any document proving that the claimant is not affiliated to any Monegasque or foreign social security fund or cannot apply to become a beneficiary of one of these funds, in particular a certificate of termination of entitlement or non-affiliation with a social security body or refusal of cover;
   
2. three proofs of refusal of insurance issued by three different insurance companies operating in Monaco or, if the applicant is Monegasque, issued by three different insurance companies operating in the applicant's place of residence;
   
3. proof that the applicant has not cancelled his/her last health insurance policy with a private insurance company;
   
4. a copy of the Monegasque identity card or resident card of the applicant and members of the household;
   
5. a copy of the applicant's family record book;
   
6. an extract from the legal separation order or divorce decree for separated or divorced persons;
   
7. a bank details form.

The Department of Social Action and Assistance (Direction de l’Action et de l’Aide Sociales) examines the application and carries out the necessary checks to determine whether the conditions for entitlement to CMS are met.

Entitlement to CMS is established, by decision of the Director of Social Action and Assistance, on the first calendar day of the month in which the complete application is submitted.

However, if, on that date, the applicant did not meet the legal and regulatory conditions to benefit from CMS, the entitlement opens on the first day from which he/she met all the conditions to benefit from it.

¤ Modalities (benefits)

CMS expenditure is covered by the Social Welfare Office (Office de Protection Sociale).

The Ministerial Order specifies that the State Medical Benefits Department (Service des Prestations Médicales de l’État) examines claims for medical benefits in kind under the CMS and settles claims, in accordance with Article 2 of Sovereign Order no. 231 of 3 October 2005 creating a State Medical Benefits Department.

¤ Termination

The CMS may be terminated at any time by the beneficiary or the beneficiary's legal representative, who must inform the Director of Social Action and Assistance at least 15 calendar days before the date on which they wish the termination to take effect.

Coverage of healthcare costs ceases on the date of termination.

If termination takes place during the course of a month, the premium paid for that month remains payable.

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