Mandatory Health Insurance Rules

Step 4 - Medical Expense Settlement & Family Members

Determining social security coverage for family members requires an independent assessment from the employee's situation. This involves evaluating if the family member can be co-insured under the employee's healthcare plan, included under a certificate of coverage, or if they need to secure their own healthcare insurance in the country of residence.

The following scenarios are relevant:

Family members with their own income

They will be independently subject to the social security system of the country where they work and likely also have mandatory insurance there. To determine that country, follow the instructions in Roadmap "Mandatory Social security Rules".

Family members without income

When a family member does not have an independent source of income, securing their healthcare coverage becomes a critical consideration that requires the following distinctions:

• Living in a social security treaty country with a Medical Expense Clause;

The family member must be registered with the designated health insurer in their country of Residence using the S1 (106) form, which is provided by the employee's health insurer in the country of Insurance.

The designated health insurer in the country of Residence will decide whether or not co-insurance under the employee's healthcare plan is possible.

If co-insurance is approved, the family member will not have a separate policy but will be included in the employee's coverage. The health insurer will issue proof of insurance to access medical care in their country of Residence under the prevailing local conditions.

For co-insured family members aged 18 or older, the insured employee must pay contributions in the country of Insurance. This is known as the "Treaty Contribution."

Co-insurance will be terminated when a co-insured family member no longer qualifies as part of the family or when they begin receiving their own income.

• Living in a social security treaty country without a Medical Expense Clause

In these cases, it is crucial to determine, based on the specific social security treaty, whether the family member can continue to be covered by the mandatory insurance of the country of origin. Some treaties allow for family members to remain covered under the same social security scheme as the employee, provided the employee also remains insured in the country of origin. In such cases, they can be included on the Certificate of Coverage (CoC), ensuring that both the employee and their family members remain insured in the country of origin.

If a Certificate of Coverage (CoC) does not extend to family members, it is essential to review the social security legislation of their country of residence. This will determine whether mandatory insurance coverage applies, or if the family member must obtain voluntary or private medical expense insurance.

• Living in a non-treaty country

When a family member resides in a third country (there is no social security treaty), it is crucial to consult that nation's social security legislation. This will determine if mandatory insurance applies, or if the family member needs to secure voluntary or private medical expense insurance.

Dependent Children

Dependent children are required to be insured under the mandatory insurance of the parent in their country of Residence. If none of the parents has mandatory insurance in the children's country of Residence, co-insurance under the employee's insurance is required.