Health insurance between countries: covering the move, visits home and the return

Health insurance is built for people who stay put. Americans abroad cross borders, and that's where the gaps hide: the weeks around a move, the two weeks home for Thanksgiving, and the first months after moving back to the States.

The short version

• Your US plan usually doesn't follow you abroad, and Original Medicare pays for care outside the US only in rare cases [3].
• Your host country's plan usually doesn't follow you home. A trip back to the US with only local public coverage can mean a full-price US hospital bill.
• International health plans come in two flavors: worldwide including the US, and worldwide excluding the US. The second is much cheaper and leaves the gap open.
• Moving back to the US is a qualifying event for a Special Enrollment Period on the ACA marketplace; you usually have 60 days [1].
• Plan the move itself so one policy ends the day after the next one starts.

Why the gaps happen

Each system has its own border rule. US employer plans and ACA marketplace plans are built around US provider networks, and many pay little or nothing for routine care abroad. Read your plan's evidence of coverage for "out of country" before you count on it.

Medicare is the clearest case. Original Medicare usually doesn't cover care outside the US. It may pay in narrow situations, such as an emergency in the US where a foreign hospital is closer than the nearest US hospital, travel between Alaska and another state through Canada, or living in the US closer to a foreign hospital than a US one [3]. Living in Portugal isn't one of them.

Host-country public systems work the other way. Your residence permit may get you into the national system, but it pays for care there, not in Ohio. Europe's reciprocal arrangements between member countries don't extend to the US.

Option 1: international health plans

An international private medical insurance plan, often called an expat health plan, covers you wherever you live, within a defined area. The big decision is whether the US is in that area.

Things to check before you sign:

1. Pre-existing conditions. Unlike ACA plans, many international plans exclude or delay coverage for conditions you already have, or underwrite them individually.
2. Age limits on buying a new policy, and whether the policy is guaranteed renewable once you're in.
3. Short-trip US cover. Some "excluding US" plans cover emergencies on US trips up to a set number of days per trip. Know the number.
4. Whether it satisfies your visa. Many residence visas require private insurance with set minimums. The consulate's list is the one that counts, not the insurer's brochure.
5. Evacuation and repatriation. Getting flown to a better hospital, or home, is expensive and often a separate benefit.

We don't name insurers, but a licensed broker who works with expats can line up quotes from several. Ask what they're paid and by whom.

Option 2: local coverage plus a plan for US visits

Many Americans join their host country's public system, add a local private top-up if it's common there, and buy separate travel medical insurance for each trip back to the States. It's often the cheapest setup, with tradeoffs:

• Travel medical policies cover emergencies and accidents, not checkups or ongoing care.
• They often exclude pre-existing conditions or cover them only if stable.
• Coverage is per trip and capped in days. A three-week summer visit and a four-month stay with aging parents are different products.

If you're 65 or older and kept Medicare, the picture changes on visits home: Medicare covers you in the US as usual. Some Medigap plans (C, D, F, G, M and N) also pay 80% of foreign travel emergency care, up to plan limits [4], which helps on trips abroad if you still live stateside, not as your main cover once you've moved.

The Medicare question

Keeping Part B while you live abroad means paying premiums for coverage you can only use in the US. Dropping it can mean a penalty later: an extra 10% for each full 12-month period you could have had Part B but didn't, usually for as long as you have Part B [5]. Our guide to Medicare when you live abroad weighs both sides.

Covering the move itself

The move is when coverage most often lapses for a few weeks, and that's when you're carrying boxes and getting on long flights.

1. Find out the exact end date of your US coverage. Employer plans often end on the last day of the month you leave the job.
2. Decide whether COBRA is worth it. COBRA lets you keep your employer plan (if the employer has 20 or more employees) for up to 18 months after leaving a job, at the full premium plus a 2% administrative charge [2]. You have 60 days to elect it and 45 days after electing to make the first payment [2]. That makes it a useful safety net for the move, but check whether the plan pays for care abroad at all.
3. Start the international plan on your departure day, not on the day you land or the day your residence permit is approved.
4. Bridge the waiting period for your host country's public system with private cover, if there is one. Some countries make new residents wait months.
5. Fill prescriptions before you go, and carry a letter from your doctor with generic drug names.

Coming back: the ACA marketplace

Moving back to the US from a foreign country is a qualifying life event. You can usually enroll in a marketplace plan within 60 days of the move, outside the November 1 to January 15 open enrollment window [1]. Moving only for medical treatment or a vacation doesn't qualify [1], and you may need to send documents to confirm your move [1].

Some practical points:

• Pick the date carefully. The 60 days run from the move, so apply soon after you have a US address.
• Your income estimate matters. Premium tax credits depend on expected household income for the year. If you earned most of the year's pay abroad, a US expat tax preparer can check how that will look on your return.
• Losing your international plan can also be a qualifying event if it counts as qualifying coverage; when in doubt, call the Marketplace Call Center at 1-800-318-2596 [6] before the 60 days run out.
• Employer coverage beats all of this if you're coming home to a job. Ask when coverage starts; some employers have a waiting period, and you'll need a bridge.
• Some states run their own marketplace with their own deadlines. Check your state's site if it isn't on HealthCare.gov.

The federal penalty for going without coverage has been zero since 2019, but a handful of states have their own coverage requirements, with a penalty on the state return. Check your state's rules before you assume a gap is free.

Our guide to moving back to the US covers the tax and credit side of the return.

A simple plan by situation

Sources

1. Getting health coverage outside Open Enrollment, HealthCare.gov
2. FAQs on COBRA continuation health coverage for workers, US Department of Labor
3. Travel outside the U.S., Medicare.gov
4. Compare Medigap plan benefits, Medicare.gov
5. Avoid late enrollment penalties, Medicare.gov
6. Special Enrollment Periods for complex health care issues, HealthCare.gov

Keep reading

• Medicare when you live abroad
• Moving back to the US: taxes, health insurance and credit
• Managing US affairs from abroad: powers of attorney and notaries
• Wills and estate planning across two countries