Health Insurance for American Expats: The Complete Guide

Let's start with the thing that surprises most Americans over 65: Medicare does not cover you outside the United States. Not in Canada. Not in Mexico. Not anywhere.

There are exactly three narrow exceptions, and none of them are useful for expats:

1. You're on a ship within six hours of a US port and the nearest US hospital is too far.
2. You're traveling the most direct route between Alaska and the contiguous US through Canada, and a Canadian hospital is closer.
3. You live near the Mexican or Canadian border and a foreign hospital is closer than any US hospital.

That's it. If you retire to Portugal, break your hip in Lisbon, and spend two weeks in a Portuguese hospital, Medicare pays exactly $0.

What this means practically: If you're planning to live abroad full-time, you're starting from zero on healthcare coverage. You need either local public healthcare, an international private plan, or both. The upside? Almost every option available to you will cost less than what you were paying in the US.

Should you keep Medicare? This is the $170.10/month question (that's the 2025 Part B premium). If you plan to eventually return to the US, keep paying Part B. If you drop it and re-enroll later, you'll pay a 10% penalty for every 12-month period you were eligible but not enrolled -- and that penalty lasts for life. Part A (hospital insurance) is premium-free for most people, so keep that regardless.

If you're 100% certain you're never coming back, dropping Part B saves you roughly $2,000 per year. But "100% certain" is a high bar. Most expat financial advisors recommend keeping it as insurance against insurance -- a safety net in case you need to return to the US for any reason.

IPMI plans are the global equivalent of a high-end PPO. They cover you in multiple countries, let you choose your doctors and hospitals, and provide comprehensive coverage including inpatient, outpatient, and often dental and vision.

The major IPMI carriers serving American expats:

Cigna Global -- The most recognized name. Plans start around $3,200/year for a healthy 35-year-old and climb to $8,000-$15,000/year for someone in their 60s. Comprehensive coverage with a global network of hospitals. You can choose to include or exclude the US from your coverage area -- excluding it drops your premium by 30-40%. Their "Gold" plan covers inpatient, outpatient, dental, vision, mental health, and maternity.

Allianz Care -- Strong in Europe and Asia. Slightly cheaper than Cigna for comparable coverage, typically $2,800-$12,000/year depending on age and plan level. Good claims processing and a well-established hospital network. Their "Essential" plan covers inpatient only (good if you're supplementing with local public care), while "Comprehensive" adds outpatient.

Aetna International -- Part of CVS Health. Solid coverage, particularly strong in Asia-Pacific. Plans run $3,000-$13,000/year. Known for good customer service and a robust wellness program.

AXA Global Healthcare -- European-headquartered, excellent in EU countries. Competitive pricing: $2,500-$10,000/year. Their "Essential" tier is inpatient-only and one of the most affordable quality IPMI options.

How to choose: The single most important decision is whether to include the US in your coverage area. Including it can double your premium because US healthcare costs are astronomical. If you're living abroad full-time and would fly home for emergencies anyway (where Medicare or a short-term US plan could cover you), excluding the US from your IPMI plan is the most common cost-saving move.

Second decision: deductible. A $0 deductible plan costs roughly 40% more than a $2,500 deductible plan. Since you're already saving massively compared to US healthcare costs, a higher deductible is often smart -- you can self-insure routine costs and let the IPMI handle the catastrophic stuff.

Not everyone needs or can afford a $5,000+/year IPMI plan. A tier of more affordable coverage has emerged, primarily targeting digital nomads and younger expats.

SafetyWing Nomad Insurance -- Starts at $45.08/month (age 10-39), scaling to $97.30/month for ages 60-69. Covers 180+ countries. It's travel medical insurance, not comprehensive health insurance -- a critical distinction. It covers emergencies, hospital stays, and urgent care, but not routine checkups, prescriptions, or pre-existing conditions. Maximum benefit is $250,000, which sounds like a lot until you realize a serious hospitalization in some countries can hit six figures. Best for: healthy people under 40 who want a safety net, not a full healthcare plan.

Genki World Explorer -- European-based, starting at EUR 35/month. Better than SafetyWing for routine care: covers outpatient visits, some prescriptions, and has higher overall limits. Popular with European digital nomads but available to Americans. Maximum benefit: EUR 5,000,000. Pre-existing conditions excluded for the first two years, then covered.

World Nomads -- Short-term travel insurance, not suitable for long-term expats. Mentioned here only because people confuse it with expat insurance. Maximum trip length: 6-12 months depending on the plan. Fine for a gap year; terrible for permanent relocation.

Insured Nomads -- A newer entrant with plans from $65/month. Covers telemedicine, mental health, and some wellness benefits. Maximum coverage up to $1,000,000 for medical and $250,000 for evacuation. Their "world" plan includes the US as a coverage area, which is rare at this price point.

The gap to understand: Budget plans are not IPMI. They typically exclude or limit outpatient care, dental, vision, maternity, mental health, and pre-existing conditions. They work well as catastrophic coverage -- you pay for doctor visits and prescriptions out of pocket (which is often very cheap abroad) and rely on the plan for hospitalizations and emergencies. In a country like Thailand where a doctor visit costs $30, this approach makes perfect financial sense. In Switzerland where that same visit costs $200, you probably want the fuller IPMI.

Many popular expat destinations have universal or near-universal public healthcare systems that you can join as a legal resident. This is often the cheapest and most comprehensive option -- if you're eligible.

Spain -- One of the best deals in the world. Legal residents can join the Seguridad Social system. Employed workers and their employers pay contributions (roughly 6.35% of salary from the employee side). Self-employed people pay a minimum of about EUR 290/month, which includes healthcare. Retirees on the non-lucrative visa can buy into the system through the "convenio especial" for about EUR 60/month if under 65, EUR 157/month if over 65. Coverage is comprehensive: GP visits, specialists, hospital care, emergency, prescriptions (small copays), and even dental for children. Wait times for specialists can be 2-6 weeks, which is why many residents also carry a private supplement costing EUR 50-100/month.

France -- The PUMA (Protection Universelle Maladie) system covers all legal residents after three months of stable residence. The government covers 70% of most medical costs. Most residents buy a supplemental "mutuelle" (EUR 30-100/month) to cover the remaining 30%. France consistently ranks in the top 5 healthcare systems globally by WHO measures. GP visits: EUR 26.50 (government pays EUR 18.55, you pay EUR 7.95, mutuelle reimburses that). Prescriptions: heavily subsidized, often free for chronic conditions.

Portugal -- The SNS (Servico Nacional de Saude) is available to all legal residents. Small copays: EUR 4.50 for a GP visit, EUR 7 for a specialist, EUR 18 for emergency room use. Prescriptions are subsidized 15-90% depending on the drug category. Quality is good in Lisbon and Porto, more variable in rural areas. Wait times for specialists can stretch to months, leading many expats to use private clinics for non-urgent care (a private GP visit runs EUR 40-60).

Thailand -- No universal coverage for expat residents, but healthcare is so affordable that many expats skip insurance entirely and pay cash. A GP visit at a private hospital: $30-50. An MRI: $200-400. A night in a private hospital room: $100-200. Full blood panel: $50-100. Thailand's private hospitals (Bumrungrad, Bangkok Hospital, Samitivej) are internationally accredited and cater to medical tourists from around the world. For those who want coverage, the Social Security system is available to employed workers for THB 750/month (about $21).

Mexico -- IMSS (Instituto Mexicano del Seguro Social) offers voluntary enrollment for residents. Costs roughly $500-800/year depending on age. Covers GP visits, specialists, hospital stays, surgery, prescriptions, dental, and even maternity. Quality varies dramatically by location -- IMSS hospitals in Mexico City and Guadalajara are decent; in smaller cities, less so. Many expats use IMSS for routine care and keep a private plan for anything serious. Private healthcare in Mexico is excellent and affordable: a specialist visit runs $40-80, and private hospital costs are roughly 30-50% of US prices.

Costa Rica -- The CAJA system is mandatory for all legal residents. Contributions are income-based, typically $80-150/month for retirees. Coverage is comprehensive and includes prescriptions. The system is well-regarded but slow -- expect significant wait times for specialists and elective procedures. Many residents supplement with private insurance from INS (the national insurer) for about $100-200/month.

Germany -- Mandatory health insurance for all residents. If you earn under EUR 69,300/year (2025 threshold), you must join the public system (gesetzliche Krankenversicherung). Contributions: 14.6% of gross salary, split between employer and employee, plus a supplementary rate of 0.9-1.9%. Coverage is extremely comprehensive. If you earn above the threshold or are self-employed, you can opt for private insurance (PKV), which starts around EUR 300-600/month depending on age and health.

If you have a pre-existing condition, navigating international health insurance gets significantly more complicated. The ACA's guarantee of coverage regardless of health status is a uniquely American regulation -- most international insurers can and do exclude or surcharge pre-existing conditions.

How IPMI carriers handle pre-existing conditions:

Most IPMI plans require medical underwriting. When you apply, you disclose your health history, and the insurer responds in one of four ways:

1. Standard acceptance -- No exclusions, standard premium. Possible if your condition is well-controlled and low-risk (e.g., mild asthma, treated hypothyroidism).
2. Acceptance with exclusion -- They'll cover everything except your pre-existing condition. Common for moderate conditions. You're covered for everything else but pay out-of-pocket for anything related to your condition.
3. Acceptance with loading -- They'll cover the condition but charge a higher premium. Surcharges of 25-100% are common for conditions like diabetes or heart disease.
4. Decline -- They won't cover you at all. This happens with serious conditions like recent cancer, organ transplants, or unstable cardiac disease.

The moratorium approach: Some insurers offer a "moratorium" option instead of full underwriting. Under a moratorium, they don't ask about your health history upfront, but any condition that existed or showed symptoms in the two years before enrollment is excluded for the first two years of coverage. If you go two years without treatment for that condition, it becomes covered. Cigna, Allianz, and AXA all offer moratorium-based plans.

Your best options with pre-existing conditions:

• Local public healthcare is almost always your safest bet. Spain, France, Portugal, Germany, and most EU countries cover residents regardless of health status. No exclusions, no surcharges. This is the strongest argument for choosing a destination with good public healthcare.
• Cigna Global has the most flexible underwriting among IPMI carriers and accepts many conditions that others decline.
• Aetna International offers a "continued personal medical exclusion" plan that covers conditions after 24 months of continuous membership.
• Group plans through international employers don't require individual underwriting and cover pre-existing conditions from day one.

Critical advice: Never lie on a health insurance application. International insurers conduct thorough claims investigations, and if they find an undisclosed pre-existing condition, they'll void your policy retroactively. You'll be uninsured and potentially responsible for tens of thousands in medical bills. Disclose everything and negotiate the best terms you can get.

Medical evacuation coverage pays to transport you to a facility that can properly treat your condition -- either within your country of residence or internationally. If you're in rural Ecuador and suffer a stroke, evacuation coverage can mean the difference between treatment at a small local clinic and a helicopter to a top-tier hospital in Quito or even Miami.

What evacuation actually costs without coverage:

• Air ambulance within a country: $15,000-$50,000
• International air ambulance (e.g., Thailand to US): $100,000-$300,000
• Commercial flight medical escort: $15,000-$25,000
• Repatriation of remains: $10,000-$20,000

These numbers are not hypothetical. They're what the bills actually look like.

Standalone evacuation plans:

Medjet -- The gold standard for evacuation-only coverage. Annual membership: $315/year for an individual, $440/year for a family. Covers medically necessary transport to the hospital of your choice (not just the nearest adequate facility -- your choice). This distinction matters enormously. Most evacuation clauses in insurance policies only cover transport to the nearest facility that can treat you, which might be in a neighboring country rather than back home. Medjet takes you where you want to go.

Global Rescue -- $329/year for individuals. Military-grade operations team. Covers evacuation plus security extraction from dangerous situations (civil unrest, natural disasters). Popular with adventurous travelers and those living in less stable regions.

How evacuation works in IPMI plans: Most quality IPMI plans include evacuation coverage as a standard benefit, typically with limits of $500,000-$1,000,000. Cigna Global includes "unlimited" evacuation. Allianz Care includes it in all plans above the basic tier. Check the fine print on two things: the definition of "medical necessity" (some plans require you to be in genuinely critical condition, not just prefer a different hospital) and whether they cover repatriation of remains.

Pro tip for developing countries: If you live in a country with uneven healthcare quality -- Thailand outside Bangkok, Mexico outside major cities, Philippines outside Metro Manila, Ecuador outside Quito/Guayaquil -- evacuation coverage is not optional. It's as essential as the health insurance itself. A $315/year Medjet membership could be the most important healthcare purchase you make.

Let's put real numbers on what healthcare costs for a typical American expat -- a reasonably healthy 45-year-old, non-smoker, no major pre-existing conditions.

Spain

• Public healthcare (convenio especial): EUR 720/year ($790)
• Private supplement (Sanitas or Adeslas): EUR 600-1,200/year ($660-$1,320)
• IPMI (Cigna Global Silver, excluding US): $4,100/year
• Typical total annual spend: $1,450-$2,100 (public + private supplement)
• Compared to US: $23,968 average

Portugal

• Public healthcare: Free with residency (small copays)
• Private supplement (Multicare or Medis): EUR 400-900/year ($440-$990)
• IPMI: $3,800/year
• Typical total: $440-$990
• Compared to US: $23,968

Mexico

• IMSS voluntary: $500-$800/year
• Private plan (GNP Seguros): $1,200-$3,000/year
• IPMI: $3,600/year
• Typical total: $1,700-$3,800 (IMSS + private supplement or standalone private)

Thailand

• No public option for non-employed residents
• Local private plan (AIA or Bupa Thailand): $1,200-$3,500/year
• IPMI: $3,400/year
• Cash-pay option: Most expats budget $1,500-$2,500/year for out-of-pocket medical costs
• Typical total: $1,500-$3,500

France

• Public healthcare (PUMA): Free after residency established
• Mutuelle supplement: EUR 360-1,200/year ($400-$1,320)
• IPMI: $4,500/year
• Typical total: $400-$1,320

Germany

• Public insurance (mandatory): EUR 4,500-9,000/year (income-dependent)
• Private insurance (if eligible): EUR 3,600-7,200/year
• IPMI: $5,200/year
• Typical total: $4,900-$9,900 (most expensive on this list, but still below US average)

Costa Rica

• CAJA (mandatory): $960-$1,800/year
• Private supplement (INS): $1,200-$2,400/year
• Typical total: $2,160-$4,200

Colombia

• EPS (public system for employed/self-employed): 12.5% of declared income
• Private plan (Sura or Colsanitas): $1,200-$2,800/year
• Typical total: $1,200-$2,800

The pattern is unmistakable: even the most expensive expat healthcare setup costs a fraction of the US average. And in most cases, you're getting comparable or better care.

Americans spend more on prescription drugs than any other country -- roughly $1,432 per capita per year, versus $285 in the UK and $466 in Canada. Moving abroad can slash your medication costs by 50-90%, but it requires some planning.

Before you leave:

1. Get a 90-day supply of all current medications. Most doctors will prescribe this for an international move.
2. Get a letter from your doctor listing all medications by generic name (not brand name), dosage, and the condition being treated. Have it translated into your destination country's language.
3. Research whether your specific medications are available in your destination. Most common drugs are available globally, but brand names differ. Atorvastatin is atorvastatin everywhere, but Lipitor might be sold as Sortis in Germany or Cardyl in Spain.
4. Check controlled substance regulations. Adderall (amphetamine salts) is a controlled or banned substance in many countries including Japan, South Korea, and Thailand. If you take a controlled medication, contact the embassy of your destination country before you travel.

Common medication costs abroad (approximate, without insurance):

• Metformin (diabetes, 90-day supply): US $90-$300 / Mexico $8-$15 / Spain $6-$12 / Thailand $5-$10
• Lisinopril (blood pressure, 90 days): US $30-$90 / Mexico $10-$20 / France $8-$15 / Thailand $6-$12
• Sertraline (antidepressant, 90 days): US $30-$150 / Portugal $10-$25 / Colombia $8-$18 / Thailand $10-$20
• Atorvastatin (cholesterol, 90 days): US $60-$400 / Spain $10-$20 / Mexico $12-$25 / Philippines $15-$30

Over-the-counter availability: Many drugs that require prescriptions in the US are available over the counter in other countries. Antibiotics in Mexico, anti-inflammatories in Spain, asthma inhalers in the UK -- the prescription/OTC distinction varies dramatically by country. This is convenient but also a reason to be cautious: self-medicating without professional guidance carries real risks.

Filling prescriptions abroad: In most countries, you can see a local doctor, get a local prescription, and fill it at a local pharmacy -- all for less than the copay on many US insurance plans. A doctor visit in Mexico ($40) plus a 90-day supply of a common medication ($15) costs less than what many Americans pay in copays alone.

Mail-order from the US: Some expats maintain US prescriptions filled through mail-order pharmacies (Express Scripts, CVS Caremark) and shipped internationally. This works but is slow (2-4 weeks), expensive for shipping, and customs can seize medications -- especially controlled substances. It's a reasonable backup but shouldn't be your primary strategy.

Dental and vision care are the healthcare categories where living abroad saves Americans the most money relative to what they're used to paying -- because US dental insurance is terrible and US dental costs are astronomical.

Dental costs abroad vs. the US:

• Dental cleaning: US $100-$300 / Mexico $30-$60 / Thailand $25-$50 / Spain $50-$80
• Dental crown: US $1,000-$3,000 / Mexico $200-$400 / Thailand $150-$300 / Colombia $150-$350
• Root canal: US $700-$1,500 / Mexico $150-$350 / Costa Rica $200-$400 / Philippines $80-$200
• Dental implant: US $3,000-$6,000 / Mexico $800-$1,500 / Thailand $1,000-$2,000 / Spain $1,200-$2,200
• Invisalign/braces: US $3,000-$8,000 / Mexico $1,500-$3,000 / Thailand $1,200-$2,500 / Colombia $800-$2,000

Dental tourism is a billion-dollar industry for a reason. Mexico's border cities (Los Algodones, Tijuana) have entire economies built around Americans crossing for dental work. But as an expat, you don't need to do dental tourism -- you just go to a local dentist.

IPMI dental coverage: Most IPMI plans offer dental as an add-on, not as standard coverage. Cigna Global's dental rider adds roughly $500-$1,000/year to your premium and covers 80% of basic procedures after a waiting period. Given that routine dental care abroad costs a fraction of the US price, many expats skip dental insurance entirely and pay cash.

Vision care: Similarly affordable. An eye exam in Thailand runs $20-$40. Prescription glasses (with lenses) cost $30-$100 at most optical shops in Southeast Asia and Latin America. In Europe, prices are higher but still well below US levels. Contact lenses are available everywhere and typically cheaper than US prices.

The dental tourism warning: If you're getting major dental work done abroad, do your research. Ask for credentials, look for dentists trained at recognized institutions, and check reviews from other expats. The savings are real, but so is the risk of substandard work. A dental implant that fails because of poor technique costs more to fix than doing it right the first time.

After fourteen years of tracking expat healthcare decisions, here's the framework that works for most Americans abroad.

If you're under 40 and healthy: Start with a budget plan (SafetyWing or Genki) for catastrophic coverage at $50-$100/month. Pay cash for routine care. Enroll in your country's public system if eligible. Total annual cost: $600-$1,200 for insurance plus $500-$1,000 cash spending. This is the digital nomad strategy, and it works beautifully in affordable countries.

If you're 40-65 with no major health issues: Get a mid-tier IPMI plan (Allianz Essential or AXA Standard) excluding the US, with a $1,000-$2,500 deductible. Enroll in local public healthcare as a backup. Add Medjet for evacuation. Total annual cost: $3,500-$6,000. This gives you global coverage with the flexibility to see private doctors anywhere while having the public system for routine care.

If you're 40-65 with pre-existing conditions: Prioritize moving to a country with strong public healthcare that covers residents regardless of health status (Spain, France, Portugal, Germany, Costa Rica). Use the public system as your primary coverage. Add an IPMI plan with a moratorium if you can get one, or go without supplemental insurance and self-fund private care for your specific condition. Total annual cost: $1,000-$4,000 depending on country and condition.

If you're over 65: Keep Medicare Part B active ($2,041/year in 2025). Enroll in local public healthcare. Consider a senior-specific IPMI plan from Cigna or Allianz (premiums will be $6,000-$15,000/year at this age, which still beats the US). Add Medjet. If you return to the US for any reason, Medicare kicks back in. Total annual cost abroad: $3,000-$8,000 for the public system plus supplemental coverage.

The universal rules:

1. Always get evacuation coverage. It's cheap and the alternative is financially catastrophic.
2. Always enroll in the local public system if you're eligible. Even if you prefer private care, the public system is your safety net.
3. Never let a coverage gap develop. Moving between countries or plans? Get bridge coverage. A single uninsured hospitalization can cost more than ten years of premiums.
4. Review your plan annually. Your health, your country, and the insurance market all change. What worked last year may not be optimal this year.
5. Keep copies of all medical records in English, in the cloud, accessible from anywhere. When you need them, you need them fast.

The American healthcare system has conditioned us to accept that health insurance is either absurdly expensive or inadequate. Abroad, it can be both affordable and excellent. That's not an exaggeration -- it's just what happens when healthcare isn't run as a profit-maximization machine. Welcome to the rest of the world.