International health insurance for American digital nomads

For anyone under 65 there is no national health system to lose. US coverage is private and tied to a domestic plan: an employer group plan, an Affordable Care Act marketplace plan, or COBRA. None of these is a government scheme that follows you overseas, and every one is built around a US provider network, so care abroad falls outside it by design.

Employer and ACA marketplace plans are domestic-network products. Marketplace plans are sold state by state and many use narrow regional networks, so some will not even fully cover you in a neighbouring state. HealthCare.gov describes marketplace coverage as care from doctors, hospitals and providers within the US. A plan might reimburse a genuine emergency abroad at out-of-network rates, but routine care once you have moved, a check-up, a prescription refill, managing a chronic condition, a specialist visit, is generally not covered at all.

COBRA is not a fix. It only lets you keep your existing employer plan for a period after leaving the job, and by federal law the coverage is identical to the active-employee plan: same network, same limits. So it carries exactly the same domestic-only gap, just at a higher premium because you now pay the full cost yourself.

Medicare, for those 65 and over, almost never pays outside the US. Medicare.gov lists only three narrow exceptions, all emergencies tied to being in or passing through the US: a medical emergency in the US where a foreign hospital is closer, an emergency while travelling the direct route through Canada between Alaska and another state, and care at a foreign hospital that is closer to your US home than any US hospital. None of these apply to someone living abroad. Dropping Part B while overseas is also a costly trap on the way back: the late-enrolment penalty adds 10% to your Part B premium for each full 12-month period you could have had it but did not, and once it applies you pay it for as long as you have Medicare, so a few years abroad without a qualifying exception can raise your premium for the rest of your life.

The return is handled through the marketplace. Moving back to the US from another country is a qualifying life event that opens a Special Enrollment Period, and you generally get 60 days from the move to choose a plan. Two catches matter: a move only for vacation or medical treatment does not qualify, and HealthCare.gov usually will not let you complete this particular enrolment online, so you have to phone the Marketplace Call Center. Coverage is not backdated, so any gap between landing home and your new plan starting is uninsured.

An HSA or FSA is not coverage, and it does not solve this either. There is no geographic bar in IRS Publication 502: qualified medical care counts even when you receive it in another country, so HSA money can legally reimburse a foreign doctor visit or prescription. The problem is practical. No foreign hospital or pharmacy bills your HSA, and many HSA debit cards are blocked on international transactions, so in reality you pay the provider in cash or on a card and reimburse yourself afterward, keeping dated, translated receipts and exchange-rate records. An FSA is worse for a nomad because it is use-it-or-lose-it within the plan year and tied to your employer. These are tax-advantaged ways to spend your own money, not a network that pays a provider on your behalf.

For lower-income Americans, Medicaid is even more locked to home. It is administered state by state, and you have to be a resident of the state you are enrolled in. It pays nothing outside the US, there is no version that travels with you, and there is no mechanism to transfer it between states, so leaving the country ends any practical use of it. If you move abroad and later return, you generally have to reapply, in whichever state you land in.

It is worth being precise about what an emergency being covered means in practice. Even where a domestic plan will consider a foreign emergency, the foreign hospital has no relationship with your US insurer and will not bill it. You pay the bill yourself, often upfront or on discharge, then file a claim and hope to recover part of it at out-of-network rates. Because the provider is out of network there is no negotiated price and none of the balance-billing protection you would have at home, so you can be left owing whatever the insurer declines to reimburse. A genuinely covered emergency still means producing cash or a working credit card at the point of care.

One narrow federal program does follow you abroad, but only for a specific group. The VA Foreign Medical Program reimburses care received in another country, and it is real, but it only covers a VA-rated, service-connected disability, or a condition that aggravates one. It does nothing for the ordinary illnesses and accidents that make up most medical spending, so even for veterans it is not general health cover overseas.