Written by
John Spencer
John Spencer is the founder of Compare Expat Plans, where he focuses on helping people compare health plans for life abroad. He emphasizes clear information, neutral analysis, and practical decision support.
Our Top Picks
American expats have a unique challenge: they need international coverage for their new home, but also want seamless access to US healthcare when visiting family. Many international plans charge 40-50% extra for US coverage. These plans build it in:
- Aetna International: Best overall for US expats. Full Aetna US network included in base price. Works like domestic insurance when you're home.
- GeoBlue: Best for Blue Cross loyalty. 96% of US hospitals in network. The international arm of BCBS.
- Cigna Global (with US module): Best comprehensive option if you also need top-tier international coverage. US is an add-on, but the global network is massive.
- IMG Global: Best budget option with US flexibility. Higher deductibles keep premiums down.
The Key Question
How often will you be in the US? If you visit family annually or might need US specialists, pay for integrated US coverage. If you're truly relocating and rarely returning, you can save 30-40% with US-excluding plans.
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Why US Expats Need Special Consideration
American expats face challenges that other nationalities don't. Understanding these helps you choose the right insurance:
The US Healthcare Cost Problem
US healthcare costs are 2-3x higher than other developed countries. A hospital stay that costs $2,000 in Spain might cost $20,000 in the US. This is why:
- International insurers charge 40-50% more for US-inclusive plans
- Many plans limit US coverage to emergencies only
- US network access (negotiated rates) matters more than for other countries
Medicare Doesn't Work Abroad
US Medicare provides essentially no coverage outside the country. If you're over 65 and living abroad, international insurance replaces Medicare—not supplements it.
Tax Obligations Continue
Americans must file US taxes regardless of where they live. Some ACA requirements and health insurance tax credits have expat exemptions, but understanding your obligations matters for compliance.
The Totalization Agreement Factor
If your US employer sends you abroad, or you're self-employed with US ties, totalization agreements may affect your eligibility for local public healthcare. For example, US workers in France may be ineligible for PUMA for up to 5 years. Check country-specific rules.
Family Ties
Most American expats maintain strong family connections. Annual visits, emergencies, graduations, holidays—you'll be in the US sometimes. Insurance that works seamlessly in both places has real value.
How We Evaluated
We focused on what matters specifically for Americans abroad:
- US network access: Do you get Aetna/BCBS/Cigna rates or out-of-network pricing?
- US in base price: Is it included or an expensive add-on?
- Direct billing in US: Can you use insurance cards at US hospitals?
- US time limits: Any restrictions on how long you can be in the US?
- International coverage quality: How good is coverage where you actually live?
- Medicare coordination: How does it work with Medicare if you're 65+?
Quick Comparison
Here's how the top options compare for US expats. The "US in Base Price" column is critical—it's the difference between straightforward pricing and surprise surcharges.
| Provider | US Network | US in Base Price | US Direct Billing | Starting Price |
|---|---|---|---|---|
| Aetna International | Full Aetna | Yes | Yes | $180/mo |
| GeoBlue | 96% BCBS | Yes | Yes | $190/mo |
| Cigna Global | Cigna PPO | Add-on (+40%) | Yes | $150/mo (ex-US) |
| IMG Global | PPO network | Optional | Limited | $100/mo (ex-US) |
| BUPA Global | Freedom network | Add-on (+50%) | Limited | $200/mo (ex-US) |
Built-In vs. Add-On
Aetna and GeoBlue include US coverage. Others charge 40-50% extra. Do the math for your situation.
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Detailed Reviews
Aetna International
The standout choice for American expats. Aetna International is designed for US citizens abroad, with full Aetna US network access built into every plan—not an expensive add-on.
Why US expats love it: When you visit the US, your insurance works exactly like domestic Aetna coverage. Direct billing at US hospitals. Aetna's negotiated rates protect you from surprise bills. 24/7 English support that understands American healthcare.
The coverage: Pioneer plans offer tiered options from hospital-only to comprehensive. Navigator plans let you build modular coverage. All include US.
Things to consider: Premiums are higher than US-excluding options (because US coverage costs money). Medical underwriting applies.
Best for: Americans who want one plan that works everywhere, including the US, without complexity.
Read our full Aetna International review →
GeoBlue
Blue Cross Blue Shield's international brand. If you've had BCBS coverage your entire life and trust the network, GeoBlue offers international coverage with that same familiar access.
Why US expats love it: 96% of US hospitals are in the BCBS network. Your existing relationships with US doctors remain intact. The mobile app makes finding care abroad easy.
The coverage: Voyager plans range from Essential (hospital-focused) to Excel (comprehensive including maternity). All include full US coverage.
Things to consider: Requires US citizenship or permanent residency—this is specifically for Americans. Some age restrictions apply.
Best for: Americans who want Blue Cross continuity while living abroad.
Read our full GeoBlue review →
Cigna Global (with US Module)
Cigna Global is one of the largest international health insurers. US coverage is an add-on (not included in base price), but the global network and service are excellent.
Why US expats like it: Massive global network (1.65M+ providers). Strong customer service. Good for expats in unusual locations. US module adds full Cigna PPO access.
The coverage: Silver, Gold, and Platinum tiers. US module adds approximately 40% to premiums but provides comprehensive US access.
Things to consider: Base price looks lower but isn't US-inclusive. Calculate total cost with US module to compare fairly.
Best for: US expats who prioritize international network quality and will add US coverage.
Read our full Cigna Global review →
IMG Global
The budget-friendly option for US expats willing to accept higher deductibles. IMG offers strong coverage at lower premiums than the premium players.
Why US expats like it: 50% deductible waived outside the US—a $5,000 deductible becomes $2,500 effective abroad. High coverage limits ($8M). Lower premiums for comprehensive protection.
The coverage: Global Medical Insurance plans with customizable deductibles. US coverage available but affects pricing.
Things to consider: Less brand recognition than Aetna/Cigna. Higher deductibles mean more out-of-pocket before coverage kicks in.
Best for: Budget-conscious US expats who want catastrophic protection without premium pricing.
Read our full IMG Global review →
Choosing the Right Plan
If you visit the US 2+ weeks per year:
Aetna International or GeoBlue. US coverage is built in, and you'll use it. The premium differential pays for itself in one US hospital visit.
If you rarely return to the US:
Consider Cigna Global or AXA Global without US coverage. Save 30-40% on premiums. Add travel insurance for occasional US trips.
If you're over 65 and Medicare-eligible:
Keep Medicare Part A (free) as US emergency backup. Use Aetna or GeoBlue as your primary international coverage. Consider whether Part B premiums are worth it based on US visit frequency.
If budget is the primary concern:
IMG Global with a $5,000+ deductible. Use local healthcare for routine care (it's often affordable). Save the insurance for expensive hospitalizations.
If you work for a US company remotely:
Check if your employer offers international coverage. If not, Aetna or Cigna are commonly used by US companies for international employees—your HR department may have group rates.
Get the Right Coverage
US expats have different needs than other nationalities. Make sure your insurance actually works in both places.
Compare US Expat PlansWe may earn a commission when you apply through our links. This does not affect our recommendations.
Common Questions
How much does US-inclusive international insurance cost?
Expect $180-400/month for comprehensive coverage including US, depending on age and deductible. Plans excluding US start around $100-150/month. The 40-50% US premium reflects actual US healthcare costs.
Can I use my US insurance abroad?
Generally no. Most US domestic insurance only covers emergencies abroad—not routine care, and reimbursement is complicated. Some employer plans have international options, but standard ACA marketplace plans don't work well overseas.
What about the ACA individual mandate?
The federal penalty is $0, but some states (NJ, CA, MA, DC, RI) have their own mandates. Expats may qualify for exemptions based on physical presence abroad. Consult a tax professional for your situation.
Should I keep Medicare if I'm living abroad?
Medicare Part A is free if you have 40+ work quarters—keep it as emergency backup for US visits. Part B has premiums and late enrollment penalties. Decide based on how often you'll receive US care.
What if I need a US specialist for something complex?
This is where US-inclusive plans shine. With Aetna or GeoBlue, you can see US specialists at in-network rates. Medical evacuation coverage (standard in international plans) can also transport you to the US for treatment if needed.
Are there limits on US time with international insurance?
Most international plans allow 30-90+ days in the US per year. Some have no limits. Check your specific policy—if you'll spend 6 months in the US annually, you may need different coverage.
Aetna or GeoBlue—which should I choose?
Both are excellent for US expats. Aetna may have slightly better Latin American coverage. GeoBlue offers the largest US hospital network (96% BCBS). See our detailed comparison.
Disclaimer: This content is for informational purposes only. We are not insurance brokers, tax advisors, or licensed agents. Coverage details, prices, and tax implications change. Verify information with insurance providers and consult qualified professionals for tax and Medicare decisions.
