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.
Most international health insurance plans exclude the United States. American healthcare costs are 2-3x higher than other developed countries, so insurers charge significantly more for US coverage. Understanding your options helps you decide whether the extra cost is worth it.
Why US Coverage Matters
The US is excluded from most international plans for one reason: cost. A hospital stay that costs $5,000 in Spain or Thailand runs $50,000+ in the US. Insurers price accordingly.
When US Coverage Becomes Critical
- Emergency during visits: A heart attack while visiting family could cost $150,000+ without coverage
- Specialist care: Some conditions are best treated at US medical centers
- Medications: Accessing US prescriptions and doctors for ongoing conditions
- Medical evacuation destination: If evacuated, you may be sent to the US
The Real Risk
Without US coverage, a medical emergency during a two-week visit home could result in bills exceeding your lifetime savings. US hospitals will treat you—then send the bill. Medical debt is the leading cause of bankruptcy in America.
Included vs Excluded: What's the Difference?
Plans That Exclude the US ("Worldwide Excluding US")
- Cover you in 190+ countries, but not the United States
- Lower premiums (often 40-60% less)
- Suitable if you never return to the US
- Emergency-only US coverage may be available as add-on
Plans That Include the US ("Worldwide Including US")
- Full coverage in the United States
- Access to US hospital networks (varies by insurer)
- Higher premiums reflecting US healthcare costs
- May have separate US deductibles or coinsurance
US Coverage Structures
Different insurers structure US coverage differently:
- Full parity: US treated same as other countries (rare, expensive)
- US with limits: US covered but with higher deductible or coinsurance
- US emergency only: Emergencies covered, routine care excluded
- US time limits: Covered for visits up to 30, 60, or 90 days per year
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The Cost Difference
Adding US coverage typically increases premiums by 40-70%. Here's what that looks like in practice:
Example: 45-year-old, Comprehensive Coverage
Worldwide Excluding US
$3,500/year
Worldwide Including US
$5,600/year
The $2,100/year difference pays for one night in a US hospital—or prevents a $200,000 bill.
Factors Affecting US Coverage Cost
- Your age: Older applicants see larger premium increases for US coverage
- Deductible choice: Higher deductibles reduce the US premium impact
- Time in US: Some plans charge based on how much time you spend there
- US state: New York and California have higher healthcare costs
Recommended Providers for US Coverage
Not all insurers handle US coverage equally. These providers have strong US networks and clear US coverage options:
| Provider | US Coverage Option | US Network | Premium Impact |
|---|---|---|---|
| Cigna Global | Optional add-on | Cigna US network | +40-60% |
| GeoBlue | Included (US-based) | Blue Cross network | Built into base rate |
| Aetna International | Optional add-on | Aetna US network | +35-50% |
| IMG Global | Optional add-on | PPO network | +30-45% |
| Allianz Care | Limited options | Third-party PPO | +50-70% |
GeoBlue (Best for US Expats)
GeoBlue is designed specifically for Americans abroad. As a Blue Cross Blue Shield licensee, they offer seamless access to the largest US provider network. US coverage is built into their plans rather than an add-on.
- Pros: Blue Cross network, US-based company, familiar claims process
- Cons: More expensive than non-US plans, US-centric
- Best for: US citizens who visit home frequently or want US-quality assurance
Cigna Global
Cigna offers US coverage as an optional module. Their US network is their domestic Cigna network—one of the largest in America.
- Pros: Flexibility to add/remove US coverage, strong network
- Cons: US add-on is expensive
- Best for: Those who want comprehensive global coverage with US option
Aetna International
Aetna International leverages the domestic Aetna network for US coverage. Good option for those familiar with Aetna from US employment.
- Pros: Established US network, name recognition
- Cons: Customer service can be slow
- Best for: Former Aetna members, corporate expats
When You Need US Coverage
Consider US coverage essential if:
- You visit the US regularly: Multiple trips per year, especially extended visits
- You have family in the US: May need to return for family emergencies
- You have a chronic condition: May need US specialists or medications
- Your destination lacks quality care: Evacuation would likely go to the US
- You're a US citizen without Medicare: No fallback coverage in America
The Peace of Mind Factor
Many expats choose US coverage not because they plan to use it, but because they can't predict when they'll need to return. A parent's health crisis, a job opportunity, or a global emergency could bring you back unexpectedly.
When You Can Skip US Coverage
You may not need US coverage if:
- You never plan to return: Permanently relocated with no US ties
- You have Medicare: Already covered for US care (age 65+)
- You have other US coverage: Through spouse, employer, or ACA plan
- Brief visits only: Travel insurance may suffice for short trips
- Budget is tight: The premium difference is significant
Alternative: Travel Insurance for US Visits
If you exclude the US from your main policy, you can buy separate travel insurance for US trips. This works if:
- Visits are short (under 30-60 days)
- You're healthy with no pre-existing conditions
- You can plan trips in advance
However, travel insurance has limitations: pre-existing conditions typically aren't covered, coverage limits are lower, and emergency-only policies won't cover routine care.
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Medicare & US Expats
If you're 65+ or approaching Medicare age, your situation is different.
Medicare Doesn't Work Abroad
Medicare (Parts A, B, D, and most Medicare Advantage plans) only covers care in the United States. Living abroad means you need international insurance regardless.
Should You Keep Medicare?
Keep Medicare Part A (hospital insurance) if you've worked 10+ years in the US—it's premium-free and provides coverage when you visit.
Medicare Part B (medical insurance) is more complex:
- Costs ~$175/month (2024) and increases if you delay enrollment
- If you return to the US permanently, late enrollment penalties are permanent
- Some expats maintain it for peace of mind; others drop it to save money
The Part B Penalty
If you drop Part B and later return to the US, you'll pay a 10% penalty for each year you weren't enrolled—permanently. A 5-year gap means 50% higher premiums for life. Factor this into your decision.
Strategy for Medicare-Age Expats
- Keep Medicare Part A (free)
- Decide on Part B based on likelihood of returning
- Get international insurance that excludes US (lower cost)
- Use Medicare when visiting the US
Common Questions
Can I use my international plan in the US if it excludes the US?
No. "Worldwide excluding US" means exactly that—no coverage in America, even for emergencies. You'd pay out of pocket for any US care.
What about emergency-only US coverage?
Some plans offer US emergency coverage as a middle ground. This covers true emergencies (heart attack, accident) but not routine care, follow-ups, or conditions that aren't immediately life-threatening. Read definitions carefully—"emergency" is narrowly defined.
Does US coverage include dental and vision?
Usually not in the base plan. Dental and vision in the US are typically separate add-ons with their own US-specific costs.
Can I add US coverage later?
Most insurers allow adding US coverage at renewal, though you may face new underwriting. It's easier to start with US coverage and remove it later than to add it.
What if I'm a dual citizen?
Dual citizens have the same options as US citizens. Your other citizenship doesn't help with US healthcare costs. Consider whether you'd seek care in the US or your other country of citizenship.
Is US coverage worth it for a 2-week annual visit?
Depends on your risk tolerance. The probability of a major medical event in 2 weeks is low, but the financial impact could be catastrophic. Travel insurance is a cheaper alternative for healthy individuals making brief, planned visits.
Do I need US coverage if I'm moving to Puerto Rico or US territories?
Yes. Puerto Rico, US Virgin Islands, Guam, and other US territories have US healthcare costs and are treated as the US by insurers. You need "including US" coverage.
Get the Right US Coverage
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Disclaimer: This guide is for informational purposes only. Healthcare costs, insurance premiums, and Medicare rules change frequently. Verify current information with insurers and Medicare directly. Consider consulting an insurance broker for personalized advice.
