Health Insurance for Americans Living Abroad (2026)

No federal law requires it. The Affordable Care Act’s individual shared responsibility payment, the penalty for lacking minimum essential coverage, was reduced to zero for months beginning after December 31, 2018 under the Tax Cuts and Jobs Act, and since tax year 2019 filers no longer report coverage or claim exemptions on Form 8965. Read the IRS provision page.

The expatriate rule still exists underneath. U.S. citizens who are outside the country for at least 330 full days in a 12-month period, or who are bona fide residents of a foreign country for a full tax year, are treated as having minimum essential coverage for those months. The Centers for Medicare & Medicaid Services restates the rule in its guidance for Marketplace assisters. See the CMS fast facts on foreign coverage. The tests are the same ones used for the foreign earned income exclusion, so most people who qualify for that exclusion qualify here.

Five jurisdictions run their own mandates with financial penalties in 2026: California, Massachusetts, New Jersey, Rhode Island and the District of Columbia. Vermont has a reporting requirement without a penalty. These apply to state tax residents, so an expat who has ended state residency is outside them; someone who keeps a state domicile while abroad should check the state’s own exemption rules. Massachusetts publishes its 2026 penalty schedule as Technical Information Release 26-1. See the Massachusetts release.

Medicare usually does not cover health care outside the United States, which for this purpose means the 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. The exceptions are narrow: an emergency where a foreign hospital is closer than the nearest U.S. hospital, care while traveling through Canada between Alaska and another state, a foreign hospital that is closer to your U.S. home than the nearest U.S. hospital, and doctor services on a cruise ship within six hours of a U.S. port. Medicare drug plans do not cover prescriptions bought abroad. Read Medicare’s travel page.

Medigap plans C, D, F, G, M and N include a foreign travel emergency benefit: after a $250 deductible for the year, they pay 80% of billed charges for medically necessary emergency care that begins during the first 60 days of a trip, up to a $50,000 lifetime limit. That benefit is for travelers, not residents; a person living abroad for years would exhaust the 60-day window on the first trip and the lifetime cap on the first serious admission.

Delaying enrollment has a cost. If you do not sign up for Part B when first eligible and are not covered by a qualifying employer plan, the premium rises 10% for each full 12-month period you could have had Part B, and that penalty applies for as long as you hold Part B. The Part D late enrollment penalty is 1% of the national base beneficiary premium, $38.99 in 2026, for each month without creditable drug coverage. See Medicare’s penalty rules. Many Americans abroad therefore keep Part A, which is premium-free for most, and decide on Part B by weighing the monthly premium against the penalty they would face on returning.

Marketplace plans generally do not pay for care outside the United States, and you cannot enroll in one while living abroad: eligibility requires that you live in the U.S. and are a U.S. resident for tax purposes. See the Marketplace eligibility rules. A Marketplace plan kept by an expat is an unusable premium unless you spend long periods in the U.S. each year.

Employer plans vary. Some domestic group plans pay emergency treatment abroad at out-of-network rates, some pay nothing, and some employers buy a separate international plan for staff on assignment. Read the certificate of coverage for the words “outside the United States,” and ask HR whether an expatriate plan exists. COBRA continuation of a U.S. plan after leaving a job carries the same geographic limits as the plan itself.

U.S. treatment is the most expensive in the world, and insurers price it as a separate area of cover. Pacific Prime’s report on international private medical insurance across 100 countries puts the average individual premium for U.S. residents at US$15,296 in 2024, up 56% on the previous year, against US$3,120 in the cheapest country surveyed. William Russell’s 2024 comparison for a 36-year-old shows the U.S. at US$15,296 against US$3,900 in Poland. Feather’s June 2026 figures for a 65-to-69-year-old show the same multiple: from €335 a month in Mexico or Costa Rica, from €559 in Spain or Portugal, and from €1,676 once U.S. cover is included.

Before paying that premium, ask the insurer three questions. How many days of U.S. emergency cover does the plan without U.S. cover include per trip? Does the plan with U.S. cover pay for planned treatment or only emergencies? And does either option restrict U.S. providers to a network? The answers decide whether the extra premium buys anything you would use.

Moving to the U.S. from a foreign country is a qualifying life event for a Marketplace Special Enrollment Period. You have 60 days from the move to pick a plan outside open enrollment, and you may be asked for documents confirming the move. See the Special Enrollment Period rules. If you return to a job with group cover, the employer plan takes over on its own start date; check for a gap between arrival and eligibility.

If you are 65 or older and did not take Part B abroad, you can enroll in the General Enrollment Period, which runs from January 1 to March 31 each year, with cover starting the month after you sign up, and the late enrollment penalty applies. If you were covered by an employer plan through current employment, you have a Special Enrollment Period without penalty. Some international insurers allow home-country cover for a limited period after you move back, which can bridge the wait; ask for the exact number of days in writing.

Use the renewal checklist to time the end of the international policy so that it overlaps the start of U.S. cover rather than leaving a gap.

1. Whether you will meet the 330-day or bona fide residence test in your first year abroad.
2. Whether you remain a tax resident of California, Massachusetts, New Jersey, Rhode Island or the District of Columbia.
3. Whether your current plan pays anything outside the U.S., and how it treats emergencies abroad.
4. If you are near 65, whether to enroll in Part B, and what the penalty would be if you wait.
5. Whether your international plan should include or exclude the U.S., and how many U.S. emergency days the excluding version allows per trip.
6. How pre-existing conditions are underwritten on the international plan, and whether a moratorium or full underwriting suits your history.
7. Whether your family is covered on the same plan and priced per person; see the expat family coverage guide.
8. Whether you need income protection or life cover abroad, which U.S. policies may not provide once you are resident overseas; see the guide to expat disability insurance and life cover.
9. If you are retiring, how age limits and price bands change at 60 and 65; see expat health insurance over 60.