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As a long-term expat who has switched among multiple international jobs, being a student, and being self-employed, I’ve had just about every type of health insurance you can get as an American abroad. I have also spent a ridiculous amount of time researching all of the possibilities, trying out the insurance that I thought would be best for me, and then changing my mind based on lived experience (multiple times). Hopefully you can learn from my mistakes and make your international health insurance decisions more easily!
Disclaimer: I am a (fairly) young, healthy person, who has had limited health insurance needs. Most of my claims are for wellness visits and a birth control prescription. I have also gotten into a couple of bad accidents requiring ER visits abroad. My experience is very different from someone who is navigating a serious or chronic illness. That said, there are a couple of takeaways below that I think could be helpful regardless of your health circumstances.
Experts who are in your corner can be very useful
For my most recent health insurance purchase I worked with International Insurance, a reputable insurance broker specializing in American expats. I told my broker my situation and what has frustrated me with international insurance before, and he quickly steered me away from the (more expensive) company I thought I wanted toward GeoBlue Xplorer. I highly recommend talking to an insurance broker. They can help you choose the best plan for you, and do it efficiently. Many brokers (including International Insurance) do not increase your premiums at all. Their commission is taken exclusively from the insurance company.
Think carefully about needing U.S. coverage
Most international insurance companies have an option for “worldwide coverage excluding U.S.” and another option for “worldwide coverage including U.S.” Adding the U.S. to your coverage will usually raise your premiums by a shocking amount. Before purchasing a plan, you should ask yourself, do you really need U.S. coverage?
When I was living in East Africa my answer was yes. Due to relatively weak health infrastructure in the countries where I was living, I wanted to be able to receive specialist care back in my home country – and I did. After a pretty terrible bike accident I received great ER care in Rwanda, but wanted to get follow-up care that was not available in the country. Conversely, now that I’m living in Costa Rica I don’t really need U.S. care. There are plentiful specialists and procedures available here. I feel comfortable relying on the Costa Rican health infrastructure.
If you’ll be splitting your time between the U.S. and other countries, one option is to maintain your current coverage in the U.S. If you have affordable U.S. insurance through your employer, Medicare, or healthcare.gov, this may be more cost-effective than adding U.S. care to an international plan.
If you’ll be splitting your time but will mostly use health services abroad, some plans allow you to add on basic U.S. care to cover you during trips home (typically emergency cover only). That said, if you won’t be spending much time in the U.S., it’s probably more affordable to take out trip insurance to cover your trip dates, rather than add this to your annual plan.
International insurance plans are not governed by the ACA
If you’ve had U.S. health insurance over the past 8 years, you may have gotten used to certain standards. For example: maternity cover upon enrollment, coverage of pre-existing conditions, and prescription coverage. None of these international health insurance plans have to be ACA compliant, and most are not. Read the fine print to be sure you understand the limitations and/or ask your broker!
It can be a pain to file claims in the U.S.
Depending on which insurance company you choose, it can be a hassle to get your doctor’s office to bill your insurance company. Particularly if you go with a plan from a company based in the U.K. (e.g. Aetna International) or Ireland (e.g. Allianz International), don’t expect for direct billing to work. You can try, but it may make more sense to pay expenses out of pocket and then file for reimbursement. This includes doctors offices that are “in network” for your insurance plan.
Plans I Have Used, and When I’d Recommend Them
I had a Cigna Silver plan through an employer that covered me for wellness checkups and emergency care outside of the U.S. (no U.S. coverage included). It worked wonderfully. Cigna is one of the most recognizable brand names, and has one of the widest coverage networks globally for direct billing.
Recommended for: non-U.S. coverage, and especially as an international insurance option if you have a separate U.S. insurance plan
Don’t use if: you are more price-conscious (Cigna is pricey), if you plan on getting pregnant (maternity is not covered at the Silver level)
I had the MHP Exclusive Plan while I was a student and a self-employed consultant. I opted for worldwide plus U.S. coverage. When using the plan internationally, there were few in-network options, but it was easy to file claims online with the doctor’s bills I had paid out of pocket. It was a bit annoying that Aetna International doesn’t cover basic prescriptions, including birth control.
In the U.S., it was extremely difficult to get Aetna International to pay for a basic wellness visit. It took roughly six months and fifteen phone calls, half due to confusion on the side of my doctor’s office, half due to some seemingly intentional barriers on Aetna’s side – apparently you have a different policy number in the U.S. than what appears on your insurance card, and you can only get it by calling Aetna.
Recommended for: Honestly, I wouldn’t recommend this insurance for American expats. It may be better for other nationalities.
Don’t use if: You aren’t willing to pay out of pocket and get reimbursed later, if you have significant prescription or medication needs
GeoBlue Xplorer Essentials
I recently signed up for GeoBlue Xplorer Essentials with worldwide coverage excluding the U.S. That said, based on a conversation with my insurance broker, GeoBlue’s U.S. coverage is easier to navigate than Cigna or Aetna International, as GeoBlue uses the Blue Cross Blue Shield PPO network and as GeoBlue is an American company.
GeoBlue Xplorer is more affordable than Cigna and provides coverage levels somewhere between Cigna Gold and Cigna Platinum plans. They also include maternity after a one-year waiting period (although your premiums will go up once you add this coverage)
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