What a US plan does outside the country

Start with the plan your employee already has. The State Department advises travelers to ask their own health insurer whether emergency and routine care abroad are covered. It is also plain that the US government does not pay medical bills abroad: the traveler is responsible for hospital and medical costs. Medicare does not cover medical costs outside the United States, which matters for an older employee, a founder or a family member who relies on it.

Evacuation is the gap people notice too late. Most health plans will not pay to fly a patient back to the United States by air ambulance, and the State Department recommends evacuation coverage for trips to places with higher risk or limited medical care. Before someone travels for work, have them confirm with the plan what it pays abroad for an emergency and for routine care, and whether the destination calls for evacuation cover.

Short trips and long stays call for different cover

Two broad kinds of cover are sold for time outside the country. Travel medical insurance is generally aimed at a trip, such as a conference or a few weeks at a client site. International health insurance, sometimes called expatriate or global cover, is generally aimed at people who live abroad and need ongoing care where they are. Product names vary, so judge each policy by what it covers, for how long and in which countries.

The questions differ by situation. For a business traveler they are emergency care, evacuation and the length of the stay. For someone moving abroad they are routine care, the family and how the cover sits beside the new country’s own system. That second set is where the international plans described in international health insurance for remote employees come in.

When a trip turns into a relocation

Once an employee actually lives in another country, that country’s rules come first. A US small-group plan is written around state law; California’s small-group law, for example, covers employers whose employees mostly work in California, so it was not designed for someone settled abroad. The new country decides whether the person joins a public system, whether a local employer must enroll them in a scheme and which insurers may cover them there.

The answers differ widely. Germany generally makes health insurance compulsory for residents, France brings anyone working there into its national scheme from the first day, Mexico expects an employer to register with IMSS, and the UK gives visa holders who pay the immigration health surcharge access to the NHS. Read the country page for each destination, and the guide to EOR employees and contractors abroad for how the hiring setup decides who provides cover.

Social security for staff posted overseas

The United States has social security totalization agreements with a number of countries, and the part that applies to a temporary posting is the detached-worker rule. An employee your company sends temporarily to the other country keeps paying into, and stays covered by, only the US system, generally for up to five years. The two countries can agree to extend that period case by case, though extensions of more than two extra years are rare.

Each agreement has its own terms. The agreement with Italy is the only one without the detached-worker rule, so a posting there follows different rules. Check the SSA pamphlet for the country before the employee leaves.

Requesting a certificate of coverage

A certificate of coverage is the document that proves the worker is exempt from the other country’s system. Employers, employees and self-employed workers can each ask the Social Security Administration for a US certificate, but only employers and self-employed workers can use the online form. SSA asks employers to apply as early as possible, ideally before the work abroad begins.

Have these details ready for the request: the worker’s personal details, the employer’s name and address in both countries, and the transfer date and expected return date. Some agreements run their own process. Under the agreement with Spain, for example, some certificates come from the Spanish authority rather than from SSA.

Tax questions that come with a move

An employee who settles abroad may ask about the foreign earned income exclusion. To qualify, a US citizen or resident alien needs foreign earned income, a tax home in a foreign country, and either bona fide residence abroad for an uninterrupted period that includes a full tax year or physical presence abroad for at least 330 full days in any 12 consecutive months. Keeping a main home in the US generally rules it out.

The exclusion lowers regular income tax only and does not reduce self-employment tax; it is claimed on Form 2555. Both points turn on each person’s facts, so the employee should check them with a tax professional before the move.

A checklist for trips and postings

A short routine for anyone working away from home:

before a business trip, confirm what the current plan pays abroad for emergencies and routine care;
for higher-risk or remote destinations, look at evacuation cover;
before a posting, request the certificate of coverage and read the SSA pamphlet for the country;
before a relocation, read the country page and decide how the person will be employed there;
list any spouse or children moving too, and the cover they have now.

The commercial side changes as well when people work away from the office; insurance changes for remote teams covers the policies we request from insurers, with each insurer deciding terms, and insurance for startups sets out coverage by company stage.

Getting an introduction for staff abroad

When someone is moving abroad or the team is spreading across countries, fill in the quote form on this page with each person’s country and the number of people involved, and we will forward it to a benefits partner that handles international and remote-team health coverage. Who is eligible, which plans are available and what they cost is decided by the partner and the insurer. Our employee benefits for small businesses section lists every country page and benefits guide.

A few useful answers

Common questions

Does Medicare cover medical care abroad?

The State Department says Medicare does not cover medical costs outside the United States. An employee or family member who relies on it needs other cover for time abroad, and the US government does not pay medical bills overseas.

Will a US health plan pay for medical evacuation?

Most plans will not pay for an air ambulance back to the United States. The State Department recommends evacuation coverage for places with higher risk or limited medical care, so check the plan before a trip to such a place.

What is a certificate of coverage?

It proves that a worker posted abroad is exempt from the other country’s social security system under a totalization agreement. Employers, employees and self-employed workers can request a US certificate from SSA, ideally before the work abroad starts.

How long can an employee stay on US social security while posted abroad?

Under the detached-worker rule in most totalization agreements, generally up to five years. The two countries can extend that case by case, but extensions past two extra years are rare, and the agreement with Italy has no detached-worker rule.

Is travel medical insurance the same as international health insurance?

They are generally aimed at different situations. Travel medical cover is usually built around a trip, while international health insurance is aimed at people who live abroad and need ongoing care.

Health Coverage for Employees Who Travel or Relocate Abroad