IMPORTANT GUIDE FOR U.S. SENIORS ABROADGUIDE FOR SENIORS ABROAD

Medicare Coverage for

Americans Living Abroad

A Comprehensive Guide for Expats, Snowbirds, and International Travelers

Coverage Abroad: Limited; Almost none

Medigap Max: $50,000; Lifetime limit

Part B Penalty: 10%/year; Permanent

MA Abroad: Ineligible; By law

Medicare doesn't cover you abroad • Get proper coverage

KEY TAKEAWAY

Medicare provides virtually no coverage outside the United States. If you live abroad full-time, you cannot rely on Medicare for your healthcare needs. This page explains the legal limitations, your options, and warns you about fraudulent schemes targeting expats.

Why Medicare Doesn't Work Abroad

Before examining specific fraud schemes, it's essential to understand why Medicare fundamentally cannot cover routine care overseas.

The Statutory Exclusion

Section 1862(a)(4) of the Social Security Act explicitly excludes items and services furnished outside the United States from Medicare coverage. Only narrow exceptions exist for emergency situations and care at qualified foreign hospitals near U.S. borders.

The Enrollment Barrier

Under 42 CFR § 424.505, providers and suppliers must be enrolled in the Medicare program to receive payment. Foreign facilities cannot satisfy enrollment requirements: they lack U.S. practice locations, cannot obtain National Provider Identifiers, cannot meet state licensure requirements, and are not subject to CMS inspections.

The Assignment Prohibition

Even when foreign services qualify for limited coverage, foreign facilities cannot bill Medicare directly. The Medicare Claims Processing Manual explicitly states: "Only the enrollee can file for Part B benefits; the assignment method may not be used."

These aren't loopholes waiting to be exploited. They're fundamental structural barriers in how Medicare operates. Schemes promising otherwise frequently violate federal law, exposing not just the operators, but potentially the beneficiaries themselves, to serious legal consequences.

RECOMMENDED APPROACH

Our Recommended Approach

For expats who cannot afford comprehensive private international health insurance, we recommend:

Maintain Medicare Part A (free if you qualify) and Part B

Purchase a Medigap supplemental policy (Plans C, D, F, G, M, or N)

Add a medical evacuation plan to get you back to the U.S. for emergencies

Maintain a reserve of approximately $50,000 for unexpected medical costs that cannot be evacuated

Consider enrolling in local government-subsidized plans (IMSS/INSABI in Mexico) as additional backup

This isn't a perfect solution, but it represents the best available option given Medicare's legal limitations.

PART 1

What the Law Actually Says

Original Medicare: Coverage Stops at the Border

The Three Narrow Exceptions

Part B Late Enrollment Penalty: A Permanent Cost

Years Without Part B	Penalty Rate	Monthly Surcharge	20-Year Cost
2 years	20%	+$37.00/mo	$8,880
5 years	50%	+$92.50/mo	$22,200
10 years	100%	+$185.00/mo	$44,400

Understanding Medicare Part A and Part B

PART 2

Medigap: The Best Medicare Option for Expats

Medigap (Medicare Supplement) policies are your best option if you want to maintain some connection to the Medicare system while living abroad. These policies can be purchased regardless of where you live, with no residency restrictions on eligibility.

Foreign Travel Emergency Benefit

Medigap Plans C, D, F, G, M, and N include a standardized foreign travel emergency benefit. Here's what it actually covers:

Benefit Feature	Coverage Details
Lifetime Maximum	$50,000 (cumulative across all trips, never resets)
Annual Deductible	$250 before coverage begins
Coverage Percentage	80% of billed charges (you pay 20%)
Trip Duration Limit	First 60 days of each trip only
Type of Care	Emergency medical care only
Medical Evacuation	NOT covered

IMPORTANT LIMITATIONS

The $50,000 lifetime maximum could be exhausted by a single serious hospitalization abroad
Coverage only applies during the first 60 days of any trip, making it useless for full-time expats
Medical evacuation (often the most expensive component of foreign emergencies) is completely excluded
You must pay foreign providers upfront and submit documentation for reimbursement
Plans A, B, K, and L offer NO foreign travel coverage

Bottom Line: Medigap is useful for short-term travelers and snowbirds, but it is not a solution for full-time expats. The 60-day trip limitation makes it fundamentally incompatible with permanent residence abroad.

PART 3

Medicare Advantage: Why It Does NOT Work for Expats

Medicare Advantage (MA) plans are where we see the most confusion, and the most potential for fraud. These plans work fundamentally differently from Original Medicare + Medigap, and they are structurally incompatible with expat life.

How Medicare Advantage Works

With Medicare Advantage, the government takes the premium you would pay for Medicare and gives it to a private insurance company. That company then provides your coverage like a traditional private insurance plan, often with additional benefits like dental, vision, and prescription drugs.

Some MA plans do include travel benefits for emergencies abroad, which may seem attractive compared to Medigap's 60-day limit. However, there's a fundamental problem: residency requirements.

The Service Area Residency Requirement

Under 42 CFR 422.50(a)(3), enrollment in a Medicare Advantage plan requires permanent residence within the plan's service area. The CMS Medicare Managed Care Manual defines this as your "primary residence" and permits MA organizations to verify it through voter registration, driver's licenses, tax records, or utility bills.

This isn't a suggestion. It's a legal requirement, and there are consequences for violating it.

Mandatory Disenrollment Rules

The consequences of extended absence from your service area are codified in 42 CFR 422.74(d)(4):

Time Outside Service Area	Consequence
Up to 6 months	Coverage continues
6+ months	MANDATORY DISENROLLMENT REQUIRED
Up to 12 months (exception)	Only if plan offers visitor/traveler benefit AND you remain within the United States

Critical point: The 12-month visitor/traveler exception under 42 CFR 422.74(d)(4)(iii) applies only when the beneficiary remains within the United States. Foreign travel does not qualify. If you live abroad, the 6-month rule applies.

An MA plan must disenroll any member who has "left the service area for more than 6 months," with notice provided within 10 calendar days of confirming the extended absence.

There Are NO Medicare Advantage Plans for Expats

No CMS-approved Medicare Advantage plans exist for Americans living permanently abroad. Despite what some brokers may claim, there is no legal way to maintain Medicare Advantage coverage while residing full-time in another country.

Why Medicare Advantage May Not Be the Best Choice

In general, Medicare Advantage plans are often not as beneficial as traditional Medicare. Many brokers push these products due to their high commissions rather than what's best for the client. Here's an informative segment if you want to deep dive into why:

PART 4: FRAUD WARNING

Medicare Advantage Fraud Targeting Expats

We have identified multiple fraudulent schemes targeting American expats who attempt to use Medicare Advantage plans abroad. These schemes have multiple layers of illegal activity that can expose you to criminal liability.

The Residency Fraud Problem

To get around the service area requirement, many expats (often at the encouragement of brokers) will lie about their residence. Common tactics include using a mailing service address, using a relative's address, or maintaining a nominal U.S. address while actually living abroad full-time.

This is fraud. Under 42 CFR 422.74(b)(1)(iii) and (d)(3), MA organizations may disenroll individuals who "knowingly provide fraudulent information on the election form that materially affects eligibility." Misrepresenting your residential address to receive government-subsidized benefits is a federal offense.

Some brokers argue there's a "grey area," claiming that crossing the border every 6 months "resets" the clock, or that the definition of residential address is somehow flexible. We disagree with this interpretation and believe it exposes clients to serious legal risk.

The Consequences Are Serious

The consequences extend beyond simple coverage termination. MA organizations must report fraud-based disenrollments to CMS, and cases may be referred to the Office of Inspector General for investigation. Potential consequences include:

Coverage termination and forced disenrollment

Requirement to repay benefits received while ineligible

False Claims Act liability with treble damages

Anti-Kickback Statute penalties

Criminal prosecution under federal healthcare fraud statutes

REAL CASE

Florida-Nicaragua Medicare Fraud Prosecution

Want to see how this plays out in reality? In 2015, ten people were prosecuted for a scheme that convinced U.S. citizens living in Nicaragua to enroll in Florida Healthcare Plus's Medicare Advantage plan. The fraudsters placed ads on buses and clinics in Nicaragua promising "premium U.S. healthcare with no copay." Since the MA plan only operated in specific Florida counties, patients were told to maintain fake addresses in those counties.

The result: Eight defendants cooperated with the Department of Justice. Six received prison sentences ranging from 15 months to 4 years. The government lost $25 million to this scheme and recovered only $1 million.

Government Loss: $25M

Prison Sentences: 15mo-4yr

Amount Recovered: $1M

Read the full case analysis: Florida Medicare Fraud Goes Beyond Borders

Third-Party Medicare Billing Networks in Mexico

Beyond the residency fraud issue, we've identified an even more concerning trend: third-party foreign corporations operating fraudulent Medicare billing networks that target American seniors in Mexico. These operations involve multiple layers of illegal activity.

Red Flag #1: "We Can Bill Medicare Directly for Your Foreign Care"

Foreign entities cannot bill Medicare. Period. The enrollment requirements under 42 CFR § 424.505 and § 424.510 require U.S. practice locations, National Provider Identifiers, state licensure, and eligibility for CMS on-site inspections. No foreign facility can satisfy these requirements. When someone claims to be "billing Medicare" for foreign services, they're either misrepresenting the service location, using phantom U.S. provider credentials, or operating an outright billing fraud scheme. Each false claim triggers liability under the False Claims Act, with penalties of $13,946 to $27,894 per claim plus treble damages.

Red Flag #2: "Sign This Power of Attorney So We Can Handle Your Claims"

Federal law explicitly prohibits this arrangement. Under 42 CFR § 424.86(a): "Medicare does not pay amounts that are due a beneficiary...to any other person under assignment, power of attorney, or any other direct payment arrangement." The Claims Processing Manual reinforces this specifically for foreign services: "The assignment method may not be used" for Part B benefits involving foreign care. Any organization requesting such arrangements is either ignorant of Medicare regulations or intentionally attempting to circumvent federal law.

Red Flag #3: "We'll Waive Your Copays and Deductibles"

Routine waiver of cost-sharing violates federal law. The Anti-Kickback Statute (42 U.S.C. § 1320a-7b) prohibits offering remuneration to induce referrals. The Civil Monetary Penalties Law (42 U.S.C. § 1320a-7a(a)(5)) specifically addresses beneficiary inducements, with penalties up to $20,000 per item or service plus treble damages. Important: Beneficiaries who unknowingly receive waived cost-sharing are not criminally liable. The statute targets those offering inducements. However, routine waivers are a significant red flag that the provider is likely engaged in other fraudulent conduct.

Red Flag #4: "We Bill at U.S. Rates Even Though Care Is Cheaper Here"

This "billing arbitrage" constitutes fraud under multiple statutes. The Supreme Court addressed analogous conduct in United States ex rel. Schutte v. SuperValu Inc. (2023), where pharmacies charged cash customers $4 to $10 for generic drugs but billed Medicare $81 to $109. The Court unanimously held this constituted False Claims Act liability. Billing U.S. rates for services rendered abroad at lower costs while misrepresenting service location or nature violates both the False Claims Act (31 U.S.C. § 3729) and the Healthcare Fraud Statute (18 U.S.C. § 1347), which criminalizes schemes to defraud healthcare benefit programs with penalties up to 10 years imprisonment.

Red Flag #5: "We Have a Special Arrangement to Bill for Services You've Already Received"

"Phantom billing" (billing for services not rendered) is the most straightforward form of healthcare fraud. Under 18 U.S.C. § 1347, knowingly executing schemes to defraud healthcare benefit programs carries fines plus up to 10 years imprisonment. If serious bodily injury results: up to 20 years. If death results: life imprisonment. The 2025 National Health Care Fraud Takedown charged 324 defendants for schemes involving $14.6 billion in intended losses. Individual prosecutions include Aaron Neil Williamsky (87 months federal prison and $172 million restitution) and Dr. Ronald David Dean (charged with $39.6 million in false telemedicine claims).

Red Flag #6: "Use This U.S. Address to Keep Your Medicare Advantage Plan"

Medicare Advantage eligibility explicitly requires residence in the plan's service area under 42 CFR § 422.50(a)(3). Using a false address violates 18 U.S.C. § 1001 (False Statements) with penalties up to 5 years imprisonment, and 31 U.S.C. § 3729 (False Claims Act) because CMS pays MA organizations capitated monthly payments based on enrollee residence. MA organizations can and do disenroll members for fraud or failure to maintain residence in the service area under 42 CFR § 422.74.

Red Flag #7: "Our Insurance Broker Gets Paid by Partner Hospitals"

The Anti-Kickback Statute applies to "whoever" solicits or receives remuneration for referrals, with no exemption for brokers or agents. Under 42 U.S.C. § 1320a-7b(b)(1), it's illegal to knowingly and willfully solicit or receive remuneration "in return for referring an individual" for services payable under a Federal health care program. Recent enforcement: Oak Street Health paid $60 million (September 2024) for kickbacks to insurance agents. DOJ v. Aetna, Humana, Elevance + eHealth, GoHealth, SelectQuote (May 2025) alleged "hundreds of millions of dollars in kickbacks." Criminal penalties include fines up to $100,000 and 10 years imprisonment per violation.

Red Flag #8: "Your Medicare Advantage Plan Covers Full Healthcare Abroad"

We've identified brokers who:

Routine care abroad: NOT COVERED
Planned procedures abroad: NOT COVERED
Extended stays beyond 6 months: Coverage typically terminates
Emergency/urgent care (if plan offers benefit): May be covered with limits ($25,000-$50,000 annual caps, 20-40% copays)

Foreign travel coverage is an optional supplemental benefit, not a standard requirement. Under 42 CFR § 422.74(d)(4)(ii), MA plans must disenroll members who leave the service area for more than 6 consecutive months. Some plans offer "visitor/traveler" benefits extending this to 12 months under § 422.74(d)(4)(iii), but this exception only applies to travel within the United States, not to expats living abroad. Anyone promising comprehensive MA coverage abroad is misrepresenting how these plans work.

Protecting Yourself

If you're an American expat, protect yourself by understanding these fundamental truths:

Medicare generally doesn't cover care outside the U.S. Anyone promising otherwise is either mistaken or attempting fraud.

Never sign assignment of benefits or POA documents for Medicare claims to foreign entities. This violates federal law.

Be suspicious of waived cost-sharing. While you won't be criminally liable, routine waivers indicate the provider may be engaged in fraud.

Don't use false addresses to maintain MA enrollment. This is federal fraud carrying potential prison time.

Question broker arrangements where the broker is paid by healthcare facilities rather than by you. This may constitute illegal kickbacks.

Read your MA plan documents carefully. Foreign travel benefits, when offered, cover only emergencies during temporary travel, not expat living.

Report suspected fraud to the HHS-OIG Hotline: 1-800-HHS-TIPS (1-800-447-8477) or oig.hhs.gov/fraud/report-fraud

ENFORCEMENT

The Enforcement Reality

Medicare fraud enforcement has intensified dramatically. The government is actively pursuing these schemes with significant resources and severe penalties.

$14.6B
2025 Fraud Takedown: Largest in U.S. history

324
Defendants Charged: Including 96 medical professionals

$10.6B
Operation Gold Rush: Transnational fraud scheme

10 yrs
Max Prison Sentence: Per healthcare fraud count

Key Enforcement Trends

Medicare Advantage Focus

DOJ has identified MA as a priority enforcement area

Transnational Networks

Operation Gold Rush demonstrated DOJ's ability to pursue international fraud networks

Broker Kickbacks

December 2024 OIG Special Fraud Alert signals increased scrutiny of agent/broker arrangements

False Enrollment

DOJ enforcement priorities explicitly include "inappropriate enrollment" schemes

Health Care Fraud Data Fusion Center

The Department of Justice has announced creation of a new center combining resources from the Criminal Division, HHS-OIG, FBI, and other agencies to leverage artificial intelligence and advanced analytics for identifying fraud schemes.

PART 5

Medicare Options by Expat Scenario

Official Sources and Regulatory Citations

We believe in providing authoritative information. Here are the official government sources for everything discussed in this article:

Primary Legislation

Social Security Act Section 1862(a)(4) [42 U.S.C. 1395y(a)(4)]: General exclusion of foreign services
Social Security Act Section 1814(f) [42 U.S.C. 1395f(f)]: Three foreign hospital exceptions

Code of Federal Regulations

42 CFR 411.9: Definition of "United States" and foreign service exclusion
42 CFR 422.50(a)(3): Medicare Advantage service area residency requirement
42 CFR 422.74(d)(4): Mandatory disenrollment for extended absence from service area
42 CFR 422.74(b)(1)(iii): Disenrollment for fraudulent enrollment information
42 CFR Part 403 Subpart B: Medigap standardized benefits including foreign travel coverage

CMS Publications

Medicare Benefit Policy Manual (Pub. 100-02), Chapter 16, Section 60: Foreign service exclusions
"Medicare Coverage Outside the United States" (Publication 11037): Official beneficiary guidance
Medicare Managed Care Manual: Service area and eligibility verification requirements

Additional Resources

Medicare.gov: Official Medicare Information CMS.gov: Centers for Medicare & Medicaid Services SSA.gov: Social Security Administration eCFR.gov: Electronic Code of Federal Regulations

Conclusion

Medicare's geographic limitations create fundamental coverage gaps that cannot be solved through creative interpretation of the rules. The regulatory framework is clear:

Original Medicare covers virtually nothing outside U.S. borders
Medicare Advantage requires U.S. residency within a specific service area. Period
Medigap provides only emergency coverage for the first 60 days of any trip with a $50,000 lifetime cap

For American expats, the critical insight is that Medicare cannot serve as primary coverage for anyone residing abroad. The penalty structure for Part B creates incentives to maintain enrollment even when coverage is unusable, while Special Enrollment Periods offer penalty-free re-entry paths for returning workers and volunteers.

If you're contemplating expat life, or already living abroad, you need supplemental or replacement coverage from day one. Don't let unscrupulous brokers convince you that Medicare Advantage "works" for expats. It doesn't. And participating in schemes to make it work could expose you to serious legal consequences.

Important Notice: This article is provided for educational and informational purposes only and does not constitute legal, tax, or professional advice. The information presented reflects federal regulations and enforcement trends as of January 2026 but laws and their interpretation may change. Nothing in this article creates an attorney-client relationship or should be relied upon as a substitute for consultation with qualified legal, tax, or healthcare professionals regarding your specific circumstances. Readers are strongly encouraged to conduct independent research, review primary sources, and consult licensed professionals before making any decisions regarding Medicare coverage, healthcare services abroad, or related matters.

Need Help Finding Coverage?

At Expat Insurance Inc., we specialize in helping American expats navigate healthcare coverage abroad. We'll never recommend products you're not eligible for, and we'll always explain the limitations of any coverage option. Contact us for a free consultation about your specific situation.

Or call: +1 (800) 577-4308

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