Expat Retirement Healthcare: Medicare Alternatives Abroad (2026)

An estimated 4.4 million Americans live abroad, and a growing share of them are retirees. The appeal is obvious: lower costs, better weather, slower pace, and in many countries a quality of life that stretches a fixed-income pension far further than it would in the US. But there is one critical problem that trips up nearly every American retiree who moves overseas: Medicare does not work outside the United States.

This is not a technicality or an edge case. Medicare Parts A, B, and D provide virtually zero coverage for healthcare received in foreign countries. The program that most Americans have paid into for their entire working lives becomes effectively useless the moment they board an outbound flight. And yet, most retirees do not plan for this until they are already abroad.

This guide covers the actual healthcare options available to American retirees living overseas: enrolling in foreign public healthcare systems, purchasing international health insurance, using local private insurance, and the medical tourism strategy. Each option has real costs, real limitations, and real trade-offs. Explore our retire abroad hub for a broader look at the best countries for retirement.

The Medicare Reality

Let us be precise about what Medicare does and does not cover abroad.

Medicare Part A (Hospital Insurance): Does not cover inpatient care at foreign hospitals, with three narrow exceptions: (1) a foreign hospital is closer than the nearest US hospital in a medical emergency, (2) you are traveling through Canada between Alaska and the contiguous US, or (3) you live near the US–Mexico or US–Canada border and a foreign hospital is closer. In practice, these exceptions apply to almost nobody living overseas.

Medicare Part B (Medical Insurance): Does not cover doctor visits, outpatient care, or medical services received outside the US. No exceptions.

Medicare Part D (Prescription Drugs): Does not cover prescriptions filled at foreign pharmacies. You must fill prescriptions at US pharmacies to receive coverage.

Can you keep Medicare while living abroad?

Yes, and in most cases you should. Part A is premium-free if you have 40+ quarters of US work credits, so there is no financial penalty for keeping it active. Part B costs $185/month (2026 standard premium) and you can either continue paying it while abroad or disenroll and re-enroll later. The catch with disenrolling: you will face a 10% late enrollment penalty for each 12-month period you could have had Part B but did not. This penalty applies for the rest of your life. If you plan to ever return to the US, keeping Part B active is usually worth the cost as insurance against that permanent surcharge.

Option 1: Enroll in Local Public Healthcare

Many countries allow foreign residents — including retirees on residency visas — to enroll in their national healthcare system. This is often the most cost-effective option, providing comprehensive coverage at a fraction of US healthcare costs. The quality varies by country, but several systems rival or exceed US standards.

Portugal: The Servico Nacional de Saude (SNS) covers all legal residents, including retirees on D7 visas. Registration at your local health center is free. Basic consultations cost EUR 4.50–7. Emergency visits are EUR 18–20. Prescriptions carry small co-pays. The catch: SNS wait times for specialists can stretch to months, which is why many retirees maintain supplemental private insurance (EUR 50–150/month) alongside SNS access. Overall quality is strong, particularly in Lisbon and Porto. See Portugal profile.

Spain: The convenio especial program allows non-EU residents to buy into Spain’s public healthcare system for approximately EUR 60 per month (EUR 157/month for those over 65). This provides full access to Spain’s extensive public hospital and clinic network. Spain’s healthcare system consistently ranks among the top 10 globally. Wait times for specialists exist but are generally shorter than in Portugal or the UK. See Spain profile.

Costa Rica: The CAJA (Caja Costarricense de Seguro Social) is a universal healthcare system that covers all legal residents. Retirees on the pensionado visa are required to enroll, paying approximately 7–11% of declared income (typically $80–$120/month for retirees). Coverage includes doctor visits, hospital stays, prescriptions, and surgeries. Quality is variable — excellent at major facilities in San Jose, more basic in rural areas. See Costa Rica profile.

France: PUMA (Protection Universelle Maladie) provides healthcare coverage to all stable residents after 3 months. Once enrolled, the state covers approximately 70% of medical costs, with many retirees purchasing a mutuelle (supplementary insurance) for an additional EUR 50–100/month to cover the remainder. France’s healthcare is widely regarded as one of the best systems in the world. See France profile.

Thailand: Thailand’s public system does not enroll foreign retirees in its Universal Coverage Scheme, but retirement visa holders (O-A / O-X) can access the social security system if they meet certain conditions. In practice, most retirees in Thailand rely on private insurance or out-of-pocket payments at private hospitals, where costs are a fraction of US prices. See Thailand profile.

Option 2: International Health Insurance

International health insurance is the most straightforward option for retirees who want comprehensive global coverage without relying on any single country’s system. These plans are designed for people who live abroad and provide coverage across multiple countries.

The major providers for US retirees abroad include Cigna Global, Aetna International, Allianz Care, and IMG (International Medical Group). Plans can be tailored by region, deductible level, and inclusion or exclusion of the US.

What to expect on cost

For retirees aged 65 and older, international health insurance typically costs $300–$800 per month depending on the plan level, deductible, and whether the US is included as a coverage region. Excluding the US from your plan (meaning you would not be covered for medical care during visits back) can reduce premiums by 30–50%. A common strategy is to maintain Medicare Part A (free) for US visits and carry an international plan that excludes the US for day-to-day coverage abroad.

Pre-existing conditions

This is where international insurance gets complicated. Unlike the ACA marketplace, international insurers can and do deny coverage for pre-existing conditions, impose waiting periods, or charge significantly higher premiums. The best time to purchase international insurance is immediately upon moving abroad — ideally before your 65th birthday if possible. Applying at 60 with a clean health history is dramatically cheaper than applying at 70 with diabetes and a cardiac history.

Guaranteed-issue options

A few providers offer guaranteed-issue international plans that do not underwrite pre-existing conditions. These plans are more expensive (often $600–$1,000/month for 65+) but provide a safety net for retirees who cannot qualify for standard underwritten coverage. GeoBlue and some Cigna Global plans offer versions of this.

Option 3: Local Private Insurance

In many countries, you can purchase health insurance from local private insurers at a fraction of what international plans cost. This is a popular option in countries with well-developed private healthcare sectors like Thailand, Mexico, and Costa Rica.

Advantages: Dramatically lower premiums (often $100–$250/month for 65+ in Southeast Asia or Latin America), acceptance at local hospitals and clinics with direct billing, and coverage designed for the local healthcare market. Disadvantages: Coverage is limited to the country of purchase (no global portability), pre-existing condition exclusions are common and often permanent, policy documents may be in the local language, and regulatory protections vary by country.

Local private insurance works best as a complement to, not a replacement for, broader coverage. Many retirees use a local plan for routine and specialist care in their country of residence, combined with a catastrophic international plan or maintained Medicare for emergencies and visits to the US.

Option 4: Medical Tourism + Catastrophic Coverage

For healthy retirees in countries with affordable healthcare, a viable strategy is paying out of pocket for routine care and carrying only a catastrophic coverage plan for major events.

In Thailand, a standard doctor visit at a private hospital costs $15–$45. An MRI runs $230–$430. A comprehensive blood panel is $50–$100. In Mexico, a specialist consultation is $30–$60. In Portugal, a private GP visit is EUR 40–80. For retirees in good health, paying out of pocket for routine care while carrying a catastrophic plan with a high deductible ($5,000–$10,000) can be significantly cheaper than comprehensive insurance.

The risk is obvious: a single serious medical event — cancer treatment, cardiac surgery, a stroke — can cost $50,000 to $300,000+ even in “cheap” countries. The catastrophic plan exists to cover exactly this scenario. Plans with a $5,000+ deductible run $100–$250/month for 65+ from providers like SafetyWing Nomad Insurance (which now offers plans for older adults) and IMG.

Country-by-Country Healthcare Costs for Retirees

For context: the average American retiree on Medicare + Medigap supplement pays approximately $400–$600 per month for healthcare (Medicare Part B + Part D + supplement premiums + co-pays and deductibles). In every country listed above, total healthcare costs for retirees run 30–80% lower — often with comparable or superior quality of care.

Planning Your Healthcare Strategy

The right healthcare strategy depends on your health status, budget, risk tolerance, and where you plan to live. Here is a framework for making the decision.

If you are healthy and under 70

The best time to lock in international health insurance. Premiums are lowest, pre-existing condition exclusions are least likely to be an issue, and you have the most options. Consider a comprehensive international plan (Cigna Global, Aetna International) with a moderate deductible. In countries with strong public systems (Portugal, Spain, France), enroll in the public system as your primary coverage and use the international plan as a global safety net.

If you have pre-existing conditions

Prioritize countries with public healthcare systems that accept all residents regardless of health status. Portugal’s SNS, Spain’s convenio especial, Costa Rica’s CAJA, and France’s PUMA do not exclude pre-existing conditions. This is a significant advantage over private insurance markets. Supplement with a guaranteed-issue international plan if budget allows.

If you are on a tight budget

Enroll in a local public system where available ($0–$120/month). For countries without public enrollment options, use local private insurance ($80–$250/month) for routine care and carry a catastrophic plan ($100–$250/month) for major events. Keep Medicare Part A active (free) for US emergency visits.

If you plan to split time between countries

An international health insurance plan with multi-country coverage is the clearest solution. Look for plans that cover your primary country of residence plus your secondary locations. Keeping Medicare active provides coverage during US visits. This is the most expensive approach ($500–$800/month) but the most comprehensive.

For a deeper comparison of healthcare systems across retirement destinations, see our retirement healthcare comparison. For a broader guide to health insurance options for all expats (not just retirees), read our expat health insurance guide.

The Bottom Line

Medicare’s uselessness abroad is the single biggest financial blind spot for American retirees moving overseas. But the alternatives are not just adequate — in many cases, they are better and cheaper than what Medicare provides at home. A retiree in Portugal pays $0–$150 per month for healthcare that ranks in the global top 15. A retiree in Spain gets full public coverage for EUR 60 per month. A retiree in Costa Rica joins a universal healthcare system for $80–$120 per month.

The key is planning before you leave, not after. Research the healthcare system in your target country. Apply for insurance while you are healthy. Keep Medicare Part A active as a free safety net. And budget realistically for healthcare as a non-negotiable line item in your retirement abroad plan.