Medicare for expats: Part B enrollment, penalties & IRMAA

Medicare coverage for expats depends on whether you earned enough US work credits to qualify, which parts you enroll in, and whether you plan to return to the US.

Here is what you need to know at a glance:

• Part A is premium-free if you have 40 or more quarters of US work history. Part B is optional and costs $185.00 per month (2025) or $202.90 per month (2026).
• The late enrollment penalty for Part B is 10% of the standard premium for every full 12 months you could have had coverage but did not sign up. It is permanent.
• The Initial Enrollment Period is seven months long, centered on your 65th birthday month. The General Enrollment Period runs January 1 – March 31 each year.
• Original Medicare generally does not pay for care outside the US. If you live abroad full-time, you are paying premiums for coverage you largely cannot use.
• IRMAA adds a surcharge to Part B and Part D premiums for higher earners. It is based on your modified adjusted gross income from the two tax years prior.

The sections below cover eligibility, enrollment from overseas, premiums, penalties, IRMAA, Medicare tax obligations, and how all of this connects to your US tax return.

Are expats eligible for Medicare? Who qualifies abroad

Yes. US citizens and lawful permanent residents qualify for Medicare while living abroad as long as they meet the standard requirements:

• Age 65 or older, or qualifying disability
• US citizen, or lawful permanent resident with 40 quarters of Medicare-covered work through yourself or a spouse
• If you’re a lawful permanent resident without 40 qualifying quarters through either route, you can still buy into Part A and Part B once you’ve resided in the US continuously for five years

Your eligibility does not change when you move overseas. Where you live has no effect on whether you qualify. It only affects whether you can use the coverage.

 

If you have fewer than 40 quarters, you can still buy Part A, but you will pay a monthly premium: $285 per month with 30 – 39 quarters of coverage (2025) or $518 per month with fewer than 30 quarters (2025). For 2026, those premiums rise to $311 and $565, respectively.

Medicare for a non-US spouse or family abroad

A non-US spouse can qualify for premium-free Part A on your work record if the marriage lasted at least one year, you have 40 qualifying quarters, and your spouse is a US citizen or lawful permanent resident.

The five-year continuous residency rule only comes into play if your spouse needs to buy into Part A separately, without qualifying through either of you.

According to Medicare Interactive, a spouse who is not a US citizen or lawful permanent resident generally cannot enroll in premium-free Part A on your work record, even if you are fully insured.

A divorced spouse may qualify for premium-free Part A on your work record if the marriage lasted 10 or more years, the divorce is final, and the ex-spouse is unmarried. The five-year continuous residency rule only applies if the ex-spouse doesn’t qualify through your work record and needs to buy into Part A separately.

See our guide to Social Security benefits for Americans abroad for how spousal and derivative benefits interact with Medicare eligibility.

Do expats get Medicare? Parts A, B, C, D and Medigap

Expats keep their Medicare entitlement, but only Part A and Part B travel with you in any meaningful sense. Here is what each part covers and how it works abroad.

 

The practical takeaway

Part A carries no premium for most people and is worth keeping. Part B costs money for coverage you likely will not use abroad. Part C and D rarely apply overseas. Medigap is the only option that offers limited foreign emergency coverage.

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Does Medicare cover expenses abroad? The limited exceptions

Medicare coverage abroad is extremely limited.

Original Medicare does not pay for health care outside the 50 states, DC, and US territories except in four narrow situations:

1. You are in the US when a medical emergency occurs, and the nearest hospital that can treat you is across the border in a foreign country.
2. You are traveling between Alaska and another state through Canada without unreasonable delay, and a Canadian hospital is closer than the nearest US hospital that can treat your condition.
3. You live in the US near the border, and a foreign hospital is closer to your home than the nearest US hospital, regardless of whether you have an emergency.
4. You receive care aboard a cruise ship within US territorial waters – specifically, within six hours of a US port.

Outside these exceptions, Original Medicare pays nothing for care delivered in a foreign country.

Medigap foreign travel emergency benefit

Medigap Plans D, G, M and N include a foreign travel emergency benefit. (Plans C and F offer the same benefit, but neither is available anymore to anyone who became eligible for Medicare on or after January 1, 2020.)

This covers 80% of the cost of emergency care that begins within the first 60 days of a trip abroad, after a $250 annual deductible. The lifetime benefit cap is $50,000.

This is not a substitute for international health insurance. The $50,000 lifetime cap is low, and it only covers emergencies, not routine care. If you live abroad permanently, Medigap foreign travel coverage is a backstop, not a health plan.

What happens to Medicare if I move overseas?

Medicare when moving overseas stays with you, but your practical options narrow significantly.

Here is what to do before you leave: update your address with SSA, decide whether to keep Part B, review your Part C and Part D status, and set up premium payments that work from abroad.

• Part A stays active and premium-free if you have 40 quarters. There is no reason to drop it.
• Part B continues as long as you pay the premium, but it does not cover care outside the US. You are paying for future access – coverage that activates when you return.
• Part C and Part D coverage typically ends once you leave the plan’s service area. Most Medicare Advantage plans require you to live within the network zone. Part D similarly requires a US address and access to US pharmacies.

Do expats give up Medicare benefits by living abroad?

No. You do not forfeit Medicare by living overseas. Part A remains on your record. Part B stays active as long as you keep paying.

What you do lose is practical access. Original Medicare does not pay for care outside the US. If you live in London, Tokyo, or Mexico City, your Part B premium buys you coverage you cannot use day-to-day.

The real question is cost versus future value. Skipping Part B saves the monthly premium but triggers the 10% per-year late enrollment penalty if you ever come back and sign up later. If you are reasonably likely to return to the US – even part-time – keeping Part B avoids that penalty entirely.

If you are certain you will never return, dropping Part B is a defensible choice. But “never” is a long time, and the penalty is permanent.

Medicare enrollment periods and deadlines for expats

Medicare for Americans living abroad follows the same enrollment windows as domestic coverage, but missing the Initial Enrollment Period while overseas is one of the most common – and most costly – mistakes expats make.

 

COBRA does not count

If you elect COBRA after leaving an employer, the 8-month Special Enrollment Period clock starts when the employment or group coverage ended – not when COBRA ends. This is a common and expensive mistake. If you rely on COBRA for two years and then try to enroll in Part B, SSA will treat you as having delayed enrollment since the day your group coverage ended.

The 7-month Initial Enrollment Period is the most common and most expensive missed deadline.

Missing it and enrolling during the General Enrollment Period means a permanent premium surcharge. Coverage will start the first day of the month after you sign up – but you’ll still have gone without Part B for however long you delayed, and the surcharge is permanent.

Part B late enrollment penalty for expats

The Part B late enrollment penalty is 10% of the standard monthly premium for each full 12-month period you could have had Part B but did not sign up. It is permanent – the surcharge stays on your premium for as long as you have Part B.

How the math works

Suppose your Initial Enrollment Period ended April 30, 2020, and you first enrolled during the General Enrollment Period in January 2026. That is 69 months, or five full 12-month periods of delay. The penalty is 50% of the standard premium.

At the 2026 standard premium of $202.90, a 50% surcharge adds $101.45 per month – $1,217.40 per year – for as long as you have Part B.

The penalty is calculated against the current year’s standard premium and recalculated each year as the premium changes. It never goes away.

There is one exception: if you delayed enrollment because you had group health plan coverage through a current employer, you can use the Special Enrollment Period and avoid the penalty entirely. But the employer must be current – retiree coverage and COBRA do not count.

Can I cancel Medicare Part B if I live abroad?

Yes. You can cancel Part B while living abroad by submitting Form CMS-1763 to SSA. Coverage ends on the last day of the month after the month you submit the form – not the month SSA finishes processing it.

Before you cancel, understand what you are giving up:

• If you re-enroll later, the late enrollment penalty applies. The longer you are out, the higher the permanent surcharge.
• You can only re-enroll during the General Enrollment Period, which means a gap in coverage.
• If you visit the US often, even Part B’s limited coverage may be worth keeping.

Cancelling Part B makes sense if you have established permanent residence abroad with no realistic plan to return and you have reliable international health coverage. It does not make sense if there is any chance you will move back, because the penalty accumulates every year you are not enrolled.

 

IRMAA for expats: how income-related surcharges work

IRMAA – the Income-Related Monthly Adjustment Amount – adds a surcharge to your Part B and Part D premiums if your income exceeds certain thresholds.

SSA uses your modified adjusted gross income from the tax return filed two years earlier. Your 2025 IRMAA is based on your 2023 return. Your 2026 IRMAA is based on your 2024 return.

The IRMAA brackets are adjusted for inflation each year. Note that the tax year 2025 return you file in 2026 feeds your 2027 premiums – it does not affect your current year’s IRMAA.

2025 IRMAA – Part B (based on 2023 MAGI)

 

2026 IRMAA – Part B (based on 2024 MAGI)

 

Part D IRMAA surcharges follow the same bracket structure but add a smaller monthly amount on top of your plan premium:

 

IRMAA is an extra monthly charge on top of your standard premium. It is not a one-time fee, and it recalculates every year based on the return from two years prior.

Retirement withdrawals feed directly into MAGI.

What expat income counts toward IRMAA

SSA bases IRMAA on your modified adjusted gross income as reported on your US return. For expats, this means the following income sources all count:

• Foreign pension income, US retirement withdrawals, Roth conversions
• Capital gains on a home sale, stock sales, and tax-exempt interest
• According to SSA’s program manual, MAGI for IRMAA is your adjusted gross income plus tax-exempt interest – it does not list foreign earned income excluded under the FEIE as an add-back.

An expat earning $130,000 (2025) abroad and excluding all of it under the FEIE lowers the income counted toward MAGI accordingly, since SSA’s MAGI definition does not add it back. Foreign tax credits do not affect MAGI either.

 

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Do expats pay Medicare tax?

Yes, in many cases. US citizens and green card holders living abroad owe Medicare tax on self-employment income, and on wages paid by an American employer or by a foreign affiliate of an American employer covered by a voluntary agreement with the US Treasury.

Wages from a foreign employer for work done abroad are generally not subject to US Medicare tax.

 

The Additional Medicare Tax is reported on Form 8959.

It applies to wages and self-employment income above the threshold – $200,000 for single filers, $250,000 for joint filers, $125,000 for married filing separately (2025).

These thresholds have not changed since 2013 and are not adjusted for inflation.

The Net Investment Income Tax at 3.8% applies to higher-income taxpayers on investment income and is reported on Form 8960.

It is not technically a Medicare tax, but it uses the same income thresholds and is commonly grouped with Medicare tax obligations.

The Foreign Earned Income Exclusion does not exempt you from Medicare tax. You can exclude up to $130,000 (2025) of foreign earned income from your taxable income, but the excluded income is still subject to self-employment tax, including the Medicare portion.

US expats receive an automatic two-month filing extension to June 15, but this is an extension to file – not an extension to pay. Self-employment tax, including the Medicare tax portion, is due by April 15.

See our article on US tax obligations for citizens living abroad for a broader overview of how expat income is taxed.

Medicare tax for self-employed expats and totalization agreements

Self-employed expats pay both halves of Medicare tax through Schedule SE – a total of 2.9% on net self-employment income, as part of the 15.3% self-employment tax rate.

The Social Security wage base is $176,100 (2025), but Medicare tax has no wage cap.

If you live in a country that has a totalization agreement with the US, you may be exempt from US self-employment tax – including the Medicare portion – if you are covered by that country’s social security system. A certificate of coverage from the host country proves the exemption.

The US currently has totalization agreements with 31 countries.

The full list: Australia, Austria, Belgium, Brazil, Canada, Chile, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Luxembourg, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, South Korea, Spain, Sweden, Switzerland, United Kingdom, and Uruguay.

If your country is not on this list, you generally owe US self-employment tax in full, even if you also pay into the host country’s social security system.

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Medicare Part D living abroad: what happens to drug coverage

You can drop Part D when you move abroad, and most expats do. Part D generally does not work outside the US – the plan networks, formularies, and pharmacies are all US-based.

However, going 63 or more continuous days without creditable drug coverage triggers a late enrollment penalty.

The penalty is 1% of the national base beneficiary premium for every full month you went without coverage.

The 2025 base premium is $36.78, and the 2026 base premium is $38.99. Like the Part B penalty, this surcharge is permanent.

Whether to keep Part D depends on whether you can demonstrate creditable coverage – drug coverage that is at least as good as Medicare’s standard benefit. Some foreign health plans meet this standard, but most do not.

If you cannot demonstrate creditable coverage for the period you were abroad, the penalty applies when you eventually sign up.

Medicare Advantage and Medigap for expats

Medicare Advantage and Medigap are two different types of supplemental coverage. Here is how they compare for someone living abroad.

 

• Medicare Advantage plans generally require you to live in the plan’s service area. If you move abroad, you typically lose coverage. Some plans offer limited travel coverage, but it is not designed for long-term overseas living.
• Medigap is the more relevant option for expats. The foreign travel emergency benefit covers genuine emergencies during trips abroad, but it is not a substitute for full international health insurance. The $50,000 lifetime cap and the 60-day trip requirement mean it works as a safety net, not a primary plan.

Neither option provides routine medical coverage for someone living abroad permanently.

Most long-term expats purchase a private international health insurance policy for day-to-day coverage and keep Medigap for US visits and emergencies.

Foreign health insurance, Medicare and US tax reporting

Medicare Part A counts as minimum essential coverage under the Affordable Care Act. If you have Part A, you satisfy the coverage requirement for federal tax purposes.

The individual mandate penalty has been $0 since 2019, so there is no federal tax penalty for going without coverage. However, Part A satisfies the requirement in any state that still enforces its own mandate.

Foreign health insurance generally does not qualify as minimum essential coverage under US tax rules. You cannot use a foreign policy to satisfy the ACA individual coverage requirement – though, again, the federal penalty is $0.

If you keep Medicare and also buy foreign health insurance, the foreign premiums are not deductible against your US taxes unless you itemize and they exceed the 7.5% of AGI threshold for medical expenses.

For most expats, the standard deduction is higher, and foreign premiums remain a non-deductible personal expense.

Expats who maintain both Medicare and local foreign coverage effectively pay for two systems. This is one of the reasons many expats drop Part B – the premium buys US-only coverage they do not use, and the foreign insurance they do use is not deductible.

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