Expat health insurance in the United States

An expatriate moving to the United States may consider local insurance, international insurance or the CFE. The right arrangement depends on residence, immigration status, employer benefits and treatment needs. No option automatically removes the need to check compliance and policy terms.

This guide explains eligibility, networks, routine care, hospitalisation and visits to France. It helps you ask the right questions; it does not replace your contract or the competent authorities.

Resident or visitor: distinguish the situations

The French state does not pay your medical, hospital or repatriation costs abroad. A travel policy generally covers a limited trip outside your country of residence, rather than a permanent move. If you are moving for work, study or retirement, state that you will be a resident when requesting cover.

Obamacare: understanding the Affordable Care Act

“Obamacare” refers to the Affordable Care Act (ACA), a law, not a single public insurance scheme. Health insurance Marketplaces offer private ACA-compliant plans through HealthCare.gov or a state's platform. These plans include protections concerning pre-existing conditions but still have deductibles, cost-sharing and provider-network rules.

Mandatory insurance: requirements vary by state

The federal penalty for not having qualifying cover has been zero since 2019. This does not mean that the ACA was repealed or that no requirement applies to you. Review your state of residence, exemptions, immigration status and any visa-specific obligations separately.

• California, Massachusetts, New Jersey, Rhode Island and the District of Columbia: local mandates can result in a penalty for affected residents who lack recognised cover and do not qualify for an exemption.
• Massachusetts: check its specific Minimum Creditable Coverage (MCC) standard.
• Vermont: a coverage requirement exists without an individual financial penalty for being uninsured.
• Other states: the absence of this type of state penalty does not remove any visa, employer or educational-institution requirements, or the financial risk of medical bills.

Each scheme has its own residence rules and exemptions. A visitor's position is not automatically the same as that of an employee or family living permanently in the country.

Does international insurance or the CFE satisfy the requirements?

“USA included” does not itself prove compliance with local requirements. Ask for written confirmation for your state, including Minimum Essential Coverage (MEC) and, in Massachusetts, MCC. Some expatriate plans may qualify: do not assume either that all do or that none do. The CFE is not automatically proof of US compliance.

Marketplace eligibility, financial help and arrival from abroad

Some lawfully present immigrants can enrol in Marketplace coverage. Eligibility to buy a plan and eligibility for financial assistance are separate questions. Residence, precise immigration status, income and family circumstances matter. A visa or residence card alone does not guarantee financial help.

A move from abroad may open a Special Enrollment Period, subject to the applicable conditions. Check deadlines and supporting documents before departure. HealthCare.gov also announces restrictions on eligibility for financial assistance for certain immigration statuses from 1 January 2027. This is not a general ban on buying coverage. Check the rules for the requested coverage year.

Before comparing premiums, identify your state, status, beneficiaries, employer benefits and planned stays in France. Then compare compliance, networks, deductibles, cost-sharing and your remaining expenses.

Employees, families and retirees: different starting points

• Employees: ask your employer which people and countries are covered and what happens when employment ends.
• Families: a partner and children may not have the same benefits as the employee. Check beneficiaries, children's age limits and maternity benefits.
• Retirees: the European S1 mechanism concerns the EU, EEA and Switzerland, not the United States. Do not assume it applies to a US move.

The CFE and first-euro cover

The Caisse des Français de l'Étranger can help maintain continuity of French-style social protection during expatriation and on return. Our CFE guide explains its role.

Reimbursement abroad does not always use French tariffs. The CFE's 2026 benefit schedule uses coverage zones, percentages of actual costs for some hospital treatment and capped flat rates for other services. Compare the applicable benefit with the actual expense, especially for US hospital care.

“First-euro” insurance does not mean no deductible or full reimbursement. It operates without prior reimbursement from a French basic scheme, within policy limits. CFE health insurance is also separate from pension contributions.

Whether CFE-only protection is appropriate depends on your needs and the financial risk left to you. It is not automatically proof of local compliance. Examine both compliance and the potential gap between a medical bill and reimbursement before deciding whether to add cover.

Routine care: payment and claims

Under international insurance, you generally pay for consultations, tests or medicines and then submit a claim. For CFE claims, check the current member-account or app procedure, the supporting documents and receipt-retention rules rather than relying on older instructions.

International insurers also require itemised invoices, proof of payment and compliance with deadlines. Some contracts allow direct billing for expensive or recurring treatment with insurer approval and provider acceptance, but it is not automatic. Read about claiming routine-care expenses abroad.

Hospitalisation: prior approval and guarantees of payment

Under an international policy, the right to choose a facility does not guarantee direct billing. Request prior insurer approval and check whether the hospital accepts the guarantee of payment. You may still need to pay some expenses upfront.

CFE benefits also require prior approval for certain treatment or transport. Check the applicable schedule and our guide to hospital direct billing.

Local networks and international facility choice

Local insurance may restrict reimbursement outside its provider network. Some international policies provide free choice of hospital subject to prior approval for direct billing. Do not assume every international contract has a compulsory network, or that every provider will accept its payment guarantee.

Our comparison of local and international US insurance explains the distinction. Ask what happens if you use an out-of-network provider under the actual policy you are considering.

Coverage area and visits to France

Check cover in your country of residence and during temporary stays in France, including duration limits and reimbursement ceilings. Health insurance is not automatically medical repatriation insurance. Check territorial exclusions, repatriation benefits and any excluded countries or regions. CFE cover for temporary stays in France also has conditions.

Fictional example

Camille moves for an assignment with her partner. The employer covers Camille but not her partner. Before comparing a family international plan with a CFE-based arrangement and local cover, she checks the destination state, compliance, beneficiaries, maternity benefits and continuity when employment ends. This is a fictional illustration, not a client case or promise of cover. The decision depends on hospital benefits and remaining expenses, not just the monthly premium.

Checklist before taking out cover

1. Is the policy appropriate for a resident rather than a visitor?
2. Does it meet the requirements of my state and any visa or employer conditions?
3. Who is covered: employee, partner, children?
4. What network or hospital-choice rules apply?
5. How do prior approval and hospital guarantees of payment work?
6. Which routine-care bills must I pay upfront, and what are the claim deadlines?
7. What limits, deductibles, cost-sharing and exclusions apply?
8. Are visits to France and medical repatriation covered?

Questions for your broker

• How is compliance confirmed for my state of residence?
• What gap could remain between actual expenses and CFE reimbursement?
• Which hospital treatments require prior approval?
• What happens if my employer changes or I return to France?

The Izem Diagnostic helps you clarify your needs. You can also request personalised offers and speak with an Izem Expat advisor free of charge and without obligation.