Expat health insurance in the USA and Canada: a practical guide

Expat health insurance in the USA and Canada: why it needs planning

Moving to North America is exciting, but healthcare is where many newcomers get caught out. Expat health insurance in the USA and Canada works very differently in each country. The United States has some of the most expensive medical care in the world and no universal public system. Canada has public health insurance run by each province, but it has gaps and, in some provinces, a waiting period for newcomers.

This guide explains how each system works, what private care costs, which rules may apply to your visa and what to look for in an international health plan when you move to New York, Toronto, Vancouver or anywhere in between.

How does healthcare work in the USA and Canada?

United States: a mostly private, insurance-based system

In the USA, most people get health insurance through their employer, buy a plan individually or qualify for a government programme. The two main public programmes, Medicare (mainly for people aged 65 and over) and Medicaid (for people on low incomes), have eligibility rules that most newly arrived expats will not meet. Hospitals and doctors are largely private or non-profit, and they bill the patient or the insurer for every consultation, test and night in hospital.

Hospital emergency departments must assess and stabilise anyone who arrives with an emergency, whatever their ability to pay. That does not make the care free: the bill comes afterwards.

Canada: public cover run by the provinces

Canada's public health insurance is organised by each province and territory, for example OHIP in Ontario, MSP in British Columbia and RAMQ in Quebec. If you are eligible, medically necessary doctor and hospital services are covered without a bill at the point of care. Eligibility depends on your immigration status and on the province, and some provinces, such as British Columbia and Quebec, currently apply a waiting period of up to about three months for new residents. Check the latest rules with your provincial health ministry before you arrive.

Public plans also leave gaps. Dental care, glasses, private hospital rooms and many prescription medicines taken outside hospital are usually not fully covered, which is why many Canadians have extra cover through their employer. Waiting times for specialists and planned surgery can also be long.

How much does private care cost, and where do expats get treated?

The USA is the main reason international plans offer an area of cover "excluding the USA". Without insurance, a short hospital stay or an operation can easily cost tens of thousands of dollars, and even routine specialist visits and scans are expensive. Prices also vary a lot between hospitals and states, which makes it hard to predict what you will pay.

The quality of care is high in both countries. In the USA, well-known hospitals that treat many international patients include, for example, NewYork-Presbyterian and Mount Sinai in New York, Cedars-Sinai in Los Angeles and Massachusetts General Hospital in Boston, as well as specialist centres such as Mayo Clinic and Cleveland Clinic. In Canada, most hospital care is delivered in public hospitals, including large university teaching hospitals in Toronto, Vancouver and Montreal, while private clinics mostly offer services outside the public plans, such as some diagnostic tests, physiotherapy or dental care.

Before you rely on any hospital, check that it is in your insurer's network and whether it offers direct billing, so the insurer pays the hospital and you do not have to advance large sums. Our guide to direct billing vs reimbursement explains how this works.

Is health insurance compulsory for expats in the USA or Canada?

There is no single rule for everyone, so always check the latest official requirements for your visa and your state or province.

• USA: there is currently no federal penalty for being uninsured, although a few states have their own rules. Some visas also come with insurance conditions. Exchange visitors on J-1 visas, for example, must hold health insurance that meets minimum standards set by the US Department of State, and many universities require international students to join their student plan or prove equivalent cover. Employers often provide a US group plan, but it may not cover you well when you travel or return home.
• Canada: public cover is not automatic on arrival. Newcomers often need private insurance to bridge a provincial waiting period, and people who are not eligible for public cover, such as many visitors, need private insurance for their whole stay. Parents and grandparents applying for the Super Visa must show proof of private medical insurance.

Do you need medical evacuation cover in North America?

Most of the USA and Canada has excellent hospitals, so evacuation is less about reaching good care and more about distance. In remote areas, such as northern Canada, Alaska or large national parks, an emergency may require an air ambulance to the nearest major hospital, which is very expensive.

Repatriation matters too. If you fall seriously ill, you may prefer to be treated, or to recover, in your home country, close to your family. A good international plan includes medical evacuation and repatriation, but the conditions vary from plan to plan. Our guide to medical evacuation explains how it is organised and what is usually covered.

What to look for in a health plan for the USA and Canada

• The right area of cover. If you live in the USA, you need a plan that includes the USA. If you live in Canada but often visit the USA, check how the plan handles those trips: depending on the plan, the USA may be covered only for emergencies or in full for a higher premium. Our guide Area of cover: should you include the USA? explains the choice.
• High overall limits. Because US prices are so high, an annual limit that looks generous elsewhere can be used up much faster after a serious illness.
• Outpatient cover. Specialist visits, scans and prescriptions add up quickly in the USA. In Canada, outpatient cover helps fill the gaps of the public plan.
• Networks and direct billing. In the USA, insurers usually work with networks of providers, and using a hospital outside the network can cost you more, depending on the plan.
• Maternity, dental and optical, if you need them. Maternity benefits often have a waiting period, and dental care is costly in both countries.
• Deductible and co-payments. A higher deductible lowers the premium, but make sure you could afford it after a stay in a US hospital.

Practical tips for expats moving to North America

• Arrange cover that starts on the day you arrive, not on the day your public or employer cover begins.
• In the USA, compare any employer plan with an international plan: the employer plan may only work in the USA and ends with the job, while an international plan follows you when you travel or move again.
• In Canada, apply for your provincial health card as soon as you are eligible, and keep private cover in place until it arrives.
• For planned treatment, ask your insurer for pre-authorisation before booking. In the USA, this step can save you from a large bill.
• Keep your insurance card and your insurer's 24-hour assistance number on your phone.
• Tell your advisor about any pre-existing conditions: how each insurer handles them can change which plan suits you best.

With US prices, choosing the right plan really matters. Answer a few questions and get an instant quote comparing plans from 20+ international insurers, sent by e-mail in about 2 minutes, with free advice from a real advisor if you want it.

Useful resource: Pan American Health Organization