Group International Medical Coverage: A Decision Guide For Employers
A domestic group health plan is built for care in the United States. Once employees travel for work or live abroad, the questions change: who is covered where, how claims are paid, and which federal rules still apply. This guide sets out how to decide.
What To Weigh.
General information, not legal or tax advice. Check the cited sources before you act.
Group International Medical Coverage
The overview of what group international coverage includes.
Employees Abroad: Expatriate Benefits
The benefits questions that follow employees overseas.
Multi-State And Multinational Benefits
Designing benefits for a workforce in several places.
Three Groups, Three Needs.
Business travelers take short trips and return home. Their need is emergency care, medical evacuation and a 24-hour line to call, more than a full local network.
Long-term assignees live abroad for a year or more, often with family. They need routine and specialty care, maternity, mental health and prescription coverage in the country where they live, with claims paid in local currency and direct billing where possible.
Organizations that send groups abroad, such as schools, need coverage for the group for a defined trip or term, with evacuation and a plan for care far from the home network. Local-hire employees working outside the United States are a fourth group, usually covered under local rules.
What The Expatriate Act Does.
The Expatriate Health Coverage Clarification Act of 2014 says the Affordable Care Act does not apply to qualifying expatriate health plans, their sponsoring employers and expatriate issuers. It applies to plans issued or renewed on or after July 1, 2015.
A plan qualifies only if substantially all of its primary enrollees are qualified expatriates, which includes people who have worked outside the United States for at least 180 days in a consecutive 12-month period overlapping the plan year. The plan must also meet coverage conditions, such as providing inpatient hospital, outpatient facility, physician and emergency services in specified locations, covering dependents to age 26, offering reimbursement in the local currency of at least eight countries, and meeting the infrastructure standards for an issuer, including provider networks, call centers and evacuation coverage.
The Act does not remove the coverage reporting requirements in Internal Revenue Code Sections 6055 and 6056, although a more liberal electronic delivery rule applies.
When ERISA Still Applies.
A plan a United States employer sponsors for its employees is generally an ERISA plan, wherever the employees work. ERISA does not apply to a plan maintained outside the United States primarily for the benefit of people who are nonresident aliens, which is why local-hire coverage is often handled separately.
If you cover assignees under an ERISA plan, the plan document, the summary plan description and the claims procedure should say how care abroad, evacuation and foreign-currency claims are handled.
The Questions To Put To A Carrier.
Ask whether the plan is an expatriate plan under the Act or a domestic plan with an international rider, because the compliance position differs. Ask what happens to a member who needs care in a country with limited English-speaking providers, and how a claim is paid when the member pays upfront.
Ask what evacuation and repatriation cover, who decides whether evacuation is medically necessary, and whether the plan covers a return home for routine care. Ask how pre-existing conditions, maternity and mental health are handled.
Where To Begin.
List who is abroad, for how long, with whom and where. A short-term traveler list and a long-term assignee list need different coverage and may need different carriers.
Decide whether the group is better served by a domestic plan with an international extension or a separate international plan, and document the reasoning. Put the decision in the plan documents.
Tell employees before they travel what is covered, whom to call and how claims work. The worst time to learn that a plan has a limited network abroad is in an emergency.
Common Misreadings.
A domestic plan that reimburses emergency care abroad is not the same as a plan that provides routine care and evacuation abroad. Read what each pays for before you rely on either.
The Expatriate Act is an exemption with conditions, not a label. A plan that does not meet the conditions does not qualify, whatever the carrier calls it.
Do not copy a carrier’s international product into your plan documents without reading how it defines a covered person and a covered location.
Related Guides.
Foreign National Employees
Group coverage questions for employees from other countries.
Remote Employees Out Of State
Network and coverage issues for people who work away from home.
ERISA For Employer Health Plans
How ERISA applies to the plan you sponsor.
Laws And Sources
H.R. 4414, 113th Congress: The Expatriate Health Coverage Clarification Act of 2014.
ERISA Section 4, 29 U.S.C. 1003: Coverage of ERISA and the exemption for plans maintained outside the United States for nonresident aliens.
26 U.S.C. 6055 and 6056: Information reporting of health coverage that continues to apply.
General information, not legal or tax advice. Check the cited sources before you act.
Quick Answers.
Short replies on this page’s topic, each tied to a fuller guide.
Does the ACA apply to an expatriate health plan?
Under the Expatriate Health Coverage Clarification Act of 2014, the ACA does not apply to qualifying expatriate plans, their sponsors and expatriate issuers, for plans issued or renewed on or after July 1, 2015.
Who counts as an expatriate?
Among others, people who have worked outside the United States for at least 180 days in a consecutive 12-month period overlapping the plan year. Substantially all primary enrollees must qualify.
Is a business traveler covered by an expatriate plan?
A business traveler on short trips is usually covered by the domestic plan, sometimes with an international extension for emergency care and evacuation. The Act is aimed at people who live abroad.
Does ERISA apply to plans for employees abroad?
A plan a U.S. employer sponsors for its employees is generally covered, wherever they work. ERISA does not apply to a plan maintained outside the United States primarily for nonresident aliens.
What should I ask a carrier about international coverage?
Ask whether it is an expatriate plan or a domestic plan with a rider, how claims are paid abroad, what evacuation covers and who decides, and how pre-existing conditions are handled.
More On Multi-Location Workforces.
Multi-State Leave Compliance
Leave rules across states.
Remote Multi-State Workforces
Benefits for a distributed team.
Medical Travel Account
Help with the cost of traveling for care.
Employee Plan Comparison Calculator
Compare total cost across plans.
Employer Shared Responsibility
The ACA employer rules that apply to U.S. employees.
Dependent Coverage To Age 26
How dependents are covered under group plans.
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