Sending staff to the United States: worldwide excluding USA.

In short: Most international private medical policies are written on a worldwide-excluding-USA area of cover, so an employee transferred to the United States holds a policy that covers everywhere except where they now live. The area of cover has to be changed before the flight, and adding US area roughly doubles the insurance line. The United States ranks first of fifty countries in the SIP Health Cost Index 2025.

Every international insurance programme has one clause that can void more cover in a single personnel move than everything else in the file combined, and it is four words long: worldwide, excluding USA. Most international private medical policies are written on that basis — rationally, since American treatment costs dominate global pricing, and excluding them keeps premiums sane for the majority who will never need Boston. Then your company transfers someone to Boston. The policy does not break, or warn, or lapse; it simply continues covering the entire planet except the city your employee now lives in. The clause sits in plain sight on the schedule — the five-minute area-of-cover check shows where to find it. We review corporate mobility programmes for a living, and the excluding-USA employee living in the USA is the finding we make most often and most urgently. This post is the US assignment file, from the insurance side.

A different category, with a number

Start with the scale, because US budgeting-by-analogy is how companies get this wrong. In the SIP Health Cost Index 2025 — fifty countries, seven international insurers, three ages — the United States ranks first, at about $17,969 a year for comparable cover: roughly 2.9 times the cheapest market measured, twice Switzerland, and carrying the single highest figure anywhere in the dataset (about $22,368 for the 50-year-old profile). And one methodological detail makes the point sharper than the rank does: every other country in the index is priced on worldwide-excluding-USA cover — the US row is the only one that includes US treatment. The exclusion your policies carry and the premium gap between the US and everywhere else are the same fact, seen from two sides.

For a mobility budget the arithmetic is blunt: adding US area to an assignee’s cover roughly doubles the insurance line, and an assignment letter that carries the salary uplift, the housing and the schooling but prices insurance at the home-country rate is underfunded before the flight books.

The three ways companies actually insure US assignees

The US group plan. For long assignments and permanent transfers, putting the assignee on the domestic employer plan is the standard answer and often the right one — it is how the US system is built, since employer-sponsored insurance effectively is the national scheme, and larger employers face coverage obligations under US law besides. The costs are structural rather than hidden: networks that end at the border, deductibles and cost-sharing unfamiliar to anyone from a European system, family cover priced per head, and — the leaver problem in its harshest form — cover that ends with employment in a country where individual replacement is expensive and, past the enrolment windows, awkward. An assignee who localises onto the US plan and later exits the company mid-year discovers the US version of the cliff every country’s post in this series describes, at American prices.

International cover with US area. The portable route: the assignee keeps one policy — before, during and after the assignment — underwritten once, moving with them at repatriation or the next posting, with no re-entry questions at exit. The price of that continuity is the doubled premium above, and one operational requirement companies miss: US networks and direct billing matter enormously at American hospitals, so the insurer’s US administration — not just the area-of-cover words — needs checking before you rely on it. This route usually wins for assignments under a few years and for career-mobile staff who will move again; it is what we most often end up building for the genuinely international cadre.

The default of not deciding. The third route is the one we are writing this post to end: the assignee stays on whatever they had — the group IPMI with the exclusion, the home-country plan with token travel cover — because nobody owned the question. It is compliant with nothing, cheaper than everything, and fine until the first claim, which is then not a claim but a bill, at the prices in the index above.

Two directions, one desk

The US file runs both ways. Inbound — covered above. Outbound — the American employee posted abroad — is its own puzzle: US domestic plans travel badly, Medicare does not follow, and the expatriate American often needs exactly the international structure their colleagues take for granted, with the added twist that returning home later means re-entering the US system at an older age. A company running both directions benefits from one desk holding the whole map — which policies exclude what, who is currently standing outside their own area of cover, and what each planned move does to each person’s insurability. That map is the deliverable of our corporate review: send the shape through the companies page — headcount in or moving to the US, current policies, assignment lengths — and a written scope comes back within a working day, including the list that matters most and embarrasses most: who, today, is on excluding-USA paper while living in the USA. In our experience of first reviews, it is rarely nobody.

We are advisers, not a carrier — anything eventually placed runs through SIP’s licences on a courtage basis we publish, and the review costs nothing whichever way it ends. The right moment for this one is not renewal but the assignment pipeline: the day a US transfer is agreed is the day the area-of-cover question opens, and it needs answering before the flight does.