Medicare for Canadians 65+ becoming US permanent residents in Florida

Section 01Who this guide is for, and who it is not for

This guide is for a Canadian who:

1. Has become, or is about to become, a US lawful permanent resident (LPR, a green card holder), typically through family sponsorship, employment-based adjustment of status, or the EB-5 investor pathway.
2. Is age 65 or older, or will reach 65 within the next several years.
3. Intends to make Florida (or another US state) their primary residence on a permanent basis, which means terminating provincial Canadian residency for tax and health-insurance purposes.
4. Wants to understand the US Medicare system, what they qualify for, when they qualify, and what the alternatives are during any waiting period.

This guide does not apply to:

• A Canadian snowbird who keeps a Canadian provincial health card and travels to Florida seasonally. That reader should consult the snowbird travel insurance guide and the provincial health card cancellation guide.
• A Canadian under 65 becoming a US permanent resident. That reader should consult the ACA marketplace and employer-sponsored health insurance guide for Canadian permanent residents (in this same chapter).
• A US citizen returning to the US after years in Canada. The Medicare rules are different and somewhat simpler for citizens, since the five-year residency wait does not apply to US citizens.
• A Canadian on a non-immigrant visa (TN, H-1B, L-1, B-2). Non-immigrant visa holders generally cannot enroll in Medicare regardless of age, and rely on private insurance.

Section 02Section 01: The five-year continuous-residency rule

The single biggest surprise for a Canadian becoming a US permanent resident at 65+ is that a green card does not unlock Medicare. The Social Security Act, at 42 U.S.C. § 1395o(2)(B), restricts Medicare Part A and Part B to US citizens, and to lawful permanent residents who have continuously resided in the United States for at least five years.

The five-year clock starts on the date the green card is granted (the date of admission as an LPR or the date of adjustment of status). It does not start at any earlier visa entry or any prior temporary residency. A Canadian who held a TN visa for ten years in the US and then becomes an LPR on March 1, 2026 still must wait until March 1, 2031 to be eligible to enroll in Medicare. The TN years do not count.

"Continuous residency" means physical presence in the US, with the LPR not having abandoned their permanent residency status. Travel outside the US is permitted, but extended absences (over six months) can interrupt the five-year clock. A Canadian who lands in March 2026 and then returns to Canada for two years in 2027-2029 may have their five-year clock reset.

The five-year rule is not waived for age, for need, for spouse-of-US-citizen status, or for any other circumstance short of US citizenship. The only path to Medicare during the first five years of LPR status is to first naturalize as a US citizen (which itself typically requires 3 to 5 years of LPR status before eligibility to apply, with the spouse-of-citizen path being shortest at 3 years).

Section 03Section 02: Premium-free Part A, and why Canadian credits do not count

Medicare Part A covers inpatient hospital stays, skilled nursing facility care after a hospital stay, hospice care, and some home health care. For most US-born retirees, Part A is premium-free, because they have accumulated 40 quarters of FICA-taxed work over their career. Premium-free Part A is the structural foundation of US retiree health coverage.

A Canadian becoming a US permanent resident at 65+ does not have these 40 US work credits. They have, instead, decades of Canadian Pension Plan (CPP) or Quebec Pension Plan (QPP) contributions, plus Old Age Security (OAS) entitlements. None of those count toward US Medicare Part A. This is the single most expensive misunderstanding new Canadian permanent residents make.

The Canada-US Social Security Totalization Agreement, in force since 1984, allows the combining of work credits between the two countries to qualify for retirement, disability, and survivor benefits under either country's social security program. A Canadian with 6 US work credits and 30 years of CPP contributions can use the agreement to qualify for US Social Security retirement (a small benefit, calculated on US-only earnings). The same Canadian can also use the agreement to qualify for OAS or CPP from Canada with US work history factored in.

This is the structural reality. A Canadian who wants premium-free Part A must have personally accumulated 40 US-earned quarters, which is roughly ten years of US work. A Canadian who immigrates to the US at 67 has, in nearly all cases, no realistic path to those 40 credits. They will be in the buy-in tier for life.

Section 04Section 03: Buying into Part A if you do not have 40 credits

Federal law allows individuals who do not qualify for premium-free Part A to buy in. The Part A monthly premium in 2026 has two tiers, set by the number of US work credits the individual has accumulated.

Reduced premium tier (30 to 39 US credits): 311 USD per month in 2026. This is a 26 USD increase from 2025 (285 USD). The reduced premium reflects partial work history under the US system.

Full premium tier (fewer than 30 US credits): 565 USD per month in 2026. This is a 47 USD increase from 2025 (518 USD). Most Canadians who immigrate to the US at retirement age fall into this tier.

Annualized, the buy-in cost for a Canadian permanent resident with fewer than 30 US credits is 6,780 USD per year for Part A alone, in addition to the Part B premium below. Over a typical retirement of 20 years, this is roughly 135,000 USD in Part A premiums (subject to annual increases).

Spousal coordination matters. If a Canadian permanent resident is married to a US citizen who has 40 US work credits and is at least 62, the Canadian spouse may qualify for premium-free Part A based on the US spouse's work record. The same applies in reverse: a Canadian with US work history can extend premium-free Part A to a non-working spouse aged 65+. This is the cleanest planning path for couples where one spouse has US work history and the other does not.

In addition to the monthly premium, Part A has cost-sharing in 2026:

• Inpatient hospital deductible per benefit period: 1,736 USD (2026, up from 1,676 USD in 2025)
• Daily coinsurance, day 61-90 of a hospital stay: 434 USD per day
• Daily coinsurance, lifetime reserve days (60 days max over a lifetime): 868 USD per day
• Skilled nursing facility coinsurance, day 21-100: 217.50 USD per day

These are the cost-sharing amounts the patient owes after Part A pays its share. Medigap supplemental insurance (Section 06) is the standard mechanism for covering them.

Section 05Section 04: Part B premium, deductible, and IRMAA

Medicare Part B covers outpatient services, physician visits, durable medical equipment, lab work, preventive services, and most professional services not part of an inpatient hospital stay. Unlike Part A, Part B always carries a monthly premium for every enrollee, regardless of work history.

The 2026 standard Part B monthly premium is 202.90 USD, an increase of 17.90 USD (9.7 percent) from the 2025 standard of 185.00 USD. The 2026 annual Part B deductible is 283 USD, an increase of 26 USD from 2025.

After the deductible, Original Medicare Part B pays 80 percent of the Medicare-approved amount for most services. The patient owes the remaining 20 percent, with no annual out-of-pocket maximum. This is a critical structural gap for Canadians used to the integrated provincial system: there is no upper limit on the patient's annual share without supplemental coverage.

The IRMAA surcharge. For higher-income beneficiaries, an income-based monthly surcharge is added to the standard Part B premium. The 2026 IRMAA brackets, based on the modified adjusted gross income (MAGI) reported on the 2024 federal tax return, are as follows.

For a Canadian permanent resident drawing significant income from Canadian sources (RRIF distributions, CPP, OAS, taxable Canadian investment income, rental income on a Canadian property), MAGI can quickly exceed the IRMAA threshold even without significant US-source income. The Canadian-side income flows through to MAGI because a US permanent resident is taxed on worldwide income.

The IRMAA determination uses tax data from two years prior. The 2026 IRMAA bracket is set on the 2024 tax return. A Canadian who became an LPR mid-2024 and had a high-income year (RRSP collapse, capital gain on Canadian real estate sale, etc.) may face a higher IRMAA in 2026 even if their 2026 income is normal.

Appealing IRMAA. A "life-changing event" (retirement, marriage, divorce, death of spouse, work cessation) can be the basis for requesting an IRMAA reduction using SSA Form SSA-44. Becoming an LPR is not by itself a qualifying event, but the retirement transition often is.

Section 06Section 05: Part D prescription drugs and Part C Medicare Advantage

Part D (prescription drug coverage). Part D is administered by private insurers under federal regulation. Premiums vary by plan, geography, and formulary, with a national base of around 36 USD per month in 2026. Part D also has IRMAA surcharges, ranging from 14.50 to 91.00 USD per month for higher earners on top of the plan premium. Part D enrollment is voluntary in name but penalized in practice (Section 07).

Part C (Medicare Advantage). Medicare Advantage plans are offered by private insurers approved by Medicare and bundle Parts A, B, and usually Part D into a single plan, with additional benefits (vision, dental, hearing, gym memberships) that Original Medicare does not cover. The trade-off is a closed network of providers and pre-authorization requirements that Original Medicare does not impose. Medicare Advantage enrollees still pay the standard Part B premium (and IRMAA if applicable) in addition to any Medicare Advantage plan premium.

Florida is one of the most competitive Medicare Advantage markets in the country, with dozens of plans available in each of the major counties (Miami-Dade, Broward, Palm Beach, Lee, Collier, Hillsborough, Pinellas). Many Florida Medicare Advantage plans carry a 0 USD additional premium beyond Part B, recovering their cost through provider network discounts. The downside for snowbird-style retirees who travel back to Canada or to other US states is that Medicare Advantage networks are typically state- or county-limited; care received outside the network area may not be covered except in emergencies.

Original Medicare versus Medicare Advantage decision. For a Canadian permanent resident who values flexibility (provider choice, ability to travel within US, predictable supplemental coverage via Medigap), Original Medicare A+B+D plus a Medigap policy is structurally simpler and more portable. For a permanent resident who plans to stay in one Florida county year-round and values bundled benefits, Medicare Advantage often offers a lower total premium.

Section 07Section 06: Medigap supplemental insurance

Medigap (Medicare Supplement Insurance) is private insurance that covers some of the cost-sharing in Original Medicare: the Part A deductibles and coinsurance, the Part B 20 percent coinsurance, and (in some plans) the Part B deductible. Ten standardized Medigap plans (A, B, C, D, F, G, K, L, M, N) are sold across most states, with identical benefit packages from carrier to carrier; only the price varies.

Plan G is the most popular and the most comprehensive plan available to new Medicare enrollees in 2026. Plan G covers everything except the annual Part B deductible (283 USD in 2026), which the enrollee pays out of pocket. Once the deductible is met, Plan G covers the patient's share of all other Medicare-approved services with no out-of-pocket cost.

Plan G monthly premiums in Florida vary by age, gender, smoker status, and ZIP code, and typically range from 130 to 250 USD per month for a 65-year-old non-smoker, scaling upward with age.

Critical timing rule for Canadian permanent residents. During the six-month Medigap Open Enrollment Period that begins on the first day of the month you turn 65 AND are enrolled in Part B, insurers cannot deny coverage or charge higher premiums based on pre-existing conditions. This is the only window when guaranteed-issue protection applies in most states. For a Canadian permanent resident who first becomes Medicare-eligible at 70 (because of the five-year LPR wait), the six-month Medigap Open Enrollment runs from the first day of the month they turn 70 and enroll in Part B. Missing this window can result in being denied coverage or being charged a substantially higher premium based on health status.

Florida is one of a few states with additional consumer protections beyond the federal minimum, including limited annual open enrollment for switching Medigap plans without underwriting (the "birthday rule" in some implementations), but the rules are complex and change. For a Canadian permanent resident with significant pre-existing conditions, enrolling in Medigap during the initial open enrollment is essential; deferring that enrollment to save premium dollars often locks in higher costs or denial later.

Medigap does not cover prescription drugs (Part D is the separate vehicle), and Medigap does not cover health care received outside the United States with very limited exceptions. A Canadian permanent resident who plans to maintain travel to Canada for family visits should also maintain a private travel insurance policy for those trips.

Section 08Section 07: Late enrollment penalties

The most expensive trap for a Canadian becoming Medicare-eligible at the end of the five-year LPR wait is missing the Initial Enrollment Period and incurring a permanent late enrollment penalty.

Part B late enrollment penalty. If you do not enroll in Part B during your Initial Enrollment Period (the seven-month window that includes the three months before, the month of, and the three months after the month you first become eligible), and you do not have qualifying coverage from another source, your monthly Part B premium will be increased by 10 percent for each full 12-month period you could have been enrolled but were not. This penalty is for life and applies to every monthly premium until death.

A Canadian permanent resident who becomes Medicare-eligible in March 2031 but does not enroll until March 2034 (three years late) will pay a 30 percent surcharge on Part B premiums for the rest of their life. At 2026 rates, that is an additional 60.87 USD per month, or 730 USD per year, indefinitely.

Part D late enrollment penalty. If you do not enroll in Part D when first eligible, and you do not have "creditable" prescription drug coverage from another source, your monthly Part D premium will be increased by 1 percent of the national base beneficiary premium for each full month you could have enrolled but were not. The 2026 national base is approximately 36.78 USD, so each full month of delay adds about 0.37 USD per month for life. Three years of delay adds approximately 13 USD per month for life. A small amount monthly, but compounded over a 25-year retirement it adds up to roughly 4,000 USD.

Special Enrollment Period exception. A Canadian permanent resident who has continuous "creditable coverage" through an employer plan (their own employer or a working spouse's employer with 20 or more employees) when first becoming Medicare-eligible can defer Medicare enrollment without penalty. When the employer coverage ends, an 8-month Special Enrollment Period opens for Part B and a 63-day window opens for Part D. This exception is the standard reason a Canadian permanent resident over 65 might defer Medicare enrollment.

Section 09Section 08: Coverage during the five-year LPR waiting gap

The single largest financial planning question for a Canadian becoming a US permanent resident at 65+ is how to be insured during the five-year wait. There are five practical paths.

Path 1: Employer-sponsored coverage (own employment). A Canadian permanent resident who continues to work after immigrating, for a US employer offering health insurance, is covered by the employer plan. This is the cleanest gap-coverage path. Most US employers cover 70 to 90 percent of the employee premium. For a 67-year-old continuing part-time consulting work, even modest employer coverage can substitute fully for Medicare during the five-year wait.

Path 2: Spousal employer coverage. If a US-citizen or LPR spouse is working for an employer with 20+ employees and is enrolled in the employer plan, the Canadian permanent resident can typically be added as a dependent. Premiums vary widely; common employee-plus-spouse premiums in 2026 are 600 to 1,500 USD per month, with the employee sharing 100 to 500 of that and the employer covering the rest.

Path 3: ACA marketplace (HealthCare.gov for Florida). A Canadian permanent resident with a Social Security number and a Florida address can enroll in an Affordable Care Act marketplace plan. Premiums are based on age, plan tier (bronze, silver, gold, platinum), tobacco use, and ZIP code; for a 67-year-old non-smoker in Broward County in 2026, unsubsidized silver plan premiums typically range from 1,100 to 1,800 USD per month. Premium tax credits are available for households with MAGI between 100 percent and 400 percent of the federal poverty level (and beyond, under post-2021 expansions extended through 2025; status for 2026 depends on subsequent legislation). For a couple with combined MAGI of 50,000 USD, the silver-plan benchmark cost is capped at a percentage of income (8.5 percent in recent years), making the effective cost roughly 4,250 USD per year per person rather than 15,000+. A Canadian permanent resident with substantial income from Canadian sources may not qualify for the premium tax credit, since the income threshold is on worldwide MAGI.

Path 4: COBRA continuation. A Canadian permanent resident who had US employer coverage and lost it (job loss, retirement, hours reduction, divorce from a covered spouse) can elect COBRA continuation for 18 to 36 months at the full premium plus a 2 percent administrative fee. COBRA is expensive (the employee now pays both the employee share and the employer share) but is the same plan with the same network. For a Canadian permanent resident in the late stages of the five-year wait, COBRA can bridge the final 12 to 18 months until Medicare eligibility.

Path 5: Private cross-border or international insurance. A small market exists for international medical insurance designed for non-US-citizen residents and expatriates. Plans from Cigna Global, GeoBlue, IMG Global, and others offer coverage for permanent residents during the Medicare wait. Premiums vary widely; for a 67-year-old, expect 800 to 1,800 USD per month for comprehensive coverage. These plans often have annual benefit caps (typically 1 to 5 million USD per year), which is generous but not the unlimited Medicare coverage. They are also typically less integrated with US provider networks, leading to more out-of-pocket exposure than ACA plans.

Section 10Section 09: Worked example: Quebec retiree, age 67, becoming LPR in March 2026, settling in Naples

A 67-year-old retiree from Saint-Lambert, Quebec, married to a US citizen, becomes a US lawful permanent resident on March 1, 2026 through spouse-of-US-citizen sponsorship. The couple settles in Naples, Florida. The Canadian spouse has worked exclusively in Canada for 35 years (RRSP and CPP fully accumulated); the US spouse has 40 US work credits and turns 65 in 2027.

2026 (year 1 of LPR status, age 67). Not eligible for Medicare. The Canadian spouse enrolls in an ACA marketplace silver plan in Collier County, with combined household MAGI of 95,000 USD (Canadian RRSP withdrawals, Quebec QPP, US spouse's modest investment income). At 95,000 USD MAGI, the household qualifies for partial ACA premium tax credit. Effective premium for the Canadian spouse: approximately 950 USD per month, or 11,400 USD for the year. The US spouse is on Medicare Part A premium-free + Part B (185 USD/month in 2025, then 202.90 USD/month from January 2026).

2027 (year 2 of LPR status, age 68). Same ACA enrollment. US spouse turns 65 in May; the Canadian spouse considers (and rejects) requesting premium-free Part A based on the US spouse's work record, because the five-year LPR rule still blocks Medicare enrollment. ACA premium adjusts modestly with age.

2028, 2029, 2030. Continued ACA enrollment. RRSP collapses are managed to keep MAGI under 109,000 USD to avoid future IRMAA cliffs.

2031 (year 6 of LPR status, age 72). First eligible for Medicare. Initial Enrollment Period runs December 2030 (3 months before 72nd anniversary of LPR) through June 2031 (3 months after). The Canadian spouse enrolls in:

• Part A: premium-free, based on US spouse's 40 US work credits (spousal benefit). This is the major financial win of the marriage-to-US-citizen path.
• Part B: 202.90 USD/month (in 2026 dollars; will be higher in 2031). No late enrollment penalty because the ACA marketplace coverage qualifies as continuous coverage from a creditable source.
• Part D: prescription drug plan, approximately 40 USD/month in 2031 dollars, no penalty.
• Medigap Plan G: approximately 220 USD/month in 2031 dollars at age 72.

Total monthly out-of-pocket for the Canadian spouse from 2031 onwards: approximately 463 USD/month or 5,556 USD/year, plus IRMAA if MAGI exceeds the threshold, plus Part B annual deductible (283 USD), plus any uncovered care.

Counter-factual: same Canadian spouse, marriage to a Canadian rather than a US citizen. Without the spousal Part A premium-free benefit, the Canadian spouse would face Part A buy-in at 565 USD/month in 2026 dollars, or roughly 6,780 USD per year for life. Total monthly cost would be approximately 1,028 USD or 12,336 USD per year.

The 6,780 USD per year delta represents the practical financial value of the spousal premium-free Part A benefit, over a 20-year retirement: roughly 135,000 USD in 2026 dollars.

Section 11Section 10: Common mistakes by Canadian permanent residents

1. Assuming the Totalization Agreement covers Medicare. It does not. CPP credits do not transfer to premium-free Part A. This misunderstanding causes the largest single-event financial loss in the new LPR's first year.
2. Missing the Medigap six-month Open Enrollment window. A Canadian permanent resident who becomes Medicare-eligible at 70 (after the five-year wait) must enroll in Medigap within six months of starting Part B to access guaranteed-issue protection. Pre-existing conditions can otherwise lead to denial or much higher premiums.
3. Failing to enroll in Part B during the Initial Enrollment Period without qualifying creditable coverage. Triggers the lifetime 10-percent-per-year late enrollment penalty.
4. Underestimating IRMAA exposure from Canadian-source income. RRSP/RRIF withdrawals, Canadian capital gains, Canadian rental income are all part of MAGI for a US tax resident. A high-income year (especially the year of Canadian property sale or RRSP collapse) can push IRMAA into the highest tier two years later.
5. Choosing Medicare Advantage and then traveling outside Florida. Medicare Advantage networks are typically Florida-only. Snowbird-pattern travel to Canada or to other US states often results in non-covered care.
6. Continuing to rely on RAMQ/OHIP/MSP after becoming an LPR. Provincial health insurance is contingent on provincial residency. An LPR resident in Florida is not a Quebec or Ontario resident for health insurance purposes; provincial coverage typically ends within months of departure. See provincial health card cancellation.
7. Not appealing IRMAA after a life-changing event. Retirement is a qualifying life-changing event for an SSA-44 IRMAA appeal. A Canadian permanent resident retiring in 2027 with high 2025 MAGI should file SSA-44 to request an IRMAA reduction based on lower retirement-year income, rather than passively pay the higher premium.
8. Ignoring spousal Part A planning. A US-citizen or LPR spouse with 40 US credits unlocks premium-free Part A for the Canadian spouse at 65+ (or after the five-year LPR wait, whichever applies). Failing to confirm this with SSA leads to unnecessary buy-in premiums.
9. Underestimating Medigap premium escalation with age. A Plan G premium that is 200 USD/month at age 70 may be 400 USD/month at age 85 with the same insurer. Switching plans later is generally subject to underwriting; locking in a competitive insurer at initial enrollment matters.
10. Buying private cross-border international insurance for the long term. These plans are appropriate for the five-year LPR wait, but are typically not portable into Medicare-supplement role. They become financially irrational once Medicare eligibility opens.

Section 12Section 11: Actionable checklist

Before becoming an LPR (planning phase, 6 to 12 months out)

1. Confirm in writing the date of LPR admission. The five-year Medicare clock starts here.
2. If married to a US citizen with 40 US credits, request a Social Security earnings statement (SSA Form SSA-7050) for the US spouse to confirm credit count.
3. Obtain a Social Security number for the Canadian spouse promptly after LPR admission. Required for ACA marketplace enrollment, employer benefits, and eventual Medicare enrollment.
4. Map the retirement income picture for the next 5 to 10 years. Identify high-MAGI events (planned RRSP collapse, Canadian property sale, etc.) and consider sequencing them either before LPR status or after the IRMAA-relevant 2-year lookback window.

Year 1 of LPR status

1. Enroll in ACA marketplace, employer plan, or COBRA within 60 days of any qualifying event. The annual Open Enrollment window (typically November 1 to January 15) is the standard enrollment window otherwise.
2. Cancel provincial health insurance (RAMQ, OHIP, MSP, AHCIP, etc.) within the timeline required by the province. See provincial health card cancellation.
3. Establish a Florida primary care physician. Most Florida health insurers require a designated PCP for routine care.

Year 4 of LPR status (one year before Medicare eligibility)

1. Verify the precise date of fifth LPR anniversary with USCIS (the date Medicare eligibility opens).
2. Begin researching Medigap plans available in Florida; identify three insurers with competitive Plan G premiums for your county.
3. If MAGI is approaching the IRMAA threshold, begin tax planning for the lookback year.

Year 5 of LPR status (Medicare Initial Enrollment Period)

1. Enroll in Part A, Part B, Part D, and Medigap during the IEP (the 7-month window straddling the fifth LPR anniversary).
2. If continuing employer or spousal employer coverage, document the coverage as creditable for both Part B and Part D late-enrollment penalty waiver purposes.
3. If MAGI is high in the IEP year, file Form SSA-44 Life-Changing Event request for an IRMAA reduction if a qualifying event applies (retirement, work stoppage, etc.).

Annual recurring

1. Review Medicare Advantage and Part D plan annually during the October 15 to December 7 Open Enrollment Period. Plans change formularies and networks each year.
2. Monitor Canadian-source income for IRMAA implications (the 2-year lookback applies to MAGI on the US joint or single tax return).
3. Maintain private travel insurance for any travel back to Canada (Medicare and Medigap do not cover Canada).

Section 13Section 12: FAQ

Can my Canadian work credits qualify me for premium-free Part A? No. The Canada-US Totalization Agreement covers Social Security retirement, disability, and survivor benefits, but does not extend to Medicare. Premium-free Part A requires 40 US-earned quarters of coverage, period. The exception is spousal benefit: if your US-citizen or LPR spouse has 40 US credits and is at least 62, you can qualify for premium-free Part A based on their record.

Does my green card date or my visa date start the five-year Medicare clock? The five-year clock starts on your green card admission date (the date you became a lawful permanent resident). Time spent in the US on temporary visas (TN, H-1B, B-2, etc.) does not count toward the five years.

If I leave the US during the five-year wait, does my clock reset? Extended absences (typically over six months) can interrupt continuous residency for Medicare purposes and reset the clock. Brief travel does not. There is no bright-line rule, but absences exceeding six months should be reviewed with an immigration attorney.

Can I be on Medicare and the ACA marketplace simultaneously? No. Once you enroll in Medicare Part A (premium-free or buy-in), you cannot continue to receive ACA premium tax credits. You must transition off the marketplace plan. The reverse is also true: if you become Medicare-eligible and are receiving an ACA marketplace plan, Medicare typically becomes your primary coverage.

Does Medicare cover health care if I travel back to Canada? With very narrow exceptions (Medicare may cover certain emergencies if the nearest hospital is in Canada and Canada is on a direct route, e.g., crossing the border in northern Maine to access a Canadian hospital), Medicare does not cover health care outside the US. A Canadian permanent resident who plans regular trips to Canada must maintain a separate travel insurance policy for those trips.

Can I keep my RAMQ/OHIP/MSP coverage after becoming a US permanent resident? No. Provincial health insurance is contingent on provincial residency. Becoming a US LPR generally terminates Canadian provincial residency for health insurance purposes within months of departure. See provincial health card cancellation.

My US-citizen spouse has 40 US credits. Can they share them with me for Medicare? Yes for premium-free Part A spousal benefit. You qualify for premium-free Part A based on your spouse's record once your spouse is at least 62 and you are at least 65. This is the single most valuable spousal benefit for a Canadian permanent resident married to a US citizen with US work history.

How is IRMAA calculated on my Canadian-source retirement income? IRMAA uses Modified Adjusted Gross Income (MAGI) from your US tax return, two years prior. As a US tax resident, your worldwide income (including RRSP/RRIF withdrawals, CPP, OAS, Canadian rental income, and Canadian capital gains) is reported on your US 1040 and flows through to MAGI. A high Canadian-side income year can push your MAGI into a higher IRMAA bracket two years later.

What is the cheapest path to coverage during the five-year LPR wait? For most Canadian permanent residents over 65, the ACA marketplace silver plan with premium tax credit (if MAGI qualifies) is the cheapest single-person path, typically 600 to 1,200 USD per month. If a US-citizen or LPR spouse has employer coverage that allows dependents, that is usually cheaper. COBRA is most useful as a bridge in the final 18 months before Medicare eligibility.

Can I delay enrolling in Part B without penalty if I have private insurance? Only if your private insurance is "creditable coverage" recognized by Medicare. Employer-sponsored plans with 20+ enrolled employees are creditable; ACA marketplace plans are not creditable for Part B late-enrollment penalty waiver purposes (though they are creditable for Part D). A Canadian permanent resident relying on the ACA marketplace through the five-year wait will not be exempt from the Part B late enrollment penalty if they then delay enrolling at the end of the wait.