By Dr. Rajesh Ramanathan, WCI Columnist

Non-US citizen physicians make up a quarter of the physician workforce and the graduating medical education (GME) pool in the United States. International medical graduates (IMGs) include non-US citizen foreign medical graduates who complete US residency programs and US citizens who return to the US after completing medical school in the Caribbean, Europe, or elsewhere. This post is primarily directed towards those without US citizenship or permanent residency, and those that anticipate retiring outside of the United States.

In this post, I will provide a summary of:

  1. Employment visas and tax status
  2. Types of tax-advantaged accounts
  3. Strategies to manage these accounts for the non-citizen leaving the United States

As an IMG, I didn’t know during residency if I would choose to, or be able to, remain in the United States long-term. As a result, I eschewed tax-advantaged retirement accounts and contributed instead to high-yield savings accounts and taxable accounts. Given that my training period was long (9 years of postgraduate training), you'll soon see why that was likely a mistake.


Employment Visas and Immigration

Foreign medical graduates without US citizenship or permanent residency are dependent upon a work visa for employment authorization. While some training programs offer a dual-intent/immigrant-intent work visa (H1b), most GME programs offer a non-immigrant-intent exchange visitor visa (J1).

The J1 visa for medical trainees includes a home residency requirement. The home residency requirement mandates that the trainee must return to their home country upon the completion of clinical training for a minimum of two years, prior to qualifying for immigration to the United States.

As with any rule, there are several exceptions to waive the home residency requirement. The most common of these include a 3-year commitment to practice in a medically underserved area (Conrad 30 waiver) or a job at a Veteran’s Affairs Medical Center.

Further Reading

Doctors Seeking Green Cards


IRS Tax Status for Foreign Medical Graduates Without US Citizenship

For IRS purposes, resident aliens (non-citizens), including J1 and H1b visa holders, are taxed similarly to US citizens and those with permanent residency.

A resident alien is defined as an individual that passes the substantial presence test which includes meeting two conditions:

  • 31 days of presence in the current year AND
  • 183 days of presence during the most recent three-year period

Most practicing physicians and trainees will meet this threshold, so generally, IRS rules apply equally to IMGs and citizens.

Nonresident alien taxation is more complicated as it involves country-specific treaties that dictate taxation of US income and management of dual taxation. This is something that should be discussed with your accountant or lawyer.


Tax-Advantaged Investment Options for Non-US Citizens 

Just as with US citizens, there are generally two types of tax-advantaged accounts available to the non-citizen.


#1 Pretax

Pretax accounts include a 401(k), 403(b), 457(b), and an HSA (health savings accounts).

Pretax accounts allow you to invest before having any taxes taken out on that money. You will be taxed on the withdrawals, but the overall idea is that you expect to be in a lower tax bracket at withdrawal (usually in retirement) as compared to when contributing (peak earning years).

Employers will generally offer a 401(k) or a 403(b), and sometimes a 457(b). The contribution limit for each of these accounts is $19,500 for those below 50 years of age. Furthermore, most employers will match a percentage of your contribution to a 401(k)/403(b) as an incentive after a certain period of employment.

Health savings accounts are available to those on high deductible plans, with contributions limits of $3,600/$7,200 for single/families. When offered through an employer, it is pretax. If it is done post-tax by an individual, it is still deductible at the end of the year. When used for health-related expenses, the withdrawals are not taxed. There is quite a range of expenses that can qualify for health-related withdrawals (glasses, contacts, dental work), so be sure to check that out.

#2 Post-Tax 

Post-tax accounts include IRA and Roth accounts and are funded individually with after-tax dollars. This means that at withdrawal, no taxes will be realized regardless of your tax bracket. This is a great option during years of relatively lower-income (medical school, training, gap years). And, in higher-income years, can be done using a backdoor Roth IRA. Roth IRA contribution levels are $6,000 for those below 50 years and $7,000 if over age 50. If married, both spouses can contribute for a total of $12,000 in Roth IRA contributions. Roth IRAs are not tied to an employer. There are 401(k) Roth options as well, but we will not discuss that here.

Benefits of Tax-Advantaged Plans

Beyond the tax benefits on the principal, tax-advantaged accounts have tax-free compounding growth, which is a powerful force. In a taxable brokerage account, taxes must be paid annually on dividends and capital gains, but in tax-advantaged accounts the gains are not taxed, thus enabling even higher compounding growth. In that sense, pretax accounts have a triple tax benefit of tax-free contribution, tax-free growth, and withdrawal in a typically lower future tax bracket. This is what makes 401(k) and 403(b) accounts such great investment vehicles. An employer match sweetens the deal further by essentially providing free money.

non us citizens tax deferred accounts

Post-tax Roth IRA accounts are equally valuable since the taxes have been paid upfront, the investment grows tax-free and the income from withdrawals is not taxed.

HSAs are also a fantastic stealth investment vehicle since the investments in an HSA can be completely tax-free by pretax contribution, tax-free growth, and tax-free withdrawal when used for medical expenses.

And by the way, the above accounts also provide varying degrees of asset protection!

These benefits make contributions to a tax-advantaged plan a no-brainer in most cases… except if you do not plan to remain in the United States long-term and therefore may withdraw early.


What Should You Do With Retirement Accounts if You Leave the US?

If you move from the US to another country there are three options to managing contributions in a 401(k): Leave it, cash out or roll it over.

Leave It

The most straightforward option is to leave the money in the 401(k) until you reach age 59 ½ years. You are not required to be a US resident to continue to enjoy the tax-advantaged compounding benefits of a 401(k). Keep in mind, however, that 401(k) fees will continue to apply, and you will need to make sure to receive communications in the unlikely event that your employer decides to terminate the plan.

Cash It Out

The second option is to cash out the 401(k), but be ready for a hefty IRS bill which includes a 10% early withdrawal penalty on top of ordinary income tax. For example, if you cash out $50,000 from your 401(k) and are in the 20% tax bracket, you will have a $15,000 tax bill. One strategy to reduce this tax burden is to time your withdrawal a year after your return to your home country so that you drop into a lower US income tax bracket.

Roll It Over

The third option is to roll over your 401(k) into an IRA. An IRA offers more exceptions to waive the early withdrawal penalty (note that you will still need to pay income taxes on the withdrawn amount). In a 401(k), the only way to waive the early withdrawal penalty is with total and permanent disability. Within an IRA, however, the early withdrawal penalty can also be waived for unreimbursed medical expenses, qualified education expenses, and first-time homebuyers. This offers a lot of maneuverability since that first-time home does not have to be in the United States. With regards to qualified educational expenses, the FAFSA site has a comprehensive list of qualifying foreign institutions.

A secondary benefit of an IRA rollover is that you would have total control of the funds and would not have to worry about employer fees, options, or the risk of the employer terminating the 401(k). One caveat with IRA rollovers is checking with your brokerage about a primary foreign address. Most major brokerages allow you to open an IRA with a local address and then change it to a foreign address. TD Ameritrade even allows for opening an IRA with a foreign address, but make sure to consult with your brokerage in these situations.

If you have investments in a Roth IRA account or other IRA account, all the above apply.


Taxation in Retirement Outside the United States

Once you have moved to your home country and are eligible for withdrawals, you can withdraw your contributions as a lump sum or a fraction.

If you choose to withdraw as a lump sum, it will be subject to a 30% withholding by your brokerage, unless your country of residence has a treaty with the United States. If the tax due on your distributions is greater than the withholding, you will have to pay the difference to the IRS. Alternately, if the distributions are less than tax withholding, you will have to file a Form 1040-NR to apply for a refund.

Fractional payments work similarly with a 30% federal withholding tax. However, most foreign nationals should be eligible for a refund of that amount as taxes typically only have to be paid in the country of residence.

Research your country’s tax treaty and tax code for management of a large income windfall in the United States or consult with a CPA/attorney versed in international tax treaties.


Concluding Thoughts on Investing for Non-US Citizens

If you are highly likely to return to your home country in the near term (within 2-5 years), pursuing retirement accounts in your home country with US income will likely be the most straightforward path for retirement investing. Keep in mind, however, that contributions to foreign retirement accounts are not deductible against your gross US income. Alternately, allowing that money to grow in a taxable, money market or high-yield savings would also guarantee liquidity when planning to eventually move your assets to your home country.

On the other hand, if you are planning to, or hoping to, remain in the United States for a longer time period, you should strongly consider maximizing tax-advantaged opportunities since there are still options if you do decide to eventually return to your home country.

At this point, I plan to stay in the US at least until retirement. As a result, I personally max out my 401k, backdoor Roth IRA, and HSA. I do that with the understanding that the tax-advantaged growth over time is going to far exceed any penalties/lump sum withholding taxes in the event that I return to my home country of India in retirement.

Are you a foreign physician working in the United States? Are you maximizing tax-advantaged retirement accounts? Why or why not? Comment below!