I would like to preface this article by stating, I am not a lawyer, or an MD so do your own due diligence.

I would like to thank Daniela Cordero at Cuenca Expat Insurance for providing private insurance and support. I came to this country 3 years ago from the US and kept Medicare even though it only provides coverage in the US. Fast forward 2 years to the time I had to update my visa. I kept BMI but dropped Medicare for cost savings (about 200/month).

If you do not take Medicare when eligible you may have a fine of 10% each year and wait for the open enrollment period. I found an exception buried in an internal memo.
EXCEPTION. If you are working overseas and that government has a universal insurance plan (IESS).

1. KEEP YOUR PRIVATE INSURANCE HERE.
2. FILE YOUR TAXES CORRECTLY HERE AND THE USA. American citizens can be double taxed, so do your FBAR (IRS) and RIMPE (Ecuador tax) if needed.
3. ENROLL IN IESS. I had Daniela do it. Personal note, Daniela and I visited an IESS facility. She would not use the bathroom.
4. CANCEL MEDFICARE PART B AND LIST IESS AS YOUR PRIMARY INSURER. This was the most difficult thing. BE PERSISTENT. Personal note. I used an internet-based phone system that was linked to a poorly set up of a supposed security camera. That made things worse.
5. DOCUMENT YOUR BUSINESS INCOME IN ECUADOR. I do not have a regular job with pay stubs but I report income from self-employment on my taxes. I met the physical presence test and avoided double taxation. To qualify as self-employed for Medicare you must have an employee.
6. IF NEEDED, return to US for good in future, get Medicare and drop BMI and IESS. I think the worse that will happen is that Medicare will say no, you are paying the fine and waiting just like anyone else that refused Medicare when eligible.