Medical insurance outside the US

We are SO CLOSE to launching on Our Big Adventure - hoping to cross over to the Bahamas this month or next, and not bring the boat back to the US for at least 3 years, maybe longer. We will come back to visit for a week or so at a time, about 3 times a year, but the rest of the time, we'll be in the islands. (The boat will stay - too slow to keep going back and forth.)

We've done a lot of research into medical insurance, and have found a Cigna plan that will cover us, but with one quirk - we have to provide them with our address out of the country, which is a little difficult living on a boat that's constantly moving around. We can pick an address (we know a few people with homes in the Bahamas), but that just seems a bit weird.

Can anyone recommend an insurance company that provides medical insurance for full-time out-of-the-country travelers?

Thanks so much,

Brian

Several questions. Are you eligible for medicare? Do you want to come back to US for medial care in a serious situation? Are you talking about a travelers plan?

We had IMG for 11 years and the coverage was very good. The only requirement for the plan our was we had to reside outside the US for 6 months a year or more. After 18 months they gave us each $250/year for wellness exams. You could also come back to the US to seek treatment, if you did, and went to an in network provider, they cut your deductible in half. We had a claim for >$57K and all we did was write a check for 1/2 of our deductible $2.5K. I left IMG in 2013.

Travel Insurance, Travel Health Insurance, International Travel Insurance – IMG Insurance

BrianSmith said:

We've done a lot of research into medical insurance, and have found a Cigna plan that will cover us, but with one quirk - we have to provide them with our address out of the country, which is a little difficult living on a boat that's constantly moving around. We can pick an address (we know a few people with homes in the Bahamas), but that just seems a bit weird.
Brian...

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Brian: During our renewal time, which was usually during cyclone/hurricane season, we would frequently be in a marina. We used that address. We still had a US address for mail forwarding/bill paying and never had any issues. During our initial enrollment, we had to send them our intended itinerary with a specific departure date from the US.

Bay Pelican said:

Several questions. Are you eligible for medicare? Do you want to come back to US for medial care in a serious situation? Are you talking about a travelers plan?

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Marty,

No Medicare yet - just turned 58, and my wife is in her 40's. For a very serious condition, we would definitely want to come back to the US for treatment / surgery. We have DAN's best dive / travel plan already, which will cover us for dive-related issues, and includes emergency medical evacuation for any medical emergency, dive-related or not.

I don't think I'm talking about a traveler's plan, as we'll really be living out of the country for most of the next 3 - 5 years, not just traveling a lot of the time.

I'd look at companies that offer crew insurance. Here are just a few:

Sevenseas offers insurance through at least three providers including BCBS.

Seven Seas International Health Insurance

This site has an extensive list.

Travel Individual Insurance

IMGlobal offers global insurance.

Global Crew Medical Insurance - health insurance for yacht crew or crew

Geoblue

https://www.geobluetravelinsurance.com/products/longterm/navigator-crew-overview.cfm

Pantaenius offers a plan through Kiln.

Lloyd's also offers.

Now, one precautionary note. You may want to keep a US policy too. It may be necessary to protect you against exclusions for pre-existing conditions at some time. You need to check that carefully. Also, many of the travel and crew policies do not cover your home country, assuming you have that insured separately.

BandB said:

I'd look at companies that offer crew insurance. Here are just a few:

<snip>

Now, one precautionary note. You may want to keep a US policy too. It may be necessary to protect you against exclusions for pre-existing conditions at some time. You need to check that carefully. Also, many of the travel and crew policies do not cover your home country, assuming you have that insured separately.

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BandB,

Thanks! We'll look at those, and make sure we ask about the pre-existing condition issue.

BandF

BrianSmith said:

Marty,

No Medicare yet - just turned 58, and my wife is in her 40's. For a very serious condition, we would definitely want to come back to the US for treatment / surgery. We have DAN's best dive / travel plan already, which will cover us for dive-related issues, and includes emergency medical evacuation for any medical emergency, dive-related

I don't think I'm talking about a traveler's plan, as we'll really be living out of the country for most of the next 3 - 5 years, not just traveling a lot of the time.

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I M driving now. Will respond later. In what state will you maintain your residence/ domicle?

Bay Pelican said:

I M driving now. Will respond later. In what state will you maintain your residence/ domicle?

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Marty, we will remain legal residents of Florida.

Looking forward to hearing what you have to say.

Thanks,

Brian

Larry M said:

We had IMG for 11 years and the coverage was very good. The only requirement for the plan our was we had to reside outside the US for 6 months a year or more. After 18 months they gave us each $250/year for wellness exams. You could also come back to the US to seek treatment, if you did, and went to an in network provider, they cut your deductible in half. We had a claim for >$57K and all we did was write a check for 1/2 of our deductible $2.5K. I left IMG in 2013.

Travel Insurance, Travel Health Insurance, International Travel Insurance – IMG Insurance

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Thanks, Larry - we'll check them out!

Some things to think about, deal with. Since Obamacare things have gotten complicated for those without employer plans who are not eligible for Medicare.
Many states do not have individual plans that will cover you outside of the United States. Some will cover you for emergency treatment only. If you can find a plan in your state of residence (domicle) that will cover you outside of the United States then consider yourself fortunate. One issue with any plan is whether it satisfies the Obamacare requirements. The state plans will, the travel plans usually will not. If not you are subject to a penalty.
You may be exempt from the Obamacare penalty if you are outside of the US for at least 330 days. Two complications. Do you have a tax home outside of the US, which is the basis for this exemption? You need to check the tax home issue as I was not able to find a solid answer. Also for these purposes are the US territories and Puerto Rico part of the US. I couldn’t find this answer either.
A further issue is whether your plan will cover you if you need to come back to the US for treatment. This is a personal decision.
Since we are not outside the United States full time we choose to have a US plan. Like all these plans in Indiana it has a large deductible. The plan does not cover my wife outside of the US. For that we have a travel plan for 130 days, like the one Larry cites. We use HTH Worldwide Medical Insurance, but have never made a claim. In addition we have a medical evacuation contract to bring up back from a foreign hospital to our preferred US hospital. For this we use Medjet Assist. Again we have not used this contract.
One of the reasons for coming back to the US is that the US coverage is unlimited.

Since you are Florida residents I would check to see what would be the cost of a high deductable plan and whether that plan will cover you for emergency treatment outside of the US. If so you could add to this a low level ($25,000 or $50,000) travel type plan to cover the small routine expenses that would normally be covered. A travel plan is fairly inexpensive if it excludes coverage in the US. This is what our combination of US plan and a travel plan accomplishes.

You may want to check DANboater to see if there is anything they cover that DAN doesn't.

I echo what Bay Pelican said that for many reasons the ideal answer is likely to be a US plan and a separate travel plan. I'd be very hesitant to drop all US insurance if I ever planned on returning and/or if I felt like I'd want major treatment, if required, in the US. Two reasons travel is low if it doesn't cover US are that US care is the most expensive and that they assume you'll return to the US if it's really major.

Affordable Healthcare Act - Eligibility

Hello everyone (I am the "F" in BandF), and thanks for all the wonderful feedback, we are still in the middle of research, and all of your advice has pointed out some things we hadn't considered.

One thing I have found out for sure is that we are not required to have a plan under the AHA/ Obamacare requirements, simply because we intend to reside outside the US for at least 330 days out of each year...

"U.S. citizens living in a foreign country for at least 330 days of a 12-month period are not required to get health insurance coverage for that 12-month period. If you're uninsured and living abroad under this definition, you qualify for a health insurance exemption. This means you don’t have to pay the fee that other uninsured people must pay."

I believe not only are we not required, but we are not eligible to have a plan under the AHA/ Obamacare, though I do need to verify this.

Because of that, I am still researching what that means for us when we do decide to return to the US in the next 3-5 years, in regard to BandB's concern over how it affects us if pre-existing conditions are a factor.

Travel plans would work well in conjunction with a US plan, but since we are not required (and possibly not eligible) for a US plan, I believe our best options are the true International plans for expats. The two that seem the most comprehensive are IMG as Larry M mentioned, and Cigna Global. What is amazing, is because these plans DO have the pre-existing condition clauses in place (like most US plans pre-AHA had), they are a lot more affordable. In some instances, less than 1/2 the cost of our high deductible HSA plans here in the US with same coverage or better.

I will post what I find out about our eligibility and returning information as soon as I find out - thanks everyone!

Fran

US Territory requirements

Bay Pelican said:

You may be exempt from the Obamacare penalty if you are outside of the US for at least 330 days. Two complications. Do you have a tax home outside of the US, which is the basis for this exemption? You need to check the tax home issue as I was not able to find a solid answer. Also for these purposes are the US territories and Puerto Rico part of the US. I couldn’t find this answer either.
A further issue is whether your plan will cover you if you need to come back to the US for treatment. This is a personal decision.

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Marty, in addition to us being exempt from the Obamacare penalty, as you mentioned, I also found out this on the Marketplace website:

"Residents of U.S. territories are not required to have health coverage under the health care law."

I still have to look at the "tax home" thing, but I believe since we are not working in the US or abroad, this should not be a factor. I definitely need to verify it though.

The other thing I found in the 2 companies I am looking at (IMG and Cigna Global) is you can choose to include US coverage or not. We will definitely choose to have US coverage, that way we can see our normal doctors when we visit home.

We are both fortunate in that we are quite healthy with no on-going medical issues or Rx's except for the normal aches and pains of wear and tear!

Cheers,
Fran

I just got off of the phone with a very helpful person at the Insurance Marketplace who gave me the following information...

1) By residing outside the US for 330 days or more, we are indeed not required, nor eligible for Marketplace/ Obamacare coverage under the law, and must apply for an exemption.

2) The exemption can be granted either through the Marketplace, by downloading a form, and sending back to the Marketplace for approval. Or, simply file an IRS 8965 form with our taxes when filing for the year we are exempt from coverage.

3) I found a very simple definition for "tax home" on Investopedia...

"The general locality of an individual's primary place of work. A person's tax home is the city or general vicinity where his or her primary place of business or work is located, regardless of the location of the individual's residence, and has an effect on his/her tax deductions for business travel."

Since Butch and I are lucky enough to be retired, having a tax home is a non-issue in this case.

Now, all I need to do is choose the right company... no pressure, haha!

Pre-existing conditions is not an issue under current law. However, if the Affordable Healthcare Act is repealed, then it could be come one again.

Bay Pelican posted "for these purposes are the US territories and Puerto Rico part of the US. I couldn’t find this answer either" I was wondering if medicare will work in the US territories and Puerto Rico?

Pre-existing conditions

BandB said:

Pre-existing conditions is not an issue under current law. However, if the Affordable Healthcare Act is repealed, then it could be come one again.

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Yes, that was another question I asked the Marketplace expert. Going to a Global Medical plan means we are definitely subject to pre-existing conditions clauses for those plans (which is what makes them so much more affordable than US plans). But, coming back to the US and purchasing a US plan, we will qualify for whatever the law says at that time. Essentially, we will qualify for the same coverage as though we never left the country.

Fran

Greetings,
Be very, very careful with a "pre-existing conditions" clause. A close relation was refused medical coverage due to a "pre existing condition". She had suffered a sports injury to a ligament and had undergone a lengthy regime of physiotherapy which, at the time, had been covered by her employer but after leaving that employer and applying for her own coverage, was deemed too great a medical risk in spite of the fact she was willing to not include ligament injury or similar in the new policy.
This was pre AHA.

RT Firefly said:

Greetings,
Be very, very careful with a "pre-existing conditions" clause. A close relation was refused medical remuneration for a medical problem not in the least related to her "pre-existing" condition. This was pre AHA.

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Thanks RTF, we will be asking specifically what each global medical company has in place before choosing one. We don't really have any pre-existing conditions that would be costly issues, but we want to be fully informed. I really hope they remain history in the US for when we return.

RT Firefly said:

Greetings,
Be very, very careful with a "pre-existing conditions" clause. A close relation was refused medical coverage due to a "pre existing condition". She had suffered a sports injury to a ligament and had undergone a lengthy regime of physiotherapy which, at the time, had been covered by her employer but after leaving that employer and applying for her own coverage, was deemed too great a medical risk in spite of the fact she was willing to not include ligament injury or similar in the new policy.
This was pre AHA.

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Yes, not legal today. We can't know tomorrow.

Now, in getting a global plan that has a pre-existing condition clause, I'd be very tempted to also continue my US plan for some period of time. One key is the definition of pre-existing. If it's defined as something for which you'd received treatment in the previous year then you can clearly know what that is. However, if it's open ended definition and pre-existing includes things you knew nothing about, then it's dangerous.

I've followed the trends in pre-existing clauses on group plans in the last 27 years or so, and there were times they were horrible. We eliminated them for new hired sometime a couple of decades ago and also for those who had qualifying events.

There are many parts of the AHA that haven't been widely discussed and are only known by those who have benefited by them. Eliminating pre-existing condition exclusions is one of those parts.

Was not able to fully research the tax home issue. The 330 days comes from the tax law that exempts $75,000 in non US income from those working and living abroad. If I were to guess Obamacare just referenced the code sectiom. If that is the case you may be required to have a tax home (pay taxes) outside of US.

I have been told that touching down in the PR or the US Virgins restarts my 60 day coverage under medicare supplemental plan F.

Your choice on not carrying US coverage. That is a two fold risk. If you require major medical work were will you go and what will be coverage. Also it is reasonable to assume Obama care as we know it will be gone in a few years. Then what.

Bay Pelican said:

Your choice on not carrying US coverage. That is a two fold risk. If you require major medical work were will you go and what will be coverage. Also it is reasonable to assume Obama care as we know it will be gone in a few years. Then what.

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Her choice is to have a global plan including rather than excluding US coverage. That would allow US treatment. As to changes in laws of any type, it's hard to know. However, once a benefit has been provided such as no pre-existing exclusions, taking it away is very difficult and, while one can't be sure, I'd think highly unlikely.

We maintain and US policy and a Global Policy which excludes the US, but then we spend the majority of our time in the US.

There are two different views of what medical insurance provides. The first is to even out the cost over the year of routine medical expenses. Thus the premium pays for wellness visits, medicines, routine treatment and other items costing less than $5,000 US for a year (arbitrary number). This function is more important at lower income levels.

The second function is more of an insurance function. The major expense. An expense unlikely to happy to any one person but which does happen to someone every day. These expenses can range into hundreds of thousands, if not millions of dollars.

Before Obamacare many Americans purchased ultra high deductible plans assuming that they could cover any expense under e.g. $20,000. However, if they needed an organ transplant the insurance would cover the million dollar plus cost.

Travel plans have a cap on their coverage. The needed medical procedures may exceed that cap. Also some travel plans require you to be outside of the US for a certain period of time each year. Unsure of what happens if you are in a US hospital and can't leave as far as eligibility to renew coverage.

As my comments indicate medical insurance for traveling Americans is much more complicated now then it use to be. (Remember immediately prior to Obamacare my wife and I had worldwide coverage, $1,000 deductible, and a five million dollar cap for $335 per month each.)

Thanks everyone, lots of great advice out there. We are looking to get Global Medical (different from Travel Insurance), which has the option to include or exclude US coverage, as BandB mentioned, so we will definitely opt to include US coverage. With that, we can get medical treatment no matter where we are in the world, and up to 90 days treatment in the US. I am unsure what happens if we are unable to leave after 90 days, so I will be asking that question of the broker next.

2 of the 3 Global Medical companies offer unlimited coverage (GeoBlue and CignaGlobal) - no cap per year. You pay more, of course, but for catastrophic events, it would be worth it, we will likely choose one of those plans.

I will keep you posted to any details I find out about pre-existing condition clauses, and catastrophic care in the US that goes beyond 90 days.

Cheers,
Fran

And never forget, if you need emergency care outside of the US, the provider may not accept whatever insurance you have. They may have never heard of Aetna, or IMG, or insurance, for that matter. A hospital in Colombia, for instance, will not be interested in submitting claims to some foreign insurance company. They may demand cash. Yes, your insurance will reimburse you at the end, but that won't get you in the door.

There are companies that cover this hole. My employer uses iSOS. I'm not pushing iSOS, they have competitors. But iSOS has a network of care providers around the world who will accept iSOS (and speak English). And if the provider doesn't accept iSOS, supposedly iSOS will show up with cash (never had to test this). And some big insurance companies also have international networks, but it doesn't help if you're where they're not.