Maintain U.S. Health Insurance While Traveling Abroad?

[Shane]

Curious what others who are long-term traveling are doing for health insurance? Are you maintaining your U.S. based ACA compliant health insurance while traveling abroad? Travel insurance? Both?

Apparently, if we stay outside of the U.S. for at least 330 days during any 12 month period, it's possible to be exempt from the current requirement that U.S. citizens maintain ACA compliant health insurance. My wife, daughter and I have tickets to fly to Japan at the end of June, and we're planning to travel outside of the U.S. for at least one year, so it sounds like we could cancel our U.S. based insurance if we wanted to and not have to pay a penalty. However, our current U.S. based health insurance will not pay any medical bills incurred outside of the U.S., so it's pretty much useless to us while we're traveling.

The only reason I can see to maintain our U.S. health insurance while traveling is for the unlikely event that one of us gets seriously ill and we have to quickly come back to the U.S. to receive extensive medical treatment. If we already had health insurance in the U.S., it would be simple to come home, go to a hospital or doctor and get treated and have everything covered right away.

We're planning to take out a travel insurance policy through World Nomads. For a family of 3, it's about $150/month to get coverage for emergency medical stuff anywhere outside of the U.S. It only pays for emergencies, though. The travel policy will also pay to transport us back home in the event that one of us gets really sick while traveling.

The other option we're considering is to cancel our U.S. based health insurance, qualify to be exempt from the ACA penalty based on being physically outside of the U.S. for at least 330 days, maintain travel insurance, and in the event that we need to come back to the U.S. for medical treatment, just reapply for U.S. insurance as soon as we return to the U.S. I'm assuming that returning to the U.S. from traveling abroad would be considered a "Qualifying Event" which would allow us to sign up for insurance as soon as we return. Does anyone know if we would be able to get retroactive coverage back to the day that we landed back in the U.S.? Assuming one of us were really sick, we wouldn't be able to wait days or weeks to get re-approved for insurance.

What are others who are traveling long term doing for health insurance? Thanks in advance for any ideas you guys can give us.

[forummm]

I don't think you can get retroactive coverage in the scenario you describe. I think at best, it takes effect the next month (and usually only if you enroll by the 15th of the month--otherwise it could be the month after next).

[Eric]

I don't think the travel insurance is all that valuable, as if you really need it, and it's cheaper for them to ship you back to the US than to treat you, that's what will happen.  Then you'll be in the US needing treatment without having health coverage.  That's the stuff of nightmares.  Here's a list of Qualifying Events and I don't think just showing back up in the US would work.  You could probably make a qualifying event by moving your permanent address to a new state, but of course that's not going to be an instantaneous thing.  Plus there's bound to be some enrollment delay, and if you're getting shipped back because it's serious, you're going to rack up some serious bills.  Like your FIRE is fucked bills.  So your only option would be to combine the travel insurance w/ an ACA policy that you'd basically never be able to use.  It's an option, but obviously not a good or effecient use of your money.

I think the better solution is to buy an international health insurance policy.  There are a number of them out there, through major companies like Clements, Cigna Global, and Allianz and I'm sure others.  They usually cover you for basically any country you'd travel to besides the US & Canada.  (Like North Korea or Iraq aren't covered, but that probably won't matter).  I priced a Clements policy for my wife and I, around age 40, for $2200/yr.  Varies with deductible of course.  This is the route I'm planning to go.  And then when I travel back to the US, I'll pick up a super high deductible non-complaint policy for emergencies.

If you develop a chronic condition that you feel would be better treated in the US, you can always move back during the open enrollment period.

[Lake161]

We are staying out of the US for 330+ days this year, so we bought an international policy from Cigna that covers us everywhere except the US, Japan, and a few other countries. For a 50 and 54 year old it runs about $250 a month. It has a $2000 out of pocket maximum, so we pay for ordinary visits and tests ourselves (cheap in Panama).

Then, when we traveled back to the US to visit family, we bought a travel policy for the US ($44 for a week, with a $10k max). We had to shop around a bit to find that one, as some of the travel policy companies wanted us to have been resident outside the US for 6+ months. In hindsight, we probably should have bought more than $10k in coverage as a single ER visit or brief hospital stay could have wiped that out.

[LAGuy]

I'm in the same boat as you OP. Looking to go abroad leaving in July.

I'm still doing my research, but I'm not totally sure how the 330 day exemption works, but it sounds like it's for a tax year. That is, if you leave in June, you're going to need US based health insurance through the end of the year to not run afoul of the mandate. Because you'll only be gone from the US for 6 months in 2016. Then, come 2017 you could not buy insurance and when you return you could enroll in the ACA under the exemption that you're returning from abroad. Can anybody confirm that's how it works? I was looking around but can't find anything that relates to this specific issue.

[Lake161]

When I did my taxes, I had a partial year being out of the country, and just filled out the exemption form indicating that I had coverage Jan-Jun and was overseas July-Dec.  I will meet the 330 days requirement officially in June of this year. For 2016 I will fill out the form stating I was overseas Jan-Aug and then had coverage Sep-Dec when we return to the US. The regulation says 12 consecutive months, it doesn't say they have to be in the same tax year as far as I can tell.

[LAGuy]

When I did my taxes, I had a partial year being out of the country, and just filled out the exemption form indicating that I had coverage Jan-Jun and was overseas July-Dec.  I will meet the 330 days requirement officially in June of this year. For 2016 I will fill out the form stating I was overseas Jan-Aug and then had coverage Sep-Dec when we return to the US. The regulation says 12 consecutive months, it doesn't say they have to be in the same tax year as far as I can tell.

Ok, that's good to know. What if an emergency strikes, though and you have to return before your 12 month period is up? Wouldn't you then be on the hook for the penalty? It seems like the "safest" way would be to carry ACA insurance, leave the country for 330 days and THEN drop the coverage. I mean, I guess the penalty isn't the end of the world or anything.

[Shane]

I don't think you can get retroactive coverage in the scenario you describe. I think at best, it takes effect the next month (and usually only if you enroll by the 15th of the month--otherwise it could be the month after next).

I'm not certain, but I think I remember when I applied for ACA benefits last summer, the day after I had quit my job, that the person taking my information told me that if my application were accepted, benefits would be retroactive to the date that I had applied.

Maybe someone else on the board knows the answer or can link to a rule for us, or else I could probably just call up and ask someone at the healthcare exchange...

[Shane]

I don't think the travel insurance is all that valuable, as if you really need it, and it's cheaper for them to ship you back to the US than to treat you, that's what will happen.  Then you'll be in the US needing treatment without having health coverage.  That's the stuff of nightmares.  Here's a list of Qualifying Events and I don't think just showing back up in the US would work.  You could probably make a qualifying event by moving your permanent address to a new state, but of course that's not going to be an instantaneous thing.  Plus there's bound to be some enrollment delay, and if you're getting shipped back because it's serious, you're going to rack up some serious bills.  Like your FIRE is fucked bills.  So your only option would be to combine the travel insurance w/ an ACA policy that you'd basically never be able to use.  It's an option, but obviously not a good or effecient use of your money.

I think the better solution is to buy an international health insurance policy.  There are a number of them out there, through major companies like Clements, Cigna Global, and Allianz and I'm sure others.  They usually cover you for basically any country you'd travel to besides the US & Canada.  (Like North Korea or Iraq aren't covered, but that probably won't matter).  I priced a Clements policy for my wife and I, around age 40, for $2200/yr.  Varies with deductible of course.  This is the route I'm planning to go.  And then when I travel back to the US, I'll pick up a super high deductible non-complaint policy for emergencies.

If you develop a chronic condition that you feel would be better treated in the US, you can always move back during the open enrollment period.

Thanks for your input, Eric. I, too, have been looking at some international health insurance plans. My wife, daughter and I are generally pretty healthy, but we're older than you guys, have a child and as of 2 weeks ago my wife has a preexisting condition.

One problem with international health insurance is that I'm pretty sure they won't pay for any medical care related to preexisting conditions, which might be a problem for us. A good thing about U.S. insurance is that they can't exclude preexisting conditions.

Don't you think that moving back to the US after living abroad would be a qualifying event based on this criterion from the document you linked?

Changes in residence
Moving to a different ZIP code or county

If you inform the ACA people before you leave that you're cancelling your insurance because you are leaving the country, when you return to the U.S. wouldn't you be moving to a different ZIP code or county, i.e., no longer outside of the U.S.?

I don't know the answer, but it seems like it's an important question to which many of us on here who are planning extensive, long-term travel during FIRE need a clear and accurate answer in order to make good decisions. It would be great if we could hear from some members who are already traveling long term like ARS, Spoonman, EndlessJourney, etc. I'd like to hear from them and anyone else who has already BTDT.

[Shane]

We are staying out of the US for 330+ days this year, so we bought an international policy from Cigna that covers us everywhere except the US, Japan, and a few other countries. For a 50 and 54 year old it runs about $250 a month. It has a $2000 out of pocket maximum, so we pay for ordinary visits and tests ourselves (cheap in Panama).

Then, when we traveled back to the US to visit family, we bought a travel policy for the US ($44 for a week, with a $10k max). We had to shop around a bit to find that one, as some of the travel policy companies wanted us to have been resident outside the US for 6+ months. In hindsight, we probably should have bought more than $10k in coverage as a single ER visit or brief hospital stay could have wiped that out.

That's interesting that the policy you got from Cigna won't cover you in Japan. I wonder why?

We already bought plane tickets leaving at the end of June, and the first place we're flying to is Japan, so your policy might not work for us... :)

Do you know if your policy will cover medical expenses related to any preexisting conditions you may have?

Have you ever tried to make a claim on your policy?

[Shane]

When I did my taxes, I had a partial year being out of the country, and just filled out the exemption form indicating that I had coverage Jan-Jun and was overseas July-Dec.  I will meet the 330 days requirement officially in June of this year. For 2016 I will fill out the form stating I was overseas Jan-Aug and then had coverage Sep-Dec when we return to the US. The regulation says 12 consecutive months, it doesn't say they have to be in the same tax year as far as I can tell.

Ok, that's good to know. What if an emergency strikes, though and you have to return before your 12 month period is up? Wouldn't you then be on the hook for the penalty? It seems like the "safest" way would be to carry ACA insurance, leave the country for 330 days and THEN drop the coverage. I mean, I guess the penalty isn't the end of the world or anything.

I wondered the same thing as @LAGuy. What if we cancel our U.S. based insurance because we're planning to stay out of the country for 330+ days, but then one of us gets sick and has to come back home? I guess we'll have to pay whatever the penalty is at tax time.

I'm pretty sure the penalty is based on a percentage of your income, so depending on how much money you make during the year you have to pay the penalty it could be a little bit or a lot.

[jim555]

When I did my taxes, I had a partial year being out of the country, and just filled out the exemption form indicating that I had coverage Jan-Jun and was overseas July-Dec.  I will meet the 330 days requirement officially in June of this year. For 2016 I will fill out the form stating I was overseas Jan-Aug and then had coverage Sep-Dec when we return to the US. The regulation says 12 consecutive months, it doesn't say they have to be in the same tax year as far as I can tell.

Ok, that's good to know. What if an emergency strikes, though and you have to return before your 12 month period is up? Wouldn't you then be on the hook for the penalty? It seems like the "safest" way would be to carry ACA insurance, leave the country for 330 days and THEN drop the coverage. I mean, I guess the penalty isn't the end of the world or anything.

I wondered the same thing as @LAGuy. What if we cancel our U.S. based insurance because we're planning to stay out of the country for 330+ days, but then one of us gets sick and has to come back home? I guess we'll have to pay whatever the penalty is at tax time.

I'm pretty sure the penalty is based on a percentage of your income, so depending on how much money you make during the year you have to pay the penalty it could be a little bit or a lot.

If your income is low enough you might be eligible for Medicaid which requires no open enrollment period and is retroactive up to three months, provided your income was low enough in those three months.

[Lake161]

We are staying out of the US for 330+ days this year, so we bought an international policy from Cigna that covers us everywhere except the US, Japan, and a few other countries. For a 50 and 54 year old it runs about $250 a month. It has a $2000 out of pocket maximum, so we pay for ordinary visits and tests ourselves (cheap in Panama).

Then, when we traveled back to the US to visit family, we bought a travel policy for the US ($44 for a week, with a $10k max). We had to shop around a bit to find that one, as some of the travel policy companies wanted us to have been resident outside the US for 6+ months. In hindsight, we probably should have bought more than $10k in coverage as a single ER visit or brief hospital stay could have wiped that out.

That's interesting that the policy you got from Cigna won't cover you in Japan. I wonder why?

We already bought plane tickets leaving at the end of June, and the first place we're flying to is Japan, so your policy might not work for us... :)

Do you know if your policy will cover medical expenses related to any preexisting conditions you may have?

Have you ever tried to make a claim on your policy?

Our policy seems to exclude the more expensive countries. They do sell a true global policy. I think it's about $1k a year more and does include the US and the other excluded countries. It does not meet ACA standards.

When we applied, they asked about pre-existing conditions. One of our conditions was excluded from the policy, but others were not.

We have not had any claims, as healthcare is so cheap here it's easy to pay out of pocket for minor stuff ($12 for office visit, $10 for basic labs, $10 for a 30-day supply of a generic prescription drug, $50 for a specialist visit).

[forummm]

I don't think you can get retroactive coverage in the scenario you describe. I think at best, it takes effect the next month (and usually only if you enroll by the 15th of the month--otherwise it could be the month after next).

I'm not certain, but I think I remember when I applied for ACA benefits last summer, the day after I had quit my job, that the person taking my information told me that if my application were accepted, benefits would be retroactive to the date that I had applied.

Maybe someone else on the board knows the answer or can link to a rule for us, or else I could probably just call up and ask someone at the healthcare exchange...

It might be possible to have same-day coverage. It could also depend on the state you're in.

[spoonman]

@shane: Since we didn't quite know how long we would be outside the US, we just stuck with our ACA compliant health insurance.  Earlier this year we were  thinking of ditching our ACA plan for a cheap, international plan through Cigna Global (around $100 /mo for two of us), but didn't sign up because we decided to head back to the US.

The next time we spend a long time out of the US, we'll sign up for the Cigna Global plan and perhaps also sign up for cheap evacuation insurance in case we want to apply for a long term "D" visa in Italy or France (which require evacuation insurance).

[EndlessJourney]

I received a PM asking me to weigh in on what we do for insurance.

We've been traveling around the world by motorcycle for the last four years, so far we've been through North, Central and South America, Europe, Africa and Asia.

We do have third-party insurance but we've not had any serious incidences which involved any claims.

I've gone through three different companies over the length of our trip. Mainly because of price-shopping, but also because of reading reviews about the claims process of the insurance providers I was dealing with.

I hesitate to name the insurance companies I used because I think you can only fairly endorse a company after you've gone through their claims process.

The way insurance companies make money and stay in business is to deny claims. Your goal is to try to find one that has a fair  claims process and has an unambiguous policy of what they will or will not cover.

Someone above mentioned World Nomads. We were also looking at them because they have a competitive pricing on their policies. But what good is a cheap policy if they deny you coverage based on small print?

I'm on a few motorcycle travel forums and have heard lots of horror stories of World Nomads denying coverage. Here is the latest one (Oct 2015)

http://advrider.com/index.php?threads/worldnomads-com-travel-insurance-worthless.1102208/

More info:

http://www.rideasia.net/motorcycle-forum/general-discussion/7497-best-med-evac-insurance-tours-asia.html

Keeping in mind that World Nomads is a marketing brand. There are different underwriters depending on where your home country is. Still, if the umbrella company is not willing to stand up to one of their underwriters on behalf of their customer, then it tarnishes the reputation of all of their underwriters.

I think too often shopping around for insurance providers boils down to two things: 1) How much does it cost? 2) How much am I covered for?

My advice when shopping around for insurance is to Google reviews on the claims process as well as the responsiveness of the "24-hour call center" (they all have them).

What I also suggest is if you do find an insurance provider is to test out their responsiveness. Call their hotline with a generic question. Do you get a live person or a recording? How quickly do they get back to you? Often 24-hour call center means they will get back to you within 24 hours...

We didn't renew one of our providers because we found out that their 24-hour call center was an answering machine. Not what you want when you're lying on the side of the road with a broken leg.

Another piece of advice is to familiarize yourself on how the claims process works before you have an accident. Any decisions about where to go for hospitalization, evacuation, flights, treatment, etc. can be denied if not run through your insurance provider first. Know what phone numbers to call. Have your policy numbers on hand. Make sure all members of your family have this info, not just you.

Review all the claims forms so you know what information is required when you need to fill them out and keep a copy on your laptop or a thumb drive in case you don't have Internet access.

[Shane]

@shane: Since we didn't quite know how long we would be outside the US, we just stuck with our ACA compliant health insurance.  Earlier this year we were  thinking of ditching our ACA plan for a cheap, international plan through Cigna Global (around $100 /mo for two of us), but didn't sign up because we decided to head back to the US.

The next time we spend a long time out of the US, we'll sign up for the Cigna Global plan and perhaps also sign up for cheap evacuation insurance in case we want to apply for a long term "D" visa in Italy or France (which require evacuation insurance).

Thanks for your response @Spoonman. I didn't realize you guys had already returned to the U.S. The last time I checked out your journal, I think you were still in Greece. Welcome back!

I'll check out Cigna's Global Plan.

[Shane]

@EndlessJourney, Thanks for all of your solid, detailed advice.

Researching for our trip, I've read many negative things about World Nomads online, but they always seemed kind of petty: "I left my suitcase in the middle of a crowded bus station while I went to the bathroom. When I came back my bag was gone, and World Nomads refused to pay for the $5K worth of camera equipment that got stolen..." DUH!

The links you provided seemed a lot more incriminating, though, because the guy was all banged up from a motorcycle crash, and it sounds like, basically, all World Nomads was good for was to pay for his ticket home to Chiang Mai.

World Nomads' insurance is pretty cheap, so I guess you get what you pay for. They quoted us like $850 for 6 months for a family of 3. Maybe, if we only consider it as insurance to fly us home in the event of an emergency, don't expect them to pay for anything else and then maintain an ACA compliant policy in the U.S., then it might still be worth it to have that or maybe some other international evacuation plan in addition to our regular insurance at home. It seems like, if one of us were really sick, we might not be able to fly home in coach. At the very least, we might need to pay for 1st class tickets home, and that, right there, would be more than the cost of the policy.

Your suggestions on checking out the claims process and calling the 24-hour hotline numbers before buying insurance were priceless. Thank you. We will definitely do that!