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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

  

 

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TRAVEL and VACATIONS WITH A MAJOR ILLNESS OR DISABILITY: ARE YOU COVERED?

By Thomas P. McCormack  10/18/05

We hear a lot about planning for vacations and travel while ill: how to stock, pack and carry medications; what immunizations to get; how to stay in touch with your doctor; etc., etc. But what we never hear is what happens to benefits—including health coverage—for those traveling out-of-state or out-of-country. Here’s a brief overview.

Health Coverage

Neither Medicare nor Medicaid ever pays for care outside the United States. State Medicaid programs generally refuse to pay for anything other than life-or-death emergency room and emergency hospitalizations in other states in the Union. And then, since Medicaid is a welfare program, eligibility workers may well demand to know how and why a supposedly poor person on Medicaid can afford the “luxury” of travel.

 (Federal law does require state Medicaid programs to allow their patients to see medical providers anywhere in the country [but not overseas] in the case of life-and-death emergency or for ongoing, regular care in state border areas [e.g., the Washington, DC or New York City areas, where patients could get care in adjacent suburban states]. But this is generally an empty right because only hospitals---because of the very large bills at stake for cases of emergency hospitalizations of visitors—are willing to bother to enroll as providers in another state’s Medicaid program. Doctors and other providers only enroll in their own state’s Medicaid program with great reluctance; few, if any, bother with other states. And, of course, if one is treated by a medical provider who is ineligible or unwilling to enroll in one’s home state Medicaid program the bills must then be paid with one’s own funds. )  

State AIDS Drug Assistance Programs (ADAPs)---like all state programs for the needy—require one to be a resident and assume that long absence means a loss of residency. They don’t offer out-of-state and out-of country coverage. Hence, ADAP purchase of prescriptions in other states or overseas is generally forbidden. (To take one example, California ADAP discovered a recipient who’d left the state [to give long term care to an ailing old friend] by monitoring claims for prescriptions by drugstores which shipped to the customer at an out-of-state address and by checking on mail forward orders on disconnected and forwarded telephone numbers. They terminated his coverage, of course. He then found that his income was above the new state’s ADAP eligibility level.)

    

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Some Medicare supplement insurance (Medigap), in the few states which even offer it on an equal access basis to the disabled,  don’t cover care outside the country—while some do. Check plan brochures to be sure. Some Medicare HMOs often don’t either---while, again, some do. Few, if any, Medicaid HMOs cover care while overseas and few even cover non-emergency care in other states of the Union. .In other words, while Medicare and Medicaid themselves never cover foreign care, it may be that the HMO plan purchased by Medicare or Medicaid on behalf of a patient  does happen to cover foreign care. To be sure, read plan brochures carefully and question the staff closely.  (If you plan a long trip and carefully stock up on and pack all the drugs you’d possibly need during travel---and if Medicare is your primary health insurance—it might be possible to enroll in a foreign care-covering Medigap plan or Medicare HMO  before leaving in order to secure its out-of-country coverage. And if HMO care really isn’t your cup of tea, you could  then disenroll upon returning. )

Most—but far from all! —private health insurance plans and private HMOs offer at least some foreign care: again, one must read the policy carefully and question staff about details.

VA health care is not available outside the United States and the Philippines except for emergency care at European and Far East U.S. military bases for “service-connected” compensationers. (Compensationers are those veterans who get VA checks for illnesses or injuries which began while on active duty.) Compensationers can have medical care from approved foreign sources covered by seeking advance permission for such coverage from the VA. Contact the Foreign and Insular Affairs Unit, Medical Administration, Veterans’ Affairs Medical Center, 50 Irving Street, NW, Washington, DC 20422 (202) 745-8242; numerous forms must be completed. Even so, because the clerical staff at overseas U. S. military medical facilities don’t know the complex VA rules well, other, non-compensationer veterans who already have and present VA patient identity cards at  emergency rooms of overseas U.S. military medical facilities  have been known to mistakenly receive free care.

Mexican Government Medical Plan for Resident Foreigners; American Health Insurance in Mexico; and Health Insurance for Those Residing Overseas

Foreign residents of Mexico can sign up, for only a few hundred dollars yearly, for a major medical plan sponsored by that nation’s government. It pays for a progressively greater range of health costs during the first three years of enrollment but it doesn’t cover those with pre-existing chronic conditions (e.g., diabetes, heart disease or HIV). Details are available, in Spanish only, on the Instituto Mexicano del Seguro Social  website http://www.imss.gob.mx (or search using  the agency’s proper name with any web-browser). 

By late 2005, Blue Shield of California’s Access Baja  plan  and Health Net of California

offered employer group health insurance coverage to permanent US residents living in or visiting  Mexico---and had begun, or were considering, offering individual policies too. Because of lower Mexican medical costs, premiums are less than for US-based coverage. 

In 2002 premiums for a single adult were around $1700 yearly for health insurance through AllNation http://www.allnation.com/, which took over Blue Cross Blue Shield  International, with a $2500 deductible. It covers care anywhere in the world, but one must reside permanently outside of the United States. Check carefully about any pre-existing condition rules.

Income and Related Programs

Supplemental Security Income (SSI), Temporary Assistance to Needy Families  (TANF), VA disability pensions, general assistance, home relief, home energy assistance, food stamps, school lunch program enrollment, Women’s, Infants’ and Children’s (WIC) benefits, HOPWA and other housing subsidies are canceled for anyone out of the country (or, usually, even the state) over 30 days. And, again, when officials discover the travel, or when those dropped from benefits reapply upon their return, difficult questions about how the “luxury” of travel could have been affordable (for someone supposedly poor enough for welfare) must be answered satisfactorily.

(While it’s possible to simply not tell public agencies about the travel to avoid this problem, the difficulty is that one is on written notice---under penalty of fraud---to alert agencies to just these changes of circumstances. And agencies’ telephone calls and letters—if not promptly and properly answered---can and do quickly alert them that a disqualifying loss of residency has occurred. Agencies swiftly cancel benefits when they get “not at this address” , “moved”, “addressee unknown” or  change-of address responses through the post office and they respond similarly when they encounter telephone recordings announcing a disconnected number or referring callers to new numbers out-of-state.)

Social Security retirement benefits, Social Security Disability Insurance (SSDI) and VA disability compensation are payable to Americans citizens outside the country over 30 days. However, in many cases Social Security is not payable overseas to any alien—even aliens who are qualified U.S. “permanent residents”!. This is so even though many aliens fairly acquired those benefits through taxes paid while working. See http://www.ssa.gov/international/your_ss.html for details.

Of course, Social Security and other benefits are not payable at all---even for work on which taxes were paid---to illegal aliens, whether they are in the U.S. or outside it.  Provisions of private, employer and union old age and disability pensions and income-insurance programs vary: check the plan materials and ask detailed questions before leaving.

Congress and the Social Security Administration recently became alarmed when it was discovered that untold thousands of  SSI checks were going to post office boxes in small U.S. towns near the Mexican border, causing  crowding in post offices and nearby check-cashing facilities and banks on the first of the month, with recipients quickly then dispersing back across the border for the rest of the month. Many citizens and permanent residents had, in effect, “retired” to Mexico while on SSI---illegally! As a result, severe new restrictions on and monitoring of post office box usage are going into effect in some of these border areas. In addition, the General Accounting Office reports widespread receipt of SSI by persons not residing within the U.S. See “Supplemental Security Income: Sustained Management Attention Needed to Address Residency Violations”. GAO-04-789T, May 20,2004  http://www.gao.gov/cgi-bin/getrpt?GAO-04-789T . (Again, U.S. citizens can receive Social Security checks at foreign addresses; aliens, even legal ones, can’t; and neither citizens nor aliens can be eligible for or get SSI checks while residing outside the country.)

    

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Travel Insurance

Readers should beware: Many policies are sold as “travel health insurance” when all they offer is trip interruption and cancellation, medical transport/evacuation benefits and telephone advice lines—but not actual travel health insurance. Mutual of Omaha, International Trip Assist and Carefree  (www.carefreemedicaltravel.com) policies may well include genuine health insurance coverage that can be used by traveling patients with pre-existing conditions. If interested, make careful inquiries---being sure to ask if and how  the all-important pre-existing condition policy clauses can be waived, if at all.

 But Travel Guard www.travelguard.com [(800) 826-1300] and CSA Travel Protection www.csatravelprotection.com [(800) 873-9855], however, definitely do offer travel health insurance policies that do this. They even cover pre-existing medical conditions for those who purchase the insurance within seven or fourteen days of making an advance trip down payment through a travel agent. Besides paying health costs up to $10,000, the policies also cover trip cancellation, delay and interruption; medical evacuation; a medical advice line; luggage and document loss; assistance in expediting cash advances from one’s credit card or bank; auto rental insurance; and accidental death benefits. In 2000, typical premiums were $235 for a $3,000 trip purchase (Travel Guard, which ties premium prices to length and price of trip) or $87 for up to a 31 day trip for someone under age 55 (CSA Travel Protection, which ties premium prices to age and length and price of trip). Access America www.accessamerica.com [(800) 284-8300] Specialty Risk International www.specialtyrisk.com [(800) 335-0611) and Travel Insured International www.travelinsured.com [(800) 243-3174] also offer travel health insurance policies.

For an exhaustive list of many available travel medical insurance plans and related services, go to http://www.hivlawtoday.com/s?k=travel+insurance&b=48&m=s&t=1042136149250 . In addition, www.Insuremytrip.com compares and gives quotes  on over 60 travel insurance policies from 14 companies, and presents them in chart form. Another site that reviews as many travel policies is www.quotetravelinsurance.com .

“Hospital indemnity” insurance (“$100 a day direct to you while you’re in the hospital!”) will often pay for days in foreign hospitals. For about $35 monthly, and with a 12 month preexisting condition waiting period, Mutual of Omaha and Physicians’ Mutual offer benefits of about $100 per day . Those over age 50 can get similar coverage—with only a 3 month preexisting condition waiting period—through the AARP (www.aarp.org ). (Check with their 800 numbers and make detailed inquiries about foreign hospital coverage)

Some credit cards offer limited benefits. The American Express platinum card, which costs $300 yearly, pays for emergency medical evacuations and some treatment . But read the fine print to be sure. Visa offers ”optional enhancements” for those banks issuing  its credit cards to cover, at extra cost, emergency evacuation and some actual medical insurance coverage. Cards issued by credit unions often carry this coverage as a marketing tool . Again, read plan materials with care to make sure that you’re buying actual insurance and not just medical evacuation and medical advice line services.

No matter what your own health conditions, it so happens that you can get the best, most up-to-date advice about travel health insurance from those travel agents who have long catered to a gay clientele. This is because of their long experience serving HIV-positive customers (many of whom--even those receiving benefits for low income persons-- have taken, or been treated by loved ones to, “dream” foreign vacations as their health threat worsens). As the American Express advertisement tells us: “Don’t leave home without it!”:  Check in advance about your health coverage and other benefits before you leave!

Resources

www.insuremytrip.com sells travel health insurance from 14 companies

http://www.hivlawtoday.com/s?k=travel+insurance&b=48&m=s&t=1042136149250 offers an exhaustive list of available medical travel insurance plans and related services

http://www.ssa.gov/international/your_ss.html for details about Social Security, SSI and Medicare, as does

http://www.socialsecurity.gov/pubs/10137.html
HIV-Positive Travel primer at www.outandabout.com (has list of gay-friendly travel agents)

CDC’s HIV Traveler Precautions at www.cdc.gov/travel/hivtrav.htm.

Travel (Oct. ’99) a Consumer Reports newsletter  (800-234-1645; $5 to POB 53016, Boulder, CO 80322)

Society for the Advancement of Travel for the Handicapped (212) 447-1928 or 447-0027 www.sath.org

Access-Able Travel Source (303) 232-2979 www.access-able.com

International Association for Medical Assistance for Travelers (716) 754-4883

Hecker, Helen. Directory of Travel Agencies for the Disabled, Twin Peaks Press, 1998 ($19.95).

American Society of Travel Agents (703) 739-2782

www.carefreemedicaltravel.com is particularly useful on medical support services needed while traveling

The American Association of Retired Persons (AARP)  www.aarp.org has an international affairs office with pages on its website; AARP members and even others can email intaffairs@aarp.org for information

Thomas McCormack wrote the AIDS Benefits Handbook and did benefits policy work with the federal Department of Health and Human Services and several AIDS and disability advocacy groups. He now consults with the Title II Community AIDS National Network. Email him at tomxix@ix.netcom.com.