This topic pisses me off. I was reluctant to write this article and have been putting it off because I know it will leave a foul, foul taste in my mouth. To mitigate the negative headspace that thinking about applying for health insurance in the United States will put me in, I’m going to populate this article with cat photos.
Like so:
Okay. That’s better. First, a little backstory. If you’re not interested, feel free to (tl;dr) skip ahead to the next cat photo for the moving-back process. When we left on the trip, we didn’t want to be insurance-free for ten months in which anything could happen, so Lea researched insurance plans for expats. The one we settled on was the GeoBlue Xplorer Essential plan, but I highly encourage anyone taking a long-term trip to investigate the options for yourself. For the GeoBlue plan, there were two options – one that would provide health coverage in pretty much every country in the world except the United States, and one that included the U.S. in the package.
There were two problems with the latter option: first, the plan wasn’t ACA compliant, so if we opted for U.S. coverage through GeoBlue we’d still get hit with a tax penalty at the end of the year. Second, adding the U.S. to our coverage would double the cost of our premium. That’s right: health coverage in the United States would have cost us just as much as health coverage in every other country in the world combined. We chose not to take the U.S. coverage and stick to hospitals overseas if anything bad should happen.
So then our options then were to either 1) sign up for an ACA-compliant health plan good in the U.S. that we would pay for but not use, 2) eat the tax penalty, or 3) somehow get an exemption from the tax penalty on the grounds of being unemployed and in another hemisphere. We were able to work out option #3 and get the exemption, but it involved applying for ACA coverage just to confirm that it was unaffordable, filling out a lengthy form buried on the ACA website, mailing a physical copy of the form to a hidden HealthCare.gov bunker, then making several phone calls from Peru months later to get our form out of the junk file and have someone actually process it.
GRRRRRRRR.
Luckily (or not, depending on which way your political views lean) the “Individual Mandate” was stripped from the ACA for tax year 2019 going forward, so there’s no need for anyone else to worry about this until the pendulum swings the other way and the Individual Mandate gets reinstated. If you’re moving back to the U.S., though, you still need to get insurance or run the risk of letting an unexpected illness or accident bankrupt you in the emergency room.
Cat photo:
Our return to the United States was scheduled for May 17. Our GeoBlue coverage was good through the end of May, but since it only covered care in other countries we would have to get ourselves medevacked to Mexico City if anything bad were to happen. We had to get American insurance, and once we had a signed lease with a physical address to show residency, I tried to do so in advance of our return.
I did not succeed. Perhaps my problem was trying to get health insurance from the HealthCare.gov marketplace and not directly from an insurance company, but being scared of what the premiums would be on the open market I went for HealthCare.gov and ACA coverage instead.
Here’s the problem. In order to apply for insurance through the ACA marketplace outside of the open enrollment period (Nov. 1 – Dec. 15) you have to fill out a questionnaire to determine if you’ve had a qualifying life-changing event to justify your need for insurance and to grant you a “special enrollment period.” You would think that moving back to the country from somewhere else in the world would be such a qualification – and it is, but with a catch.
The key question on the questionnaire for expats coming home is one that asks “Have you moved within the last 60 days?” Nowhere does it ask “Will you move in the next 60 days?” When I filled out this application while in Colombia, I had to answer “No.” When I competed the form, the website informed me that my wife and I did not qualify to apply for insurance.
Cats:
I picked up the phone and called HealthCare.gov’s helpline. (Another goddamn international call.) I explained the situation and the person on the other end let me know that as soon as we got back to the U.S. we should apply for the special enrollment period again, this time answering the question “Yes.” (We would, of course, have to upload proof of our new address and start date.) I said OK, shrugged my shoulders, and made it a priority to sign up for healthcare the day we got back.
(Which I actually did the morning of our flight, before we left Colombia. After all, assuming our plane didn’t crash, that would be the day of our return.)
What the person on the phone didn’t tell me:
Health insurance plans bought through the ACA marketplace always begin on the 1st of a calendar month. The deadline for submitting an application and the necessary paperwork to begin your plan (on June 1st, for example) is the 15th of the preceding month.
I applied on the date of our return, the 17th. See the problem?
I answered Yes to the “Have you moved?” question and we were approved for a special enrollment period. We selected a health plan from the ones offered – not the cheapest, but not the most expensive – and waited for information on our new coverage to arrive.
When we learned that our coverage would not begin until JULY 1 we were livid. How were we to go six weeks without health coverage in the country with the highest health care costs in the world? First we called our new insurance provider to see if there was anything they could do to bump up the start date on our plan. We were informed that since the plan was purchased through the ACA marketplace there was nothing they could do on their end, but they could transfer me over to the HealthCare.gov people so we could speak to them.
The HealthCare.gov helpline informed me that there was nothing they could do either; that was the policy and there was nothing they could do about it. When we asked what we were supposed to do if we needed healthcare in the interim, the HealthCare.gov person told us she could “send us a list of clinics in our area that might be able to help out” – as if we were destitute or homeless. When we pushed further, expressing that that answer was unacceptable to us, the HealthCare.gov helpline hung up on us.
Llama throwing shade:
We called our actual insurance provider back. This time, they were able to help us out by providing information that the HealthCare.gov helpline either 1) didn’t have, or 2) didn’t care enough to mention: There are companies out there that provide 30-day short term medical policies to fill in gaps in your health coverage. They don’t cover much, and don’t cover any pre-existing conditions, but at least they’ll help you not go bankrupt should you get run over by an S.U.V. or have a sudden heart attack from spending too much time on the phone talking to health insurance providers.
Our provider transferred me directly to a sales rep for one of these companies, and within thirty minutes we had a policy to cover us for the month of June until our regular policy took over in July. We still didn’t have any coverage for the remainder of May except what was provided by our rental car company. The joke I told people was that if either Lea or I had a health issue during that period, we would have to get in our rental car and crash it before going to the emergency room.
Cat, or specter of death:
So, to summarize, if you’re a long-term traveler returning to the U.S. and don’t have a job lined up with employer-provided insurance, here are your options:
1. Buy a plan on the open market, and damn the premiums.
We didn’t research this option, so I can’t list any pros or cons. I can say that I fear what those premiums might cost, given how high the “Affordable Care” premiums are.
2. Apply for a plan on HealthCare.gov before the 15th of the calendar month before the month you plan to return.
In order to do this, you may have to bend the truth about your return date in order to answer “Yes” to “Have you moved in the past 60 days?” knowing that you’re going to have to provide documentation that someone may or may not actually look at. Whether you’re comfortable doing that, I leave to you. If lying to the government isn’t your style, then you’ll also want to get on board with the next step:
3. Purchase a 30-day short term medical policy to close any gaps in coverage you may experience.
In the U.S. health system, any coverage is better than no coverage at all. Unless you can meet the criteria for option #4:
4. Be so filthy rich that you don’t have to worry about paying for health care out of pocket.
While overseas, Lea and I did on occasion use our health coverage and the healthcare systems in other countries. What we learned from the experience is that healthcare in South America, as far as we could tell, is just as good as it is in the U.S. while being an entire order of magnitude less expensive.
Now we’re back. We’ve got “cheapie” plans that don’t cover much and have high deductibles, so we’re still reluctant to see a doctor for anything less than an emergency. But at least we’re covered until we get something better.
It ain’t the best situation, but for long-term travelers it’s something to definitely keep in mind as you plan for the end of your journey.
Next week: Fun With Furniture! And now, one last kitty for the road:
