International health insurance for moving abroad: an example

Janet Ruiz is 62. She spent 30 years as a school librarian in Asheville, North Carolina, and retired in June. In August she moved into a rented apartment in Porto, Portugal.

Her daughter and two grandchildren live in Charlotte, North Carolina. Janet planned to fly back twice a year, including about six weeks at Christmas.

She has high blood pressure, managed with one daily medication. Until June, her health coverage came through her job.

This story follows her first eight months abroad with Worldwide Premier, a long-term plan from BlueCross BlueShield Global Solutions (formerly GeoBlue). It shows why she chose it, how she used it and what it did not do.

Why her coverage at home wasn’t the answer

Her coverage through work was ending when she retired. Even if it hadn’t been, the carrier’s comparison page says most domestic plans offer limited coverage abroad, and that a U.S. health plan “might stop at the border.”

She also asked herself whether she needed private coverage at all in a country with a national health system. The carrier’s own FAQ makes its case this way: if you are moving to a different country, “you might not want to depend on national health insurance.” It gives reasons: you might wait a long time to see certain doctors, and if you move on to another country or back to the U.S., you lose that coverage. Janet wanted a plan that would follow her between Porto and Charlotte.

Why she chose Worldwide Premier

The carrier’s main living abroad page offers two plans.

• Outside U.S. covers care outside the U.S. There’s a version with limited U.S. coverage, which the carrier says includes coverage for up to 3 trips back to the U.S., with a maximum of 21 days per trip per calendar year.
• Worldwide Premier covers care anywhere in the world, including inside the U.S.

Janet’s six weeks at Christmas alone ran past 21 days, so she chose Worldwide Premier.

Here is what that plan offers, in the carrier’s terms:

• An unlimited annual and lifetime medical maximum.
• No deductible for office visits, preventive care and more.
• Outside the U.S., covered care is paid at 100% of the allowed amount after any deductible. Inside the U.S., it is 80% at participating providers and 60% at non-participating providers.

Inside the U.S., claims can go through the BlueCard Program, which lets members use providers in the network of the local Blue Cross and Blue Shield company.

She chose the “1,000” deductible option. Under it:

• Her deductible is $500 per calendar year for care outside the U.S.
• In the U.S., it is $1,000 at in-network providers and $2,000 out of network.
• Her coinsurance maximum is $4,000. The carrier says the out-of-pocket maximum is the deductible plus the coinsurance maximum.

Applying, and the letter that mattered

To be eligible, she had to be a U.S. citizen or permanent resident living outside the U.S. for more than three months, and under 75 when she applied. The carrier says its living abroad plans are not guaranteed: it reviews the details on the application, including your overall health.

Her blood pressure was the question. For Worldwide Premier, the carrier says that without proof of prior coverage you may wait up to 6 months for current health conditions to be covered. With a letter from your previous insurer showing at least 6 months of coverage, coverage can start right away.

Janet asked her old insurer for that letter. The certificate credits prior coverage that ended no more than 63 days before the new plan starts. Her work coverage ended June 30. The certificate says a plan starts on the first or the fifteenth of the month after approval, so once she was approved in July, she chose August 1. That gap was 31 days, inside the limit, and her blood pressure was covered from day one.

Settling in: a doctor, a physical, a prescription

In September, Janet used the provider search in the carrier’s app to find a general doctor in Porto who was contracted with the carrier.

Office visits outside the U.S. are covered at 100% with no deductible and a $10 copay, and the copay is waived at contracted providers. Her first visit, to check her blood pressure and get a local prescription, had a covered charge of $65.

The plan paid $65. Janet paid nothing.

In October, she had her yearly physical with bloodwork. The plan covers one annual physical per calendar year, up to $1,000, at 100% with no deductible outside the U.S. The covered charge was $310.

The plan paid $310. Janet paid nothing.

Her blood pressure medication cost $27 for a three-month supply at a pharmacy in Porto. Prescriptions under the plan’s basic benefit are paid at 100% of the actual charge with no deductible, up to $3,500 per calendar year. Outside the U.S., the certificate says you pay the pharmacy in full and then send a claim form with the receipt.

The plan paid her back $27.

December: a sinus infection in Charlotte

Two weeks into her Christmas visit, Janet came down with a sinus infection. She went to an urgent care clinic in Charlotte that participates in the local Blue Cross and Blue Shield network.

At participating U.S. providers, urgent care is covered at 100% with no deductible after a $75 copay. The covered charge was $210.

Step 1. Covered charge: $210.

Step 2. Janet pays the $75 copay.

Step 3. The plan pays the rest: $210 minus $75 is $135.

The plan paid $135. Janet paid $75.

The doctor prescribed an antibiotic, which cost $16. Janet hadn’t bought the plan’s optional prescription rider, so she paid the pharmacy in full and sent in the receipt.

The plan paid her back $16.

March: appendicitis in Porto

In March, Janet woke with a sharp pain low on her right side that got worse through the morning. She called the Global Service Center, which is open around the clock with multilingual staff, and was pointed to a private hospital in Porto that was in the carrier’s network. She had appendicitis. The surgeon removed her appendix that afternoon, and she stayed two nights.

The plan requires pre-certification for hospital stays only inside the U.S., so she didn’t have to call for approval first. The hospital billed the plan directly.

To keep the numbers simple, this example assumes no other plan paid any part of Janet’s bills. The certificate has coordination of benefits rules for people covered by more than one plan.

The arithmetic

Inpatient hospital care outside the U.S. is covered at 100% after the deductible. This was a new calendar year, so her $500 deductible was fresh.

Step 1. Covered charges for the surgery and two nights: $9,400.

Step 2. Subtract her $500 deductible: $9,400 minus $500 is $8,900.

Step 3. Pay 100% of the rest: $8,900.

The plan paid the hospital $8,900. Janet owed $500.

Her daughter flew over to help for a week, at her own expense. The plan’s emergency family travel benefit, up to $2,500 per calendar year for one person’s economy airfare and hotel, applies when someone is expected to be in the hospital for more than 7 days or is in critical condition, and it has to be approved in advance. A two-night stay didn’t qualify.

Her first eight months, added up: in the fall, $65 plus $310 plus $27, or $402, all paid by the plan. In December, $210 plus $16, or $226, of which the plan paid $151 and Janet paid $75. In March, $9,400, of which the plan paid $8,900 and Janet paid $500.

Total costs: $402 plus $226 plus $9,400 is $10,028. The plan paid $402 plus $151 plus $8,900, or $9,453. Janet paid $75 plus $500, or $575. And $9,453 plus $575 is $10,028.

What the plan did not do

It doesn’t cover routine dental care or glasses unless you add them. Dental and vision come as an optional rider, covered only if you choose it and pay for it. Janet didn’t, so her dental cleaning and new reading glasses in Porto were hers to pay. The plan does cover dental care needed because of an injury, up to $1,000 per calendar year and $200 per tooth.

Its basic prescription benefit has a ceiling. It pays up to $3,500 per calendar year. An optional prescription rider raises that to $25,000. Someone on costly medications should look closely.

U.S. care costs more out of pocket. Inside the U.S., the plan pays 80% at participating providers and 60% at non-participating ones, after a higher deductible, and many U.S. services need pre-certification.

Some visits carry a charge. An emergency room visit that doesn’t lead to an admission has an additional $50 copay. Providers outside the network can bill you for the amount above what the plan allows.

A deductible rule to know about. The certificate says deductible amounts incurred in October, November or December also count toward the next year’s deductible. Janet’s fall care had no deductible, so it didn’t come up.

Renewal isn’t automatic. The carrier says its long-term plans can be renewed every year as needed. The certificate says that at the start of each new period of coverage you re-apply, and the re-application is subject to the insurer’s approval. To renew, you must be under 84.

Leaving the plan has rules. The carrier says most of its plans have a 6-month enrollment minimum and that it doesn’t refund partial months.

It isn’t Affordable Care Act coverage. The certificate says it is not Minimum Essential Coverage. If Janet moves back to the U.S. for good, she will need a different plan.

Emergency evacuation is included, up to $250,000 as a lifetime maximum for all evacuations, when the plan’s medical director decides adequate care isn’t available locally. Janet’s surgery was done in Porto, so it never came up.

Is a plan like this right for you?

How much time will you spend in the U.S.? If you rarely come back, the Outside U.S. plan may fit. If you’ll spend weeks at a time with family, look at Worldwide Premier.

Do you have a condition you manage now? Get a letter from your current insurer showing at least 6 months of coverage, and time the new plan so the gap is no more than 63 days.

Which deductible? The options set a different deductible outside the U.S., in network and out of network. Check all three numbers, not just the first.

Are you ready for the paperwork? Network hospitals can bill the plan directly. Outside the U.S., you pay the pharmacy yourself and claim it back. Give notice of a claim within 60 days of an event and send proof within 90 days.

The short version

In Janet’s first eight months abroad, Worldwide Premier paid $9,453 of her $10,028 in medical costs: her doctor’s visit, her physical and her prescriptions in Porto, most of an urgent care visit in Charlotte, and all but her $500 deductible for an appendectomy. She paid $575. It did not pay for her dental cleaning or glasses, it limits prescriptions to $3,500 a year without the rider, and each year’s renewal is subject to approval.

This is an outline of how the plan works. The certificate of coverage sets the full terms, including the exclusions and the limits.