American Expats using Medicare as a way to cover medical needs

[charliebadenhop]

Is there anyone here that has had a medical issue here in Thailand and has returned to the US to get treatment there under Medicare?

I would love to know more!

I am 67 years old.

What I have learned after contacting several insurance companies here is the following-

Policies for full protection here start out at about B115,000 a year and then go up from there. Rates climb to B160,000 a year and above as time goes on.

This is a lot more than I was expecting, and thus I am wondering if it makes sense to depend on Medicare and a trip back to the US.

Of course something like a heart attack would need immediate treatment here, and that would need to come out of pocket.

But there could be lots of different serious ailments that would allow one to fly back to the States.

I saw on a website that heart bypass surgery in Thailand would likely be about B1,200,000 or so.

Angioplasty goes for around B500,000.

I don't have heart problems but just trying to understand some potential costs.

I am currently in good health.

Anyone with some info?

TIA,

Charlie

[Jingthing]

Don't people on Medicare need to have an official U.S. state residence? I know many U.S. expats fake it but they can end up biting you. So without being signed up you'd have to go back and sign up. Plus in any emergency you'd need air repatriation costing how much? 100K USD? Not sure, but A LOT! I don't think it's a great plan but it might make more sense to retire closer to the U.S. such as in Mexico or Costa Rica.

[CaptHaddock]

If you are not legally resident in the US, you are not eligible to enroll in any Medicare programs except Part A and Part B. A & B alone are not sufficient to cover major surgery costs in the US.

Medical care in Thailand is availlable from both private hospitals and govt hospitals, where costs are much lower.

[charliebadenhop]

Ah hah, so first learning for me is that I need to be able to show that I am "residing" in the US to use Medicare.

(I already have my Medicare card).

I guess I need to find out the legal definition of "residing in". Guessing the Medicare site will show that.

And yes, costs for operations etc. are a good deal cheaper here than in the US.

Short of a stroke or a heart attack, or a major injury from a car accident, I can't think of why I would be incapacitated but still needing medical treatment.

???

Just trying to understand what will make the most sense for me.

[CaptHaddock]

Ah hah, so first learning for me is that I need to be able to show that I am "residing" in the US to use Medicare.

(I already have my Medicare card).

I guess I need to find out the legal definition of "residing in". Guessing the Medicare site will show that.

And yes, costs for operations etc. are a good deal cheaper here than in the US.

Short of a stroke or a heart attack, or a major injury from a car accident, I can't think of why I would be incapacitated but still needing medical treatment.

???

Just trying to understand what will make the most sense for me.

You may be able to maintain a US address that establishes residency, but if it is in a state that has an income tax you are likely to be establishing tax domicile in that state ipso facto, which would make you liable for state income taxes forever.

If you do not maintain a US residence and if you carefully avoid qualifying for tax domicile in the state according to the state's particular rules, then you will never have to pay state income tax again.

My earlier point on medical costs in Thailand is not that they are cheaper than in the US, which is certainly true, but that the same treatment in a Thai govt hospital will be much cheaper than in a Thai private hospital.

[Suradit69]

What I have learned after contacting several insurance companies here is the following-

Policies for full protection here start out at about B115,000 a year and then go up from there.

I'm surprised that any insurance company here would be even willing to initiate coverage for someone at 67 or to quote some upper limit to what the premium would be in future. I imagine if you were accepted, a whole lot of issues would be deemed pre-existing conditions and not insurable, at least not in the short term.

[JESSVANPELT]

Go to the BUPA website it will tell you all you need. I'am 62 and my policy costs 40,000 baht and will cover a bypass.

Good luck

[DogNo1]

You don't need to be a US resident to enroll in Medicare, just a Social Security recipient. I enrolled through the US Embassy in Japan where I am a permanent resident. I had to sign a document acknowledging that I would need to return to the USA to be treated. Residence is a non-issue. Once you return to the US, you will obviously be residing in the US.

I don't understand why Medicare Parts A & B would not cover major surgery costs. A Medicare Advantage program would cover more costs but would not be cost effective and besides, I don't think that you can enroll in an Advantage program if you live outside of the USA because the cost of the programs is based on Zip Codes. Check online.

How older people (65+) can cover their medical costs in Thailand has been discussed exhaustively and the answer is always to self-insure. Catastrophic illness must be paid for out-of-pocket here but in cases where you are well enough to travel on commercial air, it might be feasible to return to the US for treatment if you have Medicare Parts A & B. A will cover hospitalization and B will cover outpatient costs. Maybe not all but a major portion.

[TallGuyJohninBKK]

You may be able to maintain a US address that establishes residency, but if it is in a state that has an income tax you are likely to be establishing tax domicile in that state ipso facto, which would make you liable for state income taxes forever.

Of course, it's also perfectly possible to establish and maintain a U.S. mailing address in a non-income tax state such as Florida or Texas, among others. (Though I'm not sure doing that alone establishes legal "residency" in that state.

But the question is, does maintaining that kind of "residence" satisfy whatever requirements Medicare may have, either for the Part A & B coverage, or for the self-purchased MediGap coverage that's based on zip code.

The latter are questions I don't know the answer to.

However, I did inquire recently about the similar issue of state residency as relates to making last wills, which are governed by individual state law. And the answer I got back was that maintaining a mailing address in a particular state probably is not sufficient to establish legal residency for purposes of executing a last will based on that state's laws. And I was advised instead that my last physical residence in the U.S. -- even if I hadn't lived there for years -- would be the state whose laws my U.S. will should comply with.

[DogNo1]

US residency is not required for enrolling in Medicare parts A & B. Neither is it for creating a will. I am a resident of Japan and had my will written by the Yokota Air Base legal office. My executor lives in Washington State so it would be executed according to the laws of Washington. Residency is required for enrolling in a Medigap program. You will have some costs for having medical care under Medicare in the US without a Medigap program. I am not sure what posters are looking for. If you're looking for totally free medical care - good luck.

[gk10002000]

Isn't there a steep penalty or higher price if one did not sign up for medicare or buy one of the "optional" coverages, Plan B or something like that when first eligible? I am not there yet but I am 58 and look into the future now and than and something like that is sticking in my mind

[CaptHaddock]

Isn't there a steep penalty or higher price if one did not sign up for medicare or buy one of the "optional" coverages, Plan B or something like that when first eligible? I am not there yet but I am 58 and look into the future now and than and something like that is sticking in my mind

Only Part B penalizes you if you sign up later than age 65. If you return to the US after having residence abroad you then have a two-month window during which you are eligible to sign up for any of the other Medicare plans (Medigap, Medicare Advantage, Part D, etc.) without exclusion of pre-existing conditions.

[Srikcir]

Medicare is also available in US Territories: Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. The island of Guam is located approximately 3,300 miles West of Hawaii, so much closer to Asia. Guam Regional Medical City offers many hospital services found in the US states.

[CaptHaddock]

You don't need to be a US resident to enroll in Medicare, just a Social Security recipient. I enrolled through the US Embassy in Japan where I am a permanent resident. I had to sign a document acknowledging that I would need to return to the USA to be treated. Residence is a non-issue. Once you return to the US, you will obviously be residing in the US.

I don't understand why Medicare Parts A & B would not cover major surgery costs. A Medicare Advantage program would cover more costs but would not be cost effective and besides, I don't think that you can enroll in an Advantage program if you live outside of the USA because the cost of the programs is based on Zip Codes. Check online.

How older people (65+) can cover their medical costs in Thailand has been discussed exhaustively and the answer is always to self-insure. Catastrophic illness must be paid for out-of-pocket here but in cases where you are well enough to travel on commercial air, it might be feasible to return to the US for treatment if you have Medicare Parts A & B. A will cover hospitalization and B will cover outpatient costs. Maybe not all but a major portion.

It is not necessary to be a SS recipient to sign up for Medicare. I am not receiving SS benefits currently, but have enrolled in Parts A & B both of which are available to expats.

What parts or plans did you sign up for at the US Embassy in Japan? Are you military or US govt employee? The rules may be different for them. Do you maintain a US residence?

Part A covers hospital service including nurses, but not doctors. Part B is outpatient care. So, for a major surgery, for example, those two parts alone would not cover the cost of the surgeon or anesthetist or the costs or drugs, which are covered in Part D.

Residence is definitely an issue. Here are the requirements per medicareadvantage.com to sign up for Medicare Advantage (Part C):

Medicare Advantage Eligibility Requirements

There are 3 general eligibility requirements to qualify for a Medicare Advantage plan

(Medicare Part C):

1. You must be enrolled in Original Medicare (Medicare Parts A & .
2. You must live in the service area of a Medicare Advantage insurance provider that is accepting new users during your application period.
3. You do not have End Stage Renal Disease (ESRD).

https://www.medicareadvantage.com/part-c/eligibility

[Langsuan Man]

Isn't there a steep penalty or higher price if one did not sign up for medicare or buy one of the "optional" coverages, Plan B or something like that when first eligible? I am not there yet but I am 58 and look into the future now and than and something like that is sticking in my mind

Only Part B penalizes you if you sign up later than age 65. If you return to the US after having residence abroad you then have a two-month window during which you are eligible to sign up for any of the other Medicare plans (Medigap, Medicare Advantage, Part D, etc.) without exclusion of pre-existing conditions.

Don't forget the 10% per year premium penalty for not signing before your 66th birthday

In other words you have a year to sign up and since you pay part B monthly (deducted from your social security check) you can save yourself 11 months of payments by signing up right before your year is up and not incur the 10% penalty. Bottom line if you put it off till you really need it, it can end up costing a lot more than the current $104.90 minimum

[taxout]

1. Are you now paying Medicare B premiums, or are you covered only by Medicare A? Theoretically, Medicare A covers hospital bills and B covers doctors fees and lab work, but looking at the fine print it seems that a lot of hospital stuff now falls into Medicare B. In short, Medicare A alone doesn't cover as much as you thought.

2. Yes, there are co-pays and such with Medicare A and B, but they still offer very heavy coverage. If you don't want to risk the co-pays and such, there are private Medicare Gap policies you can buy which will pay them, but you have to have U.S. residence to buy these policies, and if you don't buy one soon after you take Medicare B you usually don't have a guaranteed right to buy one. Some Medigap policies covered limited care outside the U.S., but only if your stay outside the U.S. has been less than two months.

3. If you've got a Medicare card, you're covered for treatment in the U.S. regardless where your residence is.

4. There are penalties if you sign up for Medicare B late, and you can only sign-up a during a limited time window each year. There are special exceptions to this rule, but they do NOT apply just because you've been living overseas; they usually apply when you've been covered by some other insurance policy, as at work, which you're relinquishing because of retirement.

All of which is to say that Medicare rules are about as complex as tax rules, and deserve the same sort of close inspection, for it's the details that often count. (The post above about having 11 months to sign up for Part B to avoid the penalty is a good example of this. You have three months after your 65th birthday to sign up for Part B, and after that you can only sign up during a special window (unless you qualify for an exception). But if you sign up during the special window, coverage won't start till July.)

Edited November 26, 2015 by taxout

[CaptHaddock]

Isn't there a steep penalty or higher price if one did not sign up for medicare or buy one of the "optional" coverages, Plan B or something like that when first eligible? I am not there yet but I am 58 and look into the future now and than and something like that is sticking in my mind

Only Part B penalizes you if you sign up later than age 65. If you return to the US after having residence abroad you then have a two-month window during which you are eligible to sign up for any of the other Medicare plans (Medigap, Medicare Advantage, Part D, etc.) without exclusion of pre-existing conditions.

Don't forget the 10% per year premium penalty for not signing before your 66th birthday

In other words you have a year to sign up and since you pay part B monthly (deducted from your social security check) you can save yourself 11 months of payments by signing up right before your year is up and not incur the 10% penalty. Bottom line if you put it off till you really need it, it can end up costing a lot more than the current $104.90 minimum

For returning expats, that 10% penalty per year for not signing up at age 65 only applies to Part B. For Medicare Advantage, Medigap, Part D, and the rest, an expat returning to establish residence in the US does not have to pay a penalty and his or her pre-existing conditions will not be excluded. The returning expat has a 2 month window of eligibility after returning to avoid penalties and exclusions.

[taxout]

No, just being a returning expat alone will not qualify you for guaranteed late enrollment in a Medigap policy. You need to qualify under another exception, which usually requires you to show you were covered by other health insurance after age 65. Alternatively, you can postpone enrollment in Part B until you return to the U.S., since you have a guaranteed right to enroll in a Medigap policy within six months after you first enroll in Part B. But then you may have to pay increased Part B premiums as a late enrollment penalty.

To repeat, the details count, and overlooking them can be expensive.

[CaptHaddock]

No, just being a returning expat alone will not qualify you for guaranteed late enrollment in a Medigap policy. You need to qualify under another exception, which usually requires you to show you were covered by other health insurance after age 65. Alternatively, you can postpone enrollment in Part B until you return to the U.S., since you have a guaranteed right to enroll in a Medigap policy within six months after you first enroll in Part B. But then you may have to pay increased Part B premiums as a late enrollment penalty.

To repeat, the details count, and overlooking them can be expensive.

Do you have a reference for that?

My understanding is that since Medigap is an insurance company product, each carrier would only cover you if you live in their service area so expats are not eligible to buy it, just like Medicare Advantage. Therefore, since we cannot buy it, we are not penalized when we do buy after returning to the US.

In order to avoid the late enrollment for Medigap until the conditions above, we would have to expose ourselves to late enrollment penalties for Part B, unless we were excluded from such penalties by virtue of participation in a qualifying alternative insurance plan. Doesn't seem consistent, but not impossible.

For example here is an excerpt from Aetna's page on its Medicare Supplement product:

You can apply for an Aetna Medicare Supplement Plan^SM insurance policy, underwritten by Aetna Life Insurance Company (Aetna), if you are:

1. A resident of a state where the policy is offered; and

https://www.aetnamedicare.com/plan_choices/supplement_eligibility.jsp

Edited November 26, 2015 by CaptHaddock

[TallGuyJohninBKK]

But it still comes down to, for purposes of this subject ALONE, what does it mean to be a resident of a particular state? And the issue/answer isn't necessarily going to be the same as requirements for voting or DLs or other governmental things.

--What if you have a U.S. mailing address only?

--What if you live in the U.S. 3 months and Thailand 9 months?

--What if you divide your time 6 months in the U.S. and 6 months in Thailand?

And how's the insurance company going to know, one way or another, anyway, as long as you pay your premiums, respond to their requirements and mailings, and seek medical treatment when needed in the U.S.?

Just asking...

For example, when I signed up for private life insurance before I moved here, the insurer sent a nurse to my home for a routine physical check, and that included verifying my address and wanting to see a copy of my driver's license confirming my address.

I suspect (but don't know) that none of that kind of thing occurs with the private Medicare insurance add-ons.

Edited November 26, 2015 by TallGuyJohninBKK

[CaptHaddock]

But it still comes down to, for purposes of this subject ALONE, what does it mean to be a resident of a particular state? And the issue/answer isn't necessarily going to be the same as requirements for voting or DLs or other governmental things.

--What if you have a U.S. mailing address only?

--What if you live in the U.S. 3 months and Thailand 9 months?

--What if you divide your time 6 months in the U.S. and 6 months in Thailand?

And how's the insurance company going to know, one way or another, anyway, as long as you pay your premiums, respond to their requirements and mailings, and seek medical treatment when needed in the U.S.?

Just asking...

For example, when I signed up for private life insurance before I moved here, the insurer sent a nurse to my home for a routine physical check, and that included verifying my address and wanting to see a copy of my driver's license confirming my address.

I suspect, none of that kind of thing occurs with the private Medicare insurance add-ons.

Well yes, but it is apparently the insurance company that sets the standard for what constitutes residency, not the IRS or the ACA, for instance. Standards may be inconsistent and vary over time without notice, for example.

If you were to attempt to defraud the insurance company they could be in a position to rescind your policy when you make a claim. Although a lot of their opportunities for rescission, of which they were very fond, were eliminated by the ACA, a fraudulent claim of residency might still enable them to cut you off at the knees. The very possibility of losing your insurance just when you need it, effectively defeats the whole peace-of-mind purpose for buying insurance in the first place.

As to the likelihood of being found out and penalized, I have no idea, but the possibility alone would be enough to dissuade me. YMMV.

[TallGuyJohninBKK]

I agree, but my point was to raise the issue that it seems we're not very clear on how the various private insurers actually define in their Medicare policies what they consider to be "residency." I suspect the actual policies have some language about that -- I just don't know what it is. But I'd like to know...

If you know their precise definition, it might be possible for someone to conform their circumstances to fit/meet that specific definition.

[CaptHaddock]

I agree, but my point was to raise the issue that it seems we're not very clear on how the various private insurers actually define in their Medicare policies what they consider to be "residency." I suspect the actual policies have some language about that -- I just don't know what it is. But I'd like to know...

If you know their precise definition, it might be possible for someone to conform their circumstances to fit/meet that specific definition.

I doubt very much if their policies spell out precisely what constitutes residency. The number of non-residents who would like to buy their policies must be vanishingly small.

[JLCrab]

Deficit Reduction Act of 2005 Section 5115 As of February 28, 2006:

Waiver of part B late enrollment penalty for certain international volunteers.

Provides for the waiver of the Part B late enrollment penalty and establishment of a special enrollment period for beneficiaries who are volunteering outside of the U.S. through a 12 month or longer program sponsored by a tax-exempt organization defined under section 501c(3) of the Internal Revenue Code and who have other health insurance coverage.

I am Director US based 501c3 non-profit/NGO in Thailand and 10+ years BUPA Platinum subscriber. When sent to me the Part B application form -- as I am already automatically enrolled in Medicare A -- I told them I will decline for the above reason.

Edited November 26, 2015 by JLCrab

[taxout]

Yes, that's a special exception from the Part B late enrollment penalty for a particular type of expat, but there's no exception for expats generally.

As to Medigap,

"The best time to buy a Medigap policy is during your 6-month Medigap open enrollment period, because you can buy any Medigap policy sold in your state, even if you have health problems. This period automatically starts the month you're 65 and enrolled in Medicare Part B (Medical Insurance). After this enrollment period, you may not be able to buy a Medigap policy. If you're able to buy one, it may cost more. During open enrollment. Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy. However, if you apply during your Medigap open enrollment period, you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health."

https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/when-can-i-buy-medigap.html#collapse-2283

Nonetheless, you might still have a guaranteed right to buy a Medigap policy after that period if you fall into one of these exceptions, or if you live in a state with more liberal rules on guaranteed acceptance:

https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights-scenarios.html

Further, if you're applying late and don't have a guaranteed right to buy a Medigap policy, an insuror can still agree to sell you a Medigap policy, though perhaps at a higher rate.

[CaptHaddock]

Yes, that's a special exception from the Part B late enrollment penalty for a particular type of expat, but there's no exception for expats generally.

As to Medigap,

"The best time to buy a Medigap policy is during your 6-month Medigap open enrollment period, because you can buy any Medigap policy sold in your state, even if you have health problems. This period automatically starts the month you're 65 and enrolled in Medicare Part B (Medical Insurance). After this enrollment period, you may not be able to buy a Medigap policy. If you're able to buy one, it may cost more. During open enrollment. Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy. However, if you apply during your Medigap open enrollment period, you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health."

https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/when-can-i-buy-medigap.html#collapse-2283

Nonetheless, you might still have a guaranteed right to buy a Medigap policy after that period if you fall into one of these exceptions, or if you live in a state with more liberal rules on guaranteed acceptance:

https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights-scenarios.html

Further, if you're applying late and don't have a guaranteed right to buy a Medigap policy, an insuror can still agree to sell you a Medigap policy, though perhaps at a higher rate.

Hmmm. That's looks less than definitive for the case of expats since the carriers exclude us from buying Medigap policies because of lack of residency. For other policies such as Part D and Medicare Advantage we have an eligible period after returning than US residents do not have.

Generally, the govt is not going to penalize us for not buying something that we are not allowed to buy. It could be hard cheese for us that we fall between the cracks of the govt and the insurance carriers, but I would need to see that case addressed directly before I could be convinced.

[bluebluewater]

I can't imagine why anyone would still just be using the Medicare Part A & B when Medicare Advantage plans are far better. One still needs to pay the Part B premium but the benefits are better, drug coverage is better, and there is a maximum annual out-of-pocket cost.

Coverage for medical care here in Thailand is VERY dependent on pre existing conditions (primarily with high blood pressure and/or cholesterol being the two biggies) and, even though it might be well controlled by taking those medications, virtually any medical problem that you will have will be deemed to been caused by those pre existing and there will be no coverage. Have a stroke, heart attack, or aneurysm (those things that older men are most likely to have jump up and bite them in the arse) and your claim is going into the bin.

It's all well outlined in the policy conditions and exclusions but somehow many do not either read it or understand what they are reading so good chance they will find this out well after the fact as well!

Good advice for many is to have very excellent cover for the motorbike and auto (where the biggest risk to health here in Thailand comes from) and be prepared to self insure the rest.

Of course if there is no pre existing and no medications then fill your boots!

Edited November 26, 2015 by bluebluewater

[JLCrab]

Yes, that's a special exception from the Part B late enrollment penalty for a particular type of expat, but there's no exception for expats generally.

<snip>

You're absolutely right and I had no idea such a waiver would be available years later when I first got into the NGO racket. Sometimes one just lucks out in this life.

[taxout]

As I recall there is a general exception for expats from the late enrollment penalty for Part D, but I haven't looked up the details. (That's why I didn't mention it above.)

But there's no general exception for Part B, and the guaranteed right to take a Medigap policy is tied into Part B enrollment.

Nonetheless, make your own plans on the basis of whatever you think the rules ought to be.

As to Medicare Advantage vs. traditional A & B coverage:

Yes, coverage is often broader under Medicare Advantage and, in a sense, a better deal. But Medicare Advantage is managed care that ties you to a network in your own area. It works for some, but traditional Medicare gives you far more flexibility to select the care and doctor you want, though perhaps at higher out-of-pocket cost. Myself, I would want more control over my care than managed care offers.

(Indeed, it's a separate point, but I think those used to getting care in the Thai private hospital system might find it difficult to adjust to U.S.-style managed care.)

Edited November 26, 2015 by taxout

[JLCrab]

<sip >

Coverage for medical care here in Thailand is VERY dependent on pre existing conditions (primarily with high blood pressure and/or cholesterol being the two biggies) and, even though it might be well controlled by taking those medications, virtually any medical problem that you will have will be deemed to been caused by those pre existing and there will be no coverage. Have a stroke, heart attack, or aneurysm (those things that older men are most likely to have jump up and bite them in the arse) and your claim is going into the bin.

It's all well outlined in the policy conditions and exclusions but somehow many do not either read it or understand what they are reading so good chance they will find this out well after the fact as well!

< snip >

So that's why it is good to take out health insurance before you have any of the above conditions and regularly visit one your insurer's network hospitals to establish a medical record that shows that, years earlier to any onset of the above conditions, those conditions did not exist.