USA topic -- Expat specific issues regarding repeal and replace of Obamacare

[Jingthing]

7 minutes ago, tomwct said:

As an American Expat, I would just let Obama Care die and offer a second market based alternative to the folks managed by

the states. Obama spent billions advertising ObamaCare because it was a terrible product. 50% of folks who signed up for

ObamaCare pay Zero $0 and many of these folks can work, but don't! So, no more advertising, no more mandates, no more taxes

and ObamaCare will die on it's own.

You're missing the point of this thread.

It is not a political debate thread and cannot be one on this subforum.

It's about PRACTICAL information. That is all. 
If you can't respect that, all you're doing is destructively trying to close this topic that may prove useful to some people as this situation develops.

If you want to debate U.S. health care issues, you can search the forum under WORLD NEWS and find an ACA and/or trumpcare related topic and then post your opinions there. That is the only place such debate is allowed here. 

 

Edited June 6, 2017 by Jingthing

[beachproperty]

"practical information" about WHAT? nothing has passed yet and you, yourself has said that the senate probably is changing what was passed in the house.

 

Better to get a life than have one that relies on ACA

[Jingthing]

Well. We're going to need to wait for an unknown amount of time to see whether a repeal and replace bill is ever passed and if so what's in it. But even during this period there are things happening. For example the Nevada proposal may never happen but if it does it will be a big deal. Some people from other states and some returning expats would move there for the chance to buy into Medicaid if the premium structure is considerably cheaper than other alternatives in other states. Keep in mind under current trumpcare proposed structure premiums for people aged 60 to 64 can be 5 times more than younger people with subsidies based on income gone replaced by very small subsidies based on age. In other words completely unaffordable for the non wealthy.

But you're right that for right now nothing definite.

Here is a place to keep a watch until things become more definite.

 

 

 

[Jingthing]

Time to add a definitely expat specific concern about the news on health care.

The SENATE is currently working on their version of the bill.

If they manage to pass it then they join a negotiation process with the house to develop a more final bill, which would inevitably be signed by the president.

 

The DETAIL about this which I think is important is that there is a new item in the senate bill process that might survive all this. It is called AUTOMATIC ENROLLMENT of everyone, currently they are talking about some kind of bare bones catastrophic type of coverage. Then all Americans would need to ACTIVELY opt out of the automatic enrollment.

 

The reason for automatic enrollment is to create a big a POOL as possible, with lots of younger and healthier people. The theory is that if people are automatically enrolled, that pool would be bigger than if it was optional. 

 

I think expats can see the issue with that, if it comes to pass.

 

Of course ACA has mandates and penalties (with exceptions based on low income, being an expat, etc.). But the person has to take action to sign up.

 

This would be different in that it would be AUTOMATIC sign up.

 

Of course, big caveat, it may never pass, but it's something to keep an eye on. 

Edited June 7, 2017 by Jingthing

[Pib]

Don't worry....Donald is working this hard between his golfing, calls to Vladimir, and tweeting.

[Jingthing]

3 minutes ago, Pib said:

Don't worry....Donald is working this hard between his golfing, calls to Vladimir, and tweeting.

This is a matter of house and senate working on this. If they manage to send any bill branded as "repeal and replace" to the executive branch (obviously still uncertain) the current office holder would sign it. 

[Pib]

1 hour ago, Jingthing said:

This is a matter of house and senate working on this. If they manage to send any bill branded as "repeal and replace" to the executive branch (obviously still uncertain) the current office holder would sign it. 

The House bill sent to the Senate was dead on arrival at the Senate.  The Senate has no bill of its own...just in the initial stages of developing one.  Donald providing zero leadership because he's clueless.  The 2018 elections have all of our elected representatives running scared with the Republican running in circles the fastest.   Don't hold your breath for any repeal and replace law anytime soon.

[Jingthing]

51 minutes ago, Pib said:

The House bill sent to the Senate was dead on arrival at the Senate.  The Senate has no bill of its own...just in the initial stages of developing one.  Donald providing zero leadership because he's clueless.  The 2018 elections have all of our elected representatives running scared with the Republican running in circles the fastest.   Don't hold your breath for any repeal and replace law anytime soon.

Your tone is too political opinion for the purposes of this thread. 

But to extract the information part of it that can be stated more neutrally --

 

-- Yes, there is consensus the full house bill as passed will never become law.
-- Yes, the senate is working on their version of a bill and nobody knows whether they'll even get to the point of being able to pass it. If they do, then the next steps are conferencing between the house and senate, and if they can both agree on the result, it goes to the president.

 

So, as stated numerous times before, it is premature to presume any final details. This is a WATCH situation at this point.

 

HOWEVER, it is an objective fact that when you're talking about health insurance coverage a very wide pool of different ages and health states is much better than a smaller pool with lots of health problems. So the FACT that the senate is seriously considering something new, an AUTOMATIC ENROLLMENT of the entire population, is worth taking note of. 

Edited June 7, 2017 by Jingthing

[Pib]

Seriously considering?   It's just one idea they have thrown on the table and has been around for almost a decade.   Plus the current idea would most likely include an opt out option...kinda like how some people are automatically signed up for Medicare Part B but can then opt out.

 

https://www.vox.com/policy-and-politics/2017/5/22/15655782/automatic-enrollment-health-insurance-gop

Quote

Republicans last explored the idea of automatic health insurance enrollment in 2009, when House Speaker Paul Ryan (R-WI) and Sen. Tom Coburn (R-OK) introduced a plan that would let states set up such programs.

 

[Jingthing]

I already said there would be an opt out option.

If mandates are nixed and they presumably would be in any trumpcare bill an automatic enrollment scheme might be a logical replacement.

 

Again. Something to watch. There is no bill yet.

 

But that doesn't mean there isn't news.

 

Such as the very creative Nevada idea.

 

 

 

 

[Jingthing]

Posting this link even though it contains a fair amount of political opinion, because it supplies credible information on how a repeal and replace bill may actually pass. 

Some people are saying it will definitely never happen.

Others (not as many) are saying it definitely will happen.

This article provides a strong case that it indeed MAY happen.

 

Quote

Make no mistake. Republicans can still succeed in destroying Obamacare.
...
“The virtue of getting everyone into the same room is to get them out of the public eye, where they can come to a final agreement that then would be put to an up or down vote in both chambers,” Binder tells me, adding that at that point, the situation would be, “this is it: Are you for or against getting rid of Obamacare? This would increase the pressure on individual Republicans who are skittish.” To be sure, it’s possible that Republicans could still fail. But “success” is also a very real possibility.

 

https://www.washingtonpost.com/blogs/plum-line/wp/2017/06/07/make-no-mistake-republicans-can-still-succeed-in-destroying-obamacare/

 

The expat tie-in is that potential repatriating expats that may need either ACA, expanded Medicaid, etc. and feel sure those things will still be available options, probably shouldn't be so sure.

 

Back to the theme here -- UNCERTAINTY.

Edited June 7, 2017 by Jingthing

[Jingthing]

Well, we're back.

The trumpcare thing is now in the senate and generally given a 50 - 50 chance of passing.

If it doesn't pass soon, they could address it later as happened in the house.

If/when the senate passes something then it goes into conference with the house.

Anyway, the EXPAT SPECIFIC issue that's come up again is that the initial senate bill had killed the mandate (as the house passed version did) but didn't replace it with anything. The house passed bill had replaced it with a continuous coverage thing where you could still buy in but with a penalty surcharge for a set number of months.

Well, now the senate is considering their version of that kind of thing. A LOCK OUT if you've fallen out of continuous coverage for six months with no option to get insured even with a penalty surcharge.

I think you can see the expat implications. How would repatriating expats be treated if that passed? Would they need to wait six months after repatriation to buy insurance? 

[Jingthing]

To add, an aspect of this that I know very little about.

Medicaid and nursing home care.

Apparently over half of the funding of nursing home care comes from Medicaid.

I guess that's about long term care, but not sure.

As many know, both the house and senate versions of trumpcare involve involve deep cuts to traditional Medicaid spending. 

Something to consider for the longer term.

Are you better off in Thailand and the options you might have here for long term nursing care if/when needed or back there.

Edited June 26, 2017 by Jingthing

[Ruffian Dick]

I don't know of any insurance plan that would qualify under any version of the ADA that would also cover hospital bills and care incurred while in Thailand. If there is something, I'd like to hear about it.

 

 

[Jingthing]

As I said before I don't know very much on how the proposed Medicaid cuts would impact on Americans already old enough for Medicare.

Medicaid as in help for nursing home bills and long term care bills.

Well, I think this article explains it pretty well.

As far as expat impact, plans or not, many older expats do eventually repatriate so they might be hit by this situation.

 

 

Quote

 

 

This is the same Medicaid that our representatives in Washington are aiming to cut right now. While there is no telling how the debate over health care legislation will end, it ought to matter plenty to everyone who hopes to grow old and is not certain that their savings could last for decades. While many people don’t realize it until well into old age, it is Medicaid, not Medicare, that pays for most nursing home and community or home-based care for older adults who run out of money.

 

 

 

https://www.nytimes.com/2017/07/07/your-money/one-womans-slide-from-the-upper-middle-class-to-medicaid.html

Edited July 9, 2017 by Jingthing

[jmd8800]

On 6/26/2017 at 3:22 PM, Ruffian Dick said:

I don't know of any insurance plan that would qualify under any version of the ADA that would also cover hospital bills and care incurred while in Thailand. If there is something, I'd like to hear about it.

 

 

@Ruffian Dick It is so hard to find good info. This post might help you some depending on what you seek

 

When I was shopping around for insurance after I retired (I was unable to purchase the employment based insurance from my work) I found it very hard to obtain any reliable info about what was covered and where under the ACA and in my case since I'm a resident of California the system is CoveredCA. I chose not to purchase any coverage on the ACA as everyone I spoke with (help specialists of CoveredCA, insurance agents, online forums etc) said there would be no coverage outside of the USA.

 

I had chest pains last fall and went to the hospital here and ended up having angioplasty surgery. I paid for this out of my pocket. The doc advised me to return to the USA as I had other problems to address. I didn't have enough money on hand to do all that he wanted to do.  I did return to US and I purchased a blue shield plan in CA to get the rest of my plumbing fixed. In digging through the paper work sent to me about my policy and I find that emergency situations are indeed covered outside of the USA. There is a network of international hospitals / care providers that this insurance company has agreements with. Had I have known this I probably would have maintained coverage even while living in Thailand. And I would guess this event would have been covered.

 

I questioned the coverage further and asked, for example, if I were experiencing a heart attack would the emergency room AND subsequent angioplasty be covered.  Here is the response:

 

"Urgent and emergency care is covered by Blue Shield, regardless of whether you use one of BlueCard Worldwide providers or not.However, medical necessity will be determined when we review your claim."

 

While it's not overly clear about the angioplasty I'm sure a doctor could write it in such a way to convince the insurance company that he was saving your life. Those things are over my head. But say you got hit by a car and you were dying..... I'd say Blue Shield would pay.

 

One doesn't get any paper work to dig into until they purchase a policy. Unfortunately, people have unanswered questions unless someone in the know can advise them which is hard to find. How would I have known? And that brings me around to 2 points. 1) All of the hatred surrounding the ACA clearly lead to chaos and confusion. This probably was by design by those who oppose it. Secondly, many of the pieces of info I read were on forums and websites where people were spouting off stuff they really had no clue about. Remember the old saying: “A lie can travel half way around the world while the truth is putting on its shoes.” -- Mark Twain

 

[Pib]

4 hours ago, jmd8800 said:

 

I questioned the coverage further and asked, for example, if I were experiencing a heart attack would the emergency room AND subsequent angioplasty be covered.  Here is the response:

 

"Urgent and emergency care is covered by Blue Shield, regardless of whether you use one of BlueCard Worldwide providers or not.However, medical necessity will be determined when we review your claim."

 

While it's not overly clear about the angioplasty I'm sure a doctor could write it in such a way to convince the insurance company that he was saving your life. Those things are over my head. But say you got hit by a car and you were dying..... I'd say Blue Shield would pay.

 

 

Well, every medical insurance policy will be different but most U.S. policies do not provide any coverage outside the U.S. unless it's an emergency and you were just vacationing to/travelling through a foreign country when the emergency occurred.  That is, need  unexpected medical service "now" that simply could not wait even a few days to get back to the U.S. for medical care.   

 

While medical insurance companies always look at medical necessity (even with the care is provided in the U.S.) they also evaluate were you were really just on a short vacation/briefly traveling through a foreign country....and you might have to provide proof you are really not living for an extended time or like snow-birding in another country (i.e., a few months in the U.S., then a few months in another country, etc).   If they found out you were staying for an extended time/snow-birding they would probably disallow you claim and say you needed travel insurance instead.  Preaching to the choir that a lot of U.S. medical insurance polices have a lot of fine print and care outside the U.S. is typically of emergency nature only.

[Jingthing]

Yes, my understanding is that any general U.S. health insurance policy (ACA or not) that may provide care abroad does so with the stipulation that the residence is the U.S. and the travel abroad is temporary. So it's not really a "real expat" issue. 

For tourists, there are travel insurance offerings if your general insurance doesn't cover you while abroad as a tourist (which I wouldn't assume that it does). 

[jmd8800]

13 hours ago, Pib said:

 

While medical insurance companies always look at medical necessity (even with the care is provided in the U.S.) they also evaluate were you were really just on a short vacation/briefly traveling through a foreign country....and you might have to provide proof you are really not living for an extended time or like snow-birding in another country (i.e., a few months in the U.S., then a few months in another country, etc).   If they found out you were staying for an extended time/snow-birding they would probably disallow you claim and say you needed travel insurance instead.  Preaching to the choir that a lot of U.S. medical insurance polices have a lot of fine print and care outside the U.S. is typically of emergency nature only.

Can you show some proof of this? I will ask my insurance company what their policy is concerning how many days one can be out of the country and not lose coverage. This may vary from policy to policy and from state to state. 

 

I'm guessing here but I think this actually hinges on legality of someone's residence. I'm sure some expats have severed ties with their home country completely but I have not. I am required to keep an address in the US to have a US bank account. My pension funds will not direct deposit into a foreign bank account. (Bangkok Bank setup exempted here). So I do keep address, registered to vote and a lot of other things that make me a 'resident' of California. I had to be a resident of California in order to buy the health plan through the CoveredCA marketplace. But does this constitute residency if I am out of the country for say 2 years? That I don't know. Maybe on would have to make yearly trips home??

 

 

 

 

[jmd8800]

8 hours ago, Jingthing said:

Yes, my understanding is that any general U.S. health insurance policy (ACA or not) that may provide care abroad does so with the stipulation that the residence is the U.S. and the travel abroad is temporary. So it's not really a "real expat" issue. 

For tourists, there are travel insurance offerings if your general insurance doesn't cover you while abroad as a tourist (which I wouldn't assume that it does). 

Can you cite this 'travel abroad is temporary'?

 

If the insurance company puts restrictions on travel then I think the 'real expat' is the issue. At what point does one cease being a resident of USA and become a resident of another county for insurance purposes. I have address, bank accounts, drivers license, registered to vote,  and pay taxes to both federal and state governments. 

 

I have not found travel insurance that covers pre-existing conditions so for me that is out of the question. I may as well buy Thai insurance and accept the lack of preexisting exclusions.

[Jingthing]

That's a more general grey area. Expats that are acting like they aren't expats for practical purposes. 

Seems beyond the scope of this thread. 

This thread is focused on potential changes to the current situation for expats and people repatriating in case ACA is repealed and replaced. 

[jmd8800]

1 minute ago, Jingthing said:

That's a more general grey area. Expats that are acting like they aren't expats for practical purposes. 

Seems beyond the scope of this thread. 

This thread is focused on potential changes to the current situation for expats and people repatriating in case ACA is repealed and replaced. 

Noted. Sorry to veer off course....

 

Last comment from me. I called my insurance company and there is no restrictions on length of time I can be out of the country. Also, they are sending me information to make my regular coverage 'portable' internationally.

[ubonjoe]

Several baiting and bickering posts have been removed. Time to end it or formal warnings will be given.

 

Edit: And now 3 more.

Edited July 12, 2017 by ubonjoe

[Pib]

11 hours ago, jmd8800 said:

Can you show some proof of this? I will ask my insurance company what their policy is concerning how many days one can be out of the country and not lose coverage. This may vary from policy to policy and from state to state. 

 

I'm guessing here but I think this actually hinges on legality of someone's residence. I'm sure some expats have severed ties with their home country completely but I have not. I am required to keep an address in the US to have a US bank account. My pension funds will not direct deposit into a foreign bank account. (Bangkok Bank setup exempted here). So I do keep address, registered to vote and a lot of other things that make me a 'resident' of California. I had to be a resident of California in order to buy the health plan through the CoveredCA marketplace. But does this constitute residency if I am out of the country for say 2 years? That I don't know. Maybe on would have to make yearly trips home??

 

Yes, as I mentioned earlier every medical insurance policy will be different.  Like Blue Cross/Shield has 36 different business units within its corporate family...and dozens upon dozens of different policies/benefit plans to choice from, both employer-provided (current employees and retirees) and individual/family.   Like GeoBlue is the Blue Shield/Cross unit that focuses on worldwide medical coverage...not to imply your current Blue Cross/Shield policy does not provide X-amount of international coverage.

 

What residence someone has on file with an insurance company, bank, etc., is not the only thing an insurance/bank/etc., will look at to confirm if you "really live" there especially when it comes to paying out a significant amount of money.  

 

Easy enough for a medical insurance company to determine if you were merely on a short vacation by asking for a notarized copy of your passport to see when you entered  country in comparison to when the medical care was provided.  If you entered say on 1 Jan, submitted a claim for medical care provided from 1 to 5 May, but then didn't leave the country until say 1 Aug (or maybe you have not even left yet) would sure indicate you live/snow bird in that foreign country, but just never notified your insurance company, bank, whoever although you still have a residence also in the U.S. somewhere.   And there are no shortage of posts/news stories in ThaiVisa where an insurance company denied medical care for an accident/disease but the insurance company denies coverage saying the person needed travel insurance instead....the fine print.

 

Heck, I still have  U.S. Residence but I've lived in Thailand for almost the last decade..  And some of my U.S. bank accounts were opened "without" my U.S. residence within the 50 states but my overseas APO address....under the Patriot Act/Know Your Customer rules having a U.S. physical residence is not a hard core requirement to open a U.S. bank account...individual bank policies are used to meet Know Your Customer requirements especially since so many U.S. folks, civilians and military, live overseas.

 

I would recommend you closely review (read) your current policy versus totally relying on a call or email to a rep to confirm the rules, to include what would be considered emergency care (like a heart attack, stroke, etc.) to care that didn't have to be provided immediately and your insurance company wants the care provided by one of its network providers.

Edited July 12, 2017 by Pib

[Jingthing]

If an expensive claim comes in yes then insurance companies are more likely to challenge it any way they can.

[beachproperty]

2 hours ago, Pib said:

Yes, as I mentioned earlier every medical insurance policy will be different.  Like Blue Cross/Shield has 36 different business units within its corporate family...and dozens upon dozens of different policies/benefit plans to choice from, both employer-provided (current employees and retirees) and individual/family.   Like GeoBlue is the Blue Shield/Cross unit that focuses on worldwide medical coverage...not to imply your current Blue Cross/Shield policy does not provide X-amount of international coverage.

 

What residence someone has on file with an insurance company, bank, etc., is not the only thing an insurance/bank/etc., will look at to confirm if you "really live" there especially when it comes to paying out a significant amount of money.  

 

Easy enough for a medical insurance company to determine if you were merely on a short vacation by asking for a notarized copy of your passport to see when you entered  country in comparison to when the medical care was provided.  If you entered say on 1 Jan, submitted a claim for medical care provided from 1 to 5 May, but then didn't leave the country until say 1 Aug (or maybe you have not even left yet) would sure indicate you live/snow bird in that foreign country, but just never notified your insurance company, bank, whoever although you still have a residence also in the U.S. somewhere.   And there are no shortage of posts/news stories in ThaiVisa where an insurance company denied medical care for an accident/disease but the insurance company denies coverage saying the person needed travel insurance instead....the fine print.

 

Heck, I still have  U.S. Residence but I've lived in Thailand for almost the last decade..  And some of my U.S. bank accounts were opened "without" my U.S. residence within the 50 states but my overseas APO address....under the Patriot Act/Know Your Customer rules having a U.S. physical residence is not a hard core requirement to open a U.S. bank account...individual bank policies are used to meet Know Your Customer requirements especially since so many U.S. folks, civilians and military, live overseas.

 

I would recommend you closely review (read) your current policy versus totally relying on a call or email to a rep to confirm the rules, to include what would be considered emergency care (like a heart attack, stroke, etc.) to care that didn't have to be provided immediately and your insurance company wants the care provided by one of its network providers.

I personally had Kaiser for my medical insurance. I have lived in Thailand for close to 15 years. Aprox 10 years ago I had done in Bangkok Hospital an angiogram

which showed I had two blocked arteries. They told me I needed angioplasty (stents) for the two arteries which they wanted to do the next day. I was going back to the US for a visit so I told them to hold off until I got back.

 

When I got back to the US I went to my Kaiser doctor who said "What's the problem? you still have one good artery." I told him that Bangkok Hospital wanted to operate the next day. He said OK I refer you to a heart specialist ...unfortunately one was not available for an Appointment for 3 months.I told him that I live in Thailand and couldn't wait. He then said that although he could not make an appointment sooner I could go to the administrative office and maybe if there was a cancellation I could get in. Which I did explaining, that "I live in Thailand", and got a call 4 days later of a cancellation. I met with the Heart doctor whereupon

she said the same thing "I don't see a problem ...you still have one good artery". Well I said in Thailand they wanted to operate the next day to which she replied "well in that case do you want me to set up an appointment for the operation next week!" ...I replied '"sorry, I 'm going back to Thailand. Can I set it up in 3  months when I will return" , She said OK

 

Bottom line is that I got reimbursed for the angiogram when they knew full well that I lived in Thailand AND did the angioplasty ($70,000) for free.

[Jingthing]

I wonder how common it is for full time expats to maintain "faux" U.S. residences  and also maintain U.S. based health insurance coverage. 

Obviously, some people are doing that, but I do wonder how common. 

I reckon it's much more common for part time expats. Like people that spend six months in the U.S. and six months abroad.

 

ANYWAY, for the context of the topic of THIS thread, such cases are relevant if the U.S. based health insurance policies are under the ACA law. As the thread is about the potential repeal and/or changes to the ACA law.

 

Also, if any people are doing that with an ACA expanded Medicaid or traditional Medicaid coverage. 

 

So employer provided insurance not relevant here.

Medicare not relevant here. 

 

[Jingthing]

I can provide an update now on how the Senate bill is going.

There are lots of details of course, but in my view these are the most important points:

 

-- Medicaid funding cut long term. This will have a huge impact on nursing home care/home health care of interest even to the over 65 set.

-- ACA Medicaid expansion still planned to be phased out

-- Allow states to offer unregulated plans with much fewer benefits/higher deductibles to the young/healthy market as long as at least ONE ACA compliant plan is offered. BUT ... a very big BUT ... this would necessarily mean the ACA compliant plans would be much more expensive as they would be filled mostly with older people/people with preexisting conditions. 

 

Not sure about the current details on the SUBSIDIES. 

No doubt at all if passed the subsidies would still hit older/sicker people harder than under ACA though. 

 

It's still entirely possible the senate will pass something.

It's also possible they won't.

If they do, it would be surprising if a bill doesn't move forward past the house/senate reconciliation to the president's desk.

 

Obviously, the things on this list may impact repatriating Americans.

 

Edited July 12, 2017 by Jingthing

[Ruffian Dick]

Thanks, lots of good information here!

I'm still in CA until next year; for now I have Kaiser for an embarrassing low rate. Everything is up in the air for me, however: I'm going back to LOS next year; probably picking up a Thai-based program; I might want to register with the VA (if I qualify) just to cover my bases; soon I will qualify for Medicare; and who knows what kind of health insurance maybe available in the States by that time.

 

[Jingthing]

8 hours ago, Ruffian Dick said:

Thanks, lots of good information here!

I'm still in CA until next year; for now I have Kaiser for an embarrassing low rate. Everything is up in the air for me, however: I'm going back to LOS next year; probably picking up a Thai-based program; I might want to register with the VA (if I qualify) just to cover my bases; soon I will qualify for Medicare; and who knows what kind of health insurance maybe available in the States by that time.

 

Well, the current repeal and replace effort is not addressing changes to Medicare but of course Medicare isn't useful abroad.

However, as I mentioned, the proposed Medicaid cuts have an big impact on people over 65 as well because of funding for nursing home and long term home care.

I realize most people don't think about such depressing things until they or a relative needs them. But it's real. 

Edited July 13, 2017 by Jingthing