Medicare – 2 Pathways to Comprehensive Coverage
Medicare is a great benefit for retirees and can work wonderfully to provide urgent and emergent care coverage (Coverage) for people who spend much of their time outside the US (OUS) – particularly for folks spending most of their OUS time in Mexico and other near-US locations.
Medicare has continued to grow in 2022, now serving 62 million Americans with a total annual budget of $767 billion – and almost half of the total is now Medicare Advantage participants. Medicare is a benefit that Seniors have earned through a life of work and taxes and requires additional payment every year (at a minimum for Part B) to provide comprehensive coverage. We want to provide a highlight of how Coverage can best be utilized by folks enjoying much of their retirement outside of the US. Additionally, we would like to review trends we have seen in the market for the benefit of our readers.
There are two pathways to comprehensive coverage through Medicare – Original Medicare and Medicare Part C – also known as Medicare Advantage. Both can provide Coverage subject to different criteria summarized below.
These Pathways are obviously very different, and appeal to different types of retirees. Over the past year we have had the pleasure of working with hundreds of folks who spend a lot of time in Mexico and other places outside the US – and they fall into three broad categories: Gone Forever Expats, Snowbirds, and Short Timers. Medicare Coverage issues for each category include:
Summary of Best Fits
Everybody has a unique circumstance, but we can generalize that people who spend more than 2 months consecutively outside the US, are best served with an Advantage plan. The plans differ widely by zip code and county, so careful Plan review and selection in your local market is critically important. People who travel OUS less than 60 days at a time can be well served by either an Advantage plan or original Medicare with a Supplement and Part D plan.
If you do not meet the residence requirements for Advantage plans (too much time spent OUS), or do not have any acceptable plans in your local market in the US, we still encourage maintaining your Part B, and suggest that you tell Social Security that you are a permanent resident outside the US. If you live outside the US, you do not accrue any Part D penalties, and you can use your Medicare immediately upon return to the US, and have a special election period (SEP) to enroll in an Advantage Plan the month following your return.
If you are a Snowbird and maintain your Advantage plan while you are outside the US, your plan may offer worldwide coverage indemnity coverage for urgent and/or emergency care while you are abroad – subject to co-pays, co-insurance or caps depending on the plan. These benefits may track the same out-of-network emergency and urgent care protocols used in the US.
What’s New in the Mexican Market?
We have been barraged by questions from folks in Mexico wondering about Mexican hospitals, clinics and physicians that now “accept” Medicare. I have received photos from US retirees of signs in Mexico stating “Acceptamos Medicare”, and references to websites with long lists of accepted plans. What is most interesting is that these medical groups claiming to accept Medicare are clear in the fine print of their websites that they cannot accept Medicare for regular service, and that Medicare will only pay for emergency care inside the US.
What seems to be the point of confusion is what is meant by “accept”? In the US that means that the physician or facility will process the claim for you, and only bill you for the part not paid by the insurer.
Medicare beneficiaries need to understand that is not how either Advantage or Supplements work for emergency care coverage outside the US. The worldwide emergency care coverage means that you pay for the service, and then submit it for reimbursement. The Advantage plan has no relationship with the provider or facility in Mexico and has no obligation – and probably no legal ability – to pay any part of that claim directly. Most typically, the process starts with you putting a credit card up to cover expenses.
The language in many Advantage plans that pay for care OUS are very clear – if you need emergency treatment in Mexico or elsewhere outside the US, you need to call the Plan and make them part of the solution from the start. For many plans, these same (or similar) protocols apply for out-of-network emergency care apply in the US. They will speak with the doctors as appropriate and ensure that you get the care you need – they are typically responsible their contractual portion of costs until you are stabilized.
We recommend that you also speak with your credit card company to ensure that no charges related to your care are approved without your voice approval. Finally, we encourage you to call us when you think you may need emergency or urgent care and let us be involved from the start. We may be able to help – but only if you let us know what is happening.
Urgent + Emergency Care – a Growing Trend in Worldwide Coverage
We are seeing increasing numbers of Advantage Plans that provide worldwide cost coverage for both urgent and emergent care. This is a wonderful thing to see, as it should make coverage decisions easier and more in favor of beneficiaries. Urgent care is typically a lower standard of need, and therefore presents the potential for more comprehensive coverage. As an example, if you have severe abdominal pain and go to the hospital thinking you have appendicitis, receive a battery of tests, and only have a serious stomach bug. It is an emergency if it is appendicitis, but may only urgent care if it is a bacterial infection – but how were you to know until you went to the hospital? This is a big step in the direction of better care, and we applaud the change.
A Growing Trend to Nationwide Networks
We are seeing increasing numbers of Advantage Plans that include provision for “in-network” care defined as care within their US-wide network. This is a great benefit for Snowbirds both in and outside the US. Imagine that you spend the winter in Cabo San Lucas, and your home is in Michigan. If you have a medical emergency either in Cabo – or just need a regular medical visit – you can go to an in-network facility in San Diego and pay in-network rates. Importantly, your physicians can coordinate care to ensure that continuity of care is maintained. Great stuff.
Make Sure You Can Get to the Hospital, Then Get Home!
Remember – neither Supplements nor Advantage plans cover medical costs once you have been stabilized in the hospital in Mexico. And at that point you really need to get home!
Many Advantage plans now pay for local ambulance services to hospitals outside the US, but they will not pay for costs to get you home. And you may need specialized transport if you are still sick. We strongly suggest that if you need to get back to the U.S. for care, purchase emergency evacuation insurance. It is not terribly expensive, but well worth it!
Everybody’s Needs Are Different – Let Fortende Health Help Get You the Right Solution
We hope that this educational article helps you frame the range of alternatives and coverage available to you. Get in touch today or give us a call and let us help you figure out the best solution for your needs.