Most cruisers I know of have just paid cash for their medical coverage outside the states. Example, emergency appendectomy with airlift to La Paz and 3 days in the hospital, $1800.

...

I had health insurance with Conseco at a cost of about $2K per year, but they denied the measly $220 in charges that I incurred the first year and made me do all the inquiries to the doctors office about the billing! What the hell did I pay them for ?

... I second the motion for D.A.N. insurance. It's very cheap, and we have used them a half dozen times over the past few years to evacuate folks out of Honduras. ... and you are pre-admitted to the hospital on arrival. This is a big advantage if you have no other health insurance or in circumstances where you have no one with you to help with the admittance procedure (read that financial guarantees). Only one or two of the ones we evacuated were dive-related accidents, the others were critical health problesm (3 heart attacks as I recall and an accident victim). Highly recommended to anyone traveling abroad.

I think I pay about $35 / year.

Evacuation policies range from about $79 to $450 per annum. We are in the process of reading policies and trying to digest the facts.

Unfortunately, Blue Cross/Blue Shield is about as consistent as the weather. The franchise where we currently live has NO interest in talking to transient "boat people". And yet, one district to the south of us, where we are going to have our permanent "address of record", the Blue Cross franchise people are most welcoming, and receptive and very interested in helping us to create the most economical, efficient coverage. Go figger. ...

For most of our cruising life we felt comfortable carrying no health insurance for several reasons.

First, it is an amazingly healthy lifestyle, as we are usually away from the crowds that carry contagious diseases, have far less unmanageable stress and we don't spend much time driving on freeways during rush hour. Second, medical costs in foreign countries are usually far lower than in the USA. (Larry had a terigium removed from his eye by a highly recommended doctor working at a fine facility in Cape Town at a total cost of $330 US in l995.) Third, until recently, health insurance for people like us who traveled constantly outside their own country was almost non-existent.

But, as we near the golden ages (58 and 62) the chance of medical problems being of catastrophic proportions (cost-wise) increases. Also, we intend to spend more time in more advanced countries where medical costs can be quite high. Therefore we began researching what we call catastrophe medical insurance. We are willing to carry a quite high deductible (excess) and cover the first $5,000 of medical expenses in any year. But want something to cover the "big one".

Fortunately we talked with Beth Leonard about this and read the story she put in Blue Water magazine in June. We looked up the various insurance programs she mentioned and compared them, then looked at each of the insurance programs listed on the SSCA web site under links of interest to cruisers. The two programs that let us voyage year round, visit the US for up to six months in a year and be covered well are the International Citizens Series Platinum Health Plan underwritten by Multinational Underwriters Inc. and offered by several agencies, or the Lifeboat Medical Insurance World Health Insurance underwritten by Specialty Risk International.

We chose the Lifeboat plan, offered by Kuffel, Collimore because it has organized a type of group coverage for charter boat crews in the Caribbean and allows other sailors to join that group for $25 a year. This gives you a discount of almost 25% over the non-group cost. Total price, $2,700 a year for up to $5,000,000 coverage including medivac. For younger folks, the price is far lower.

Please read all fine print carefully.

• Change from years ago: now non-citizens must pay their own bills in countries with socialized medicine.
• If you self-insure, getting reinsured later may be a problem.
• USA companies may do a bad job of paying foreign-country claims, since they aren't familiar with international procedures.
• If staying in one country for a long time, look into local health insurance.
• Local rescue groups (such as BASRA) may offer air evacuation to members.
• When crossing borders, expect to have to pay bills in full long before the insurer reimburses you.
• Fewer cruisers are self-insuring these days.
• In USA, state of residence has a big effect on cost.
• Premiums really start going up as you reach your late 50's.

I had an claim with Travel Underwriters, Worldwide Mediclam. They insisted I give them a credit card number so they can put all my expenses on it and force me to go to court to get reimbursed. I told them I don't have a credit card. They refused to pay the claim. I've since met others who have had similar experiences with them. Steer clear of Travel Underwriters Worldwide Mediclaim. Their policies aren't worth the paper they are written on.

• If you apply in writing for insurance, and get turned down, that rejection has to be reported on all future applications to other companies. So ask/apply in person or by telephone to get a feel for whether you have a good chance of approval, before applying in writing.



• You may have a health record at Medical Information Bureau (MIB). The contents affect your chance of being approved for insurance. Check your record for errors. You can get a copy free once a year, by phone only: 866-692-6901.

• Go to health fairs, for free screenings, or at least to discuss symptoms with nurses.
  [Go extremely early; slots fill up fast.]



• Look for a medical or dental school that might have a low-cost clinic open to the public. The downside: more time spent, while teaching is done.



• Look for a Walmart or Target or large pharmacy that might have an in-store clinic.



• Look for a nurse-practitioners office, instead of a doctor's office. For many things, they are cheaper and just as good at diagnosis.



• For chronic conditions such as back pain or stress-related illness, consider alternative therapies such as acupuncture, massage, yoga.



• For simple conditions such as sinus infection, consider telephone doctors such as TelaDoc. It's lower cost, little waiting, and they can call in prescriptions to a nearby pharmacy.



• For drugs, comparison-shop among pharmacies and on the internet.
  Consider generic drugs or other brands.
  Or ask about two separate cheaper drugs that add up to the same ingredients as one expensive drug.
  Ask if it's cheaper to buy pills in a different size and then take two at a time or split one pill in half, to get the proper dose (don't do it for capsules or time-release or long-acting).



• Don't buy supplies or items from your dentist or doctor directly (unless it's an emergency); markups can be huge.



• If you have extremely low income and assets, you may be eligible for free or low-cost drugs through your state or a manufacturer or Medicare. Consumer Reports Best Buy Drugs.



• For eyeglasses, try an optometrist inside a Walmart.



• Unless it's an emergency, don't check in to a hospital on the weekend; little will happen until Monday.



• Check hospital bills line by line; most have errors or overcharges.
  Ask hospital accounting person to explain it to you.
  Maybe hire a claims assistance person through ACAP.
  If you're uninsured, find out what Medicare and insurance companies would pay for same procedures, and bargain hospital down to near those rates. Many hospitals price-gouge the uninsured, because the insurers have such power that the hospitals can't make money from the insured.



• Pricey medical equipment: see if you can buy it used somewhere (check with churches, senior centers, etc).

About that medical insurance thing ... we also don't have it. When I contracted thyroid cancer, we were able to negotiate the Medicare rate along with a 40% discount for cash. It turns out that here in California there are so many folks without insurance, that many cities are falling in line with this type of procedure. ... God forbid, if you ever have to deal with something like this, you may want to ask about the CPT numbers (Certified Procedure/Treatment number ?) for certain costed-out medical procedures. That, along with the Medicare rate and a cash discount, may make the powers that be more receptive. Stay healthy!

... According to the Healthcare Blue Book, ... the fair price for an appendectomy in Northern California is $8,309 (including a four-day admission) for the hospital and an additional $1,325 for the doctor. ...

... Hospital charges are all over the map: according to the report published Monday in the Archives of Internal Medicine, fees for a routine appendectomy in California can range from $1,500 to — in one extreme case — $182,955. Researchers found wide variations in charges even among appendectomy patients treated at the same hospital.

"We expected to see variations of two or three times the amount, but this is ridiculous," said Dr. Renee Y. Hsia, the study's lead author and an assistant professor of emergency medicine at the University of California, San Francisco. "There's no rhyme or reason for how patients are charged or how hospitals come up with charges."

"There's no other industry where you get charged 100 times the same amount, or 121 times, for the same product," she said.

...

For-profit hospitals tended to charge more than county hospitals, and charges increased with a patient's age. Charges were also higher for Medicaid patients and the uninsured, and for patients with other health problems like diabetes and congestive heart failure [even though those conditions weren't addressed as part of the treatment].

...

If you're uninsured or have a high-deductible policy, and if your state has hospital pricing transparency laws, contact the appropriate person at each hospital for pricing information. State hospital associations may help. Consult the Healthcare Blue Book to get an idea of fair prices, but remember that's no guarantee.

Under the Affordable Care Act, all hospitals are supposed to publish their prices for common services by 2014. If you manage get an estimate of charges from a hospital, make sure you know exactly what services are included. Physician fees are billed separately, for instance — an anesthesiologist's charges are separate from a surgeon's. Having medical billing codes is helpful.

Broach the subject of charges with your doctor, even if it's uncomfortable. FairHealth, an independent nonprofit corporation, provides medical pricing information. Healthcare Blue Book suggests asking your doctor to sign a binding price estimate in advance and suggests language. An example is at PricingAgreement.

If you are healthy, or cannot afford a good health insurance plan, buy the absolute cheapest one you can find.

It is fairly easy to find a health plan that is very affordable because it has a giant deductible. I am talking $5,000-$20,000 deductible for $50-$100 a month

Even though you have a giant deductible, which means you will be paying for all your bills until you hit that deductible, you will still benefit from the HUGE discounts the insurance company has negotiated with the hospital/doctors.

For example, I had a PET scan done. The retail charge, the amount billed to the insurance (and how much a non-insured patient would be billed) was $8500. My insurance company's "Negotiated Rate" was $846. That was the amount applied to my deductible, and the only thing the hospital could bill me for.

So in short, even though you may be paying for most of your bills, you will benefit greatly from the giant discount insurance companies have, and as long as you go to an "in network" provider, they have to honor those discounts. And as a plus, if you do have a catastrophic illness, you will meet your giant deductible pretty quickly and then have the insurance kick in.

You also benefit from having access to the insurance company "rules" that doctors have to follow. For example, if you walk into a Lab to have blood tested, you will get billed a charge for drawing the blood and a charge for each test done. Under most insurance, the blood draw fee is considered "incidental", meaning, it's included in the cost of doing the blood test, so the blood draw fee gets denied, and they cannot bill you for that.

[When faced with a big bill:]

Start asking for documentation. Have them send a line-item list of everything you were charged for and then flat-out tell them you are not going to be able to pay that amount and you believe many of the items on the bill were not actually provided, but were still charged.

Talk them down on the amount. They are only charging this amount so that they can get more out of insurance companies. If you tell them there is absolutely no way you will ever pay that bill they will negotiate down quite a bit just because they would rather make some money on it than to have you ignore it.

Also, if they get a court date for a judgement go to the court date and tell the judge that there is no way in the world that you can pay that and you believe they are overcharging you. This is where the documentation becomes important. If you can show they added more line items to the bill than what they provided you it may, possibly, have some effect on the outcome. If you are not sure you should probably ask for advice from a competent lawyer in your jurisdiction who is familiar with medical suits.

All I know is that most hospitals will negotiate the rate down to as little as 25% or less of the "full" price. They are hoping you pay for yourself and three other people who never paid their bills. Welcome to our national free health care system, to participate just ignore that bill until they stop bothering you ... someone else will pay 4X as much as they should for their services and subsidize your bills.

If you cannot pay a medical bill, call the hospital/doctor's office as soon as you get the bill. The office is much more likely to negotiate early in the process than after they sent you to collections. Some places will even give you a discount if you pay in cash / pay in full up front.

[from another person:] What is this "bill" you speak of ?

[and then another:] Away with thee, foul demon of socialized medicine !