medical insurance

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This page updated:
August 2014

How to save money on health care

Article by Beth Leonard in 6/2003 issue of Cruising World magazine

I'll have someone come in and prep you for the bill


Insurance types:
  • Self-insure (no insurance; less risky if you're young, healthy, and cruising outside USA).
  • Travelers insurance (short time period).
  • Boat or home-owners insurance may include some medical coverage.
  • Medicare: starts at age 65, covers chronic illness, but pays for providers/facilities inside USA only.
  • Accident (covers incidents, not illnesses, with amount-per-hospital-day benefit).
  • Catastrophic (high-deductible).
  • Limited (PPO, must pre-certify, etc).
  • Comprehensive.

Coverage areas:
  • USA.
  • Rest of world (cheaper, because USA medical and legal systems not involved).
Residency: where you spend at least 6 months of each year.

Fine print:
  • Coverage of pre-existing conditions ?
  • Air evacuation and repatriation ?
  • Is boating (or snorkeling or diving) excluded as a "risky activity" ?

From "Modern Cruising Under Sail" by Don Dodds:
"Health insurance has very little use on a world cruise. ... We keep only a high-level deductible policy in case of catastrophic disease."

From Mark Mech on The Live-Aboard List:
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 ?

Divers Alert Network (DAN):
It covers snorkeling and diving-related injuries, costs $29 membership per year.

DAN apparently provides medical coverage for diving accidents, and air evacuation for any medical emergency.

From Terry on the Morgan mailing list:
... 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.

From Tom and Mel Neale: Check medical evacuation insurance terms carefully: it may cover only fixed-wing airplane evacuation, only life-threatening conditions, only if recommended by a local doctor, etc.

From Dick Giddings on Cruising World message board 1/2001:
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. ...

From Wade on Facebook (maybe 2013 ?):
If you don't have health insurance for the USA, then beware of DAN evacuation. Yes, simple membership in DAN will provide you with DAN evacuation insurance at a very low cost, for all types of accidents - not just diving. This is only for the flight though, not the treatment at the destination. It is also up to DAN to decide where to evacuate you to, regardless of your citizenship. They will relocate you to a place where appropriate medical treatment will be provided. Twice in the past 4 years I have personally discussed this policy with DAN and the situation has not changed. As a Canadian with Canadian health coverage, I would rather pay out-of-my-pocket for the evacuation to Canada than get a "free" flight (the DAN evacuation) to Florida - where I may be financially crippled by the cost of the resultant medical care. Sorry, I don't mean to "diss-DAN" but I just had to point this out as way too many people have an unfair "rosy impression" of this evacuation insurance.

Someone's quote of Larry and Lin Pardey:
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.

Pantaenius provides "single-trip" policies with defined start and end dates. Have to stay outside USA ? As of 7/2004, $630/year for adult, must be under 65 years old, covers sickness, accident, doctor, supplies, hospital, some dental.

USA federal government programs for US citizens:
Medicaid: eligible if you have extremely low income and assets.
Medicare: eligible if age 65 or older and have paid into Social Security for 40 quarters; no income or asset limits. Does not pay for provider/facility outside USA (but Puerto Rico and USVI are considered "inside USA").

Critical-illness (AKA "dread disease") insurance ? You pay a monthly premium, and when illness strikes, you are given a lump sum to use as you wish rather than having payments go to your medical-care providers. Only certain major illnesses are covered.


From article by Beth Leonard in 6/2003 issue of Cruising World magazine:
  • 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.


From Brent Swain on SSCA discussion boards 9/2004:
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.

A question I had, 11/2007:
> I am a citizen of USA, residing outside the USA.
> If I
> 1- buy "Global Medical Insurance / Silver Plan / Excluding U.S./Can." coverage,
> 2- and I get sick or have an accident outside the USA,
> 3- but then travel to the USA for treatment/hospitalization,
> 4- are my expenses in USA facilities/doctors covered by the plan ?

From IMG Insurance:

Yes, even if you have selected coverage Excluding U.S. and Canada the Global Medical Insurance Silver plan will still provide a benefit if you do travel to the U.S.. The policy language regarding this coverage is as follows: Treatment in US/Canada - Limited to 30 days per Insured Person per Period of Insurance for Accident or Emergency Treatment only. Treatment must be received from a Preferred Provider Organization.

A lot of policies these days are written for fixed terms, maybe one year in duration, and then you have to renew for the next year. I think they do this so they can drop (not renew) you as quickly as possible if you start to have health problems. So be aware of the end-of-policy date; if tests find an expensive problem, get it treated right away, before your policy comes up for renewal (which will be rejected).

US citizens and 'Obamacare' (PPACA, ACA):
From's "Am I eligible for coverage in the Marketplace?":
U.S. citizens living in a foreign country are not required to get health insurance coverage under the Affordable Care Act. If you're uninsured and living abroad, you don't have to pay the fee that other uninsured U.S. citizens may have to pay.

Generally, health insurance coverage in the Marketplace covers health care provided by doctors, hospitals, and medical services within the United States. If you're living abroad, it's important to know this before you consider buying Marketplace insurance.

Talked to my state's Medicaid office. At first they said "no problem, you can be on Medicaid while living outside the country". Then I asked "okay, so I go to a doctor here in country X, pay cash, and submit the bill to Medicaid for reimbursement ?". And then the answer slowly changed to "no, you have to use an in-state doctor, and residing outside the country probably means you're not eligible for Medicaid". An insurance company that does Medicaid plans said "If you live outside of [my state] for more than 30 days you will lose your Medicaid eligibility".

A person on the support phone said that ACA's penalties for having no insurance don't apply if you're living outside the country.

From Timothy J. Garrett's "A Doctor Explains: What the Affordable Care Act Means for Expats":
U.S. citizens living outside of the United States but who are not bona fide residents of a foreign country are required to have health insurance or face fines.

If you:

a) have told your country of residence that you are not a resident of that country


b) are not required to pay income tax in your country of residence,

then you are not a bona fide resident of that country.

Some articles say "read instructions for IRS form 2555 to see if you qualify as living outside USA". Those instructions (PDF) contain TWO "tests": "Bona Fide Resident Test" (live in foreign country for entire tax year, stay is indefinite, make your home there, more) and "Physical Presence Test" (in foreign countries for at least 330 days out of 12 months).

From IMG's "PPACA FAQs":
U.S. citizens who live abroad for a calendar year (or at least 330 days within a 12 month period) are treated as having "minimum essential coverage" for the year (or period) and, therefore, are not required to purchase PPACA coverage. ... They need take no further action to comply with the individual mandate. Please note that IMG's Global Medical Insurance Plan does not meet the definition of "minimum essential coverage" under PPACA.


... Exempt U.S. citizens ... a U.S. citizen who has a tax home (... your main residence) in a foreign country, and ... is present in a foreign country or countries during at least 330 full days in a twelve month period.

Asked an international health insurance company if their plans met rules of ACA, and got this 11/2013:
[Our plan] does not satisfy the PPACA minimum insurance requirements, nor do any international policies. I am an international insurance broker and I represent many companies and plans ... The law doesn't really speak to those that "don't qualify", only those that do. Since you don't live most of the year inside of the US, you most likely don't qualify for a domestic policy, and thus would not be required to carry a policy that satisfies the minimum requirements of the [more expensive] plans.

YucaLandia's "ACA - Obamacare's Effects on American Expats Living Abroad"
IRS's "Questions and Answers on the Individual Shared Responsibility Provision" (see item 12)
John W. McGee's "American Expats and How ObamaCare Affects YOU!"



Tell the insurance agent about every boating association you belong to, every certification you have, other insurance you have, other memberships you have. They might have an affiliate program with one of them, or some other special deal.

From article by Russell Wild in July/Aug 2006 issue of AARP magazine:
  • 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.

How to save money on health care

Don't skimp on routine, preventive medicine (dental checkups, periodic physicals, etc); that will end up costing you more in the long run.

Treatment and medicine is cheaper outside USA:
Wikipedia's "Medical tourism"

"We discovered as we traveled that most U.S. prescription drugs are available over the counter, at incredibly cheap prices, throughout the Caribbean."

"Prescription drugs are available on many of the islands without prescriptions and much less expensive than in the US."

"You can get prescription drugs OTC in many places at 1/4 US cost. Had teeth cleaned (very professional) in Mexico for $6."

From Bob Conrich on WorldCruising mailing list (he lives in the Caribbean):
I had some elective surgery a few weeks ago. The charge for about 3 hours in the operating room, the anaesthesiologist, a whole crowd of unidentified bystanders, general anaesthetic, various other drugs, dressings, lab tests, an EKG and the use of a private room for a few hours was about US$400. The surgeon, a highly-skilled plastic and reconstructive surgeon, board certified in Canada, who I retained as a private patient, was another $2200. Lord knows what this would have cost in the U.S.

Dental care is excellent. Most simple procedures are $6 to $12.

From Paul on Cruising World message board:
We cruised for two years with no insurance. Meds and doctors are just plain cheap in the Caribbean. Example: antibiotic here $60, same stuff, same manufacturer (Germany) in Martinique $20. BC pills in US, $28 per month, in Trinidad, $7. Teeth cleaned in Mexico - $6 - yes, the dentist was efficient, proficient, and equal IMHO to US standards. Obviously if you get weirdly and wildly sick - ain't no place like home, BUT there are good hospitals and medical services in Grenada, Trinidad, Venezuela, to name a few. IMHO they would be more likely to treat you for what you have than for what you have in your wallet!!!!

In Salinas PR 11/2007: I got Tetanus booster shot for $10 at the hospital; wisdom-teeth exam and two x-rays for $25 at the dentist. Cruisers said dentist will extract teeth for $50/tooth. Not much English spoken at the hospital. I don't think prescription drugs are any cheaper here than in USA.

From article by Russell Wild in July/Aug 2006 issue of AARP magazine:
From Paul Zane Pilzer: "Some of the best hospitals in the world today are located outside the United States, in countries such as Thailand and India. They often have US-trained physicians, and sometimes deliver safer and better services in a comfortable, resort-type atmosphere."

And - as reported on "60 Minutes" recently - a quintuple-bypass operation might run $12K, as opposed to $100K or so in the States.

Other candidate countries: South Africa and Costa Rica.

Of course, wherever you go for surgery, whether in the United States or abroad, very carefully check credentials and get referrals.

From "Living Aboard" by Janet Groene and Gordon Groene:
... socialized medicine in other countries. ... it's unlikely you will be accepted as a freeloader. ... one look at many of those "free" hospitals will send you scuttling home on the first flight. We had two medical experiences in countries that have government medicine, Canada and the Bahamas. Both experiences were ghastly, medically and financially. Other world cruisers, however, have had superior care in other countries, and for less than they would pay at home.

If something goes wrong with an overseas procedure, you do not have recourse to the USA legal system.

I spent 8 hours in Emergency Room in Martinique 11/2010, getting hydration and medicine via IV; cost was about US$250. In USA, cost might have been five or ten times as much ?

From article by Russell Wild in July/Aug 2006 issue of AARP magazine:
  • 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).

Take advantage of free screenings for glaucoma, high blood pressure, etc.
Also cheap flu-shot programs.

Look for an "urgent care clinic" or "county health clinic" or "county health department" or "community health center" or "medical van" or "dental van" instead of a hospital. Look for a "visiting nurse" for immunizations and routine screenings. Buy home test-kits (for cholesterol, etc) at a pharmacy instead of having a test done through a doctor or hospital.

Free medical/dental clinics in USA

[Not about saving money]
From DailyFinance - dentist:
Dental technology has improved greatly; make sure your dentist is using the latest. In particular, they should be using digital X-rays (clearer results, less radiation), ultrasonic cleaning (instead of scraping), and Diagnodent laser for cavity-detection.

Joe Sinclair's "'Hit and miss' warning on home health tests"

Cheap medicines:
[Laws and offerings change frequently; some of this info may be outdated.]


For a specific medicine, check manufacturer's web site for any coupons or special deals.

Patrick Allan's "Four Ways You Can Save On Prescription Drug Costs"

From Tom W:
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!

From Roni Caryn Rabin's "The Confusion of Hospital Pricing" 4/23/2012:
... 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.

From someone on reddit 2/2013:
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.

From someone on reddit:
[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.

Jeanne Pinder's "How to Figure Out the Cost of a Medical Procedure Before it Happens"
Lena H. Sun's "50 hospitals charge uninsured more than 10 times cost of care, study finds"

For a large hospital bill, you want to get a "medical billing advocate" to help you.
Some resources:

Beth Skwarecki's "How to Make Sense of Your Confusing and Expensive Medical Bills"
Dave Greenbaum's "Ask a Hospital for Financial Aid If You Can't Pay the Bill"

From someone on reddit:
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 !

You have problems if you see this.