Health and Travel Insurance Considerations for People with Disabilities
Does your participant insurance policy have exclusions for pre-existing conditions? Learn questions to investigate and examples of how some programs budget for the costs of broad coverage as it relates to disability issues and people with pre-existing conditions.
Many international exchange program providers offer travel insurance coverage for emergencies such as lost luggage, evacuation and repatriation (returns of body remains in the event of death), as well as health insurance for medical treatment in the event of an accident or illness as part of the program fee paid by participants. This insurance is typically offered as supplementary coverage for someone already covered by another medical insurance plan, but in some cases may be the only health insurance a participant uses while abroad. Travel and health insurance are generally bundled together for complete coverage while traveling outside the United States.
About this tipsheet
Some information in this tipsheet is excerpted from Building Bridges: A Manual on Including People with Disabilities in International Exchange Programs and from information gained through the National Clearinghouse on Disability and Exchange's Working Group on Travel Insurance and Disability*. The goals of the working group focused on:
- To know what options exist or how to plan for exchange participants who fall into the pre-existing condition category or who need ongoing medications and treatment about getting coverage they need abroad,
- To be proactive about having timely coverage in case of unexpected changes in a condition, failure of durable medical equipment such as wheelchairs or hearing aids, or diagnosis of catastrophic illness such as cancer while on international exchange programs.
Overview of health, insurance and disability
Disability and health should be considered separate issues. Most people with disabilities are not unhealthy or sick. By law, exchange program participants with disabilities are eligible for coverage under traditional group insurance policies. Though traditional medical insurance coverage will be sufficient for many participants with disabilities, some may request or need alternative options due to limitations on coverage. If a person is not covered under a group plan, they may look for an individual insurance health plan. However, these plans can increase costs or deny enrollment based on health status.
The most effective way to eliminate problematic situations of lack of coverage is to provide group plan options, choose insurance providers or set up in-house products with coverage of pre-existing conditions, and tap into budgeted program funds to expand disability-related services for students participating in international exchanges.
If an institution or agency offers health insurance coverage for participants, there are a number of items to consider regarding coverage for people with disabilities.
- Pre-existing conditions are an important
consideration in insurance coverage for people with and without
disabilities. Pay attention to the time period that defines a
pre-existing condition and any exclusion waiting period or general
exclusion. It is equally important to look at language for treatment
for unforeseen changes, unexpected reoccurrence or aggravation in a
condition. These are explained more thoroughly below.
- Access to an individual’s medical records and personal physician in an emergency may be important for participants with health-related concerns, such as epilepsy, diabetes and others.
- Medicaid coverage
does not remain in effect while traveling overseas and certain
services, such as personal attendant care or wheelchair repair, are
unlikely to be covered under a travel insurance plan.
Frequently Asked Questions
What defines a pre-existing condition and its coverage in an organizational or institutional group health insurance plan?
Generally, a pre-existing condition is any medical condition, injury or illness that manifested itself, for which a licensed physician was consulted or for which treatment of medication was prescribed, prior to the effective date of the insurance policy. The length of time before the effective date during which a condition would be considered to be pre-existing varies, and can be anywhere from 30 days to 6 months or longer.
A pre-existing condition exclusion waiting period is the length of time after the effective date of an insurance policy that a person must wait before any pre-existing conditions are covered. Once a person is enrolled, these policies can only have a 6-month maximum waiting period for pre-existing condition exclusions, which is reduced or waived if the individual had prior credible coverage that did not lapse in the last 63 days. However, the waiver only applies to fully licensed products, so may not be included in accident and sickness supplemental insurance policies that exchange organizations typically offer.
If organizations and institutions negotiate it, most accident and sickness group policies have the option to:
- Remove exclusions for pre-existing conditions,
- Reduce the time period defining pre-existing conditions,
- Offer limited coverage to a certain maximum dollar amount for pre-existing conditions or medications,
- Specify coverage in the case of an emergency to stabilize a pre-existing condition, or
- Exclude from the definition of a pre-existing condition, any condition in which one takes a prescribed drug or medicine that remains controlled without any change in a required prescription prior to effective coverage.
Sometimes a policy that does not exclude pre-existing conditions, or explicitly excludes the condition for which treatment is sought such as depression, will instead include language about coverage for “unexpected” reoccurrence or aggravation of a condition. Examples of unforeseen changes that are disability-related conditions might include a need for counseling, or treatment of a bladder infection, blood clot, asthmatic attack, pressure sore or adverse reaction to a medication. In order to receive coverage, a case would need to be made for why the change was unexpected. The existence of a disability would need to be clearly distinguished from the cause of an illness or injury abroad that is related to the environment (climate, activity, food, etc.) or from difficulty accessing care abroad in exasperating (i.e. making worse) the condition.
How can an organization budget for the costs of comprehensive insurance coverage for all exchange participants and/or broader coverage options for participants with pre-existing conditions?
Organizations may find it advantageous to join with an affiliated institution or similar organizations to purchase insurance coverage together in order to spread the costs of comprehensive coverage over a greater number of participants. However, an affiliation may not be created for the sole purpose of purchasing insurance together. If an association or consortium exists for other purposes, such as a coalition of community colleges, that organization may be able to purchase insurance at group rates.
(Spectrum, Spring 2006)
Tips
- Work with the insurance provider to offer comprehensive travel health insurance, including coverage for mental health-related services, chiropractic and dental care.
- Add a line item for “disability accommodations” to program
budgets in order to cover the cost of supplementary coverage or
out-of-pocket expenses (i.e. costs the patient must pay to the doctor
at the time of care) for participants with disabilities who require
broader coverage than that included in a typical group policy (e.g.
physical therapy). This can also be for those who are financially
unable to pay their portion of co-payments (i.e. set fees paid by the
patient per treatment) on the existing insurance because of regular
doctor visits, etc.
- See the Budgeting for Inclusion tipsheet for more tips.
What if an organization opts to allow or require participants to purchase their own travel health insurance?
Verify that all participants have adequate insurance coverage while abroad. People with disabilities in the United States who have Medicaid are not covered while they are outside the United States. They may be dropped from enrollment in the medical plans if they do not keep a U.S. state residence or address or lose their SSI eligibility by being out of the country for more than 30 days for anything other than studying abroad for credit through a U.S.-based educational program for up to a year. Loss of enrollment creates a gap of coverage on return home from being abroad, especially if the travel health insurance does not cover participants in their home country. As part of getting ready to travel, exchange participants who this affects should contact the Social Security Administration and the Medicaid office for more information.
For international students coming to the U.S., university student health care may not be sufficient since that coverage is often determined based on a demographic profile of relatively healthy young people with few medical needs. Treatments for illnesses that usually affect an older population, like a chronic disease, are usually not covered. Also lower maximum coverage limits and 20% co-insurance requirements may be difficult for an international student in the event of a catastrophic illness, such as multiple sclerosis.
- U.S. participants providing their own travel health insurance should thoroughly discuss the requirements with their insurance agent to be sure the policy will cover them outside the United States. Encourage participants to contact the insurance provider directly with their specific questions rather than going through an intermediary office or study abroad staff person.
- International participants may need to see if medical coverage and disability benefits from their home countries will cover costs (which are often higher) while in the United States.
If insurance is available through the study program or host institution, participants electing to purchase their own insurance will be required to provide evidence of a “mandatory plan with hard waiver,” meaning that the personal insurance coverage must be equal to or greater than that provided by the organization. For foreign J visa holders, there are minimums for insurance coverage and repatriation defined in the J-visa regulations. Some U.S. universities require individual insurance plans with no more than a 6-month pre-existing condition waiting period after the effective coverage date for international students (one or more years are the typical waiting periods). More details on finding individual insurance plans for travel abroad and what U.S. universities require of international students regarding insurance is discussed below in the Website Resources section.
Does the insurance company offer an assistance service with a 24-hour, worldwide toll free telephone number for emergencies? Is it accessible to participants who use a TTY machine?
Most health insurance providers that offer international coverage provide round-the-clock access through a travel assistance company. Services such as emergency hospitalization often must be pre-approved and arranged by the assistance company in order to be paid or reimbursed. Confirm with your agent that they provide this service and that services including TTY or text messaging are available at all hours.
In the U.S, medical treatment is commonly provided first, and bills are issued later. In other countries, treatment often needs to be paid for or payment verified from the insurance company prior to care. It is important to be able to quickly receive payment or denial of payment from the exchange participant's primary insurance (which may not have this 24 hour worldwide service); the supplementary travel insurance often can be applied only in the case of denial of the primary insurance. Additionally, HIPPA privacy and confidentiality waivers signed in advance by the exchange participants can help insurance companies to work with students when overseas when timing is critical and services need to expedited.
Can a medical office in the host country access an individual’s medical information and communicate with his/her physician if needed?
For participants with health-related concerns (such as epilepsy, lupus, diabetes, allergies and others) some Internet services offer the option to input and store personal medical information that can be accessed from around the world in case of an emergency. It may also be possible to upload participant files, including health information (with appropriate permission and security assurances) to the organization’s intranet for access. See the Website Resources listed below for more information.
What health insurance options are available for students enrolling directly into a host university?
Students who are applying directly to a university in another country should ask about health care coverage options. Students who directly enroll or are integrated into a host university may be eligible for the health services that local students in that country receive.
- Students with disabilities should investigate whether they will need additional coverage, such as pre-existing condition coverage, because requirements may vary from country to country and institution to institution.
- Find out the average cost of doctor visits or
other treatments to determine how much out-of-pocket expenses one might
need before getting reimbursed from home insurance for pre-existing
conditions.
What are some ways to assist a participant with a disability who uses a personal assistant or durable medical equipment (e.g. wheelchair, etc.) or needs prescription medications or assistance with a major medical cost to think creatively about arranging for needs while overseas?
Participants who receive funding for a personal assistant through Medicaid are not able to use that funding once outside the United States. Travel insurance companies will typically not pay for personal assistants for daily care overseas or durable medical equipment that wasn’t related to a first occurrence of an illness or injury overseas. Since these things are unlikely to be covered for people with existing needs, programs or institutions could work with a participant to cover the costs. For example, Council on International Educational Exchange has pooled funds for participants with disabilities who require broader services or accommodations, and works jointly with the student’s home institution to cost-share expenses to make coverage possible.
Some insurers may want to consider adding coverage for repair or rentals for existing durable medical equipment or personal assistants. If an individual is duct-taping a crutch or wheelchair or relying on informal assitance for transfers, for example, this could lead to a potential injury to a back, a pressure sore, etc. and added cost for the insurer who now has an injury or illness to cover as a result of lost or faulty equipment or lack of usual personal assistance.
Most travel insurance plans also offer added benefits, including coverage for lost or damaged luggage and a 24-hour traveler hotline. For example, in the event of a wheelchair that is broken in flight, this service can assist with airline claims for damaged equipment, locating rentals abroad and coordinating repair services. Information on use of personal assistance in flights and other creative ideas on ways to fund personal assistants on exchange programs can be found on another tipsheet.
For medications, a doctor and exchange organization letter to the home insurance company may allow for more months of the prescription to be filled in advance to bring overseas. Travel insurance companies often have information on what medications can legally be imported or purchased in the destination country, how to locate specialists and doctors in the destination country, and how to identify pharmacies overseas or that mail prescriptions overseas. Other consideration can be found on the medications tipsheet.
For international students who encounter major medical costs for a
catastrophic illness or surgery, and/or hearing aids or wheelchairs not
covered by insurance, various options have been tried since
non-immigrant individuals cannot qualify for Medicaid, Medicare or
other U.S. public assistance. (The exception being Emergency Medicaid,
a federal program that covers emergency care for patients who would
otherwise be eligible for Medicaid but do not have legal immigrant
status). Alternative options include inkind services or donations from
the doctor, pharmacy or hospital, contributions from associations
related to a specific disease or disability, and/or fundraising
donations from local community groups or international clubs.
What Education Abroad and International Student Advisors Can Do!
People with pre-existing conditions will often be denied enrollment by individual market plans and/or denied coverage of their conditions by “accident and sickness” policies. Therefore, individuals with existing plans that are not portable overseas (e.g. Medicaid or state-based plans) will have limited options for coverage.
By removing insurance barriers, you can support diverse students to safely participate in your programs. Options include:
- Offer group health insurance options and negotiate a plan that eliminates pre-existing condition and mental health exclusions.
- Ensure that the maximum coverage amount of the plan will cover those who are first diagnosed or become disabled overseas, extends coverage on return home, and considers case-by-case those who exceed maximum amounts.
- Assist students with or direct them to insurance companies to find out about medications that can and cannot be imported or purchased in countries abroad, and how to arrange for needed medications.
- Budget separately as an organization for assistance with durable medical equipment replacement rentals or repair emergencies abroad (e.g. wheelchairs, hearing aids, crutches, etc.) and personal assistant services.
- Check if students are adequately insured and educate
them on plans that will cover pre-existing conditions if your office
does not offer these options.
With these options in place, it shouldn’t prevent qualified individuals from participating in exchanges and alleviate some of the difficult health cost issues that exchange staff and students need to deal with during the program.
Website Resources
Websites Internationalstudentinsurance.com, Insuremytrip.com and Squaremouth.com offer comparisons of various individual travel insurance options. Their information shows what plans cover pre-existing conditions and how much they cover. This information reveals that more expensive plans will cover pre-existing conditions if purchased in advance and a person can show they are “medically able” or “not disabled from travel” at the time of purchase. General exclusions will still apply; some conditions such as mental health, may be separately excluded (iNEXT individual travel plans offer pre-existing mental health coverage options). Many individuals with ongoing health-related conditions may find that they are denied enrollment in individual insurance plans.
Many people maintain their existing insurance - if it covers overseas - as their primary insurance when abroad. Medicaid and state-health plans often do not cover overseas costs. In those cases, major travel health plans that are designed for people working or living overseas (often for over a year) may have more pre-existing condition coverage in their plans for Americans (e.g. HTH Worldwide Global Citizen or MedEx TravMed Choice plans), although these same plans often require a pre-existing condition waiting period for international citizens coming to the United States. The websites above list these types of plans too.
International Association for Medical Assistance to Travelers provides a directory of English-speaking doctors in 125 countries who provide medical assistance to travelers.
417 Center Street
Lewiston, NY 14092
Tel: (716) 754-4883
Email: iamat@sentex.net
Shoreland’s Travel Health Online Travelers health information; provides planning guide, country information, medical provider contacts.
Shoreland, Inc.
PO Box 13795
Milwaukee, WI 53213-0795
Tel: (800) 433-5256 or (414) 290-1900
Fax: (414) 290-1907
PersonalMD is
a consumer health website that provides information on a wide variety
of topics pertaining to health. One feature is the PersonalMD Emergency
Card, which allows users to enter their medical information into a
secure database that can be accessed anywhere in the world via the
World Wide Web if there is an emergency.
4725 First Street, Suite 275
Pleasanton, CA 94566
Tel: (925) 417-6840
Fax: (925) 600-7568
The United States Department of State Travel Medical Information provides travel and health information.
*The National Clearinghouse on Disability and Exchange's 2009 Working Group on Travel Insurance and Disability included:
Anne Cohen, Health and Disability Policy Consultant and Director, Disability Health Access, LLC
Cerise Roth-Vinson, Manager, National Clearinghouse on Disability and Exchange / Mobility International USA4)
Chris Bramwell, Assistant Director of Exchange Programs, AMIDEAST
Colin Davies, Director of Capacity Building Services, World Learning
David
Levin, Senior Program Manager and Diversity Coordinator, U.S.
Department of State / Bureau of Educational and Cultural Affairs
Janice Jeng, Assistant Vice President Sales & Client Services, USI/Travel Insurance Services
Jolie Vincent and Amber Lee, Wells Fargo Student Insurance
Laurie Duston, Manager of iNEXT, Council on International Educational Exchange
Michele Scheib, Project Specialist, National Clearinghouse on Disability and Exchange / Mobility International USA
