This is the last of five columns discussing what federal employees need to know about Medicare. This column discusses Medicare benefits for federal employees or retirees who travel or work overseas.
An individual enrolled in Medicare may not be aware of what Medicare covers if the individual becomes sick or is injured overseas and requires hospital and medical care. This topic is timely given that COVID restrictions are loosening, and federal employees and retirees are anxious to get out and travel.
The question is: If a federal employee or retiree travels outside the US, will they be covered for unexpected health care expenses should he or she becomes ill or gets into an accident and requires hospital care and doctor services?
In researching what Medicare covers for medical expenses incurred by individuals while they are outside of the United States, one will see that Medicare in general does not cover (with some exceptions, as explained below) emergency services needed due to injury or sickness of a sudden onset during the first 60 days of travel outside the United States.
The gap in medical coverage when an individual is traveling outside the United States can be filled to some extent with Medicare supplemental insurance, including Federal Employee Health Benefits (FEHB) program plans. Many of the FEHB program plans – in particular, the fee-for-service and the preferred provider organization plans – offer insurance coverage for an enrollee when the individual needs medical care outside the United States.
Federal employees or retirees who are enrolled in Medicare and who have Medicare supplemental insurance through a FEHB insurance plan are encouraged to check with their plan to make sure the plan offers the following foreign travel benefits:
• Covers foreign travel emergency medical care during the first 60 days of foreign travel, assuming care is needed during the first 60 days of the employee’s or retiree’s trip, and if Medicare does not otherwise cover the care, and
• Pays at least 80 percent of the billed charges for certain medically necessary care outside the United States after a deductible is met.
Medicare Coverage Outside the United States is Limited
For individuals who travel or live outside of the United States, Medicare will not cover healthcare that individuals incur. The term “outside the U.S.” means anywhere other than the 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
Medicare may pay for inpatient hospital, doctor, and ambulance services an individual gets in a foreign country in these three rare cases:
• An individual is within the United States when a medical emergency occurs that requires immediate medical attention to prevent a disability or death, and a foreign hospital is actually closer in distance than the nearest United States hospital that can treat the individual’s medical condition. For example, an individual is in southern Texas near the Mexican border, or an individual is in northern Washington state near the Canadian border.
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• An individual is traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency happens. A Canadian hospital is closer in distance than the nearest U.S. hospital that can treat the illness or injury. Medicare determines what qualifies as “without unreasonable delay” on a case-by-case basis.
• An Individual lives in the United States and the foreign hospital is closer to the individual’s home than the nearest United States hospital which can treat the individual’s medical condition, regardless of whether it is an emergency.
In the three situations above, Medicare pays only for services covered under the “original Medicare” (Medicare Part A and Medicare Part B)
• Medicare Part A (Hospital Insurance) covers hospital care (care an individual gets when the individual has been formally admitted with a doctor’s order to the foreign hospital as an inpatient).
• The individual pays the part of the charge the individual would normally pay for covered services. This includes any medically necessary doctor and ambulance services the individual gets in a foreign country as part of a covered inpatient hospital stay. The individual also pays the coinsurance copayments, and deductibles the individual would normally pay if the individual got these same services or supplies inside the United States. Note that it is important for federal employees and retires enrolled in a FEHB program health plan to ask their plan which of the mentioned expenses the plan will pay.
• Medicare Part B (Medical Insurance) covers emergency and non-emergency ambulance and doctor services an individual gets immediately before and during his or her covered foreign inpatient hospital stay. Medicare will not pay for services after the individual’s inpatient stay (such as return ambulance trips home).
Medicare Part D (Prescription Drug program) does not cover prescription drugs bought outside the United States. Federal employees and retirees need to check with their FEHB program plan and ask whether the plan covers prescriptions drugs bought outside the United States.
Foreign hospitals are not required to file Medicare claims for an individual’s foreign travel medical expenses.
An individual enrolled in Medicare who incurs medical expenses qualifying for Medicare reimbursement is required to submit an itemized bill to Medicare for the individual’s doctor, inpatient, and ambulance services if both of these apply:
• The individual is admitted to a foreign hospital under one of the situations above
• The foreign hospital does not submit Medicare claims for the individual
To file a Medicare claim, an individual must download the Medicare claim form, Form CMS-1490 (Patient’s Request for Medical Payment) (download here). There are instructions with Form CMS-1490 as to how the fill out the form including what needs to be included with the claim and where the completed form and supporting documentation are to be sent.
Another question that has been raised is what happens when a Medicare-eligible individual who is on- board a cruise ship requires medical care. Will Medicare cover medically necessary health care services require by individuals aboard a cruise?
Medicare may cover medically necessary healthcare services an individual incurs while traveling on a cruise ship if:
(1) A doctor on the cruise ship is allowed under certain laws to provide medical services on the cruise ship; and
(2) the ship is in a United States port of no more than six hours away from a U.S. port where the individual receives the medical services, regardless of whether it is an emergency.
Finally, because Medicare and FEHB program heath plans have limited foreign travel medical coverage, federal employees and retirees may choose to buy a travel insurance policy to get more coverage. An insurance agent or travel agent can give individuals more information about the cost of travel medical insurance.
Travel insurance does not necessarily include health insurance, so it is important to read the conditions or restrictions carefully. In addition, employees and retirees planning foreign travel during 2022 should check with their current FEHB program plans to make sure that hospital, doctor and other medical expenses are covered outside the United States and to what extent.
An FEHB program plan providing no or limited coverage for foreign travel may require an employee’s or retiree’s change of health plans for 2022, which can only be done during the upcoming FEHB program “open season” being held from November 8,2021 through December 13, 2021.