How Does Heath Care Work for a Long-Term Traveler?
Spoiler alert: it's complicated! But relax, we'll help you get it all figured out.
You became a digital nomad or long-term traveler? Congrats!
Now what do you do about healthcare?
If you’re an American, the answer is: It’s complicated.
There are a lot of online resources about “travel insurance” and “insurance for nomads,” but they mostly just compare different travel insurance policies.
Alas, they don’t really get to the heart of the matter of healthcare for nomads or expats. Insurance is a very important part of our healthcare picture, but it’s only one part. And travel insurance is only one kind of health insurance.
This article is about the Big Picture of nomad healthcare. But it will also hopefully include all the specifics you need to make the best possible choices for yourself.
Full disclosure: I’m not an expert! Yes, I’ve been traveling full-time outside of America for four years, I think I’m fairly smart, and I’ve made a few “travel healthcare” mistakes that I’ve been lucky enough to learn from.
In short, I think I know what I’m talking about, but I’m still just a guy on the internet. Please consider other sources too, and verify for yourself everything I’m saying. Before buying any health insurance from a company, ask a zillion questions via their online chat feature, and ask for and save a transcript of your conversation in case there’s a future dispute.
Also, this is a resource guide for Americans. It might be helpful to folks in other countries, but it’s still written for Americans living and traveling outside of America.
As I said, this topic is complicated. But I’m going to try to make it as simple as possible by breaking it down into smaller pieces.
First, let’s define exactly what we’re talking about. I think there are four different healthcare concerns for American nomads.
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The Four Healthcare Concerns for Nomads
Medical Emergencies. You ate the wrong street food in Mexico City and got really bad food poisoning, and you’re now so dehydrated you have to go to the hospital. Or you’re in a terrible scooter accident in Bangkok. These things have all happened to Michael and me, or people we know, and if you’re a long-term traveler, things like this will happen to you too.
Medical Evacuation. What if you’re in a really serious accident — so serious that the local hospital can’t handle what ails you, and you need to be transported via ambulance or plane to a better hospital in a bigger city? Or what if you’re hiking in the Himalayas, and you have an accident, and you need to be transported to the hospital in Kathmandu via helicopter? What if you need to be sent all the way back to America?
This kind of thing is called “medical evacuation,” or repatriation, and it’s also happened to good friends of ours. Obviously, this is another kind of “emergency,” but I’m putting it in its own category, because I think it’s just that important. Remember this term — “medical evacuation” — because it will come up again.
A Regular Doctor for Overall Healthcare Issues. The way I see it, healthcare is about much more than just emergencies. Michael and I are two men in our fifties, and we both have specific ongoing medical issues and needs. Plus, we both now need regular cancer screenings, and we also both have several prescription drugs for different issues. Even without any major chronic issues, our healthcare is fairly complicated. And what about any new chronic issues that may arise as we age?
I say that an essential part of any decent “healthcare” is having an ongoing and consistent doctor or healthcare provider: someone who knows your unique health history, monitors your different issues, and keeps you on track with your various treatments and medications. The older you are, the more important this kind of thing is. And, of course, women and other folks may have issues that are unique to their sex and/or gender identity.
Healthcare Coverage Back in America. You left the country to travel the world. Go, you! But then two years in, you get cancer. You could stay in the foreign country where this was all diagnosed. But do you really want to? Your emotional support system — most of your friends and family — is back in America. Plus, your visa is set to expire in two weeks. Can you get a medical visa? How would you even go about that, especially now that you have cancer? And where will you live long-term? But going back to America isn’t so easy either, because — as I will soon explain — you can’t necessarily just fly back to America with pre-existing conditions and expect to immediately be covered by insurance there, even in the Age of Obamacare.
Bottom line? You may want at least some kind of catastrophic policy back in America.
Okay, so these are the four concerns of nomad healthcare as I see them. I think every nomad absolutely needs to understand and deal with at least the first three.
They all obviously cost money. How do you pay for them?
Here are your options, again as I see them, with the pros and cons of each one:
Options for Paying for Healthcare as a Nomad
Paying Out of Pocket. Many nomads choose to go without insurance of any kind, figuring that they can simply self-finance their healthcare needs.
Here is the thinking: healthcare is generally much cheaper outside of America. And it is! Depending on the country, foreign doctors and hospitals charge anywhere from one-third to one-twentieth what you might pay in America for the same treatment. Compared to literally the entire rest of the world, American healthcare is insaaaanely expensive.
So why not just gravitate to “cheaper” countries, hope for the best, and plan to self-finance in that country if anything goes wrong?
Two reasons: even “cheap” healthcare can be expensive if the issue is serious enough; bills can easily run a hundred thousand dollars or more. And are you planning on never visiting more “expensive” countries, like most of Western Europe? Japan? Australia and New Zealand? Plus, remember how I said to remember “medical evacuation” because it’s really important? Medical evacuation is expensive everywhere — possibly hundreds of thousands of dollars for that helicopter ride off the Himalayas. This can easily bankrupt you in a day.
You really don’t want to pay out-of-pocket for any healthcare in America, because you will be totally screwed. The rabies shots I had to get last year? It would have cost six thousand dollars in America without insurance; with insurance, it cost $1200.
Did I mention our healthcare system is insane?
Travel Insurance. This is the kind of insurance tourists buy before they leave on vacation, it’s inexpensive, and it covers most emergencies — and also, usually, medical evacuation. It also can include lots of non-healthcare benefits, like liability insurance, and trip reimbursement if your flight is delayed or canceled.
But there are important caveats: these policies typically only pay for emergency treatments, and also to get you back to America, where you’ll then be on your own again. And even if they do sometimes pay for some initial serious medical treatment — for cancer, for example — these are all temporary policies. This means that when your current coverage expires, anything that happened during that time can then be considered a “pre-existing condition” and cause denial of future coverage, even with the same company. These policies will almost never cover chronic medical costs. They also often have low-ish lifetime caps.
Worse, many of these policies often instantly become null and void if you return to, say, within a hundred miles of your home and — this is the most important caveat — the majority of policies require that you buy before you leave home. They obviously don’t want people getting sick on the road and buying insurance after-the-fact, which makes sense since so many people are unethical shits.
I know of three exceptions to this “buy before you leave” policy — Safety Wing, Genki, and World Nomads, three companies that cater specifically to nomads — and I’ll have more to say about them below.
Credit Card Travel Insurance. If you’re a long-term traveler, you should have a travel credit card. And most credit cards, especially travel ones, include some kind of travel insurance. The deal is, if you make a charge on your credit card, and you have an accident that’s related to that charge, you can make a claim.
One friend who was in a crazy-bad scooter accident in Bangkok? He quickly racked up $30,000 in hospital bills and had no idea how he was going to pay — until he realized that his brother had rented their scooters with a credit that included travel insurance. They made a claim, and the card covered his entire hospital bill.
This is obviously a limited benefit: what if your accident isn’t related to a specific credit card charge? What if the flight you purchased for your trip was two months ago?
Many cards also require that “the entire trip” be paid for with the credit card, and who knows how they’ll define that? And while some credit cards will pay to fly you home if you get sick, this isn’t the sort of serious medical evacuation coverage of traditional travel insurance. But even so, credit card travel insurance is a benefit that many travelers overlook, and it’s a great reason to pay for all major travel purchases via credit card.
Also, keep in mind that, like full-fledged travel insurance, there are non-health-care-related benefits — lodging for missed flights, reimbursement for stolen items, etc. The claims process can be insanely complicated, but I’ve been surprised by what they’ve ultimately covered for Michael and me. But be forewarned: the collision car insurance that credit cards offer? It’s usually restricted to North America.
One additional advantage to credit card travel insurance? Unlike a lot of travel and nomad insurance, it may cover medical mishaps even in America. But it cannot be stressed enough: this coverage is capped. Some cards limit their medical coverage to $2500, which is nothing in America.
International Health Insurance. I get very frustrated with most nomad health insurance articles, because they act like “travel insurance” is the same thing as “health insurance,” and it’s really, really not.
International health insurance is basically “health insurance” the way Americans think of it. It pays for all of your healthcare (minus exclusions and deductibles), except it covers you all over the world. And these are not “temporary” policies, which means you’ll have coverage as long as you keep paying the premiums, even if you get seriously sick. It also lets you have a consistent doctor.
But remember how the Obamacare banned insurance companies from denying claims based on “pre-existing conditions” — and how they also eliminated annual caps and lifetime maximums? Most international healthcare policies are not Obamacare-qualifying, which means they do deny based on pre-existing conditions, and they do have annual and lifetime caps.
In other words, you have to go through underwriting for these policies. Your health and age will affect the price, and certain pre-existing conditions may be excluded. Plus, there will be maximums.
Also, these policies do not usually cover healthcare back in America. They may provide a short-term “American” benefit, but to get full coverage back home, you must pay for this as an add-on or as part of the plan you choose. And you must pay for this in advance; you can never pay for non-American coverage, get sick, go back to America, and then immediately upgrade to a plan where you are covered in America too; they’re not idiots.
Companies that offer international health insurance include GeoBlue (which is Blue Cross/Blue Shield), William Russell, Cigna International, and Aetna. Oh, and Safety Wing and Genki are working on true international plans — not just travel insurance — that will be announced soon.
You can purchase international health insurance either through a broker (based on your American mailing address) or the companies’ websites, but the price is apparently the same, and the broker will answer all your questions. Answers in writing are best.
Obamacare Healthcare Plans. Most Obamacare plans do not cover healthcare outside of America. Still, you should research your options on the Obamacare exchanges, and/or get a free broker, especially if your income is low enough that you qualify for any kind of subsidy. The Obamacare subsidies have always been very generous for poorer people, and recent programs have made them more generous still.
There are residency requirements for Obamacare, but in many states, they’re so vague that you’re eligible even if you only keep a mailing address in the U.S. Depending on your subsidy and your premium, an Obamacare plan can make real sense even for nomads.
Yes, they have high deductibles, but they’re rock solid in terms of regulation, and you can sure you’ll be covered in the case of something serious happening and you need to return to America. The “silver” plans are far and away the best value, but if you’re only using it as a catastrophic policy, a cheaper “bronze” plan may be the way to go.
One massive advantage to an Obamacare plan is that it also enables you to have a permanent doctor in America with whom you can regularly consult for your long-term healthcare needs (and who can prescribe and monitor your medications). One annual wellness care visit is free under Obamacare.
Regarding Obamacare, some people think: “Why don’t I just wait until something bad happens, and then I can return home and sign up on the exchanges? No pre-existing conditions now, right?”
Alas, you can only sign up for an Obamacare plan during the annual year-end enrollment periods. Yes, certain “qualifying life events” will open the exchanges up outside of that enrollment period — and one of those events is moving from one state to another. But does being an expat or nomad and returning to your home state in America qualify — especially if you’ve been keeping a mailing address in that state? That’s been your “legal” residence, after all.
I’ve asked this question to several brokers in our home state of Washington State, and their answers have been, “No, your returning home probably doesn’t qualify” and “No, that definitely doesn’t qualify.” So far, I haven’t been willing to hang Michael’s and my entire financial future on such confusing answers.
One nomad friend found that moving back to America to a different state than before did qualify (in Illinois). But she wasn’t arriving in the middle of a medical emergency. My gut tells me that the law doesn’t allow you to wait until you’re very sick, then move to a different state so you can use that as a qualifying event; it seems like the law was designed to prevent stuff like this. But maybe I’m wrong. And anyway, keep in mind that you’d be doing all this in the middle of some medical catastrophe. And in your new state, you still might have no personal support system. Why not just stay abroad?
Meanwhile, President Biden has been much more generous in interpreting healthcare laws than the Trump administration ever was, and enrollment periods have been kept open much longer lately due to Covid. But Covid will not be here forever, and I’m not at all confident that a Democrat will necessarily be president in the years ahead.
Insurance Through Your Generous Employer. Yes, yes, you have a generous healthcare plan through your American employer that covers you anywhere in the world, and the company also allows you to work remotely. Well, la de dah for you! I hope this article reminds you how incredibly lucky you are.
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What Are Your Specific Options for Nomad Healthcare?
I laid out what I see as the four important concerns of healthcare for nomads: (1) emergency care, (2) medical evacuation, (3) a regular doctor for overall health issues, and (4) catastrophic coverage back in America.
And then I laid out the six ways you can pay for these different concerns: (1) out-of-pocket, (2) travel insurance, (3) credit card travel insurance, (4) international health insurance, (5) an Obamacare policy, and (6) a generous employer.
Here’s the bad news: except for a generous employer, there is no one of the six payment options that covers all four of a nomad’s important healthcare concerns.
But here’s the good news: it’s possible to mix and match the different methods of payment to cover all — or maybe just most — of your healthcare needs.
Here are different ways you can get all, most, some, or just a tiny bit of your essential nomad healthcare needs covered:
Full Coverage, Expensive Method
Get international health insurance like through a company like GeoBlue (Blue Cross/Blue Shield), William Russell, Cigna International, Aetna, and (soon), Safety Wing and Genki. This will cover your emergency care and medical evacuation.
Get a plan or add-on that will cover your ongoing and routine healthcare needs.
Get a plan or add-on that covers you in America. This is even better than catastrophic coverage, and you’ll then be fully covered for what I see as the four important nomad healthcare needs. If this is too expensive, you can lower costs a bit by choosing a high deductible (and paying out-of-pocket for minor mishaps).
Full Coverage, Inexpensive Method
Get nomad-specific Travel Insurance like Safety Wing, Genki, or World Nomads. This is relatively inexpensive — much less than full international coverage — and will cover you for emergencies and also medical evacuation.
Get an Obamacare Plan in America. Assuming your state allows you to be out of the country most or all of the year, buy a silver or bronze plan on your state’s exchange. This will allow you to have a regular doctor back home, and will also act as at least a catastrophic policy in case you have a serious illness and need to return to America.
If you qualify for any Obamacare subsidy at all, this is probably the cheapest possible way to get full coverage for all of the above four important nomad healthcare concerns. Without a subsidy, it’s probably cheaper to get international health insurance even with the America add-on. Your deductibles will probably be lower too, although this coverage won’t have Obamacare’s full regulation and protections. My sense is that people have no idea how truly remarkable these protections are.
This the method Michael and I use. We spend around $220 a month total for both of us (but we have a high subsidy).
Perfectly Respectable Coverage, More Expensive Option
Get international health insurance like through a company like GeoBlue (Blue Cross/Blue Shield), William Russell, Cigna International, Aetna, and (soon), Safety Wing and Genki with outpatient and/or preventative care features but without the America add-on. This can still be excellent coverage, covering three of the four important nomad healthcare concerns. And some policies will cover you for emergency treatment in America for at least a few weeks even without the America add-on.
For example, current Safety Wing travel insurance plans cover you in America for fifteen days out of every ninety day period (but you need to have have had ninety days of continuous coverage before you qualify for this). If you have a serious health issue, these fifteen days may enable you to make other arrangements, like trying to get on an Obamacare plan, which will accept you even with pre-existing conditions.
Another option in the event of a serious health issue is to stay in a cheaper foreign country until you can apply for Obamacare during the next open enrollment period back in America.
Perfectly Respectable Coverage, Less Expensive Option
Get international health insurance like through a company like GeoBlue (Blue Cross/Blue Shield), William Russell, Cigna International, Aetna, and (soon), Safety Wing and Genki without the America coverage, also without the outpatient or preventative care coverage, and with a high deductible. Again, some policies will cover you for emergency treatment in America at least for a few weeks, giving you time to try to get on an Obamacare plan.
Pay for routine or preventative care out-of-pocket in some cheaper country you make an occasional home base. This will enable you to have three out of the four important nomad healthcare concerns; the only thing you’ll be lacking is catastrophic coverage back in America.
Riskier but Very Inexpensive Coverage
Get nomad-approved travel insurance like Safety Wing, World Nomads, or Genki. This is relatively inexpensive — $50 a month or less, depending on your age — and will cover you for any emergencies and also medical evacuation.
Attempt to use credit card travel insurance for anything your regular travel insurance will not pay. Shop for the credit card with the best possible travel insurance, and charge everything you can on that single card. In this case, it’s definitely worth paying an annual fee on your card.
Plan to pay out-of-pocket for regular doctor visits to handle your ongoing health needs, preferably in some very cheap country. If you do have a serious health issue, plan to stay in this cheap country until you can apply for Obamacare, either through a qualifying life event or during the next open enrollment period back in America.
If you choose this option, be forewarned you’re risking financial catastrophe — and even more stress and anxiety — while in the middle of some serious, chronic, long-term health issue.
Very Risky Coverage But Free — and Better Than Nothing
Attempt to use credit card travel insurance for any emergencies or accidents. Shop for the credit card with the best possible travel insurance, and charge everything you can on that single card. In this case, it’s definitely worth paying an annual fee on your card.
Plan to pay out-of-pocket for expensive accidents, and also pay out-of-pocket for regular doctor visits to handle your ongoing health needs, preferably in some cheap country. If you do have a serious health issue, plan to stay in this cheap country forever, or at least until you can apply for Obamacare, either through a qualifying life event or during the next open enrollment period back in America.
If you ever do go back to America to visit, spring for a temporary catastrophic policy beforehand.
This is a very risky plan, because you’re not covered for medical evacuation, and you probably won’t be covered even for simple emergencies. But some of us are very poor, and this is literally free. And it enables you to put aside money for future mishaps. In short, it’s slightly better than nothing.
Incidentally, what about Medicare? Sorry, except for a few weird situations, Medicare pays nothing outside of America. But, of course, Medicare can serve as your coverage back in America, meaning you might only need a robust travel insurance policy while living and traveling abroad.
But Medicare is not my area of expertise, and I’m not (yet) the person to ask if you should keep paying Part A or Part B premiums.
And obviously, your situation changes if you become a permanent resident of a different country. I may write more about this in future newsletters, but suffice to say that the rules are different for each country, and many countries still require residents (or retirees) to have and keep healthcare insurance.
My Recommendations for Nomad Healthcare Insurance
I’ve researched many companies that offer insurance for nomads and other long-term travelers, and here are the ones I like. Michael and I use Safety Wing.
This company claims to be insurance for nomads by people who are nomads themselves. They offer travel insurance (which they call “nomad insurance”) and they’re in the process of creating a fuller international healthcare policy, which they will announce soon.
I like them because they have very basic and straightforward plans, and they acquitted themselves well during Covid. They’re also the cheapest of the three options listed here — but they’re also the least comprehensive.
This is the newest player in the nomad travel insurance game, and their product is strictly travel health insurance, not offering coverage for things like trip cancellation, or theft or loss of personal items.
Unlike Safety Wing, Genki has almost no overall pay-out limits or fewer exclusions, and they have a more generous definition of “pre-existing condition.” They also cover non-emergency illnesses that require treatment (but not preventative care).
Genki also has a much more generous standard “home country” policy for Americans: we are covered for emergencies in America for up to 42 days out of every 180 days, as opposed to Safety Wing, which covers only 15 out of every 90 days (and only after 90 days of continuous coverage).
Drawbacks? They’re a new company (although they’re associated with Allianz Partners and registered in the EU, with strong consumer protections). They also don't currently insure people over 50 — though that will change by the end of 2022.
World Nomads offers a more robust travel insurance policy. They also cover some extreme sports and riskier activities.
But remember, all three of these options are still just glorified travel insurance — emergency coverage, not full international health insurance. They do not offer any option for preventative care, which would have to be paid entirely out-of-pocket.
International Healthcare Plans
Check them out through their websites and/or talk to brokers. Definitely compare quotes and prices, because they will differ.
When Michael and I do shift to full international coverage, I will look very closely at both Genki’s and Safety Wing’s new (still-unannounced) full coverage policies, which I will compare to these other international plans.
Whew! Is your brain fried yet? I warned you this was complicated. But if you’re a nomad, expat, or long-term traveler, you are now a square peg trying to fit into very round hole.
But you’re not alone! And there are already some options for us square pegs, and there will almost certainly be more and better options in the years ahead.
In the meantime, drop me an email if you know something I don’t, and I’ll be happy to correct or update this article.
Michael and I will be writing future articles on this and other topics important to travelers, so if you’re not yet a subscriber to Brent and Michael Are Going Places, become one here. Paid subscribers will have exclusive access to more specific content (and, just as importantly, they’ll also support our time-consuming, research-intensive work).
Good luck and stay healthy!
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