BajaNomad - Medicare in Baja

Medicare in Baja

oxxo - 3-20-2012 at 06:04 PM

I have elected to use Kaiser Senior Advantage for my Medicare coverage. KP is my primary provider. I pay nothing for this coverage other than the $100 taken out of my SS check every month. Although I have a California address, I spend almost all my time in Baja. I asked KP what would happen if I needed medical care in Mexico. Would I still be covered? They told me that they would not cover routine medical care but they would cover any "emergency" medical service in Mexico. I agree that routine care should not be covered, but the definition of "emergency" bothered me.

Well the unthinkable happened! Recently I had to go to Amerimed in San Jose with a severe medical problem. I spent one day in the hospital including an overnight. They were able to fix me in a professional manner. The total bill was US$820 for everything - hospital, all doctors and specialists, ultrasounds, etc. I thought that was VERY reasonable. I paid the hospital in cash and received all receipts, diagnosis, test results, and supporting documents (all in English). I sent everything in to KP in California........and hoped for the best. Today, I received a reimbursement check from KP for US$770 ($820 minus $50 deductible). No questions asked and no run around! I AM ONE SATISFIED CUSTOMER!

KP told me if a future problem is serious enough and needs medical attention in California (heart attack for instance), they will make arrangements for and pay for air evacuation! Based on this last experience, I believe them!

[Edited on 3-21-2012 by oxxo]

Bajatripper - 3-20-2012 at 07:00 PM

Nice to hear some good news about our overpriced medical coverage, oxxo.

tiotomasbcs - 3-21-2012 at 07:21 AM

Glad you are feeling better--fixed up! Great news for those of us living in Baja esp BCS. I will qualify soon for Medicare and will fill a major concern living here. Thanks for sharing. Tio

SFandH - 3-21-2012 at 07:45 AM

Significant news! Glad you're fixed up. Does the paperwork KP provided with the policy address care in foreign countries?

Expats vs. vacationers?

I'm going to have to dig into this.

Thanks for posting.

Three things

bajaguy - 3-21-2012 at 07:55 AM

1. "I have a California address"

2. "Emergency"

3. Depends on the Medicare carrier (KP)

Hook - 3-21-2012 at 08:08 AM

This is not an uncommon occurrance over here, when using the fine CIMA hospital in Hermosillo. Most US plans happily pay the amount that is often 50-60% less than the cost in the US.

Pescador - 3-21-2012 at 08:44 AM

Ok, but be careful, most of the medicare supp. plans have a requirement that you are not out of the country for more than a limited amount of time. You always need to report that you are traveling here for vacation when you get sick or need something and not that you live here.
Common sense would dictate that you would get good care for a reasonable cost here, but it is still an out of pocket expense for Kaiser whereas if you go to their facility, all the doctors and medical people are on a salary.
Another novel thought would be to read your policy for Medical coverage when you have a little spare time.

Santiago - 3-21-2012 at 09:33 AM

Quote:

Originally posted by Pescador
Another novel thought would be to read your policy for Medical coverage when you have a little spare time.

vandenberg - 3-21-2012 at 09:36 AM

Quote:

Originally posted by Pescador

Another novel thought would be to read your policy for Medical coverage when you have a little spare time.

...and don't miss the fine print..... :lol:

oxxo - 3-21-2012 at 10:55 AM

Quote:

Originally posted by SFandH
Does the paperwork KP provided with the policy address care in foreign countries?

Expats vs. vacationers?

Yes, the policy does address this. It says essentially that if you have a medical emergency anywhere in the world, get yourself to the nearest medical treatment for services and they will pick up the cost.

They don't care if you are an expat or vacationer. I discussed this with them. I told them I was an expat. They said they didn't care as long as it was an emergency. They won't cover routine medical care in a foreign country.

vacaenbaja - 3-21-2012 at 11:00 AM

Kaiser must have been pleased/shocked at the unbeatable "nice price"they were charged for the professional services that you received. They managed to
keep their cool enough not to forget your deductable!
Great news that you were able to get reimbursed at the
highest level.

oxxo - 3-21-2012 at 11:06 AM

Quote:

Originally posted by Pescador
Ok, but be careful, most of the medicare supp. plans have a requirement that you are not out of the country for more than a limited amount of time. You always need to report that you are traveling here for vacation when you get sick or need something and not that you live here.

Yes, that is true for many Medicare supplemental plans, but Kaiser Senior Advantage is the exception.

My full time neighbor, Carol, just moved back to the States for this very reason. Her Medicare plan (not Kaiser) required that she return to the States every 6 months and report in. She was having frequent serious medical problems in Mexico and her plan would't pay for her care because she was a full timer. She finally gave up and moved back because of health issues and having virtually no coverage even though she was paying a Medicare supplement premium of around $400 per month.

I return to the US a couple of times a year for "doing stuff" and that is when I have my routine medical taken care of. I can make my appointments on-line in advance while in Mexcio and I am good to go for an appointment as soon as I arrive.

Research all the plans carefully.

MitchMan - 3-21-2012 at 12:39 PM

Good research and good info, Oxxo. KP is definitely in my sights if my current medicare advantage policy doesn't work out. I use Health Net. My father-in-law is getting excellent care at KP and they built a big new facility close to me in So Cal.

estebanis - 3-21-2012 at 02:45 PM

Thanks for this Thread! Guess this is one reason for settling in Northern Baja when I retire with my wifes chronic issues. Sure will miss that tropical sun...
Esteban

Iflyfish - 3-21-2012 at 04:42 PM

Thank you so much for sharing this with us. I started a thread a while back on Medical Care in Mexico and this is a very important piece of the puzzle. I too have Kaiser Senior Advantage and it is top notch.

Iflyfish

Pescador - 3-22-2012 at 07:00 AM

For those who live most of the time in Baja and have another program in the United States, one of the things you might wish to consider is signing up with Seguros Popular which usually runs about $100 a year and covers basic medical treatment. It does a very good job with things like lab tests, diagnostics, and the like and acts as a good supplement to your US Coverage. It is not a panacea for coverage since there is a lot of private medical care in Mexico but for general coverage, I think it does a pretty good job of what it was intended to do.
As far as coverage in the United States is concerned there are several ways to go. Some elect to use HMO's or Health Maintence Orginizations like Kaiser for their services. That is a good option but it does limit you to seeing mainly their own doctors and staff. Again, that is a good option for most treatments but when you get into really specialized things where you might need treatment at Sloans-Kettering or Mayo clinic, you will normally be disappointed and unable to get into the more specialized clinics. It sometimes happens, but the HMO has to pay out of their operating expenses for you to go out of system and it normally does not occur.

The second type of coverage is with a PPO or a Preferred Provider Orginization which means the Insurance company has a contract and agreed upon rates for each procedure or treatment and the Doctor, hospital, and staff have agreed to those costs ahead of time. Again here, it is a limitation of providers who have agreed up front. This may or not mean limitations of services. For example, Blue Cross and Blue Shield is one of the largest PPO's in the country and most doctors and hospitals have discovered that it is necessary to agree to their rates and costs in order to get enough people in the door.

The final type is coverage anywhere anytime but with the rapidly rising costs of healthcare, this is almost a dinosaur and non-available anymore. There are a few remnant plans out there that do this but you will almost always find a "Reasonable and Customary Clause" that means the insurance company will only pay what is predetermined to be "Reasonable and Customary" and that usually means below what the Doctor and Hospital is willing to accept so you end up paying the difference.

about Mexico's health care

Mulegena - 3-22-2012 at 07:10 AM

Remember, you'll be responsible paying up-front before care, and you will be waiting your turn for non-life threatening care, including emergencies. I think we could venture to say Mexico's healthcare system is a form of socialized medicine.

You'll need a private attendant at your bedside 24/7. The hospital staff is minimal. On discharge, you're responsible for obtaining wheelchairs, crutches, etc.; they're not provided.

Seguro Popular is very limited in its coverage which means that even if you have membership, if your needs are not within their scope of coverage you'll still be responsible for payment up-front (which might run into thousands of US dollars).

All this being said its great that Kaiser P. offers a reimbursement option for "emergent" needs out of country.

[Edited on 3-22-2012 by Mulegena]

Alm - 3-27-2012 at 01:06 PM

Quote:

Originally posted by Pescador

The final type is coverage anywhere anytime but with the rapidly rising costs of healthcare, this is almost a dinosaur and non-available anymore. There are a few remnant plans out there that do this but you will almost always find a "Reasonable and Customary Clause" that means the insurance company will only pay what is predetermined to be "Reasonable and Customary" and that usually means below what the Doctor and Hospital is willing to accept so you end up paying the difference.

Doesn't look like Ihi Bupa is going the way of dinosaurs. I also wouldn't worry about Mexican treatment cost exceeding "Reasonable and Customary" cost - it's usually half or less of what it costs in the US. Premiums of Bupa and similar insurers are terribly high, though.

Edit - PS:
with "reasonable costs" clause they would probably pay $800 on $1,000 bill from Mexico because this is in their opinion "reasonable" in this area, even if it costs 3 times more in the US. $200 difference covered by the client wouldn't be disastrous, but there is another problem with Mexican healthcare. With only 4 real hospitals in entire Baja, chance of getting a proper care is a hit and miss. Air evacuation to SD would've been my first choice, if only the condition would allow me those 12-15 hours.

[Edited on 3-27-2012 by Alm]

durrelllrobert - 3-28-2012 at 08:48 AM

I have also had extraordinary luck with KP reimbusing me for emergency care in Baja. Once I submitted a bill in $mn and the reimbursed it (less percription drugs and equivalent hospital co-pay) in $US. Of course I brought this to their attention :spingrin:

durrelllrobert - 3-28-2012 at 08:51 AM

Quote:

Originally posted by Alm

With only 4 real hospitals in entire Baja, chance of getting a proper care is a hit and miss.
[Edited on 3-27-2012 by Alm]

There are more than 4 in Ensenada alone.

DianaT - 3-28-2012 at 09:05 AM

Thanks Oxxo,

With our retirement we have the option for Kaiser, but I need to check to see if it can be the primary or just a supplemental.

I especially like the evacuation part as our current insurance will not pay.

Hope you are now in great health!

oxxo - 3-28-2012 at 10:44 AM

Diana, sign up for Kaiser Senior Advantage and it will become your primary carrier. If you have a SoCal mailing address, there is no additional charge other than what Medicare takes out of your SS check (around $100 per month each). NorCal is in a different district and their policies and pricing may differ.

I know of 4 good hospitals in San Jose alone - one public, the others private. The private hospitals are about 25% or less of the cost of a hospital in the US. The public hospital in San Jose is not one I would recommend.

And I feel great, especially knowing that I am protected from the "big one" while in Baja.

Alm - 3-28-2012 at 01:10 PM

Quote:

Originally posted by oxxo
I know of 4 good hospitals in San Jose alone - one public, the others private. The private hospitals are about 25% or less of the cost of a hospital in the US. The public hospital in San Jose is not one I would recommend.

Right. There is more than 4 hospitals in Ensenada, the question is if any of them is worth going to.

Quote:

And I feel great, especially knowing that I am protected from the "big one" while in Baja.

As long this knowledge makes you feel better... I recall a story of a guy who had a "big one" in Ensenada. There was - don't remember, 20 or 30 hours wasted in Ensenada - and eventually, thanks to efforts of his wife and because he was so close from the border, they fixed him in SD. Not because they were unable to - they just didn't do anything in Ensenada. Which means, they were either unable or unwilling, all the same to me. Quite an eye-opener.

[Edited on 3-28-2012 by Alm]