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Carlie: Hey there, it’s Carlie with another episode of the Expat Focus Podcast. When you’re moving abroad, one of the things at the top of your to-do list should be sorting out health insurance, especially if you’re moving to a country like the USA with no universal healthcare system. So, where do you even start? What’s the minimum essential health coverage that you should have in the States? And what does a good health insurance plan there even look like? How much will you be out of pocket for medications? What would a trip to the emergency room cost you? And what health treatments are seen as extras in the USA?
To answer all these questions and more, Kate Lambon from Cigna is joining me in this episode. If you want to watch as well as listen to our conversation, you can head over to the Expat Focus YouTube channel, and don’t forget to subscribe. Kate, it’s lovely to have you on the show. Thanks so much for joining me.
Kate: Oh, it’s a pleasure. It’s a real pleasure. Glad to be here.
Carlie: We were speaking before we started recording about the fact that you’ve also lived abroad for quite a number of years and in a few different countries. So, can I ask a little bit about your own expat journey?
Kate: Yeah, of course. Yeah. So I spent…my first trip was, (well, my first trip away from home, I guess) was to Paris where I was working. Interesting decision. Paris is not the easiest place to live when you’re 18, which is how old I was when I left college. And you didn’t think about anything like healthcare or insurances or…it really was just all about trying to find a place to live that didn’t cost your entire salary at that moment in time!
Carlie: Blissful ignorance!
Kate: I know! Naivety, stupidity some might say. So, I was there for a year and while I was there, I was offered the opportunity to go and work in the United States. So, of course I took it, why wouldn’t you, you know? And in those days, because it was a year’s contract, they flew you business class, my how things have changed! So, at 19 I was flying business class to the States. And I worked in Nevada for two years across two different jobs. And again, it didn’t even strike me that I might need cover.
You know, you went there, you got paid a salary. I didn’t even ask if there was health insurance coverage. It didn’t…coming from the UK where the National Health Service has been there all my life, it didn’t even cross my mind that it might not work the same anywhere else.
I mean, complete naivety, stupidness, whatever you want to call it. And luckily I was actually pretty healthy the whole time there. I got pneumonia once while I was working in the States, which necessitated me to go to an emergency room, run some tests, find out what was wrong with me because I just couldn’t breathe. And I just paid for that out of pocket. I really didn’t understand anything about how life worked there.
Moved forward a few years and I went to (from America) I went to South Africa, so it all sounds very glamorous. It wasn’t really, but anyway, globe trotting for work. And there…there was again, I didn’t even contemplate the first time I was living in South Africa, because I’d been there twice, that I might need care. And it was only the second time I went back when their own healthcare system had completely disintegrated that the concept of having to have private medical insurance came and raised its head and suddenly you couldn’t do anything without having cover. And that was a real big eye-opener for me, especially because at that stage I had two small children that also needed cover. So yeah, that was a big sea change in how I thought and how I understood medical insurance worked and why it was necessary coming from a society that had never needed it.
Carlie: I think these days the attitudes towards health cover, even when you’re just traveling abroad are so different and in a…for the better. I know in Australia, for example, there’s advertising on TV all the time wanting you not to leave the country without making sure you have a health insurance policy. It feels like you’d be a little bit silly to take any trips without it these days.
Kate: Yeah, but I think there’s a huge difference between a travel health insurance, so, for a two week period or a three month period, versus someone who’s going to live and work abroad or is going to accompany a partner abroad where you need a much more detailed cover, I think is the way of saying it.
One that you know is going to cover anything and everything that you need. So if you have an ongoing chronic illness, if you’re diabetic or, you know, something like that, you want to know that the cover that you’ve got is going to cover…is going to enable you to carry on that care without issue, without dipping your hand in your pocket too much, that kind of thing. And I think that’s the difference between the two. And it’s something that most people don’t really understand or don’t think about.
So I mean, I’ve got some very close family friends who are in the early thirties who’ve come over here from South Africa. And because they had to stay…they came on ancestral visas, but they don’t have access to healthcare or anything here. And they couldn’t afford to take out private medical insurance. I mean, that’s all changed. They now have their indefinite leave to remain, but you kind of wonder how, you know, what position that puts you in. Of course, if there’s a massive emergency in this country, you’ll always get looked after. But it is quite interesting.
Carlie: And especially when it comes to the USA. We’ve all seen those headlines and those horror stories about the cost of healthcare. Quite frankly, it’s terrifying to me the thought of, you know, if I fall sick and need to go to hospital, I could end up, you know, paying thousands. What’s the first thing that expats moving to the USA should know about how healthcare works in the country?
Kate: I think the first thing: that it’s a legal obligation for everyone to have private medical insurance and private medical coverage in the USA, that contains at least what they call the minimum essential coverage. And that’s 10 areas that Obama actually, from Obamacare, brought in.
So, things like it covers pre- and antenatal basic birth control. It has to cover hospitalization, emergency room treatments, out of network if there is an emergency. It covers pediatric care for kids, including dental and vision, which are not covered for adults in the basic level of coverage. It covers prescriptive medicines. That will bring us onto another whole thing because they’re very expensive. Yeah, so that’s the minimum that you should have.
And in order to get that from your employer, you have to work for a company that’s 50 people or more, and you have to work for 30 hours or more a week, then the employer is legally bound to provide that basic cover for you. Then you need to look at your own personal needs and those of your family and work out if you need to top it up and how you need to top it up.
Carlie: In reality for most people, do you think that basic cover is enough or would most people be looking to top it up?
Kate: I think there is so much that’s not covered, like dental, vision. I think you have to ask questions like, what’s the copay? How much are you going to be putting out of your own pocket? On a basic plan, you’re likely to be putting quite a lot of extra cover in. What’s the flat fee limit that you have to pay? So, I think for most people you’d want to look at topping it up and broadening the scope of the plan and what it will cover. Yeah, definitely.
Carlie: Something I noticed when I was looking at those 10 essential health policy benefits is that mental health is included on that list. Is that surprising to you that they’ve included that as the essential…in the essential benefits list?
Kate: I think mental health has become such a big issue. It’s always been there, but I think post pandemic, during the pandemic…post pandemic, it is the hot topic on everyone’s list. And they always say that prevention is better than cure. So, no, I don’t…I’m not surprised anymore. Had you have asked me 10 years ago, I probably would’ve given you a very different answer.
Carlie (09:15): I’ve seen research that suggests as many as 50% of expats are at risk of mental health issues. I feel like that’s actually not very surprising.
Kate (09:26): No, I don’t think so either. I mean, if you look at sort of the top most stressful things anybody can do, you know, it’s marriage, divorce, and buying a house, sort of, not necessarily in that order. And if you look at expats who are leaving their family support network, their friends, their cultural community, if you like, and going potentially somewhere incredibly different with a different language, shops you won’t recognize.
I’ll take my little sister who moved to Hong Kong many years ago and, you know, she was really thrilled to have a very small Marks & Spencer’s food hall because it had recognizable food stuffs and wines that she loved and knew, versus all the little tiny independent Chinese stores that are very much part of life in Asia. So, I think it’s all of those things. It’s the leaving behind what you know, it’s the cultural nuances, it’s the lack of community.
All of those things make it very difficult to, you know, you get all this excitement about new job, new place, and you get there and sometimes the reality, you know, once the first buzz of excitement wears off, then suddenly you’re left with, “how do I find a doctor?” You know? “Who am I going to…where do I find a gym class or a pottery class” or whatever you happen to be doing, “how am I going to get my children if I’ve got them into clubs?” The stress levels must be absolutely off the chart. So not surprising at all.
Carlie: In my case, I had a little breakdown in the post office when I couldn’t post a letter successfully here in France!
Kate: Yeah, I mean, it’s hardly surprising. It really isn’t surprising. It just…and it’s usually those little things. It’s the straw that breaks the camel’s back, I think in those instances. Yeah. It’s not the big things.
Carlie: Definitely. I wanna talk about some other health practicalities when moving to the USA. Are vaccinations required?
Kate: They recommend some, so…and it would be nice to say that every state’s the same. They’re not. You know, you’ve almost got 52 different mini countries that have their own rules and regulations. You’ll find that some schools ask tetanus pertussis (which I’ve never heard of before), mumps, diphtheria, measles, polio and rubella, which are kind of standard across Europe as well.
Carlie: I feel like I got all these ones when I was at school.
Kate: Yeah, exactly. Me too. And I just…but some won’t, so they…in a lot of places you’ll find they’re recommended, but they’re not mandatory.
Carlie: What about (might be a really silly question) but what about rabies? Do you get a shot against that when you move to the USA?
Kate: They don’t ask for it. They don’t ask for it unless you’ve been bitten.
Carlie: I just know that there are dogs over there and I’m like, “do you need to, like, protect yourself against it?”
Kate: You know what you, it’s not an injection…I mean, back in the old days it was absolutely the most revolting injection that you could ever have if you’ve got bitten by a rabbid dog. I think it’s better these days, but I don’t think it’s something you’d offer up! Particularly. I think you put people off vaccinations for life!
Carlie: And how easy is it to find a doctor and transfer your health records from abroad to the US when you’re setting yourself up there?
Kate: Yeah, I think we all, we all look at those, don’t we? How do we find a doctor? I think the easiest way is to either get hold of the HR manager of the company that you’re going to and ask them for recommendations, or if you’ve got work colleagues or people that you’ve interviewed with or you’re gonna be working with, recommendations from them are always, I think, the first port of call.
And then your health records, the easiest way to do it is actually to get them all downloaded onto the NHS app on your phone, if you’re coming from here. If you’re coming from somewhere else, just ask for copies from your doctor and take them with you is the easiest way to do it.
Carlie: Right. And if you’re coming from a country where English isn’t the official language, I’m guessing you’d probably wanna get those translated to…
Kate: I think you’d want to get the crucial ones. Again, if you’ve got chronic diseases or you’ve had operations that people should know about, I’d get those done. But otherwise, you’re pretty okay.
Carlie: Otherwise you sit with your doctor for an hour. The first visit, “Let me tell you about my health history! When I was 12…!”
Here in France, the cost of most prescription medications are basically covered between the mandatory health insurance and the government’s public healthcare. Is that the same in the US or should you be expecting to be out of pocket for medication?
Kate: Yeah definitely budget for much higher bills. Nothing is government regulated in the States. It’s a free market. So you will find, for example, chronic disease drugs like diabetes, and I’ve mentioned it a couple of times because it’s so prevalent, upwards of $500 a month.
Carlie: Oh wow.
Kate: So yeah, I mean you can get most prescriptions filled just about anywhere. Grocery stores, department stores, drug stores, hospitals, clinics, but the cost of medicine is not cheap over there. And a lot of it you will end up paying over and above from your medical care. Yeah.
Carlie: This is, even if you have private health cover?
Kate: They will…so, again, it depends which…who you are with and it depends what policy you have and what you’ve paid for. Most of them will pay for a portion of it. If you pay for the top plan, you’ll probably find that most of it is paid for, most of it is covered within your plan. You would generally find there’s always a copay of some sort within the policies in the United States to pay out of pocket.
Carlie: I’m curious, Kate, especially if you are moving with a company to the States, are insurance policies very competitive? Like is there a lot of incentive for the employer to be offering you quite a good health insurance policy as part of your salary package?
Kate: I think it’s becoming more of a plus to a new employee to go somewhere that has a better insurance, especially given the costs of everything in the United States. I mean, I’ll take something like your ambulances are all private.
So, they can cost you anything from £500 to £5,000 a trip…$5,000 a trip, depending on where you are and which one picks you up when you need help. So, I think the same as everywhere, even in the UK now, people are looking for health insurance benefits as part of their package. So, I think having a good one is an incentive and it’s quite important.
Again, it’s different in Europe where a lot of the countries, most of the countries, have got a social system which works. But it’s still nice to know that if you want to have something done, you can get it done quickly rather than waiting for the system to actually do it in their own time. I mean, I had a partial knee replacement. Trying to do it through the national health system would’ve taken me a couple of years, and through private medical insurance, I got it done in a couple of weeks. That’s the difference.
Carlie: Definitely. My dad in Australia had two hip replacements on the public health system. And he waited 18 months to 2 years for each one. Yeah. So, definitely worth that health insurance premium sometimes.
You just mentioned ambulances before. What else should foreigners know when moving to the States about how things like 911 and the emergency rooms of hospitals work?
Kate: So each state regulates its own emergency services. As I said, they’re all privatized, to provide aid to anyone who needs it, obviously. 911 is a classic number for emergency and they’ll ask you what you want. And there’s numbers for poison controls and certain things as well that are good to note down before you go, and they’re all available on government websites, so it’s really useful. Apart from hospitals with emergency rooms, you can also have urgent care centers, and there’s 9,000 across the US.
They do things…they have physicians that will diagnose what’s actually wrong. This is if you can walk, you know, you’re not in an emergency where you need to get to hospital straight away. They’ll do basic laboratory tests, they’ll put together treatment plans and they can do basic imaging like X-rays. Those are really useful and really easy to get into and you’ll wait far less time if you can get yourself to one of those clinics rather than going to the emergency department if you don’t need to. So, I think that’s…those are the basic things about 911.
Carlie: I think I learned the number from 911 before I even knew 000 for Australia, just growing up with American TV!
Kate: Yeah, I think we all did. I think we all did.
Carlie: Kate, what about treatments that are seen as extras for health insurance? You mentioned for example, that for adults, I think it was dental and eyecare and not covered as part of those, you know, basic health rights.
Kate: No, those are…and they are…they can be really pricey. Those are two that I would always probably add to a policy. A dental examination, depending again, where you are and who you go to, can cost anything from $50 to $200. X-rays, the same. Fillings, anything from up to $200 a filling root canal $700, removals up to $300. And that’s just basic care.
So, if you go in for a clean and you need a filling or an extraction, if you don’t have cover, you’re gonna walk out having paid $500 or $600 for one visit. And if you’ve got a family, it’s prohibitive. So, those are the one thing that I would definitely add. And the same with eyecare, because again, it’s all privatized. So, you know, spectacle frames aren’t so expensive, maybe $150, but basic lenses with anti-glare: $600. And that’s without paying for the examination costs and everything else.
And again, if you’re a family, if you are a family that requires, you know, that has more than one child that needs glasses. And again, with children spending so much screen time from a very young age, certainly in the UK, there is a rise in two and three year olds needing glasses, which is a horrifying thought in actual fact. Those are the two that you definitely need to add on. Children are covered, but to a certain age, you are not.
Carlie: I see increasingly ads on Instagram and Facebook, for example, for, like, online stores where you can get your glasses prescription filled or even now Invisalign like, you know, teeth straightening treatments that you can order online. Is that like a big thing in the USA in a way to get around some of these costs or would you not recommend it?
Kate : I think it depends on what kind of prescription your eyes are. You know, if you’re just getting to the stage where you, you can go into local Boots or Superdrug and buy a, sort of, 2.0 reader, then there are actually…in fact, I was speaking to an American the other day, she was wearing amazing glasses, someone I work with, and she said, “no, I ordered them from (and I forget the name of the company) and they’re really cheap and really fabulous…”
Carlie: They’re really stylish!
Kate: Yeah. And they’re stylish. Exactly. So I think if you have a straightforward need for a glass that just magnifies rather than correcting astigmatisms or anything else, then yes, they do exist there and you definitely can utilize them. I think you have to be careful. There does come a stage where those are no longer sufficient and you are going to need to go down the route of having an eye test and getting proper prescription glasses. They are a good hold all for a while, but they’re certainly not the long-term answer to healthy eyes and eyecare.
Carlie: It puts a bit into perspective for me too, why people in the USA will do runs to Mexico for health treatments and things like that, for example.
Kate: And drugs. Yeah, definitely.
Carlie: Yes. Those, too.
Kate: Prescribe drugs, prescription drugs! Let me make that clear. Prescription drugs! Yeah. It’s gonna be interesting to see what happens there with…there’s a number of bills being passed in the United States that we know about the anti-abortion lobby there and the overturning of is it…Roe versus Wade? Yeah. They’re doing a lot against the transgender community there at the moment as well. A lot of bills are going through that are very prejudicial.
Carlie: And now they’re looking at access to mailed abortion pills too, which is concerning.
Kate: Yes. So, I think all of those things are things to be taken into consideration within your circumstances and to see what kind of policy and cover that you’re going to need. And a lot of us don’t take into consideration things that are going on in the background legally and with different states that could color the kind of policy that you need or indeed whether you should be living there at all.
Carlie: I read an article on an expat website in France just the other day, which talked about how easy is it to get an abortion in France? And I thought, “oh, this is information that I actually have no idea about as a foreigner”. It’s something that I never bothered to look up when I came to the country, and yet it’s something I should probably be aware of, you know?
Kate: Yeah. And I…you’re right, it’s not something that I would ever have thought to look up and I think for good…for better or for worse, social media has made access to what’s going on around the world a lot easier, and if you see something you want to dig deeper, Googling, you can pull up just about anything that’s going on over there. When I looked into the transgender stuff that was going on, I mean, literally there were pages and pages and pages of different bills going through in different states, some being…not (thank God) going through in others, but yeah, it’s advisable to do your homework before you go anywhere, I think is the fundamental there.
Carlie: Kate, I’ve been trying in vain in Australia, in the UK and France to get treatments like massage, needling included or a little bit, you know, covered by my health insurance. Do I have any chance of getting those sort of treatments even partially covered by health insurance in the USA or is that just completely, what’s the word…?
Kate: Pipe dream? Wishful thinking?
Carlie: Completely, like, superficial medicine. Not required.
Kate: Yeah, no, you know what some of them are and some of them aren’t. And again, depends what state, it depends what policy you’ve got. But you’ll find that some specializations like aromatherapy, nutrition are practiced by highly licensed therapists. And depending on the license that they hold, you find that those…you’ve got…stand a good chance of getting those through on your policy depending on what you’ve got.
Carlie: Maybe even botox?!
Kate: No, unfortunately not! Even things like massage, tai chi, yoga and acupuncture are rarely covered. No, I don’t know why nutrition and aromatherapy are and massage isn’t. But yeah, those two generally you can…you will get covered on. And again, you might find you’ve got policies where they give you like a savings pot where you can use it for whatever. So, I know our policy has a pot that we can use for various things like counselling, or sports nutrition or, you know, you can choose how you use it within that limit.
Carlie: Finally, Kate and I did sort of ask this question before when it came to employers and the competitiveness of health insurance policies. How competitive are health service…health insurance providers? You know, are they really trying to get you on a policy or do they have good deals to get you to sign with them in the USA?
Kate: I don’t know about deals. I think again, it comes down to your needs. You have to have it in the States. You really do. There are no other options. So your Obamacare or you’re affordable basic 10 will be the least that you can buy into. But I think there’s things that you need to look at your premiums. So, what is it going to cover? What is the fine print? You know, be really, really careful that what you need is what you are actually going to get with what you’re paying for.
Deductibles: find out the maximum amount that you’re going to have to pay before the insurance company begins to take on the rest, because that’s not your copay, deductibles is different. Then you’ve got your copay, which is a specified amount, usually $25 or less that you’ll be required to pay on everything that you do for visit to the doctors, prescription drugs, stuff like that.
So then lastly what you get is the flat fee, which is an agreed upon sum that the insurance will cover usually for your routine visits and things. Anything above that you’ll have to also pay. So, you have to be really careful because there’s lots, you know, you’ve got a deductible here, you’ve got a copay here, you’ve got a flat fee and if you go over that, you pay that as well. And I think that’s where a lot of people get caught out. And I think that’s where you can…it looks like you’re getting a bargain, but in actual fact you end up probably paying more than you would’ve done if you’d have taken a slightly more expensive premium upfront that covered more.
Carlie: Is there help available to help you decipher all of this? Can you call your insurer and speak to someone and say, “can you just give all this to me in plain English and help me understand for this upcoming surgery or procedure, how much is covered, how much I need to pay?”
Kate: Yes, there should be. The client care managers who you would be put in touch with, for example, if you were about to go in for a procedure, would absolutely be able to break that down for you. Again, I’ll just use the example of when I had my knee done a year ago. It was like, “you’ll need to pay the £100, which is your copay for the year.” It’s the first time I’ve had anything done in years, but, you know…“This is what will happen. This, you’ll leave the hospital with this, you’ll pay absolutely nothing else.” And I didn’t, that was it.
So…and she was really, really good at telling me what would be covered in the hospital, what they paid for, you know, as long as the surgeon and the anesthetist didn’t charge more than a certain amount, then it would be covered 100%. Anything over that limit, then I would have to top up. But yeah, so it was all…there should always be someone that you can call at your insurance company and the other person, if you’ve got your policy through a company, is your HR manager should be able to explain it all to you as well.
Carlie: Kate, obviously Cigna is one of the options that expats can explore when they’re looking for health policies in the States. So where can they go to find some more information?
Kate: So, we’ve got various sites. So, cigna.com is the US mother site, if you like, where you’ll get all the details about what’s available within the US specifically. If you are an expat, then I would…if you want just some more general information about health services and wellbeing, not just in the United States, but also in France, Canada and Spain, we’ve got a lovely expat site called Inside Expat Health.
And if you Google that, you’ll actually get straight onto insideexpathealth.com, which has some lovely PDFs you can download, which tells you more about the health systems and services in those countries along with wellbeing options, which are quite cool. And all the information that we’ve gathered on those sites is from expats living in those countries. So, it’s their journeys, their stories, what they found out. And it’s really, really useful place to visit as a first stop. And then cignaglobal.com if you are in the UK or in Europe and you want to explore other policies with us.
Carlie: Well, Kate, it’s been a pleasure to speak to you today about health insurance in the USA and your different options and what you should know. Thank you so much for coming on the show.
Kate: And thank you very much for having me. It’s been a pleasure.
Carlie: That’s it for today. You can find out more about health insurance options for expats over on our website, expatfocus.com, and roll back through our podcast archive for more conversations about looking after your health and wellbeing when living abroad. I’ll catch you next time.