By Michele Scheib
Do these scenarios sound familiar? An international student turns down a fellowship to study in the United States. An education abroad program decides to send a student home. An American college student planning to study in Australia has run out of options. In each case, the student has a disability and the situation involves lack of health insurance coverage for what the student needs to maintain or manage his/her condition while abroad.
In the past year, the National Clearinghouse on Disability and Exchange has talked with insurance providers, international exchange professionals, and individuals with disabilities to identify such issues and find solutions.
Disabilities represented in the real-life scenarios above ranged from regular treatments for a chronic condition to daily assistance for limited mobility to mental health counseling. In all cases, the resources the student had to cover these costs at home did not apply overseas, and the accident and sickness travel insurance policy excluded pre-existing conditions or related services.
These are not isolated issues. Of several hundred college students with disabilities surveyed who have studied or plan to study abroad, a fifth use disability supports often or very often, and 39 percent have either a mobility disability or mental or chronic health condition (National Survey on Student Engagement 2006). Similarly, almost a third of the 63 international students with disabilities responding to the survey reported mobility, mental or chronic health disabilities.
Education abroad, travel insurance, and international student professionals need to take steps to plan for exchange participants who currently fall into coverage gaps. The most effective way to eliminate problematic situations described above 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.
Overview of Health, Insurance, and Disability
Disability and health should be considered separate issues. Most people with disabilities are not unhealthy or sick, and can actively participate in overseas study. By law, exchange program participants with disabilities are eligible for coverage under traditional group insurance policies. In contrast, individual insurance plans can increase costs or deny enrollment based on health status.
If an institution or agency offers health insurance for participants, there are two major items to consider regarding coverage for people with disabilities:
- Pre-existing conditions or mental health exclusions 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.
- Medicaid coverage does not remain in effect while traveling overseas nor is it available to international students studying in the United States, and certain services these plans cover, 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. 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 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?
The costs of removing pre-existing condition exclusions can be affordable for an education abroad program's group travel insurance plan and institutions offering international student insurance. It also avoids the risk of having to pay for and manage a potential medical crisis if the participants are not covered, according to Julie Friend, International Analyst for Travel Health, Safety and Security at Michigan State University (MSU). By working with the assistant risk manager to expand coverage and eliminate exclusions, MSU's travel insurance policy increased less than 20 cents per student per day (International Educator 2008 Supplement).
For international students coming to the United States, university student health care, if offered, may not be sufficient since that coverage is determined based on a demographic profile of relatively healthy young people. Additionally, nonimmigrant international students cannot receive public assistance despite having qualifying disabilities, with the exception of federal Emergency Medicaid.
When the Illinois Institute of Technology began mandating international students to be on its institution's insurance plan, it worked with its insurer to exclude the pre-existing conditions clause for international students coming from countries with national health plans. "The numbers came in and, for the first time in several years, we were not looking at a significant increase in premium," said Vickie Tolbert, administration and operations manager (Spectrum, Spring 2006).
Additionally, it may be advantageous to join with an affiliated institution or similar organization 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.
How would an organization or institution advise students with disabilities if it opts to allow or require participants to purchase their own travel health insurance?
If insurance is available through the overseas study program or host institution, participants electing to purchase their own insurance are 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 or institution. For J-visa holders, there are minimums for insurance coverage and repatriation defined in the J-visa regulations.
People with disabilities in the United States who have Medicaid are not covered while they are outside the United States. Fewer than 10 percent of U.S. undergraduates with disabilities are eligible for Medicaid, however, they primarily are students with mobility, mental and chronic health conditions so losing this coverage can be critical (National Center for the Study of Postsecondary Educational Supports). Students who enroll at universities in countries with national health plans may find they can get some of their medications or treatments at no cost or at costs less than in the United States if having to pay out-of-pocket.
If the student's existing primary insurance is not portable overseas and program or host country coverage options are unavailable, individual insurance Web sites such as Insuremytrip.com , Squaremouth.com, and Internationalstudentinsurance.com offer comparisons of various travel insurance options students can purchase. 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. An additional option not mentioned on these Web sites is iNEXT Platinum plans, which specifically covers pre-existing mental health conditions. The Web sites also mention major travel health plans that are designed for people working or living overseas; after deductibles and pre-existing condition exclusion waiting periods, these plans often include coverage of mental health, physical therapy, home health care and durable medical equipment. Examples of these major travel health plans include HTH Worldwide Global Citizen or MedEx TravMed Choice plans. These offer more coverage for U.S. citizens going abroad but not for international citizens coming to the United States.
Typically, pre-existing condition exclusion waiting periods for international students are one year or more after effective coverage. International students attending U.S. universities that require no more than a six-month waiting period can find some plans that will offer this option (see the InternationalStudentInsurance.com website). Utilizing health coverage from home or purchasing individual travel insurance plans in their own countries may have more to offer related to conditions like epilepsy or coverage for physical therapy or other services (for example, see Cover More Travel Insurance for residents of the UK, Australia and New Zealand).
What are some ways to assist a participant with a disability who uses a personal assistant or durable medical equipment (e.g., wheelchair, etc.) to think creatively about arranging for needs while overseas?
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 who cover pre-existing conditions may want to consider adding coverage for repair or rentals for existing durable medical equipment or hiring of personal assistants. If an individual is duct-taping a crutch or wheelchair or relying on informal assistance 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 flying with a personal assistant and other creative ideas on ways to fund personal assistants on exchange programs can be found on an online tipsheet by the National Clearinghouse on Disability and Exchange, which is sponsored by the U.S. Department of State and administered by Mobility International USA (http://www.miusa.org/ncde/tipsheets).
Including more coverage and less exclusions for people with pre-existing conditions in group travel insurance and student plans will alleviate some of the difficult health coverage, risk, and cost issues that exchange staff and students need to deal with during the program, and certain qualified individuals with disabilities will no longer be prevented from participating in international exchanges.
Michele Scheib is project specialist for the National Clearinghouse on Disability and Exchange, which seeks to increase the participation of and improve services for people with disabilities in international exchange programs. Learn more about its free information and referral services at http://www.miusa.org/ncde.