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What You Don't Know Can Cost You Vacation Illnesses

THE BALTIMORE SUN

You're headed for a summer villa in the English Lake Country. You're packing the bags for a week at the beach. You're getting ready to introduce the children to Paris.

Seasoned travelers always remember to bring toilet paper to Asia, detailed road maps to Cancun and an extra water supply for California's Mojave Desert. But has anybody thought about packing a health insurance card?

In an era of managed care, when health maintenance organizations dictate who you see and when and what for, and refuse to pay up when you break the rules, now may be the time. Managed care is supposed to reduce the price of health care. But unless you pay attention to the rules, it could increase the price of your vacation.

The basic rule of managed care is familiar enough: Turn to your primary care doctor first or you'll pay extra, sometimes even the whole bill.

So what happens when you're on vacation and your doctor is thousands of miles away?

"My bottom-line advice is to call your HMO before you go," says Don White, spokesman for the Group Health Insurance Association of America, which represents HMOs.

"Tell them where you are going. Different HMOs handle it differently. Find out what the rules are -- that's the single most important thing," he says. "Some HMOs have agreements with other HMOs in areas where they don't have their own doctors."

Until the 1990s, when traditional health insurance held sway, a traveler who became ill abroad needed only to ask the U.S. Embassy for a list of doctors or hospitals. Once home, the traveler had the bill translated into English and presented it to his or her insurance company for reimbursement.

Today there are trans-Atlantic phone calls and medical conferences involved.

First, two bits of good news:

Serious illnesses while on vacation are rare. Blue Cross and Blue Shield of Maryland, for example, which insures 1.3 million people, handles a traveler emergency only once in two or three months.

Second, when emergencies do come up, they tend to be covered anywhere in the world, by HMOs or any other type of health insurance plan.

Now the caveats:

* Many plans won't pay the whole bill as they do in the United States and won't pay for immediate follow-up care, including required medications, unless the patient returns home.

* Medicare won't cover health emergencies outside the United States at all -- unless you happen to travel along the Alaska Highway through Canada on your way to to Alaska.

* Typically in emergencies, patients have to pay up at the time of service, even if the bill runs thousands of dollars. Hospitals in some countries won't discharge patients until they pay in cash -- "which means you stay an extra day waiting for money to be wired," says Guido Adelfio, whose family owns Bethesda Travel Center. "It can happen."

In such an instance, it pays to have easy access to money by wire -- some travelers deposit it with relatives ahead of time -- a travel insurance plan, or a credit card, such as the American Express Platinum Card, which carries extra health insurance and medical assistance as long as you also charge your trip. Here again, check the rules. Pre-existing medical conditions may be excluded, which makes credit-card insurance worthless for some people.

Once you are able to return home, fill out a claim form and send it to your HMO. This is the only time HMO members ever file a claim. Emergency medical care is similarly reimbursed by preferred provider networks and other forms of managed care as well as by traditional indemnity companies.

"People worry about it, but here's what they should remember: Take their health insurance card with them, bring back all their receipts, and if you are in a managed-care program, have somebody notify the insurance company within 24 hours," says Robert Gallen, chairman of GF Capital Insurance Services Inc., a San Francisco Bay Area broker that handles health insurance for the international adventure company Backroads of Berkeley and other large business clients.

Emergencies could include things like an ear ache, a severe stomach cramp, a diabetic who goes into shock, a concussion, or stitches required when a child steps on a piece of glass at the beach. Many companies also pay for transportation home to continue medical treatment.

"You could have had a bad pizza and you think you are having a heart attack," says Kevin O'Neill, senior vice president of Chesapeake Health Plan. When such a patient winds up in the

emergency room, he says, "we do pay for that."

The catch

OK, so you can enter an emergency room anywhere in the world complaining of chest pains and your care will be covered -- at least under the same rules as at home.

Here's the catch: Follow-up care may not be covered. It is up to the patient or a family member to call the insurer within 24 or 48 hours so that doctors can review and direct the quality and cost of care. Otherwise, the insurer may not pay subsequent bills. "The HMO has a right to say, 'You got your emergency service, now come home,' " says Merle Kaplan, a broker for El-Mar Associates, a Baltimore insurance firm. "And in some case, they decide what is an emergency. They may decide a broken bone that doesn't need to be set is not an emergency and they could say 'come home.' "

Insurers can also direct patients to a different hospital or health care facility.

Another catch: You may have to pay extra for using a doctor outside the plan's network even though you are traveling and your own doctor isn't accessible. Try finding an Optimum Choice provider in Albania. Who's on call for HealthPlus in London?

Whether and how much you pay depends on the benefit plan rTC your employer chooses, says Paul E. Dillon, senior vice president and treasurer for Mid Atlantic Medical Services Inc., whose managed care plans include Alliance, Optimum Choice, and M.D. Individual Practice Association.

When his own child came down with an ear ache on a family vacation in the Outer Banks, Mr. Dillon says, "We called our primary care physician and we said, 'Hey, we're here in North Carolina, what do we do?' We went to a 24-hour urgent care facility," he says.

Instead of paying a $10 co-payment, Mr. Dillon says, he paid $50. "It's a higher payment to deliver that care at a 24-hour facility," he said.

Most managed care plans issue identification cards containing an 800 number and the number of the patient's primary care physician. That's the card to keep with your passport. When to use it depends on the insurer.

Cigna, for instance, doesn't require members to call their doctor before obtaining urgent care from a doctor or clinic when traveling overseas and doesn't charge patients extra for using out-of-network doctors, the company says. But the insurer won't pay for what it considers unnecessary services. A stomach ache, yes; a battery of tests on the child that can wait until the patient returns home, no.

U.S. HealthCare covers follow-up care only when the person returns home and is treated by his or her regular physician.

Blue Cross of Maryland doesn't charge members extra to use out-of-plan doctors in emergencies, but when the bill comes in, it applies its usual "what's reasonable" rule.

In all three instances, the traveler could be left with a larger-than-usual bill for health care or lose money because he or she has to return home early.

A private doctor

When Melvin Fink broke his leg in Cancun, he says, he was taken to a private doctor instead of a hospital. He tried to give his Blue Cross card, but the doctor insisted on taking his Visa card instead. The bill was $500, and when Mr. Fink submitted it back home, he got "Baltimore rates. The doctor cheated me," he says.

For this reason, Mr. Fink and some other travel agents recommend additional medical travel insurance, which provides immediate payment to providers.

"Overseas, clinics want cash," says Julie Hawk, manager of Holiday Travel Bureau in Catonsville. But when customers come home and submit the bills, she says, "not a lot is covered."

For instance, air ambulances for older travelers. Ms. Hawk says a friend of hers who broke a hip while getting off a plane in San Antonio recently spent $5,000 to get home. Overseas travelers on Medicare almost always have to purchase additional health coverage, which ranges from a daily rate of $5.50 to $84 for the whole trip.

But those who buy Medigap insurance from Blue Cross of Maryland actually are covered overseas at the same rates Medicare would pay domestically, Blues officials say.

The Blues also are developing an international directory of hospitals to treat Blues members. Members should check with Blue Cross before they travel for a list of providers who agree to take Blue Cross rates.

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