Updated November 2017
No matter how you look at it, healthcare, and specifically health insurance, is a headache. The US healthcare system, for all of its advancements, is painfully expensive and a complicated mess.
This is an update to our previous healthcare chapter to integrate in the added challenges and benefits of the Affordable Care Act (ACA – aka ‘ObamaCare’). This article is written with the intention to help others navigate the current healthcare system as a nomad, irregardless of anyone’s political opinion.
We love comments, and welcome yours – but please do keep them non-political.
The challenge is magnified for the self-employed. And then magnified to another level for people without a fixed home. Which makes healthcare an extra challenge for us working aged, often self employed, nomads.
This article is geared specifically towards US based working-aged nomads who are not eligible for Medicare benefits.
New: It’s open enrollment season for 2018. RVerInsurance.com has put out a FABULOUS guide to navigating it as an RVer. Lots of changes this year, including less PPO options. Shop carefully. Shop Wisely!
Also, the fabulous Nina of WheelingIt has put out her non-insurance agent look at the issue for 2018:
November 2014: Video chat overview with myself and Nina of WheelingIt.US on healthcare on the road (still relevant):
The Healthcare Problem for Nomads
The US health insurance industry has grown from a foundation of locally negotiated contracts between insurers and providers, and there are very few provider networks that are extensive enough to be considered nationwide.
Many healthcare plans don’t even cross county or state lines due to different accreditation processes and regulations that vary from state to state.
This localization presents a unique problem for those who are mobile.
Nomads have always had to shop carefully for plans that have access to a provider network that are in locations they are most likely to travel, and the ACA has added some extra complexities to this by tightening down provider networks to reduce costs. Nomads should pay specific attention to what a plan’s deductible for ‘out of network’ services will be, as they stand a higher likelyhood of needing to access care while away from a provider within their network.
Some insurance companies may offer a fairly nationwide network, but still only cover emergency services when outside your state of domicile.
Some nomads specifically will shop for the lowest premiumed health plan they can find, counting on (hopefully never) using the higher out of network deductible. After all, when it comes to attempting to isolate yourself from a $100k+ medical expense, the difference between an in-network $6,000 deductible and an out-of-network $19,000 deductible can still be a shield from a bankrupting medical encounter.
Aside from provider networks, the nomad must also shop for health insurance providers who will actually insure them. Some companies in some states actually require that the insured live at their “home” address for at least 6 months out of the year.
South Dakota, a frequent state selected as a domicile, has several companies with policies like this.
Another challenge nomads face is finding consistent health care while on the road. Unless they are frequently returning to a home base where they can keep their own cadre of providers for routine check-ups, more than likely they will be accessing healthcare with providers as varied as their locations.
The Healthcare Problem for the Self-employed
Many nomads are self-employed or taking a string of contracting & temp positions. Thus they are ineligible for the sorts of large group plans that are often accessible with more traditional jobs. Our current healthcare system evolved around insurance being an employer provided benefit, thus most of the current best options remain with larger group plans.
If you’ve been insured most of your life via your or a family member’s employment – you may not have ever needed to deal with the hassle of seeking out private insurance on your own. Thankfully this is one area that the ACA brings some relief, by making individual and small business plans more accessible with less risks.
For instance, now all plans must cover pre-existing conditions and some preventative services, which will open up a lot more options for those dealing with health issues to leave big corporate America and pursue independent income sources without worry of being able to obtain healthcare.
Larger corporate plans do still have a lot more clout that significantly reduces costs, and usually have lower deductibles, co-pays and attractive benefits like prescription drugs, vision and dental.
A member of a large group is less likely than an individual to have the insurer deny benefits when you need them most.
If you’re considering going nomadic and are able to take your existing “big company” career with you – look closely at your group plan. Unless you work for a company that supports workers in many locations, most of the plan options are likely to be regionally based. This is especially true with the more affordable group plans, such as HMOs – which typically only cover emergency services when outside of your network.
If you have a PPO or indemnity option, you may be better off choosing it to at least have some coverage for out-of-network providers. Even still, you may find that your company simply doesn’t offer insurance options suitable for a traveling lifestyle – and you too will be out shopping for insurance.
Healthcare options for US based nomads
So, you’re a nomad (or want to be soon) – you’re likely going to be facing both the nomad and the self-employed insurance problem. What are your options?
- For domestic nomads without an option of a group plan, seeking individual plans is a popular choice. The section below will go into more details.
- If you own a business, you may have options for starting your own small business group plan – shop around within your state to see if you can find a plan that gives you nationwide access more affordably than individual plan options.
- You may quality for or already belong to an organization that offers access to a group health plan, or a medical sharing plan, that could be worth checking out.
- Some organizations, particularly faith based ones, offer health sharing programs that aren’t exactly insurance – but can be an affordable way to go.
- Some domestic nomads working for a company have been able to keep their group plans as they travel.
- There are travel insurance policies that cover you while away from ‘home’ that might be worthwhile checking out as a supplement to plans that don’t cover you nationwide. Check out the policies offered by WorldNomads.
- Many are left feeling like they have little option than to go without healthcare insurance and planning to self pay for all their healthcare, and pay the penalties for not having coverage. Perhaps even traveling to other countries for access to lower cost care. This can be a big gamble as healthcare costs can quickly get you into substantial debt in the event of an unexpected major illness or accident. But there are many clinics, low cost options, ability to negotiate cash payments and grant options out there.
Individual Insurance Plans
Many of the US based nomads we’ve spoken to have gone this path, so we’ll address individual plans in further detail.
If you’re used to benefit-abundant group health plans, particularly HMOs where you have nice set co-pays for everything you might need, you’re in for a shock when you start shopping for individual plans.
Most individual plans will have a substantial annual deductible ($1000 – $6000 per person) that you pay out of pocket before any substantial benefits beyond basic preventative care kick in, making these plans the equivalent of older-style ‘catastrophic’ or ‘major medical’ plans designed to protect you from the big stuff.
Under the ACA, all new plans must now provide some basic included preventative services before your deductible is met – so things have improved here. The included services are rather limited however, such as only covering basic cholesterol screenings but not kidney and liver functions. And if you have an abnormal reading on a preventative test, future testing is re-classified as diagnostic for treatments – thus no longer eligible as included pre-deductible.
So do be prepared that you’ll be paying out-of-pocket for a lot of your routine care and should have funds accessible for your deductible.
Essentially, unless you are unfortunate enough to have a health situation that puts you over your deductible – you will probably be paying your premiums AND most of your routine healthcare costs. And that’s just not going to seem fair.
On the plus side, the premiums for this sort of insurance are generally much less than fancy plans that include lots of benefits – so if you’re not actually using a lot of health care, you could come out ahead. If you’ve been covered by an employer, you may not be used to seeing your full health insurance bill – so paying for insurance yourself is going to be a big ouch no matter how you slice it.
Since private insurance generally has high deductibles anyways, many of us have selected policies that are eligible for a HSA (health savings account). This is a tax advantaged savings account you can put up to $3,300 per year (for 2014) into for spending on most medically related expenses, even if not covered by your health insurance plan (such as dental check-ups, flu shots, laser eye surgery, etc.).
It’s similar to an IRA in some ways. It’s not like a flex spending account associated with employer provided insurance, in which you lose any unspent money at the end of the year. HSA’s roll over year after year, allowing your balance to grow. And all contributions to your HSA are ‘taken above the line’ (before deductions) on your taxes, effectively allowing you to write-off all of your health care costs without itemizing or having to spend a certain percentage of your net income on healthcare.
Not all insurance plans are HSA-eligble – they have to be higher deductible and not offer co-pays – so if that’s something you’re interested in, make sure they are designated as such.
Even if your insurance deductible is so high that your plan rarely pays for anything – the often over-looked benefit of having a health insurance plan is that it can increase your access to the healthcare system as a whole.
While an emergency room can’t deny you life saving care to stabilize you, providers CAN make obtaining non-critical care difficult if you don’t have an easily demonstrated way to pay.
Having an insurance card can be a golden ticket past all this hassle when you need it. And most plans have negotiated rates that you have automatic access to, rates that you wouldn’t otherwise if you were paying full rack rates.
Of course, if you have cash in hand – some providers are willing to negotiate their services to a point that may even be cheaper than the insurance negotiated rates.
You may need to do some extensive calling around to find a provider who will be able to give you a firm quote for a cash transaction however, so many are set up for dealing primarily with insurance billing.
So where do you find Individual plans?
Some of the private insurers many nomads we’ve talked to have selected include: Assurant, Humana, Aetna, Golden Rule, Coventry and Blue Cross Blue Shield. (This is not an endorsement for any of them – do your own due diligence and shop for your needs, and make sure the plan you select will cover you.).
You can use internet brokers like ehealthinsurance.com to quickly shop multiple insurers at once to get an online quote and start playing around with numbers, or you can go to each company’s website and get online quotes individually.
Formerly RVerHealthInsurance.com – now partnered with the Escapee’s & Xscapers RV Clubs, the RVerInsurance.com Exchange is a central resource for RVer specific insurance information. They have agents knowledgable and ready to help us RVers, and track the industry.
Many insurance agents can also quote you rates and get you setup if you prefer to not do it yourself. But make sure they understand the specific needs of your mobile lifestyle.
You’ll find the rates will vary given the zip code you’re rated at, so if you’re still settling on a domicile and legal address – comparing health care costs can be a deciding factor.
And some insurance companies have access to multiple provider networks which can change the rates as well.
And for us nomads, there are some key features that can make a plan more ‘nomad-friendly’ than others:
- A healthcare provider network with services in the most likely places you’ll travel – do a search on the network’s website to see if there are providers in areas you’ll be, and if they’re included outside of your state of domicile.
- A plan that does not have limitations on what they’ll cover when you’re away from your state of domicile – some may only cover stabilization after an emergency, or have limits on how much of your medical care can be acquired out of state.
- An insurer who does not have a requirement that you live in your state of domicile for a set amount of time each year.
- Telephone and/or internet access to doctors for basic diagnostics & prescription writing, like respiratory infections, can be hugely beneficial and reduce dependence on urgent care clinics. One such service included on some policies is TeleDoc.
- A patient advocacy or concierge service for assisting you in finding healthcare options when you need them.
When shopping around, you may need to look further than the basic benefits listed to find out if these things are included or not.
And no, the headache you’ll get from shopping for insurance will not be a covered incident under your new plan.
Affordable Care Act Considerations
A lot remains to be seen how the ACA will play out as it continues to roll out – a lot of things are still being implemented and definitely still confusing.
For sure, the ACA will do a lot to equalize the playing field between individual and group plans – meaning us non-corporate employed folks will finally have more options within our reach. For instance those with pre-existing conditions will be insurable if they decide to breakaway from their corporate jobs and go independent. I hope that will enable more folks to pursue nomadic lifestyles while in their prime working years.
Another part of the ACA is the creation of state level exchanges to purchase insurance through. A few states have opted to provide this on their own, but many are going through the Federal Exchange being managed via http://www.healthcare.gov (which has had its share of roll-out problems.)
If you’ll be eligible for subsidies for health insurance, the only way to redeem them will be through the exchange (RVerInsurance or an agent can handle all that for you too). However, many folks are finding that the offerings through the exchange are limited – particularly when it comes to provider networks that are nationwide enough to be useful to nomads. And out of network deductible have risen quite a bit on many policies, or have been completely dropped – meaning you could be left with quite a risk while traveling.
South Dakota, a very popular state for claiming as a nomadic domicile, seems to have very limited healthcare options available suitable for nomads, and none offered under the exchange. Add on top of that many of the insurance companies requiring you live at your home address 6 months out of the year – we may soon be seeing a lot fewer South Dakota license plate tags in campgrounds across the country.
You may find that in your selected state of domicile, there are not adequate nomad-friendly providers offered through the exchanges to make the subsidies worthwhile claiming. Or you may find that selecting another state will make much better sense in the long run, even if it does mean paying some additional state level taxes or jumping through additional domicile hoops to claim residency.
You may also consider optimizing your health insurance plan in a state you’ll be spending time in often enough to utilize it, and then supplementing your plan with travel insurance for when traveling away from home.
Carefully shop both the exchange and outside the exchange to find your best offerings.
As nomads, it’s a lot easier for us to move states than our sticks-n-bricks colleagues who have to go through escrow and physically moving. But with offerings changing so often, it does start to feeling like playing domicile whack-a-mole trying to keep up.
Handling Healthcare on the Road
One of the hassles of nomadic travel is keeping consistency in your health providers.
Unless you return often to certain locations frequently, more than likely you won’t always be seeing the same providers. And getting into a provider in a new location when you need it may be a challenge.
So many health providers require you to be ‘established’ before they’ll see you as a patient, and good doctors sometimes have multi-month waiting lists to be seen as a new patient.
But what if you’re just in town for a week, and have a major respiratory infection? You really don’t have time to go through getting “established” just to get someone to look up your nose, listen to your lungs and prescribe some antibiotics.
Some potential solutions to this might include:
- Using a telephone/internet accessible doctor consultation that can prescribe medications for the basics. Several new options are now available ranging from helping out with basic needs like sinus infections, to virtualizing doctor’s visits.
- RVHealth – Launched in late 2017, a brand new monthly subscription service that offers a telehealth option aimed directly at RVers. Unlike other options, they can coordinate some primary care physician roles – such as keeping central medical records, ordering and reading lab results, some management of chronic conditions and referrals to specialists. (We have not tried this yet, but are considering switching to it.)
- RVer Insurance has teamed up with Careington International, to offer a package deal that includes the Teledoc service, and discounts on vision & dental services. All for under $17/month for a family. We love the Teledoc option, it gives us a huge peace of mind when we’re staying places far from medical services that we have an option for advice, care and taking care of the routine illnesses we might pick up on the road. All from the comfort of our RV and without needing to scramble to find a local doctor who will see us.
- VSee keeps a listing of virtual doctor services for more options to consider, including MDLive, Doctor on Demand, HealthTap and more.
- Utilizing urgent care clinics (which may be the same or cheaper than paying an office visit to a regular doctor).
- Self treating by stocking basic medications onboard (ie. you can get most things without a prescription over the border).
- Using a concierge service, either provided through your insurer or perhaps your credit card company, to locate available doctors for you. RVer Insurance has done it again, and worked with a network of concierge doctors who take most insurance plans, and can refer you to a local doctor when you’re not ‘at home’. This is coming in late 2015, and we can’t wait to read more about it.
Self care also becomes a great asset to a nomad. Staying fit, eating the right diet for your body and getting in tune with your body are all easy and resourceful ways to monitor your own health while in motion.
You can even order up your own lab testing across the country online (such as at http://www.healthlabs.com or http://www.directlabs.com) or attend healthfairs offering testing, without needing a doctor’s order. Learning how to read your lab results put you in better control of your health, and can alert you to lifestyle changes you might need to make or when its time to seek out the care of a professional.
Check out our RVing friend’s extensive series about self care on the road for more inspiring ideas: http://wheelingit.wordpress.com/category/health-care-2/ (Doesn’t Nina just rock?)
As a traveler who might need medical care in a variety of locations, you also need to take responsibility for your medical records and having them accessible to new providers. Now that electronic medical records (EMR) are becoming more standard, it makes it a lot easier for you to be able to log into your past provider’s website and pull up your records.
If you do become established with a primary care physician, make sure they offer such a service. You may also want to get copies of past test results and procedures, and carry around at least electronic copies, and have an off-site backup located somewhere with them.
Sadly, our cat has better centralized, nationwide, medical records with her Banfield vet plan (located in most Petsmarts) than us humans!
For humans, we have heard that Mayo offers a decent network to work from, as they have locations throughout the country. But very few health plans have them in network, and rarely the high deductible plans that many of us are navigating.
For those with ongoing health issues that need to be monitored, you may need to work with a healthcare provider who will order tests with a nationwide network of labs and then read your results.
And some doctors are better than others about communicating with their patients remotely – if you find one, keep them (and don’t let them run for public office, ask me about that story around the campfire someday!).
And always leave open the possibility that if you need extended treatments or major procedures, you may just have to find yourself a nice city to plop down in for a while to attend to matters.
One of the benefits of being a nomad is that you’re not tied to location to find the best medical treatment for you – go to where the specialists are!
A common reason that a lot folks don’t travel as much as they might like is that they have a current health condition they’re treating, and need to remain nearby trusted medical care sources.
For serious illnesses, this is an unfortunate legitimate reason to stay in one place.
However, we have met a good number of folks dealing with some chronic conditions, who despite the extra logistics – still get out there and travel.
Perhaps they plan to be near their trusted providers when major things need to be checked or treated, but the rest of the time they’re out exploring. They may have to jump through some extra hoops to set up dialysis across the country, for example – but they’re reminded of the preciousness of life, and don’t want to waste a single moment either.
And it’s also a good reminder that no matter what you’re dealing with today healthwise, things can make a turn for the worst at any time.
Why delay living our dreams? How many times have we heard the story of someone preparing their life to hit the road, then wham – they’re facing seemingly unending treatments or a terminal diagnosis?
If you’re in good health today – there may never be a better time to cure your wanderlust than now.
Staying Fit on the Road
Another concern along these lines is how do you stay in good health on the road?
One of the benefits of being stationary is establishing some routines, including fitness & diet. Stopping off at the gym after work is a lot easier when you have a gym on the way home – which won’t always be the case when you’re on the roam.
And when you’re traveling, it’s so tempting to indulge in trying all the yummy new local cuisines and constantly living it up with friends you visit. For the first several months of your travels, it may also feel more like an extended vacation than daily life, and thus makes it even harder.
If you’re anything like us, you’ll probably need to put a little attention towards making effort to keep fitness and proper diet a priority in your life.
There are some nationwide gym networks that you can join, if that’s your thing. Some dry-camping nomads even enjoy them just to have regular access to long hot showers.
Carrying fitness gear with you can be a challenge when living in a small mobile space. We’ve had our share of trouble trying to carry bikes with us in the past, so we mostly rely on walking, jogging, kayaking, hiking and just being active.
We like to seek out campgrounds with easy access to trails, as that greatly amplifies our likelyhood to get out and get our bodies in motion.
Others have reached out to locally based fitness groups to both keep active and make new local friends – such as run clubs, hashing, acro-yoga, hooping, hiking, training, kayaking, etc.
Whatever your modality of being active is, plan ahead for needing to keep it a priority. While being nomadic involves a lot of motion, it can be super easy to slip into being quite sedentary behind the wheel.
Our current healthcare solution
One of the core reasons we moved our domicile to Florida in early 2013 was because of the increased healthcare insurance options over our previous domicile of South Dakota.
For 2018, we are sticking with our BlueCross BlueShield BlueSelect EPO Bronze plan that gives us coverage across the country, on the exchange. For this year anyway, Florida remains one of the few RVer friendly states with on exchange options that meet our preferences. Combined, our premiums are around $770/month for the two of us – not taking into account any subsidies we might qualify for at the end of the year (being self employed, our income fluctuates – so we stay on the exchange to keep the option open if we do end up qualifying.)
We also subscribe to the Teledoc service we purchased RVerInsurance.com, provided as part of the Careington package. It gives us remote access to phone & internet consultations with physicians for the more typical stuff we might encounter, and they can write prescriptions for basic infections and such. There are also discounts for dental and vision included. We $149 annually, which brings this peace of mind down to a very affordable $12/month.
<— Read Chapter 11: Tackling the Overwhelm of PreparingRead Chapter 13: Lack of Continuity while Traveling Full Time —>
What happened to the eBook version of this series?
We used to offer an eBook version of this content on a ‘Pay as you Wish’ basis. That book got so out of date and we have no time to keep it updated – so we took it down.
We do our best to upkeep the segments in this blog series, but realistically can’t see republishing the book edition.
In November 2018, RV Love released their brand new (professionally published) book – Living the RV Life. It goes over a lot of similar content to this series (and more) on RVing. We highly recommend picking up a copy!
You’re of course welcome to browse the No Excuses: Go Nomadic series online for more of our tips & tricks on the logistics of nomadic travel.
If you do appreciate this series or the content on our blog, we always LOVE hearing your appreciation – leave a comment, leave a tip (link at bottom of every page) and/or share this post. Thank you!