From 2012 to2017, the number of retired workers living in foreign countries whowere receiving Social Security benefits grew by nearly 15 percent.Photo: Shutterstock)

When Karen Schirack, 67, slipped on her way into her house inJanuary and broke her left femur in multiple places, she had adecision to make. Should she get surgery to repair the fracturedthigh bone and replace her hip near Ajijic, Mexico, where she haslived for 20 years, or be airlifted back to her home state of Ohiofor surgery and rehab?

As the number of American retirees living overseas grows, moreof them are confronting choices like Schirack's about medical care.If they were living in the United States, Medicare would generallybe their coverage option. But Medicare doesn't pay for care outsidethe U.S., except in limited circumstances.

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Expatriate retirees might find private insurance policies andnational health plans in other countries. But these may not providethe high-quality, comprehensive care at an affordable price thatretirees expect through Medicare. Faced with imperfect choices,some retirees cobble together different types of insurance, a mixthat includes Medicare.

That's what Schirack has done. She pays about $3,700 annuallyfor a private insurance policy through Allianz that covered hersurgery at a private hospital in Guadalajara, about an hour fromAjijic. She also has a medical evacuation policy that would havepaid for her flight to the States, if she'd opted for that. Thatpolicy costs roughly $3,000 for five years. And she pays forMedicare Part B, which she can use for care when she visits familyin the U.S. (The standard Part B premium is $135.50monthly.)

Schirack has a scar running from her waist to the middle of herthigh, but she no longer needs home nursing care and wrapped upmonths of physical therapy in June. After five more months ofhealing, she hopes to be back to normal.

Her private plan paid the equivalent of about $20,000 for hersurgery. Before she left the hospital, Schirack had to cover herportion of the total, about $2,400, plus bills for other expenses,including blood transfusions.

After she left the hospital, she was responsible for paying forother services — home nurses, physicaltherapy and medications — and submitting receiptsto the insurer for reimbursement. She estimates she has spent about$10,000 and has been reimbursed for about two-thirds of that sofar.

If she'd had surgery in the States, she might have faced fewerpaperwork hassles, Schirack said, “but all in all, I'm not going tocomplain.”

The quality of health care varies widely by country, as do theservices available to foreign residents. And there are quite a fewof these transplanted Americans.

From 2012 to 2017, the number of retired workers living inforeign countries who were receiving Social Security benefits grewby nearly 15 percent to more than 413,000, according to the Social Security Administration. Thelargest numbers were in Canada (nearly 70,000) and Japan (more than45,000). Mexico was third, home to nearly 30,000 retiredworkers.

Commercial health care policies for them may provide decentcoverage, but people can generally be denied a policy or chargedhigher rates for medical reasons. The plans may refuse to coversome preexisting conditions. Schirack's policy, for example,doesn't cover any services related to her allergies.

Private policies can be problematic for another reason: They mayhave age limits. The GeoBlue Xplorer Essential plan, for example,enrolls only people who are 74 or younger, and coverage expires when people turn84. In contrast, Medicare eligibility generally begins at65 and continues until a beneficiary dies.

And the policies aren't cheap. A 70-year-old might pay $1,900 amonth for an Xplorer Essential plan with a $1,000 deductible, saidTodd Taylor, a sales director for GeoBlue. A plan with a $5,000deductible might run $1,400 monthly. That doesn't include coveragefor services in the United States.

Rates may also vary by country. A 67-year-old American living inCosta Rica who buys a midlevel Cigna plan with a deductible of $750for hospital care and $150 for outpatient care might pay $1,164 amonth, said David Tompkins, president of TFG Global InsuranceSolutions. The same policy might cost $913 in France, Tompkinssaid.

Claudia Peresman moved from Connecticut to San Miguel deAllende, Mexico, last November. She has opted for a privateinsurance plan, for which she pays about $100 a month. “What Iwanted was catastrophic coverage,” she says. “Things are soaffordable here that, outside of being admitted to the hospital, Ican probably afford it.”

Since medical care is sometimes much less expensive overseas,some retirees opt to pay out of pocket for minor or routineservices.

Claudia Peresman, 63, moved from Stonington, Conn., to SanMiguel de Allende in central Mexico last November. On her firstnight there, she tripped in the bathroom, hit her face on a walland split her lip. Her neighbors helped her get a cab to a 24-houremergency room at a hospital about five minutes away, where staffcleaned up the cut and sent her home. She paid the roughly $25 feein cash.

Peresman recently purchased a private insurance plan with a$2,500 deductible, for which she pays about $100 a month.

“What I wanted was catastrophic coverage,” she said. “Things areso affordable here that, outside of being admitted to the hospital,I can probably afford it.”

Even when retirees buy a private policy, Medicare is anotherpiece of the puzzle that they have to consider. Once people becomeeligible for Medicare coverage, usually at age 65, they face a10 percent premium penalty for every 12 months theyare not enrolled in Part B, which covers outpatient services.(People who are 65 but still covered by an employer plan generallydo not face that penalty.)

After paying into the Medicare system for decades, it's nowonder some expats are frustrated that they can't generally use theprogram outside the United States.

That's just the way the law is written, an official at thefederal Centers for Medicare & Medicaid Services said.

“CMS cannot speak to or speculate on congressional intent,” theofficial said.

And retirees should honestly consider whether they will spendthe rest of their lives overseas.

“Even if that is their goal, is their health and mobility goingto allow them to accomplish that?” said Dr. David Shlim, 69, whotreated many expats when he ran a medical clinic in Kathmandu,Nepal, in the 1980s and '90s. “People should imagine that they mayneed to come back to the U.S. and ask themselves how are they goingto do that and afford that.”

Rules on whether noncitizens can enroll in a national healthplan vary by country.

After living in the United States for nearly 30 years andraising a family here, Alberto Avendano, 61, is moving back tonorthern Spain in August with his wife, Zuni Garro, also 61.Avendano has dual citizenship, and his wife is a citizen of theUnited States. The couple can enroll in the Spanish universalhealth system and receive care there. They also plan to buy aprivate plan to use if they want to get medical services without await, said Avendano.

Once they turn 65, they may enroll in Medicare as well, Avendanosaid, depending on their circumstances. Their two children live inthe United States.

“It is something that is part of our American system, and wewant to have it,” he said.

Peresman also has a few years before turning 65 and making adecision, but she is leaning in the other direction. She is worriedthat the Medicare program may not exist in its current form when itcomes time to decide.

“I'd sign up if it were absolutely free,” she said. “But I'malready paying $100 a month here.”

Kaiser Health News isa nonprofit news service covering health issues. It is aneditorially independent program of the Kaiser Family Foundation,which is not affiliated with Kaiser Permanente.

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