ACA compliant insurance for missionaries and citizens working abroad
On the 1 January 2014 the Affordable Care Act (ACA) came into force in the US. This piece of legislation puts career missionaries and others who work abroad for long periods in a tricky situation. ACA-compliant insurance available through healthcare exchanges generally does not provide coverage outside the US. But international insurance available to missionaries generally provides no coverage or very limited coverage in the US – leaving American missionaries working abroad in a very real Catch 22.
Career missionaries typically reside in remote locations outside the US, and return to the US periodically for furlough. Furlough periods range from two weeks to a year. Many missionaries will arrange to address their routine healthcare needs while on furlough in the US.
US citizens working abroad, but not living permanently in another country, also fall between the gaps in the ACA legislation. I know this from personal experience as I work in Malta, Europe, returning to the US for short spells a number of times per year.
Missionaries and others who furlough in the US for more than 35 days during a year may incur a tax penalty if they do not carry ACA-compliant coverage while in the US. But some exemptions apply: under ACA, you are permitted one period of up to 90 days in any year, during which the absence of ACA-compliant coverage will not cause a tax penalty. But this is tricky because the 90 days is not cumulative. In other words, you are allowed only one break in ACA compliant insurance and that break can be anywhere from one day to 90 days.
What all this means is that missionaries who rely on their international insurance plans to provide coverage in the US may face coverage limitations and restrictions which will be costly, in addition to the possible tax penalty.
As a general rule, missionaries and people who work abroad should purchase international plans which offer at least 90 days of coverage in the US during any year. If more than 90 days in the US is anticipated, missionaries should purchase either US Short Term Medical insurance (these plans do not generally cover pre-existing conditions, but are exempt from ACA as long as the policy period is less than 365 days), or ACA-compliant insurance covering them during the time they are in the US and not covered by their international plans.