1. Cross Border Health Insurance Options that may affect Elderly Mexicans and Mexican Americans

2. Mexicans and Mexican Americans Employed in the U.S. Standard Employment Based Plan - Covers Employee and may cover dependents - Services in Mexico generally only available on an emergency basis - Usually have a gate keeper and even if on the border Mexican providers are not in the network - Elderly beneficiaries are generally only covered if they are the worker or the spouse

3. Employer Based Plans cont. Mexico only HMOs and PPOs -Available in San Diego and Imperial Counties and to some extent in Los Angeles - Available as a dual choice option from certain employers - Care limited to network in Tijuana or Mexicali except care not available in Mexico or emergencies in US - Mexicans who commute to the US for work or some with families on border choose these plans - Access Baja, SIMNSA and one of the options of Salud Con Health Net are examples - Elderly relatives are not covered - Insurance law in Texas keeps such plans from being offered

4. Dual or Complex Option Plans Salud con Health Net permits enrollees to choose clinics in LA, services in Tijuana or both or have family members pick different locations Access Baja has an option where workers far from the border can sign up for the US plan and family members on the border choose Mexico plan Western Growers provides limited package for agricultural workers in Arizona and California and a more expansive package for workers and their families in Mexican border cities None of these plans cover elderly dependents

5. Health Savings Accounts For families that live in Mexico or on the border the availability of providers in Mexico at lower cost may reduce the chance that they will outspend the accounts.

6. Discount Cards These are increasingly offered to immigrants in the US and they can offer discounts with providers in the US or in Mexico (ie. Club de la Salud) This could include discounts for elderly relatives as well.

7. Mexican Programs for Mexicans in the US with dependents in Mexico Instituto Mexicano del Seguro Social (IMSS) Family Health Insurance for Mexicans Abroad -Sold through consulates in Houston, Los Angeles and Chicago -Annual premium tied to age of nuclear family member -Pre existing exclusions and does not cover certain problems -Parents are eligible for enrollment -Low level of participation probably due to complexity and need to coordinate a lot of variables -Since family members can enroll directly it probably makes more sense to send the money to them directly

8. Mexican Programs Cont. Sistema de Proteccion en Salud (Salud Popular) - Provides a package of benefits for those who sign up (free for the poorest and subsidized for most others) - Being rolled out across the states - Immigrants to the US and their families in Mexico are eligible - Fairly low enrollment by paying eligibles so far

9. Private Health Insurance in Mexico to cover Visits to the US Health Insurance coverage is difficult to obtain over the age of 55 without many restrictions if the person has not been continuously insured by that Insurer Only about 3 percent of the Mexican population is covered by health insurance Lack of coverage when visiting may be a limit on elderly relatives visiting in the US

10. Medicare, Medicaid and Medigap Medicare and Medicaid will not cover care in Mexico except in very limited circumstance Certain Medigap policies will cover medical emergencies abroad for trips of less than 60 days duration

11. A Proposal It would make sense to have one or more demonstration projects in which Medicare and in some circumstances Medicaid will cover care in Mexico for beneficiaries who have retired there This could have the impact of permitting many to retire to Mexico who otherwise would not be willing to