NEW YORK ( MainStreet) — Getting sick on vacation - be it a broken arm or an intestinal upset - is bad. Getting sick out of the country is much, much worse.

That is because whatever health insurance you have may be worthless out of the country.

Don't your credit cards offer protections? Nope. Some premium cards throw in "medical assistance," meaning they will point you to an English-speaking physician in Vladivostok or Beijing. That can be a big help - and, note, the U.S. Embassy and its Consulates will do likewise, - but the buck stops in your pocket. It's up to you to find a way to foot the bills.

There are steps you can take to protect yourself when traveling out of the country (and, yes, the same warnings apply to Mexico and Canada as to Mongolia and Russia). But you have to know the steps and take them before you leave the U.S.

Fact: Medicare (the primary insurance for senior citizens) offers essentially no coverage outside the U.S. and only a tiny number of premium priced Medicare supplement plans do. Neither do the vast majority of employer-provided health plans offer foreign coverage, although at least some -- especially at Fortune 500 companies - cover emergency care, so ask HR. U.S. citizens living abroad are specifically excluded from the mandate to buy insurance under the Affordable Care Act, which generally offers no real options outside the U.S. borders.

The other fact: in much of the world, you may not actually want medical treatment as such. Suffer a retinal detachment or a compound fracture in much of Asia or Africa and you need a fast way to get to quality care - which, incidentally, might not be in the United States which in a 2000 survey by the World Health Organization managed to finish only 37th in terms of quality of healthcare systems. France, Italy, Australia, Germany, Canada, the United Kingdom, even tiny New Zealand all offer healthcare widely thought to be better than that found here.

So call your shots accordingly. Get hit by a speeding car in Paris, and good advice would be take an extended stay in the French capital. Suffer that injury in Lahore, Pakistan and once you were stabilized, many experts would get you on a plane home, ASAP.

That is why one kind of essential protection, especially for travelers to developing countries, is air evacuation insurance. Many firms offer this coverage, and leaders include AirMed International ($265 per year) and MedJetAssist (an 8 day membership is $99; a full year membership runs $260).

Note: evacuation plans generally do not cover medical costs in situ - that is on you. After the run in with a speeding car in Lahore, many tens of thousands of rupees will be spent stabilizing the victim and those are costs that need other coverage.