Getting Reimbursed for Medical Expenses

The private medical services insurance here is mostly through a government program called INS, a Spanish language acrostic. I finally completed the piles of paperwork with doctor signatures and original receipts (No photo copies! One of my claims was disqualified for this reason.) I mailed them to my insurance agent who got them to INS and I received an email pretty quickly telling me what was accepted and how much they would pay me with an electronic deposit in my local bank account when they received the account number. (I added to the time here by at first sending the wrong number dummy me!) When I finally got that right they informed me that since I still don’t have official residency yet, they could not auto deposit but I could come to an INS office or my agent. My agent requires 15 days, so I opted to go to INS somewhere close other than in San Jose. Alajuela is the closest and I went today and even with one problem, I completed the task within two hours! That is could! The problem was that my agent gave me the wrong address or directions to the office in Alajuela and I wasted one taxi fare ($2) in the wrong place. When I got to the right office, a typical government office with guards and take a number and wait until they call it to be served. It was surprisingly quick with only three employees needed to complete my task and they paid me in cash!

That is likely the last/only time I will do that since I canceled my expensive policy. I’m waiting to receive the government coverage after my residency is approved. Hoping that will start happening this Friday the 13th when my attorney appeals! Ironic? Probably! But I’m not superstitious!

And by the way, this experience today continues to strengthen the motivation to learn to speak AND understand Spanish. It is necessary to live here! 

Heart Arrhythmia

The Symptom
A couple of weeks ago I went to Dr. Candy because my right foot had been swollen for several days off and on, mainly when I stayed around the house rather than when walking! Strange?

The Standard First Level Treatment
She gave a diuretic to take for 10 days to see if that would reduce the foot inflammation. It did not.

(Side Note on Heel Spur)
You may have caught my earlier report on bone spurs in both heels but hurting only in the right one. This was taken care of by me stopping my 8 month habit of walking all over town in nothing but sandals. (Like walking barefoot!) I now wear tennis shoes, hikers, or regular shoes with a gel orthopedic insert in the heel. Absolutely no pain or problem now from the bone spur! And two doctors now say my new problem is in no way related except for being in the foot!  🙂

Complete Physical
Dr. Candy, my primary care doc, is very thorough and systematic and said it was time for a complete physical with an EKG because she now thinks the problem is circulatory. And I may have done a post on going to the Atenas Laboratorio Clinico for the blood and urine analysis. I walk these reports back to Dr. Candy and she says everything is normal or healthy including blood pressure EXCEPT that the EKG shows an arrhythmia which she thought she heard when listening to my heart. She emailed the EKG to the cardiologist in San Jose she works with and that doc wants me to come in and get wired with a 24-hour heart monitor.

24-Hour Heart Monitor
That was done last Thursday and Friday for my first two bus trips to San Jose and only saw a nurse to be hooked up and then uninstalled. Today I went back for the cardiologist to give me her evaluation. (Note that with a female primary care I’m being sent to female specialists! 🙂 Dr. Bouzid is so good, professional, thorough and explains everything so I can understand it! In English! Thank goodness! I’m slowly improving with my Spanish but not ready for this! She is a part of CIMA, arguably the best private hospital in Costa Rica. My private insurance covers everything after the first $300 which I reached today only when the ultrasound was added! Wow! medical costs are so much less expensive here! And when I get the CAJA, free! And by the way, some people come here from the states for cardiology including heart surgery. They call it “Health Tourism.”

The reason for 24-hour EKG basically is that it shows my real life and not just a couple of minutes in a doc’s office. I do have Heart Arrhythmia as shown in these two contrasting clips from the 24 hours:

This is a fairly regular rhythm which is good – what we want.

This one shows the irregular rhythm and other pages were worse. 

āˈriT͟Hmēə,əˈriT͟Hmēə/
noun
1.         a condition in which the heart beats with an irregular or abnormal rhythm.
Or for a more thorough definition and more info in a sidebar, see Mayo Clinic
Then a Heart Ultrasound
Then she wanted to do an ultrasound of the heart and like everything else, I am given copies of everything. She pointed to parts of the picture on her computer which was moving or a video and tried to explain why not enough blood was being pumped to my right foot. I did not really understand that, but accepted it. And here is my printout of that which doesn’t mean much to me: 
This is actually 5 photos taped to a sheet of paper.
Ultrasound of my heart today. Whatever it means.

More Blood Tests

The cardiologist sent me to Lab San Jose (another Laboratorio Clinico) just two blocks away to check 4 things in my blood related to the heart: NITROGENO UREICO, CREATININA, TSH, PEPTID NATRIURETICO B (BNP) which will be reported to her tomorrow by email. One of these has to do with the thyroid gland which if either over-active or under-active can cause arrhythmia and I’m not sure what the other things are. 
Gave Me a Prescription
I take this for two days twice a day and report to her how I am feeling. This may or may not help. Then
I Go Back to Cardiologist Friday Afternoon
She will then discuss the blood test results and with that may change the prescription or take a different plan of attack. She seems confident that she will get me back into rhythm! 🙂 
And by the way, she says I HAVE A VERY STRONG HEART! It just doesn’t have rhythm!  🙂
🙂  Well, a different kind of rhythm!   🙂
But you should know that they celebrate Elvis’ birthday here!
And most Ticos have lots of rhythm! And love music!

Government Red Tape

I spent a total of about 45 minutes on the phone today with Medicare who is part of the reason Cigna HealthSpring can’t easily disenroll me from my Rx policy, though I think it could have been done in April if they were on the ball. Disenrollment has to be during enrollment periods for Medicare and the next enrollment/disenrollment period for Medicare is October 15 to December 7. Basically, Medicare (after talking with 3 people and the last spending time researching) told me I have to wait until October 15 for disenrollment in the Cigna HealthSpring Rx plan. So I call back in about a month. At least there seems to be light at the end of the tunnel. And why didn’t Cigna know this?

All the calls meant I had to buy more time on my Sim Card for the cell phone. As a non-resident, I can’t get a monthly phone bill but must use the pay as you go sim card on my cell phone. I do it over the internet with an easy system called Mobile Recharge. But still something else to do! 

In the Shadows

My shadow on neighborhood walk.

And I feel like I’m still in the shadows of the U.S. Government and U.S. Big Business! It was very easy to cancel my MediGap Medicare supplemental insurance with Mutual of Omaha. I applaud them for their courtesy, understanding, and simplicity in dropping an unnecessary and unusable insurance plan. 

But the much less expensive or helpful Medicare Rx Plan with Cigna HealthSpring who was not helpful when I was in the states and now that I live in another country and cannot use their plan, they have been less than helpful in what they call “Disenrollment.” Three overseas phone calls since March, promises of sending me a Disenrollment Form, and still I am being charged monthly for a Rx insurance I cannot use. Grrrrrr! After today’s call I wrote a letter I will fax tomorrow that is suppose to do the same thing as the form. (?) Plus they promised again to send me the form to my U.S. address as backup plan 2, and plan 3 (that makes me shudder) is I am going to call the U.S. Medicare office tomorrow. Cigna-HealthSpring will also let the government request disenrollment. I dread another overseas call which costs enough I will need to add more time to my cell phone sim card. And I’m always surprised when a government office actually provides some help. But maybe! The embassy here has, especially with Social Security and voter registration.

Why am I canceling U.S. medical insurance? (Not Medicare) (1) None of it works while living here (not even Medicare),  (2) It is very expensive, and (3) I have private medical insurance here I will continue until my residency is fully processed and I can be on the government medical insurance plan here when I will really save money. The private plan here is less expensive than stateside insurance and similar coverage. Plus medical costs here are so much less expensive that I could come out ahead paying for it with no insurance if nothing big happened! But then, potential catastrophes are why we have insurance in the first place. 🙂  And I’m keeping U.S. Medicare for that reason, just in case I travel to the states and something happens there, I will at least have basic Medicare coverage. And it is more involved to cancel or drop it and I think the hundred something I pay a month for it is worth it for now. Maybe not later. We’ll see.
I also have a sweet deal with my primary care doctor here so that I can come in anytime I need care or just have a question. i.e. I’m going to go by this week or soon and ask for her opinion of the many dentists in town and schedule my first cleaning and checkup. Cheap! Medical tourism is big here, especially for dental work! The cost is a small fraction of the U.S. costs. 
Today my new maid cleaned the house while I went to Alajuela to pick up three internet orders. I prefer to be out of the house when she is cleaning.  I did two little posts on my new Spanish Learning Blog today.  Pura Vida!

Nickel Bananas and Other Expenses!

White-faced Capuchin Monkey, Rescate Animal zooave (photo gallery)

Though I am saving receipts and trying to live simple, I am not keeping a penny by penny account of what it is costing me like the couple up the mountain from me are doing in San Ramon. Read their blog and/or subscribe to it at Retire for Less in Costa Rica. I enjoy reading their monthly posts and admire them for the exact accounting of what they are spending in their public monthly financial report. To read one month’s costs use this link to their September Expenses or at their site find any other month.

I subscribe to their philosophy, though I’m not budgeting as detailed as they are nor keeping such records now. Simple lifestyle and enjoy the place! My expenses are similar to theirs with me spending less than a fourth of their TRANSPORTATION cost since I do not have a car like them. They spend $500 to a $1,000 on a car monthly while I spend less than $100 on bus and taxi transportation right now. Plus I walk 3 to 5 miles a day for local needs. When I start traveling across the country exploring, it will go up but seldom over $100. I can take a bus all the way to Panama or Nicaragua for around $50. So far the most expensive bus has been to San Jose at about a $1.75 while local taxis are seldom over $2 for door-to-door service. Though a taxi all the way to San Jose or Alajuela can be $25! It would still take a lot to of personal driver trips to reach their $900 budget! And I think Atenas is a more central location for my later exploring the country! (Plus better weather!)   🙂  And oh yes! Very important! Once I have my Pensionado Residencia card as a retiree, all bus trips will be free! For over age 65.

HOUSING expenses for me are right at the same as the Retire for Less couple and it is of course my largest expense at $800 per month plus my first month’s electric bill was $22 which is less than the $30 I was told to expect. But by March I plan to work with the new management on a long-term contract for rental at less than the current rate. We will see how that goes. Water, TV, internet are included in the rent here. I only pay for electricity and fortunately I seldom use the air conditioner. And oh yes, for those in Nashville comparing, that is much less than half my rent at McKendree which was increasing each year. Now note that I have looked at two houses for about $400 a month rent plus utilities, BUT . . . old town houses nearly touching the neighbors, not as nice, or quiet, or large property, and no view! I’m doing all I can to stay where I am as much for the view as anything. Plus monkeys will start coming in March or April! 🙂

Yet I spend more than the Retire for Less couple on DINING OUT which is a priority for me – my one extravagance maybe. I eat out 5 or 6 times a week with each meal ranging from USD $5 to $14 as the most expensive so far. The high end is when I add fruit drinks or smoothies and/or desserts – again that is my extravagance. When I eat out it is usually for lunch (done dinner three times with friends), sometimes a late lunch and always as my main meal. That is where I get most of my meat or fish and most veggies, though some at home. Dining out will probably be around $300 per month which is almost what I spent in Nashville in addition to the $240 dining room charge at McKendree. So I’m spending less dining out here than in Nashville.

GROCERIES for me are close to what the Retire for Less couple spend in their budget, $300+ per month for breakfast and dinner food and household items like paper goods, cleaning supplies, kitchen tools at first. That is close to what I spent in Nashville. My usual breakfast at home is similar to then except more fresh fruit. I have a half bowl of healthy, whole grain cereal with nuts and raisins to which I add a half bowl of fresh fruits and then either cow milk or almond milk which is priced a little more than in the states. Cereal is all more expensive here (even Latin American brands) as are any brand-name food items. i.e. 300 grams of American branded tortilla chips is $4 while a similar Costa Rican product is $2 for 320 grams. Same for a jar of salsa. I’m learning to look for local products! Import tax is the primary income for the government here  making all imports more expensive. My groceries come from three places: I shop at the Weekly Farmers’ Market, plus Coopeatenas Super Mercado (a local cooperative), and sometimes Maxi Pali, a corporate super market chain by Walmart with their house brand products and claim of being cheaper. It is a longer walk, so I use Coopeatenas more. And once a month or so I may go to the real Walmart store in Alajuela and maybe someday will go to a bigger one in Escazu, though more time, trouble and expense to get there. And oh yes! Bananas were a nickel apiece at Farmers’ Market yesterday.

HOUSEHOLD PRODUCTS are priced about the same as the states if I go for the Chinese brands, like a cheap wastebasket, laundry basket, kitchen utensil, hardware, etc. Again USA-made are more expensive and not as available. My house is about set up now, so I will seldom have these expenses. My new Atenas “Home Depot” is a neat little hardware/household store by the bus terminal where I’ve found things not even at Walmart. They are friendly and helpful even though I struggle for Spanish words for things. I even got a USB extender cable for the used printer I bought, so the shorter cable would not run across my desk and block access to the window. Show you my office later.

ENTERTAINMENT/TRAVEL expenses have hardly started yet as I get acquainted with Atenas and haven’t traveled further than San Jose and Alajuela which is budgeted in transportation above. My only typical tourist expense was my trip to see Rescate Animal zooave (click for my photo gallery) last week and without my residential card yet I had to pay the tourist rate of $21 to get in which would have been about $10 as a resident and maybe cheaper as a retiree. The bus trip was just a dollar there but when I had trouble flagging the bus down for my return, I spent $20 to return by taxi. All that plus lunch cost me less than $50 for a fairly local photo trip. I could spend hundreds when I start going to the beach, mountain lodges, etc. Just haven’t started yet which is good because of start-up costs. I hope to eventually be spending $300 per month on travel, my favorite entertainment. There are big movie theaters, live theater, symphony orchestra and all in San Jose, but I will be avoiding the big city as much as possible! I’m liking small town life better! I want to visit national parks, wildlife preserves, and other places for nature photos. It will take years to see them all!

A MAID has not been hired yet, but that will cost me $2 per hour for two hours once a week or about $16 per month plus a Christmas bonus of one month pay (required by law) making it $208 per year. Such a good deal that I need to get started soon! If I want to add laundry, cooking or other duties then the cost would go beyond two hours a week, but I probably will not. I’ve already got a laundry routine and getting use to sunshine clothes drying. And a single person doesn’t need a cook!

MOVE/START-UP EXPENSES have not been totaled yet, but shipping 51 boxes will end up costing me over $2,000, maybe $3,000, the biggest expense. Of course that is nothing like the people sending all their furniture in 40 foot containers. And I hope to get rid of half that stuff after I go through it here, mostly scrapbooks and artwork.

Once all the different fees and lawyer is paid, a residential card will cost nearly $2,000.

My Miami address costs according to what is sent through it, at $7 per kilo on packages plus customs/import tax on the invoiced value of the item (10-15%). Letters cost me $1.50 each when sent through Miami. They get here a little quicker than the two to six weeks when sent direct, but I am going to start encouraging people to use my Costa Rica address. I got several Christmas Cards I had to pay $1.50 each for AND had to travel to Alajuela to pick them up. I’m probably going to reserve the Miami address for internet orders, some of which require a USA address. That is what most people here use it for, including locals. It is an ongoing cost of maybe $40 to $50 per month, if I order much on internet. Two of my credit cards use that address and some other businesses, but most seem to prefer my Atenas address. The U.S. Postal Service would only accept the Costa Rica address and will not forward. But I’m glad now because if they had the Miami address they would be forwarding junk mail to me at $1.50 each! And I may try to get my own PO Box when I know I’m settling here. Right now it goes to the apartment’s box and the staff deliver to me on their time.

Local medical costs could be considered in start-up costs but I will list it separately. Even with that my total initial move cost is maybe $7,000 and I made more than that on the stuff I sold in Nashville including my car. So the balance sheet is okay for now.

MEDICAL costs will eventually cost me much less here once I am an official resident. I arrived sick with something like bronchitis. A visit to an English-speaking doctor, “Dr. Candy,” and her four  prescription meds cost me about $100 cash ($50 for her). I can try to turn it in to my Medigap insurance but it may not be worth the trouble. Medigap is good for the first 90 days here. I am applying for a private insurance policy here in Costa Rica with my physical scheduled for Tuesday morning in San Jose. It will pay 90% of all medical costs after the first $300. I will carry it for at least a year or until my residency is official. Then I can choose to keep it or go on public medical care which for about $50 a month will be 100% coverage of all medical costs including Rx, surgeries, hospital, dental, eye care, etc.(Why can’t Medicare do that?) Just longer waits for some procedures. That is my plan. Then I may drop the private plan here and will probably drop my medigap plan in states sooner. Private insurance here will cost about $3,000 a year ($250 month) which is less than half what I pay for medical coverage in the states (Medicare+Medigap+Rx+dental insurance) with fewer restrictions here. Public healthcare will be even more of a savings here. If I go back to states for any reason, temporary or permanent, I will still be on Medicare – they will keep deducting it from my SS check and I am always covered when physically in the USA, but never outside the states. I cannot drop it. So it will become my medical insurance in the states and funny thing is, the private insurance here in Costa Rica will also cover me when I’m visiting in the states!

Bottom line, I am now living on about $2,500 a month that could get to $3,000 with enough good trips! 🙂 That is less than I was living on in the states. Simple living, simple pleasures!

Well, that is a lot, but I know that a few of you have wondered about the costs and if you are considering such a move, can you afford it? Well, I hope this helps those considering and friends who just wonder but too polite to ask. Most of you know that I don’t have secrets – and/or I talk too much!  (TMI one friend will say!) But that is me and my financial report for life in Costa Rica. I don’t plan to post monthly reports like my friends in San Ramon, but for such details, subscribe to their Retire for Less in Costa Rica Newsletter.

Sorry this was so long! But that is all I’ll say on money!

The Autopista del Sol to San Jose

Well, I splurged today and hired a private driver to drive me to San Jose for my residential paperwork appointment and to sign up for medical insurance. Part of the way we drove on the Autopista del Sol (official site), or the newest, access-controlled highway from San Jose to the Pacific Beaches. See also a Nosara Surfer’s Report on the Highway. Here’s three phone photos, then I’ll tell you about the experience in the big city.

Out our way is beautiful scenery driving up the central valley.
Further from the city is only 2 or 3 lanes, but . . .
In and near the city are 6 and 8 lanes, toll plazas, and bumper to bumper in rush hour.

I have a wonderful attorney, Jose Pablo Carter Herrera, the son of another attorney with the Association of Residents of Costa Rica, a service organization for expats living in the country. I’m still waiting for an Apostille on my proof of income which Social Security in the states refused to help me with. The embassy here is supposed to do it easily, but it didn’t happen today! The only unfriendly, unhelpful place I’ve been in Costa Rica is the U.S. Embassy. I wasn’t too surprised that they wanted me to make an appointment but they would not let me make it even though I was there standing at the guard station. The correct procedure is to do it over a certain phone number between 8 AM and 11:30 AM, no exceptions! So me and my driver wasted time there. (The embassy in The Gambia was just as haughty and difficult to work with, but you have to work with them!)

The good thing I did not expect was I got my application for health insurance started and within the next week or so I will receive a call from the doctor to schedule my physical for the insurance company. I’m covered by my Medigap Policy for the first 90 days or until March 24. My Pricose agent, Juan Colero, says I will easily have it secured by or before then. It usually takes about 5 weeks after the physical. So I wait for the doc’s call on this. Then pay a whole year’s premium at once, then after a $300 deductible, 90% of everything is paid. It costs less than my Medigap and Rx insurance in the states. But when my residency is finalized I get the even cheaper government medical service if I wish. 
Tomorrow I will dutifully call the correct embassy number during the correct hours and hopefully get an appointment fairly soon. Jose can’t file my residency application until I get this last legal document. Then it will take from 5 months to more than a year, depending on which bureaucrat is assigned my application in the Immigration Office. It is all part of the laid back life of Tico-land and I will not worry about it after I have done my part. The private insurance can go on indefinitely and I could decide I like it better than the Caja or government health plan – we will wait and see. But government medicine and a long-term Visa are the reasons I’m applying for residency.

After back around 1:00 I had lunch at a new place for me, La Trilla Restaurante. I compared their Casado con Pollo with La Carretta’s and it was very similar, though they add a piece of cheese and some black bean dip and chips. I also drank another Guanabana drink, this time con leche. Muy bien! Now back to my birds!  🙂 And my study of Spanish!

P.S.
Someone asked about the inside of the apartments. During the first two weeks I linked to a photo gallery of the downstairs apartment #4. I have a smaller gallery of my upstairs apartment, since much is the same, all built-ins, granite counters in kitchen, carved doors etc. But anyway, here are the links to the Inside Apartments Galleries:

I’ll figure out how to photograph the balconies soon. They are not super grand inside, but more than adequate for me. When my boxes get here, they might get clutter or crowded.  🙂