# British citizen, considering NYC; type 1 diabetic



## type_won (May 14, 2014)

Hi,

Sorry this is a bit long -- I want to be clear. Hope you can help.

I'm considering a move from Northern Ireland to New York, given a potential relocation offer, to work in Manhattan. Although not in a VERY high-end job, it's potentially a much better future, in some ways, so I'd like to accept if possible.

The main problem (apart from NYC cost of living, tiny apartments, and endless concrete) is that I'm type 1 diabetic.

This involves two types of injectable insulin *daily* (4+ injections), along with needles, test strips, and other prescriptions. The test strips alone, which look like tiny bits of plastic with a little cotton wool in them, cost £0.50 each to buy -- £25 for a pack, which I go through in a week. God knows what the insulin costs -- the UK NHS just covers it all, without much hassle. I've read that it costs on average about $20,000 per diabetic, annually, and that's probably including type 2 diabetes, which doesn't always involve insulin.

So, my question is... what exactly should I expect in the US, as someone with an expensive chronic illness like this? I think my company would provide good health insurance, but I'm not sure if even the best health insurance would cover everything.

I'm not even sure what "cover" means in the US... would I have to jump through hoops every month to get new medication (filling in forms, or calling people and getting approval codes, just to get what keeps me alive), or would this all be approved once, or maybe once per year, and then just dispensed regularly?

Also, what should I expect if my employment ended for some reason? On the ACA site, I've seen insurance plans costing up to $5000, and still requiring copay / initial fees.

What does ACA mean for work visa holders?

Finally, what are my chances of getting a green card in five years or so, assuming I can maintain good employment and remain insured for that time?

Thanks


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## twostep (Apr 3, 2008)

Have you discussed this with your potential employer?


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## type_won (May 14, 2014)

I haven't yet, no. The offer is still being put together, so negotiations will come later. I'd like to have some idea of the details myself, though, rather than going in blind and taking the employer's word for it all. Not that I don't trust them, but I'm not sure whether I'll be negotiating with someone in the US who really knows the situation and has personal experience of relocation, medical cover issues, etc., or someone in the UK who's just guessing, for example. Plus, I should know what to ask for, and what not to ask for in the negotiation, and also have a personal sense of the "costs" of this move on my quality of life, to help decide if the pros outweigh the cons.


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## twostep (Apr 3, 2008)

I have a friend with a similar issue and will ask him. Give me a day or two.


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## type_won (May 14, 2014)

Great, thanks!


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## koppazee (Mar 11, 2011)

type_won said:


> Hi, Sorry this is a bit long -- I want to be clear. Hope you can help. I'm considering a move from Northern Ireland to New York, given a potential relocation offer, to work in Manhattan. Although not in a VERY high-end job, it's potentially a much better future, in some ways, so I'd like to accept if possible. The main problem (apart from NYC cost of living, tiny apartments, and endless concrete) is that I'm type 1 diabetic. This involves two types of injectable insulin daily (4+ injections), along with needles, test strips, and other prescriptions. The test strips alone, which look like tiny bits of plastic with a little cotton wool in them, cost £0.50 each to buy -- £25 for a pack, which I go through in a week. God knows what the insulin costs -- the UK NHS just covers it all, without much hassle. I've read that it costs on average about $20,000 per diabetic, annually, and that's probably including type 2 diabetes, which doesn't always involve insulin. So, my question is... what exactly should I expect in the US, as someone with an expensive chronic illness like this? I think my company would provide good health insurance, but I'm not sure if even the best health insurance would cover everything. I'm not even sure what "cover" means in the US... would I have to jump through hoops every month to get new medication (filling in forms, or calling people and getting approval codes, just to get what keeps me alive), or would this all be approved once, or maybe once per year, and then just dispensed regularly? Also, what should I expect if my employment ended for some reason? On the ACA site, I've seen insurance plans costing up to $5000, and still requiring copay / initial fees. What does ACA mean for work visa holders? Finally, what are my chances of getting a green card in five years or so, assuming I can maintain good employment and remain insured for that time? Thanks


Hi Type Won. Welcome to our forum. I am happy to try to help you. I am a type 2 diabetic and a former New York City resident who still runs a division of a company based in New York City. 

Anything related to medications or medical equipment in the USA is hugely expensive as the US government seems to give the pharmaceutical industry or associated industries a "free ride". States such as New York have stepped in and attempted to regulate some of the requirements demanding that the insurance industry be obligated to cover under their insurance coverage related to diabetic's needs. Although I realize that your position will not be a high end one, which could restrict your ability to negotiate your compensation coverage, there are a few things you must consider.

1. What is the size of this potential employer? If it is a larger company, they might be able to offer a larger selection of insurance options. If it is a smaller sized company, some offer very good coverage while others might actually leave it up to the employees to find their own medical insurance coverage or just offer you what they offer. 

2. If this employer offers you coverage, you then need to ask: 

A. How long must you be with this company until you can become eligible for coverage. Many are 90 days. 
B. What are the co-payments associated with doctor visits and pharmaceuticals and most importantly what is the actual cost to you?Generally speaking, there is two pricing levels for medications. Genetic and the "name brand" drugs. What will the costs be for your injections, alcohol pads, etc? There is a very strong probability that the potential employer will simply refer you to the insurance company(s) directly for this information. If so, ask them to send you material for your direct review or if there is a specific URL on their websites you can view and print this information. 
C. What will it cost you per month as your share of the actual insurance itself. 
D. If you are seeking family coverage, does thus employer offer family coverage and at what costs?
 
As I indicated above doctor visits come with a copayment and not all doctors accept every insurance. Some might accept an insurance offered by a specific insurance company but the same doctor might not accept another plan from the same insurance company. For example, Doctor Jones accepts Aetna's Privilege Plan, but might not accept Aetna's Premium Plan so if you find that you must find a doctor and people say that Doctor Jones is fantastic, you really need to ask many questions. 

Firstly, does this physician accept the specific plan you have chosen and try to actually speak with this doctor before selecting him or her as they might have a limited amount of knowledge in dealing with people with Type 1 diabetes. 

My former doctor was a cardiologist by specialization although we used him as our family doctor. When he prescribed medications, he really was "married" to the pharmaceutical industry and would only prescribe a specific company's drugs. He gave me an outdated blood testing kit where the test strips were out of date. Additionally, the educational materials he gave me were limited to two pages and his only advise was to eat less starch, drink less juice and eat a lot of chicken, so speaking with the doctor directly and not just the person who answers the phone is very, very important. 

I do realize you have experience in your condition, but a good doctor knows more about treatment options and advances in diabetes than you do. Another thought I urge you to consider is looking at the list of endocrinologists who also accept the plan you are going to accept. Often there is a very limited number of any type of specialists in a specific field and their co payments that you must make are different than the primary physician you select. 

I lived in Queens, NY. I had excellent insurance coverage but for the plan we had, there was only one endocrinologist who accepted my plan. I waited two months to see her and she turned out to be the biggest quack on the planet! This doctor called me on a Friday evening of a three day holiday weekend telling me that the last blood work had dangerously high numbers and I needed to rush into her office the following week to see her. When I told her that the prior blood work results were better than before, she actually realized that she was looking at the wrong test results. No pun intended, but just some food for thought about selecting a doctor.

As to the requirements for visa holders and how the ACA affects your situation, sadly, I am not able to assist you with this. One final thought, if I may. In New York City, there are a few pharmacy chains that are all over. CVS, Duane Reade come to mind. If you want, look up one of their stores in Manhattan on the Internet and call one to speak to the pharmacist. Ask for the "cash" price for all the drugs you are taking. The cash price is for a person without insurance coverage.

I know that test strips are hugely expensive and lancets are also expensive. Once you know what the cash price is to your actual drugs, injections, etc. you have a better understanding of where you need to be when discussing co payments and discussing compensation with this potential employer. One other thing you must know..,,In the US, if you must fill out forms for reimbursements from the insurance companies, it becomes a huge to do, often taking much time to fill them out, have doctors sign forms and at times haggling with the insurance companies to be reimbursed under their schedules of coverage.

It is not like France where your Mutuel simply refunds your copay to the doctor to your account within a week or two, I hope all this is helpful to you. I wish you the very best of luck with all this and if I can be of further assistance, please ask. New York City is a fantastic place to live and a world onto itself. 

Warm regards!


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## 2fargone (Jun 14, 2011)

type_won said:


> Hi,
> 
> Sorry this is a bit long -- I want to be clear. Hope you can help.
> 
> ...


Have you look at getting the pump? My Aunt has the pump was a life changer for her. 

I have several chronic illness. I received a letter 3 years ago saying there were not going to cover one of my meds. But, I went to my doctor and he sent my files and he wrote a letter saying I have to have this medicine everyday. 

It will be an adjustment but I would not let it stop you from moving.


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## twostep (Apr 3, 2008)

type_won said:


> Finally, what are my chances of getting a green card in five years or so, assuming I can maintain good employment and remain insured for that time?


What visa will your employer use to bring you on. Will your employer sponsor your Green Card?


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## type_won (May 14, 2014)

twostep said:


> What visa will your employer use to bring you on. Will your employer sponsor your Green Card?


I'm not sure about the sponsorship; it's something I can ask about when the time comes. Presumably that would help? I imagine the visa would have to be H1-B (as a highly skilled worker).


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## type_won (May 14, 2014)

2fargone said:


> Have you look at getting the pump? My Aunt has the pump was a life changer for her.
> 
> It will be an adjustment but I would not let it stop you from moving.



I've looked at getting a pump HERE, and it's a long, drawn out, lottery process, which you have to jump through hoops for. I guess it's no different there in terms of hoops, but I get the impression I'm more likely to get it there, and CGM isn't even an option here (I think it's not yet medically approved in the UK, but might be just not covered by the NHS).

So, the chance of getting better treatment options there, even if more expensive, is a positive aspect.


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## type_won (May 14, 2014)

Hi koppazee,

Thanks for the extensive guidance; it's a big help.



> 1. What is the size of this potential employer? If it is a larger company, they might be able to offer a larger selection of insurance options. If it is a smaller sized company, some offer very good coverage while others might actually leave it up to the employees to find their own medical insurance coverage or just offer you what they offer.


It's a bigname corporate, with reasonably good health insurance here (BUPA, with medical history disregarded). I'm already employed by them here, but I'm not yet sure if the relocation would constitute a new job or just a new position.



> [*]A. How long must you be with this company until you can become eligible for coverage. Many are 90 days.


Presumably this might matter if I'm taking a new position at the company, or being moved to a different US insurance Co., rather than just being transferred in my current role?

What would my options be in the meantime -- self-pay? Continue UK insurance in the US somehow? I think I read that someone else's insurance covered them for 90 days in a foreign country. If that applies to the NHS, is it possible to get prescriptions filled in the US based on NHS insurance, in that case?



> [*]D. If you are seeking family coverage, does thus employer offer family coverage and at what costs?


No family insurance at present. Marriage is planned, but would be another step, a bit further down the road.



> Firstly, does this physician accept the specific plan you have chosen


Ahh, I had no idea about that. Thanks!



> My former doctor was a cardiologist by specialization although we used him as our family doctor. When he prescribed medications, he really was "married" to the pharmaceutical industry and would only prescribe a specific company's drugs.


That's the kind of thing that will take a lot of adjusting to 



> One final thought, if I may. In New York City, there are a few pharmacy chains that are all over. CVS, Duane Reade come to mind. If you want, look up one of their stores in Manhattan on the Internet and call one to speak to the pharmacist. Ask for the "cash" price for all the drugs you are taking.


Excellent, thanks.


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## Bevdeforges (Nov 16, 2007)

> Continue UK insurance in the US somehow? I think I read that someone else's insurance covered them for 90 days in a foreign country. If that applies to the NHS, is it possible to get prescriptions filled in the US based on NHS insurance, in that case?


What many new arrivals do is to bring with them a 90 day supply of whatever they need. OK, insulin is tricky in that regard, due to the need for refrigeration. Though I know of people who have transported several months worth of such medications with them for a long holiday or other travel. You can check with the airline or airport people for advice on the best way to handle this - but it usually involves carrying your meds as carry-on, with a prescription to show you're authorized to have them, and packing them in styrofoam cases with a cooling agent (ice, cold blocks, etc.). 

The problem is that in the US, many states require pharmacies to insist on prescriptions from an in-state doctor, so you can't get out-of-state or foreign scrips filled at all.
Cheers,
Bev


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## twostep (Apr 3, 2008)

Why do you not contact NHS? It is highly unlikely that they will cover you in the US even for an interim period but it does not hurt to ask. 

Travel insurance will not apply and it does not cover maintenance medication.

HR can give you details on coverage in the US. I hand it out as PDF as it can be a make-or-break in negotiations. Legally you can be covered on day 1; generally it is day 31 to allow for processing or day 91 if there is a probation period involved. 

Yes, you can bring a supply of medication into the US with proper documentation. No, you will not be able to fill a prescription unless it is issued by a licensed physician. 

What are your plans for emergencies?


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## type_won (May 14, 2014)

twostep said:


> What are your plans for emergencies?


Emergencies as in not being covered for a short time? I'd have to keep enough money available to cover the expenses for a few months, I guess. I'd need to stay there and work, make a life, etc., so aside from being covered or paying temporarily, or, if very desperate, trying to find a free clinic etc., I don't know of any other options... going back to the UK and giving up the job for medical cover would be more of a cancellation than "just" coping with an emergency.


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## twostep (Apr 3, 2008)

type_won said:


> Emergencies as in not being covered for a short time? I'd have to keep enough money available to cover the expenses for a few months, I guess. I'd need to stay there and work, make a life, etc., so aside from being covered or paying temporarily, or, if very desperate, trying to find a free clinic etc., I don't know of any other options... going back to the UK and giving up the job for medical cover would be more of a cancellation than "just" coping with an emergency.


My idea of emergency was more along the line of medical issues - shock, hospitalization, sick days, ...


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## type_won (May 14, 2014)

twostep said:


> My idea of emergency was more along the line of medical issues - shock, hospitalization, sick days, ...


Ah.. Well virtually all health insurance policies cover that... right? I gathered that catastrophic insurance was the lowest cover, just for hospitalisation etc., and other policies provided more on top?

Well, either way, my current insurance with my company covers extended illness and so on, so I *hope* I can just continue that level of cover in a new location, even if it's provided by another company. I guess I'll have to discuss all that with HR if/when the formal offer materialises, though.


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## twostep (Apr 3, 2008)

type_won said:


> Ah.. Well virtually all health insurance policies cover that... right? I gathered that catastrophic insurance was the lowest cover, just for hospitalisation etc., and other policies provided more on top?
> 
> Well, either way, my current insurance with my company covers extended illness and so on, so I *hope* I can just continue that level of cover in a new location, even if it's provided by another company. I guess I'll have to discuss all that with HR if/when the formal offer materialises, though.


I am going through some issues with family 1500 miles away in the US right now with sr. medical professionals who are friends close by. Basically - you have an issue - who will take care of you, call EMT, see to things, will the company cover your time?


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## type_won (May 14, 2014)

twostep said:


> Basically - you have an issue - who will take care of you, call EMT, see to things, will the company cover your time?


I'm not sure what you're getting at here. Do you mean that the paperwork & calls would be such a burden that I couldn't hold down a normal job without the employer making exceptions for me? My current insurance through the company would cover things like being ill long-term, and there's (usually) no one to call EMT now except myself, so I don't *think* that would change much. Perhaps you're telling me it will, for some reason I don't know about?

Currently, what happens is that, every month (actually, when I start to run out, but it's about every month), I call the doctor's office, and they prescribe me new medicine. I then pick it up from a store, at my convenience. No other calls, forms, approvals, or trips required.

Also, every three to six months, I see a doctor, who asks me how I'm getting on, reviews the dosages I'm taking, etc. They try to help, but mostly, these appointments are a pain in the butt, for very little practical gain. This is the part that I'm hoping could be better in the US: here, they can't really prescribe pumps etc., so these meetings never lead to anything new / better, but they're kind of obligatory.

I'm a bit more comfortable with the whole US insurance cost / provision / procurement now. I'm still wondering what the equivalent workload (to these monthly calls / pickups, and occasional appointments) would be in terms of getting new medication, getting it paid for, etc., and how much stress / burden that would add to life, bearing in mind that just dealing with the condition, holding down a job, and trying to build a life in a new city.


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