# Moving back to US with a chronic medical condition



## Felipe USA (Dec 30, 2014)

Hi To All,
I am an American living in London and have been for the past 10 years. I am hoping to move back to California in June but I have one major obstacle. I have a blood disorder that requires a pretty expensive medication. Working and living the UK my health care is completely free at the point of service, thankfully. I know that moving back to the US is a whole other story. I have been doing my research but with so many options, it all seems very complicated, INCREDIBLY expensive and a little scary to be honest. I do have the option to carry on here in the UK, but I'd really like to return home, unless of course I'll go broke in doing it. I'm hoping there is someone out there that has had this experience and can tell me first hand what it was like. 

Any experience would be of help.

With kind regards


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## BBCWatcher (Dec 28, 2012)

Felipe USA said:


> I know that moving back to the US is a whole other story.


Well, maybe not. The U.S. healthcare world changed quite significantly on January 1, 2014. I'll briefly summarize the options.

First, you didn't mention what you'll be doing in the United States and, in particular, what you expect your income to be. If your income will be below about 133% of the U.S. federal poverty line (household basis), then you would be wise to move to one of the states that expanded its Medicaid system under the Patient Protection and Affordable Care Act. Also check to see whether your medication is covered under that state's Medicaid system. There is no longer an asset/wealth test to qualify for Medicaid. In principle you could have millions of dollars of wealth but low income (in a particular year), and you could qualify for Medicaid.

Not every doctor accepts Medicaid patients, of course, but that's true of practically every public medical insurance system in the world. That said, a move to the U.S. means you're going to be finding a new doctor anyway, so this is probably not a new concern.

If you have greater income, and if you are not going to be getting medical insurance coverage through an employer in the U.S., then you would go to Healthcare.gov to sign up for a PPACA-compliant medical insurance policy and find out if you qualify for any federal government subsidies to help you purchase that insurance. The Web site will list all the available policies in the PPACA marketplace, and then you'll need to check each policy's plan documents and details to see what's covered -- in particular, whether your specific drug (or an acceptable substitute, if relevant) is covered.

First of all you'll see the plans categorized into various "metal" colors: bronze, silver, gold, etc. The higher the metal value, the more medical expenses that plan will cover for a typical household. (That word typical I just wrote is very important. It's only an initial screen.) Of course the higher the metal value the higher your monthly premiums, typically, but if you qualify for federal government subsidies those subsidies will be tied to the price of the second most expensive silver plan. So don't automatically go for bronze -- check what your subsidies are.

In fact, since you have a perfectly predictable, ongoing medical condition requiring medication, you'll probably want to head toward the higher value metal plans, other things being equal.

High metal value plans will have lower deductibles and (often) lower co-pays, but all plans on the PPACA exchange will cap your annual expenses for all covered medical services. Let me take you through those basics, quickly:

1. Annual deductible: The amount of money you must pay before insurance starts paying anything. This is a number like $5000 or $1000, as examples. (Tip: Submit every medical expense to your insurer, even if you're not sure it is a medical service that's covered. Why? You want to whittle down whatever deductible you chose.)

2. Co-pay (or co-insurance): The amount of cost sharing you have for each medical service. Prescription drugs will have their own list of co-pays in something called the "formulary." (More on this in a moment.) Co-pays should be familiar to you since the NHS has them, at least if you're not poor.

3. Annual out-of-pocket maximum: The maximum amount of money, including your deductibles and co-pays, that you will be responsible for out-of-pocket. After you hit the annual maximum (if you do), insurance pays 100% of _covered_ medical expenses. (Very important word there again.)

You can no longer be denied insurance coverage for preexisting conditions. However, there are a couple "games" to watch out for:

A. "In-Network" versus "Out-of-Network." Again, you cannot just go to any doctor, hospital, or medical provider and expect your insurance to cover it (after the deductible). Your insurance carrier publishes a list of in-network and out-of-network medical providers. This isn't too much of a concern in your first year, probably, but it's something to be aware of each year when you go back to Healthcare.gov to check next year's options. If you like a particular doctor and want to keep seeing her, you'll have to check that. Note that providers can sometimes be added and removed sometime in the middle of a year. But in every country that's true at least to some degree -- doctors are mortal, after all. If you value a wide choice of medical providers then consider living in an area with just that, and with a lot of in-network providers in your plan.

Note that some doctors in some hospitals have been running a scam where the hospital is in-network but certain doctors, lab tests, etc. are not. Then, like vultures, the out-of-network providers swoop in, "volunteering" their services. This is of course obscene, but government authorities haven't managed to stamp out this practice yet. In the meantime, remain vigilant. Question every procedure, every provider to make sure it's "in-network." Do not pay for any service you did not consent to, and raise holy hell with state medical boards, regulators, and others if anybody tries to rip you off.

B. "Drug Formularies." This is the prescription drug equivalent of "in-network" and "out-of-network." Insurers usually have at least 3 coverage tiers for prescription drugs: "on formulary" with the highest amount of coverage, "off formulary generics" with the second highest, and "off formulary name brand" with the least coverage. You have to check your particular drug (or acceptable substitutes, if relevant) and see where they fall on your particular insurer's lists. Again, keep in mind the lists can change -- particularly at the end of the year. Also the insurer might require you to obtain prescription refills (in particular) via mail order if that's possible for the type of drug you take.

This is exactly the sort of thing public health systems do. Italy's system, for example, has 3 drug lists -- same basic principle.

You would be well advised to bring at least a 3 month supply of your drug from the U.K. when you make your move, along with a copy of the doctor's prescription, just to give plenty of time to get switched over. (I think 3 months is the U.S. Customs limit, but check me on that -- and, for the record, many people bend that rule a bit. Just don't try to import an entire drug warehouse's contents. ) Note that you have to get your medical coverage in place in the U.S. within 60 days of moving there, otherwise you might face a tax penalty. But I suspect you won't even want to come close to that deadline and will get your coverage in place as promptly as possible.

If you cannot readily find this information online -- usually you can, but if not -- you can contact your prospective medical insurers' customer service centers. Be sure to get the full name of the agent you speak with, write down the basic details of the call (date, time, etc.), and ask if they can send you a fax or letter with the same information.

Pay your premiums on time, reliably. Automatic bill payment is preferable. If you aren't paying for your insurance of course the carrier can cut you off, though it'll take a little time. Make sure you also verify that the new insurance carrier processed your first payment, and make sure you have your insurance cards (often available online) in hand by New Year's Eve each year. This'll be an annual ritual.

Once you reach age 65 you may be Medicare eligible. If so, fantastic, but that's a separate discussion. If not, you'll be able to continue buying insurance through the PPACA exchanges. PPACA exchange policy rates will increase with age (and time, i.e. inflation), but your subsidies may also increase depending on your income. Rates will not increase at the hypothetical "free market" rates as you age -- it'll be less than that.

That's a fairly quick but also fairly complete primer on today's U.S. medical system. Hope that helps.


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## twostep (Apr 3, 2008)

What speaks against medicL coverage through employer?


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## Felipe USA (Dec 30, 2014)

That is AMAZING!!!! Thank you so much for this information. INCREDIBLY helpful. I I am an occupational therapist and will plan to try and secure employment before I go, but I am finding that most employers want you in the USA before even considering an interview. So I will probably head home without work initially. I have found a broker in the San Francisco area who seems pretty reliable to help me secure either affordable heatlh insurance or Medi-Cal before I go. My drug is considered a tier 4 drug and $12,000 a month, in comparison is costs the NHS only 800 pounds a month. It seems crazy these costs. I am told that depending on the insurance i may be responsible for 20% of that costs and may have to get additional insurance. I'm learning as I go and it does seem incredibly convoluted. I'm sure wants i'm there and in the system it will be alot easier to navigate.... hopefully. Thank you so much for your very helpful response.


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## twostep (Apr 3, 2008)

You may want to look into licensing prior to making plans.


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## Crawford (Jan 23, 2011)

Felipe USA said:


> That is AMAZING!!!! Thank you so much for this information. INCREDIBLY helpful. I I am an occupational therapist and will plan to try and secure employment before I go, but I am finding that most employers want you in the USA before even considering an interview. So I will probably head home without work initially. I have found a broker in the San Francisco area who seems pretty reliable to help me secure either affordable heatlh insurance or Medi-Cal before I go. My drug is considered a tier 4 drug and $12,000 a month, in comparison is costs the NHS only 800 pounds a month. It seems crazy these costs. I am told that depending on the insurance i may be responsible for 20% of that costs and may have to get additional insurance. I'm learning as I go and it does seem incredibly convoluted. I'm sure wants i'm there and in the system it will be alot easier to navigate.... hopefully. Thank you so much for your very helpful response.


I'd be very careful of health insurance brokers, who like many insurance salespeople, are only too confident they can get you insurance - until such time as they can't.

Why would they offer you Medi-Cal insurance? This is the Californian equivalent of Medicaid - for low income residents; usually those on other welfare benefits.

You will have the option of State plans under Obamacare as BBC Watcher has described - however as an occupational therapist I would have thought that you would earn above the subsidy "poverty" levels so maybe you should budget for a few more hundred dollars a month for your insurance premiums, plus any co-pays and deductibles.

Even with Obamacare, don't underestimate how much medical costs are here in the US - especially if you don't qualify for any subsidies for your premiums; and the subsidies only apply to premiums; they don't apply to actual co-pays and deductibles you will have to pay.

Another important factor as BBC Watcher said is whether your drug is on the insurance companies "accepted list" If not, you are really going to get huge expenses.


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## BBCWatcher (Dec 28, 2012)

I agree with Crawford. I would not go through a broker. Start with Medi-Cal (while you're unemployed, i.e. income-poor), then shift over to employer-based insurance when you land a job. Take a close look at whether your drug is covered in that employer plan before you accept a job offer.


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## Felipe USA (Dec 30, 2014)

I'm already licensed but thank you for that tip.


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## Felipe USA (Dec 30, 2014)

BBCWatcher said:


> I agree with Crawford. I would not go through a broker. Start with Medi-Cal (while you're unemployed, i.e. income-poor), then shift over to employer-based insurance when you land a job. Take a close look at whether your drug is covered in that employer plan before you accept a job offer.



This is what my plan is. It's difficult to know until I get a job offer and even then, it's difficult to get HR's to give you health insurance information until you have accepted a job. I just went through this with a perspective job. It's difficult. I will put in for extended leave at this job here in the UK and then see if I can work it out. If I can't then I can alway return to my current job. It is not ideal but it seems that this is the reality in the USA at the moment.


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## Felipe USA (Dec 30, 2014)

Crawford said:


> I'd be very careful of health insurance brokers, who like many insurance salespeople, are only too confident they can get you insurance - until such time as they can't.
> 
> Why would they offer you Medi-Cal insurance? This is the Californian equivalent of Medicaid - for low income residents; usually those on other welfare benefits.
> 
> ...



The reason why Medi -Cal was brought into the mix is because i would be moving there without a job initially. Then get employed hopefull with employer sponsored health insurance that would cover my current med. It is a little harrowing all these costs.


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## Crawford (Jan 23, 2011)

Felipe USA said:


> This is what my plan is. It's difficult to know until I get a job offer and even then, it's difficult to get HR's to give you health insurance information until you have accepted a job. I just went through this with a perspective job. It's difficult. I will put in for extended leave at this job here in the UK and then see if I can work it out. If I can't then I can alway return to my current job. It is not ideal but it seems that this is the reality in the USA at the moment.


I think most people would baulk at accepting a job in the States *without* being given full details of the health insurance.

Having good health insurance is such an important part of living in the US that not having it would _seriously_ jeopardise people accepting jobs.

Keep asking the questions until you get all the information.


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## BBCWatcher (Dec 28, 2012)

If you don't mind mentioning the name of the drug, I might be able to take a look at the formularies for carriers in California to see if the drug is typically covered.


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## Felipe USA (Dec 30, 2014)

The name of the drug is Nilotinib. Thanks guys for all your enthusiasm


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## BBCWatcher (Dec 28, 2012)

Nilotinib, for the treatment of cancer, appears to be on Medi-Cal's list of covered drugs.

I checked PPACA exchange plans in California for Los Angeles, as an example. Health Net offers the lowest priced silver, gold, and platinum exchange-based plans in that market. They appear to cover Nilotinib to the extent "specialty" drugs are covered (check co-pays) but only if your doctor obtains prior permission before prescribing it. Molina Healthcare generally offers the second least expensive exchange-based plans in that market, and they classify Nilotinib in their "Tier 4" reimbursement schedule and require the same thing (prior authorization). Nilotinib is sold under the trade name Tasigna in the United States, so you'll sometimes see it listed that way.

So it's a qualified yes. Please confirm all details, of course -- preferably in writing -- prior to selecting an insurance plan.

On edit: A couple other bits of advice. One is to make sure you have knowledge of any alternatives to this drug that you and your doctor have determined would be safe and effective. You never know when you might have to switch to something else, for drug side effect, insurance, or other reasons. So if there are viable (or potential) alternatives, make sure you know about all of them. The second bit of advice is that (surprise!) the maker of Nilotinib/Tasigna offers free advice by phone on whether the drug is covered under particular public or private medical insurance plans. (You might think that's self-serving, and you'd probably be right, but nonetheless they want to make sure you can pay for their drug so they can sell it to you.) In the U.S. you could call Novartis, the manufacturer of that drug, at 1-866-692-6548. Third, you'll need to be aware whether the 150 mg or 200 mg dose is what you need -- there are two dosages marketed in the U.S.


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## Felipe USA (Dec 30, 2014)

Yes, thanks for this. I appreciate all your efforts. Unfortunately there are no generics for these specialty drugs (at least not yet) as they want to get as much $$$$ before their patents run out. I have learned of an American with cancer that did go home from here and had to return in the end because of the outrageous costs and limitations her insurance was putting on her. It seems unthinkable to have to leave the country to get affordable care.


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