The Healthcare Headache_Part 2: Am I even Insured?

Writing about healthcare stresses me out nearly as much as obtaining it...which would explain why I’ve stopped and started writing this section countless times over the past 10 weeks...BUT, this past week Tandem Diabetes announced the upcoming release of the t:slimX2 with basal IQ technology and Dexcom G6 integrated and I feel super hopeful. While health insurance and healthcare is really frustrating, there are some great companies out there working hard to make everyday diabetes management easier. 

So, let’s dive into this mess!

In the past 6 months I’ve held 4 different health insurance policies yet the question still remains...am I even covered? And, if I am “covered” what’s covered and where. Here are the things I’ve learned about obtaining and using health insurance as a Type 1 Diabetic for extended travel.

1. Always get travel insurance before booking your travel.

I did not do this. I booked my flight to the UK (stop number 1) far in advance of even getting my NZ visa. What I didn’t know at the time is that having a flight already booked as well as having a pre existing medical condition (i.e. diabetes) is an exception for most travel insurance companies (I called about 8). When I did find a travel insurance company willing to take me on it required that I also have “American Based Healthcare”. Essentially this meant I had to go onto marketplace and get a basic health insurance plan in order to even qualify for travel insurance. For all those following the mental math YES, paying for 2 insurance plans at once. 

2. You may (or may not) want to tell insurance your life story.

A small preface of location that is relevant: before traveling to New Zealand I moved from my apartment in Maine, where I had been living and working for the past 4 years, back into my moms house in New Hampshire. 

I called the marketplace hotline for help. When going onto marketplace you can go all online or, call for help. I was really confused by this point so, I called. I explained to the really kind lady on the other end of the line that I am Type 1 Diabetic and would be traveling New Zealand for a year and needed “American Based Healthcare”. She then politely told me that all plans offered through marketplace do not cover you when overseas, that I needed travel insurance. 

-You see the circle forming here- 

After re-explaining what the travel insurance had told me about the need for “American Based Healthcare” she seemed nearly as confused as I was. In short, she told me that “...by being out of the country for a year I did not qualify for a plan through marketplace and good luck”. I sat on this for a day wondering what to do then, called back and told the new customer service member that I moved from Maine to New Hampshire and needed a basic plan. Using my new permanent address (mom's house) I picked the cheapest plan, paid the monthly premium, gave no other details, and got travel insurance. 

3. Plans change, optimism and international calling credits are key.

My double insurance worry free days lasted about 8 days. Eight days after picking my plan I received an email from marketplace that the plan I was on would not be offered after December 31, 2017. *eyeroll* The process began again.

4. There is always a catch.

Let’s get back to the travel insurance plan. Again because I have a pre-existing condition and did not get the travel insurance before booking flights, I only qualified for 1 of the companies many plans. This plan was for a maximum coverage of 180 days. After that 180 days (6 months of travel) I had the option to do a 1 time 180 day extension. If, a call for extension was not place within 3 days of the 180 day mark, the insurance would be terminated with no option to continue (ask me how I learned that lesson…) 

5. Have someone(s) at home in your corner. 

Thanks to the Havard Pilgrim “American Based Healthcare” plan I am now on through that second marketplace endeavor, my Tandem and Dexcom supplies are covered. However, Harvard Pilgrim does not work directly with Tandem. This means I needed to go through a medical supplier to get more pump supplies. Step 1: I called Harvard Pilgrim and got a list of medical suppliers they work with. 

Step 2: I called each supplier to find out if they worked with Tandem Diabetes. When I found Bedard Medical supplies they informed me I needed an updated prescription in order to get my pump supplies. 

Step 3: I emailed my previous Endocrinologist in Maine and asked if he could send an updated prescription to Bedard Medical so I could continue to receive pump supplies. - Technically this doctor is now considered out of network for me (because I had to switch my insurance and permanent residence from Maine to New Hampshire) however, because the prescription was only being sent to the third party supplier, and I was not actually going in for a visit or check up I did not have to pay at all never mind “Out of Network” costs. 

Step 4: Connect with your pump representative. Luckily for me, my Endocrinologist, RD, and tandem pump representative work really closely together. We all ended up on a group email and my Tandem pump representative was able to speak with Bedard on my behalf ensuring my prescription was updated, filled, and sent to the permanent address on file. 

6. MOMS are the real MVPs! 

While I love Tandem and my t:slim pump, they cannot ship my supplies overseas. My mom has been receiving all my medical packages and shipping me the parts and pieces I need. *Important to note here that if her address was not listed as my permanent residence with my healthcare company she would not be able to receive the packages*. 

Health insurance is messy but, having strong relationships with your Endocrinologist and a pump supplier makes a world of difference. As far as the initial question “Am I covered and for what?”- I have only gone after pump supplies and it worked. The question still remains if I ever need to seek medical attention or access care in New Zealand…

I have been on a t:slim pump with integrated Dexcom G5 technology since 2016 and I love it. I am SO excited for the continued advances in technology like the X2 and G6. It’s thanks to my pump and Dexcom that I have never had to find the answers to those big healthcare coverage questions. See you soon X2. 

The Healthcare Headache_Part 1: The Stockpile

No matter your political affiliation, I think we can all agree the American Healthcare system is a cluster. I knew this but, I didn’t really know this until after my diagnosis. Diabetes does not just require a doctor, oh no, you get a team. This team consists of your health insurance, a primary care physician, an Endocrinologists, a Dietitian (yes, even as a Dietitian I have a Dietitian), a Certified Diabetes Educator, and a pharmacy/pharmacist. Generally, making a change in medication or acquiring additional supplies requires no less than 3 of the team members. Seeing as this sounds exhausting already I’ll split this healthcare mess into 2 parts. Part 1: Creating a stockpile of supplies and Part 2: finding, obtaining, and remaining insured while abroad.

Part 1: The Stockpile

Step 1 of creating a stockpile of supplies for your journey is to decide which method of insulin therapy best suits you. While this may seem like a no brainer, just continue on your current regimen, there are pro’s and con’s of both pump therapy and daily injection. At the time, and through to today, I used an insulin pump. Specifically, I use a Tandem t:slim G5 and, I LOVE TANDEM (but we’ll go more into why I’m a #fangirl later). First, some pro’s and con’s:

• Tandem pumps have so many parts! I would need a years supply of cartridges, syringes, needles, and infusion sets not to mention the alcohol wipes, skin prep and unsolved wipes, and skin barriers. This would all take up SO MUCH backpack space... goodbye pants there’s not room for you here. 
• I would only have to worry about having one type of insulin (Novolog) to manage. 
• I would be able to have the freedom of pump therapy, something I’ve really gotten used to  over the past 6 months. All T1 diabetics can speak for themselves on this one but, personally having to stab myself everytime I put a carb in my mouth makes me think Dante should reconsider the 3rd circle. 

• Pen injections would only require pens, pen tips, and alcohol wipes. Virtually no backpack space comparatively. Bring on all the pants. 
• I would need to carry, refrigerate, and manage Lantus (long acting) and Novolog (short acting) 
• Multiple daily injections...hello Circle 3...

After weighing the space in my backpack, daily life, and supplies I decided to stick with my Tandem pump. This presented another problem. Tandem is not international. I would need to either bring all my supplies with me, ship them to myself, or a combination of the two. Thus began the stockpile. 

Over the course of 5 months I ordered as much supplies as insurance would allow (usually only a 90 day supply). I was fortunate in that my employer at the time provided AWESOME coverage through Cigna which included a huge contribution to my HSA. Still, I won’t downplay that ordering the max supplies of Tandem and Dexcom costs $412.50 (Tandem) and $459.98 (Dexcom) with insurance for a whooping $872.48 every 90 days. Luckily it only took about 2 of these payments paired with a few checkups before I hit my deductible.

Step 2 of creating a stockpile is to get your doctors on board. I told my Endocrinologist about my plans early in August and he was all in for this trip. In fact, “he and his wife had recently been on vacation to New Zealand” and “...had I looked up Milford Sound yet?” In an effort to increase my growing supply collection he included in his prescription notes that I was changing my pumpsite every 2 days (instead of the standard 3) and that my insulin needs had increased. My supply of infusion sets was doubling and I was saving about 1 insulin vial for every one used. 

Step 3 of creating a stockpile is to call everyone. I wish I had thought to clock the hours I spent on the phone with Tandem, Solara (my Dexcom supplier) and Cigna. I was making daily calls asking everything. I asked for advances on my prescriptions for an upcoming trip. I was vague but included that I would be out of the country for up to a year. I asked what information was needed to get more insulin, and how long insulin would last. I had to call insurance and figure out what they needed to over supply my medication, then call my doctor and make sure the language in the prescription matched exactly to what the insurance provider was looking for. I asked how much everything would cost and how much insurance would cover. I asked if I should pick things up at a pharmacy or use the home delivery service (note: prices vary according to location). I asked if everything would count toward my deductible and fought till it was. 

Finally, after all the Tandem and Dexcom purchasing and frequent checkups to make sure my T1D was in control before leaving the country, I hit my deductible. It was time to go after the years supply of insulin. The request for a years supply was granted (because I had already talked to Cigna, my Endocrinologist, and my pharmacy at least 3 times each to ensure it would be). Picking up my 24 vials of insulin cost me $0 but, at the bottom of the receipt it showed what the cost would have been if I had not yet met my deductible $7,199.99. While I don’t remember my conversation with the pharmacist, I can remember running out of the pharmacy afraid that if I lingered they would realize it was a mistake and either charge me or take it back.

Stay tuned for Part 2: Am I Insured? Coverage While Away & Overpacked and Underweight- How to  transport a private pharmacy on your back through customs. 

Hurry Up and Wait: Getting a visa

After deciding where to go (my partner and I bounced back and forth between New Zealand and Australia for a bit) we had to figure out how to get there. This means visas. This was my first dive into the world of visas and to be honest, the work travel visa for New Zealand is incredibly easy. I think it took us about 10 minutes to fill in the online form. For my non-diabetic, English (i.e. commonwealth) partner, that 10 minutes plus submitting an online payment was the end of it. No more than a week later he was approved to fly over.

Although short, the visa application did ask if I had a “chronic illness” or “medical condition” which, I of course filled in as Type 1 Diabetic. I received a very different response:

We are writing in relation to your application for a work visa under a working holiday scheme.
On your online application form you have disclosed health information. In order to proceed with your application, you are requested to provide a General Medical Certificate and Chest X-ray Certificate by 27 July 2017. This is necessary in establishing whether you meet the requirement to have an acceptable standard of health for temporary entry to New Zealand. For more information about this requirement refer to the relevant immigration instructions at A4.25.1 and WI2.1.1 and/or the Health Requirements for entry to New Zealand (INZ 1121) leaflet. Please email me NZER reference once you have completed medical assessment.

What you should do?

Please note the following:

*       You may not be able to use a mobile device such as a smart phone or tablet to access some of the links in this e-mail and on our website. You will need to use a desktop or laptop computer to access these links.

*       DO NOT send your passport. When your application is approved, you can view and print your visa details online.

*       Check here to find out if you are in a country where eMedical is available.

*       If you are currently in a country where eMedical is available, go to Section A.

*       If you are not in a country where eMedical is available, go to Section B.

Section A: In a country where eMedical is available

If you are currently in a country where eMedical is available, the panel physician will electronically complete and send your medical information directly to Immigration New Zealand.

*       Check our list of panel physicians** to find the nearest approved doctor and radiologist.

*       Once you have completed your medical assessment, your panel physician will submit the results directly to Immigration New Zealand. Please do not email your NZER unless requested by your case officer.

*       Due date for your medical information is 15 consecutive days from the date you submitted your application. It must be received by Immigration New Zealand within this period.

Section B: Not in a country where eMedical is available
(The United States is a country where eMedical is available so I followed Section: A)


IMPORTANT NOTES:

* Unless requested to do so, you do not need to provide a new Chest X-ray Certificate (INZ 1096) if one was previously provided to Immigration New Zealand and it was issued less than 36 months prior to your current application.

** Not all countries have panel physicians. For countries without panel physicians, a registered or board certified or licensed medical practitioner or physician may conduct the medical examination.

*** If you have received another e-mail which lists additional documents which you must also provide (for example, evidence of your qualifications and English language), you should send your paper-based General Medical Certificate (INZ 1007) and Chest X-ray Certificate (INZ 1096) to the address given in that e-mail. It is important that these certificates and all your additional documents are sent to the same address.  

If for any reason you are unable to provide your General Medical Certificate and/or Chest X-ray Certificate within 15 days, we may consider an extension of the timeframe if you can provide a genuine and reasonable attempt to provide these certificates, such as a confirmation of an appointment with your physician. Please refer to our questions and answers to find out how you can contact us.

What happens if you do not send the information requested?

If your General Medical Certificate and Chest X-ray Certificate are not received within 15 consecutive days (unless we have granted you an extension) we will make a decision on your application based on the information you have already given us. We are unlikely to approve your application based on this information.

False or misleading information

Providing false or misleading information or withholding information may make you ineligible for a visa.

Need help?

You can check the questions and answers section on our website for the information you require, and/or visit our website and search our information database or submit a question. If you are in New Zealand, you can also phone the Immigration Contact Centre

That’s a lot to take in right! - This email was sent July 11th giving me exactly 15 days to complete the medical certificate with a “panel physician” from the provided list. At the time, I lived in Portland, Maine and the closest panel physicians were located in Needham and Brookline Massachusetts. *Note that the Needham office is not longer an available option*. After calling both offices and discussing price an available appointments I decided on Needham, exactly 2 hours and 2 minutes drive from Portland.

-Now if I decided not to drive to Massachusetts, the next closest panel physicians office was New York City, approximately a 5 hour and 10 minutes drive from Portland.

This next bit is going to sound sketchy and like everything in a Type 1 life, there is no sugar coating it. The medical appointment cost $600 upfront, in cash, no refunds. Remember this appointment does not mean the visa will be approved. If that’s not enough, they were going to test my a1C and compare it to their standard of 6.5… in 15 DAYS! We all know that is not enough time to change an a1C. The truth was coming out, good or bad.

Skipping ahead over taking the day off work, collecting a passport photo and my complete medical history to bring to the appointment, and fighting traffic into and out of the greater Boston area the day came and went. My a1C came in at 6.8 and exactly 35 days and 10 emails later I had my working holiday visa.

**If you’ve read through this and are thinking to yourself “what if I just check ‘no’ in the medical condition and chronic illness boxes” you are not alone. I wonder that often. But, honesty is always the best policy. This guide is not how you have to do things, it is what I did and how that has played out.

Prologue

I always wanted to travel. I never wanted to be diabetic. Yet, I woke up at 26 untraveled with “late onset Type 1 ‘Juvenile’ diabetes”. Now I couldn’t have my cake or eat it. In fact, it was highly advised that I just avoid cake in general for a while. This made me think about a couple of things very quickly:

1. What kind of expression is “have your cake and eat it too”. If I have a cake of course I am going to eat it! Who in their right mind bakes a cake just to look at it. If you want to bake something just to look at it get into pottery and get away from desserts.

2. All those dreams I had of backpacking across Europe or trekking through Asia are shot. -Don’t worry all you Type 1 travel hungry (and cake hungry) diabetics, all is not lost.

3. How convenient that I spent every year of my life from age 18 to 23 obtaining a degree and license as a Registered Dietitian. Now if only I had gone for my certificate as a CDE (Certified Diabetes Educator)...

This month is the 2 year anniversary of my diagnosis and I live in a van (a purple 1999 Toyota Previa to be exact) working and traveling around New Zealand. Like any good millennial, I began this journey by searching the web for advice or, let’s be honest, a “how to” guide for traveling with diabetes. I found very little. After diving in head first I’ve decided to share my experience the good and the bad. I hope this helps other “chronically diseased” “insulin dependents” to quit their day jobs and road trip indefinitely.