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NGoldstein

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  1. Your wife is not subject to us tax nor FACTA / FBAR being that she is not a US citizen or resident. To get a SSN residency is needed so I guess you either need a US residency application for her at US embassy in China or do it here in the US with HSA but she needs to come. Also ITINs have a validity of 5 years if not used to pay taxes.
  2. Yes. Ping'An is a highly credible insurance company, one of the largest in China. Shanghai United Family also provides direct billing with Ping'An.
  3. Overstaying your visa is not something a visitor to Thailand should do, but it can be corrected, usually with no great difficulty, but it may cost some money. Here is the straight scoop if one finds themselves in this situation. In Thailand, I live in this kingdom on a “Retirement Visa” which is renewed every year and requires me to check in to Thai immigration every three months to let ‘em know I am still alive and kicking. There are some qualifiers to the Retirement Visa that not all can satisfy, so there is a lot of people looking for an alternative to this. If one were to come to Thailand and enroll in a school to learn the local language, it is possible to get an “Educational visa” which allows a stay from 1 year to 15 months. There are many Thai language schools in the bigger cities of Thailand, including Chiang Mai. Usually, they handle it all for you after you sign up for the school. They all promote this in their advertising. Some schools require rigorous studying, and others, quite honestly, do not. If you are able to secure a legit job in Thailand — like teaching English as a second language in a school — you usually can get a work permit, and then get a business visa that allows you to stay in Thailand as long as you are working (needs to be renewed every 90 days). Just be aware that the employer has to pay money to get you that work permit, so there are some that will promise and not deliver. For those that don’t qualify for a business visa or an educational visa or a retirement visa, there is the old standby of a tourist visa. Anybody coming to Thailand with a current US passport (make sure it does not expire within 6 months), and is not on some criminal list, can get an automatic 30 day stay here. Then, you can get an additional 15 days by crossing one of the nearby borders and getting another stamp in the passport. You can get a visa for a longer period if you go to the Thai embassy or consulate I the US before you come here and apply for it and pay the fees, of course. If you are in Thailand and you know you will be here longer than the visa stamp permits, you can go to the Thai Immigration Office and get an extension for a fee. This has to be done before it expires. Don’t go to Thai Immigration after your visa expires (you may be thrown in jail). Also, check the economies of the situation. Find out how much it costs for the extension, because if it is needed for just two or three days extra time in Thailand, it may be cheaper to pay the fine at the airport. Once inside Thailand, unless you are involved in some nefarious enterprise, you are not likely to ever be required to show your visa status to anyone unless you go to Thai immigration and want to change status. There is no “ICE” (Immigration and Customs Enforcement police) like in the US going around checking foreigners for their “papers”. You often show your passport, for domestic flights for instance or for hotel check in, but they are not looking at your visa status. This has led some Americans and other foreigners to simply come in for a 30 stay, and then just “overstay”. In order to do this, one must not be paranoid about the consequences, but it is important to get the “straight scoop” of what the punishment or penalty will be. For sure, if you take this route, you are taking a chance of having some problems. The chances are slim, but they are real and it does happen. If by chance you get picked up by the police for something you can have some trouble (but if you are not involved in criminal activity, this is not likely for most people — stay away for Ganja — “pot”, or even suspicious behavior that may infer drug use). You can be jailed and deported until you can show a ticket back to your home country. If you are prepared (financially), that is not such a difficult task, but the key is to keep a low profile by not getting involved in activity that will involve police scrutiny. The chances of getting picked up by the police for overstay is remote, but it is a real possibility that you should be aware of. If you ended up in an Alien Detention Center, it is extremely uncomfortable, and there have been a few cases with Westerners that get picked up that have made the newspapers. Traffic police are not going to be checking your visa status for an infraction as long as you have an International Driving License or a Thai license (and usually pay the required “fine” on the spot to the police officer). For an overstay, you can take care of it at the international airport when you finally decide to go and do it fairly easily. The big international airport in Bangkok has a special area for people to pay the fines for overstay. If you overstay for one day, there is no charge (your grace period). After that, it is 500฿ per day (USD $16). Two days overstay will be a fine of 1000฿ and three days will be 1500฿, etc. It takes about 3 minutes at the airport to clear it up, and you will not be jailed for anything by voluntarily paying the fine. There won’t be any hassles. The maximum fine for an overstay in Thailand is 20,000฿ (USD $666). So if you overstay your visa by about a half a year, you won’t be paying 500฿ per day as a penalty. A half a year (182 days) paying the maximum fine, has a cost to you of less than 110฿ per day (about USD $3.50). If you overstay your visa by several years, there is a stronger possibility of trouble. Many still get away with it, pay the 20,000฿ fine and have no problems. There are reported cases, however, where Thai immigration has interpreted the overstay for years as deliberate fraud requiring a court case and possible prison time. In Thailand, that is a very bad thing to have happen to you. When a US passport has expired and the owner surrenders to the Immigration Office, the owner will be fined 200 baht per day from the date of passport expiration up to the day of surrendering. By surrendering, the owner of the passport will only have to pay a fine up to the maximum of 20,000฿ and have no further hassles. But having an expired US passport can actually become more serious than an overstay of a visa because the passport is checked more often for ID (like with a domestic flight), and you can be arrested immediately by a policeman and taken quickly to court where you must pay the fine and have a ticket to leave the country, plus enough money to transport you to the international airport. So don’t travel in Thailand with an expired passport, or even one that will expire within 6 months. And remember, you have to have the return ticket back to the home country. If you live in Hong Kong and have a job and apartment there, it doesn’t matter. You will have to have that air ticket back to the USA. And if your problem comes up on a Friday evening, you will end up staying in jail till Monday morning when the courts and Immigration Offices reopen. There are Thai immigration attorneys that can help make things a bit smoother, but even they cannot get action done when the offices and courts are closed for the weekend. So an overstay or a passport expiring is not for the faint of heart or for anyone that tends to get stressed out with some rational paranoia (that would include me), but there are those vagabonds that are able to go through life without worry no matter what could possibly happen, and the odds are they won’t have a serious problem with the overstay except for paying the necessary fines when they leave. With a stamp in your passport that you overstayed in Thailand, in almost all cases you will not have a problem coming back to the country later. Unless you are interpreted as a serious criminal, you won’t be put on a do-not-enter list for the future.
  4. LATELY, I HAVE BEEN CONTEMPLATING AND RESEARCHING THE IMPLICATIONS OF BEING AN EXPAT AS IT RELATES TO STATE INCOME TAXES (NO PROBLEM UNDERSTANDING FEDERAL INCOME TAXES). IT SEEMS THAT MANY STATES MAY CONSIDER SOMEONE TO BE DOMICILED IN THEIR RESPECTIVE STATE EVEN IF THAT INDIVIDUAL IS NO LONGER RESIDING IN THAT STATE. IF SOMEONE STILL HAS A BANKING RELATIONSHIP, AND/OR IS STILL REGISTERED TO VOTE AND HAS A DRIVER’S LICENSED ISSUED FROM THAT STATE, MY UNDERSTANDING IS THAT THE STATE IN QUESTION COULD EXPECT THAT INDIVIDUAL TO FILE AND PAY STATE INCOME TAXES (AGAIN EVEN IF THEY NO LONGER LIVE THERE)…. As no doubt every American expat understands, the United States requires every American expat to file a US federal tax return for their worldwide income (meaning including income not earned in the US). This citizen-ship based demand for tax filing is being decried by many, and is the toughest tax demand on expats of any country. Only if your annual income is less than USD $9350 (single person) or USD $18,700 (joint return) are you exempt from filing. You will not have to pay taxes on income earned outside of the US if it is $92,900 or less, but you are still required to report to the IRS what you earned even if it is very little (this is truly an over reach by the US government, but as an expat we don’t have a representative going to bat for our interests). And most expats are aware of the FBAR rules that require expats to report any bank account or other financial assets that have an accumulative value of USD $10,000 anytime within the year. Another question arises about STATE income taxes. Many States, like my home state of California, are very aggressive about abstracting income taxes from their residents, and often the burden of proof about residency is on the citizen. You are guilty until proven innocent, so what is the situation for an expat that used to live in the State and maintains a mailbox or friends/relatives address in the State as a connection back home? Some states, such as Alaska, Florida, Nevada, South Dakota, Texas, Washington and Wyoming, have no state income tax at all. Consequently, no one that is from one of these states and maintains an address there will be required to pay any state tax at all as an expat. If a prospective expat can easily make their contact location in the US in one of these states, it is to their advantage to do so. Some States have made it easy for expats to not owe any state tax when they have been gone for more than six months. Two states, Tennessee and New Hampshire, only collect taxes on interest and dividends earned in the State, so they also make it easy for expats to work around. And some States have made it extremely difficult, like California, Virginia, South Carolina and New Mexico to eliminate the requirement for income taxes being filed when abroad. Understand if you are a resident of one of these states, you are considered an asset of the State (i.e., slave) and as much as possible must be taken from you before you expire. It will be difficult to shake the shackles from these States (in addition to carrying the shackles from the federal government). If after leaving one of these 4 severe case States you intend on returning back to the State (like having a temporary assignment overseas for a year or two), understand it will be extremely difficult for you to escape the State income tax filing requirement. These States are looking for ties that suggest future residency. It is likely they will demand a return from you if they can connect you to the State with any of the following: Telephone and/or utility bills Voter registration Library card Mailing address Association memberships In-state dependents Property mortgage or lease State drivers license State investments or bank accounts Sound Draconian? Yes it is, and believe me when I say that California tax people (whom I have had personal experience with) go to enormous lengths to try and pin State income taxes on people. They are like bounty hunters and you are the bounty, and living full time on the other side of the Earth may not protect you. What should you do in order to escape these tax collectors? Be ready to cut ALL ties with your former home. In my particular situation, the only connection I have with California is my daughter-in-law’s address for one bank account, and even with that I put my name “in care of” hers. I file my federal tax return using my Thai address, social security has my location in Thailand, and everything else has my Thai home address. state taxesIf you have within one of these severe States property or dependents (both of which will probably be on your federal return), you will have great difficulty proving you are a non-resident of the State. All other States not mentioned above in this posting make it fairly easy to prove your residency outside of the State. Most require that you have been out of their State for at least 6 months, and if you get a letter from them after not filing, you may have to supply them with copies of documents showing you live elsewhere. In My Opinion… It is my opinion that the associations for lawyers and accountants have lobbied hard to make dealing with State and Federal taxes difficult, thus requiring most Americans needing their services. This is what I call the “Accountant Tax”, which is the American public subsidizing one small group of professionals an almost guaranteed income just to complete the stupid forms our government requires of us. This can be hundreds of dollars per family, or even thousands for those needing complex forms. The CPA accountant association is one of the few groups, for instance, that has lobbied in support of the evil FATCO (FABAR) reporting requirements. Did you know that America spends more money each year on tax preparation than consumers in the US spend on all the new cars and trucks sold in the country? We should support those very few politicians that advocate a smaller government with fewer regulations, whether on a federal or state level.
  5. Something that most of us will experience at least once in our life is being hit up with a serious medical problem. Most medical problems fortunately can be fixed, but the serious medical treatments are going to cost a lot of money. In the US, you might be OK if you have good medical insurance. If you don’t have insurance or are inadequately insured for your medical malady, you may be starting a financial problem that is going to be with you for perhaps 10 or 20 years, or even the rest of your life. If you are in this daunting situation, all alternatives must be looked at. There may be government assistance by the State, or a repayment plan set up that will last for many years, or there is the option of getting the same medical care in another part of the world that is affordable. More than a million and a half people visit Thailand for serious medical care every year, making Thailand near the top of the list of places in the world to consider for treatment. In this report, I will give you information about my experience and what I have seen with other people that have gotten care in the Thai Kingdom to assist you in making the right choice. In Thailand, there are private hospitals and public hospitals. For an American coming to Thailand for treatment, they should only consider private hospitals. In very general terms, you can expect to pay about 10% to 20% in Thailand of what the total cost would be for that service in the United States. Before you make a commitment to travel here for treatment, you should be able to get fairly accurate estimates of your total costs for your care. The more information you have about your diagnosis, the better your estimate will be. This is a very serious issue when you might be facing medical care that can cost $100,000 in the US. If that can be brought down to $10,000 or $15,000 by coming to Thailand, it makes a huge difference in your life for a very long time. For me, growing up in the USA, I was always told that the best medical care in the world was in my country, and no other country could compare. I have since learned that is not exactly true. You can get your first indication of this in an American hospital by meeting the doctors. You are likely to have a doctor from India, China, Philippines, or from some other exotic place, like Thailand. These foreign born doctors in American hospitals are often doctors in training. And when they complete the training, they usually go home. When you go to a hospital in Thailand, you will find most doctors speak perfect English, and have been trained in the West, including the US, Germany and Australia. The doctors in Thailand are as qualified as doctors in America. Perhaps you have this idea (and I can understand why you may think this) that hospitals in Third World countries are basically Third World. Rustic accomodations, nurses fresh from the rice fields, and second hand medical equipment that have been handed down by the great hospitals of America. Nothing could be further from the truth. A good room in a Thai hospital The accomodations for patients staying in Thai hospitals are far superior to what is available in the US. Typically in the US, you share a room with another patient, or even perhaps 3 other patients. There is virtually no privacy, except a weak little cotton sheet that is hanging between you and your roommate(s). When you are checking into a Thai private hospital, you are usually given a choice of accomodations. You can have a shared room, a private room or a private suite. In your standard private room, you are likely to have a balcony to go out on for fresh air, a couch and nice chairs for your guests, and even another bed to accommodate your spouse or significant other to stay with you during the night. The hospital staff, the nurses and the techs, in Thai hospitals are very different than the staff in US hospitals. For various reasons, US hospital staff have morphed into wearing “scrubs” (or a better description is “pajamas”). Perhaps because the hospital staff have been recipients of rough treatment by patients in the past, they themselves have become very gruff, barking orders, and pretty much abusing the patient’s patience. Hospital clients in the US are no longer regarded as “customers” responsible for generating the income of the whole industry, they are generally regarded as people that need to unquestionably do what the nurse says, move quickly, and wait whenever the staff deems it necessary. “Take a number, sit down and shut up.” It is definetly a relationship of the “bosses” vs. the ungrateful “recipients” of the bosses’ talent. It is not pleasant if you are the receiving end (and as a patient, that’s where we are). When you go the reception of the Thai private hospital, you are likely assigned a nurse (or nurses’ aide) that will accompany you (or escort you) on your trips to the various departments that you must visit (like the Blood Lab, the X-ray, etc.). Your escort will speak decent English, and be dressed in a spiffy starched uniform with a little hat on top of her head with a cross on it. Wow, like in the old movies. Your escort and all the nurses and staff you meet are also dressed in spiffy uniforms and treat you with respect and courtesy. It is almost a shock to our system to have this higher level of service. In each department that you visit, the wait time is short, or there is no wait time at all. You start feeling good because of the service you are getting. If you have just been going to American hospitals, this may be a big shock for you. When you meet the doctor, you are likely to be impressed. Almost all speak excellent English. They have the latest equipment, probably better than what you have seen in the US. One of my problems is high blood pressure. In the US, I see a general practitioner doctor that is pleasant, and I do like her service. I have to try and get an appointment a week or two or three before I want the appointment, since they have to schedule me in. She looks at the results of my blood test and the other readings taken by the nurse in pajamas that assists the doctor. I also go to a doctor when in Thailand for the same high blood pressure problem. I call the day before I would like an appointment to see my Thai doctor who is a Cardiac Surgeon, trained in Australia. I take all the tests prior to seeing him of course, and he has access to this information. He also has in his office a electronic sonogram machine that he hooks me up to and gives me a chance to see my heart as it is pumping in full color, and he gives me all the details of my heart, and shows me specifically where my problems are on the video screen. It is a real education. He gives me information on supplements that contain Omega 3 and other ingredients that are beneficial in the reduction of my blood pressure, and explains to me how they work. He prescribes the appropriate medicine for me, and my escort nurses’ aide takes me to the pharmacy to get this filled. My whole experience is on a much higher level than what I get with my appointment in the US. Later, any time between my semi-annual appointment, if I have a question about my treatment of blood pressure or I have an adverse reaction to medication, I can email directly to my doctor and will get a fairly quick response (have done this several times). My US doctor does not have this kind of communication with me. In Thailand, I don’t have medical insurance (because of a rocky history in health matters), but my wife does. I pay cash for my visits. My typical semi annual visit for my blood pressure, including all the labs, meeting with the doctor and my medicine for a half a year, will cost me at the most $150 US. Back home in America, I would pay much more than that just for the medication. If I ever require heart surgery, I will consider getting it in Thailand first, even though in the US there is some coverage for me by the V.A. and in a couple of years, Medicare. If someone from the US with a rather serious medical situation decided to go for treatment in Thailand, and they did not have adequate insurance coverage in America, they would (1) save a huge amount of money, bringing the cost of the situation to a manageable level, and (2) have treatment equal or, more likely, much superior to what they would get in the US. That’s the bottom line. And stressing about the money you owe the hospital will not help you get over the problem. Where to Go Bumrungrad Hospital The biggest private hospital in Thailand is the Bumrungrad Hospital in Bangkok. There are many good Thai hospitals spread all over the country, but the Bumrungrad is the most accustomed to working with people coming from the West. There is even a shopping area in the hospital that includes a Starbucks, and in much of the hospital you may think you are in a nice hotel, not a treatment center. This is the hospital that I would most recommend. It is centrally located in Bangkok, close to hotels, shopping and good restaurants. First step would be to go to their website at Bumrungrad Hospital, and start sending emails and making calls. You are likely to get very good attention to your requests. Bumrungrad is the premium private hospital in Thailand. Other private hospitals in the country can be lower in cost, but not by huge amounts. If you must lower your costs, I would suggest you look at what else is available in Thailand. A pretty complete list of private Thai hospitals are on this website, Thai Medical Tourism, with direct links to each one that you can start communicating. Thai Visa Forums is the expat site that can provide you with a lot of answers to types of care, where to go, and more reports to the level of treatment. The forum for health issues is at this location, Thai Visa Forum – Medical & Health Section. Good to look over, and if you have your own questions still unanswered, I would recommend that you become a member of the forum (it is free) and you can ask away. There are many qualified expats on the site that will help you. Then, start making your travel plans. There are some specialty travel agencies in Bangkok that service medical travelers (Google them), or you can try your own regular travel agent. Air fare to Bangkok from the US usually runs from about $1100 to $1600 rt economy, so this has to be added in your mind to your medical expense. Time outside of the hospital in Bangkok is not expensive, with excellent hotels under $100 per night, down to as low as 25% of that. If you need assistance in travel plans, feel free to contact me directly and I can help make arrangements.
  6. Ever since I was a little biddy boy, I have heard the mantra about American healthcare: “The Best Medical Care on Earth is in the Good Ole’ USA”. Now I am a bit older and a lot wiser, and have learned that it just ain’t so. My wife and I were involved in a serious car crash. I escaped with no more scratches then what I get after trimming some bushes in the garden, but my wife had a very severe injury to her right hand. She had to have her hand literally reconstructed, and she has lost a middle finger and half of two others. Certainly not happy about losing part of an appendage, but very happy we did not lose a life (which at times was a real possibility). My wife stayed at the huge Bangkok International Hospital for nearly a month, and will have a couple of months of outpatient attention to her injury, and I now feel safe in reporting about the medical care in a good Thailand hospital from first-hand experience. In Thailand, there are two types of hospitals: government hospitals which offer basic service at little to no cost for the general Thai public and the private hospitals, which are not government subsidized, and care is paid for by cash or covered by private health insurance, which is inexpensive for Thais and expats alike (that will be subject of another post on this site soon), luckily we did have Thai health insurance for us both. Initially after our incident, we were delivered by locals that witnessed the accident to the closest hospital, which was a government shop (yes, the spirit of getting involved to help others in a crisis is very much alive in Thailand, thank God). We stayed there just to take care of the most immediate requirements, and then proceeded via ambulance to go quite a distance to Bangkok Hospital. Bangkok traffic is one of the worst in the world, and despite sirens and flashing lights, our ambulance inched forward to its destination. This is expected for an ambulance run in this city, so there is a lot of medical care provided inside the vehicle. After about an hour and half, we pulled into the Emergency Room of Bangkok General, and the medical staff jumped to our attention. A word about the medical staff: they look and act much more professional than you will see in a typical American hospital. All nurses are dressed in white, spiffy and starched uniforms with the little nurses’ caps we see sometimes in old American movies from the 50’s or earlier. Bangkok Hospital is an International Hospital, so many of the staff speak other languages, most often English. There seems to be more nurses, more tech people and more doctors than I would see in the US. And Bangkok Hospital works on the philosophy that they do what the patient (customer) wants, and that is for immediate attention to injuries and pain, and also have the patient as comfortable as possible in every way. For me, this is a contrast to the US where nurses dressed in pajamas (aka scrubs) seemed to be mainly concerned about giving medical care, but not a great deal of attention to the small needs of the patient to make things comfortable. And absolutely no regard for the families involved. Thai doctors almost universally speak English perfectly, and often other languages as well. Like American doctors, they are well trained, most having spent some time studying in the UK, Germany, the US, or Australia. Bangkok Hospital is truly an International Hospital, with patients coming from all over the world. You will see Arabs, Africans and Australians, along with every other possible nationality. Hospitals actually competefor their reputation in Thailand (remember when America was all about competition?), and also compete with medical care available everywhere in the world. In order to get international customers, they have to provide superior service than what you will find in Dubai, Detroit, or on the Danube. And in my opinion, they do it, and do it very well. In Bangkok Hospital, all rooms are private rooms, and all are much bigger than a private room in an American hospital. They are similar to a small suite in a nice hotel. They even have “bellmen” with hotel style carts to take your luggage (or whatever you have) up to your room. In the room, there is always a second bed designed for the spouse (again, providing the service that customers want and will be most comfortable with). I have stayed with my wife every day and every night as she went through her treatment, and I like to think that this has helped her to get better during her treatment. We also had a third bed added for my wife’s adult son to stay with us as well. Also in the room is full size refrigerator, microwave and personal safe (at no cost). All the standard hospital food is excellent, with several styles of food for different cultures, and another menu is provided that delivers various cuisines from better restaurants in the area. The room is serviced every day by a cleaning crew similar to what you see in a good hotel. And of course there is wifi and television with stations in a dozen or so languages. Within the hospital lobby there are at least two Starbucks, a MacDonalds, several Delis, Japanese restaurants, Indian restaurants, nice casual dining restaurants, restaurants catering to Muslim tastes, a cafeteria that is like a food court in a shopping mall and plenty of other shops, including a big 7-11. Also in the hospital lobby there is often a classical music quartet playing, sometimes with a singer, that is first rate. Everything is designed to make patients, family and visitors extremely comfortable about coming to Bangkok Hospital. One of the large buildings on this huge hospital campus is specifically for heart and cardiac system issues, and this place is noted as one of the world’s best. There are also huge areas devoted to medical treatment of diabetes, spinal injuries, sports medicine and just about anything else that are major issues. And all of it is super clean, super modern, super professional looking, .with extremely polite service given by all sorts of people around the lobby. It is like there are hundreds of Concierges catering to every need. I am no expert in evaluating a doctor’s performance, but as a patient here, the doctors come across as very professional, knowledgeable and helpful. Maybe we were just lucky with the doctors we ended up getting, but the professionalism from the doctors seemed much higher than the level I have gotten in the US. And the bottom line is that my wife will fully recover to the best level that could be expected with her injury. But Bangkok Hospital does not accept Medicare, Obama-care (or more accurately, Obama-control), the V.A. System or any other US government socialized medical system. They may take US private medical insurance (like Blue Cross), but that needs to be verified in the US. If you have to pay cash, the cost of staying at this hospital is about 10%-15% of the cost in a US hospital. Thai private medical insurance is available to expats, and pays 100% of the costs if you check into a hospital (under most plans). My wife has a good program with BUPA (the big Thai medical insurance company) and she pays the equivalent of $900 USD per YEAR at age 56. It will not go up in price as she gets older. And when (or if) she turns age 65, she gets an annuity retirement check from the policy each month, which will return much of what she paid in premiums before. This is the kind of system that evolves when the government is not controlling healthcare. I am kind of an old hand at getting medical service in American hospitals. I have stayed in several US private hospitals (including one of the finest, Stanford Hospital) and government hospitals (VA hospitals) for very extended periods with a host of medical problems that hit me a dozen years ago. Compared to the service we seem to get at Bangkok Hospital, the US hospitals seem absolutely “third world”. My personal opinion is that with more and more government interference, medical care has deteriorated in the US over the last several decades. Doctors in the US work under constant fear and pressure of litigation. The FDA has evolved into an agency designed primarily to protect big pharmaceutical companies, and the same holds true for the AMA. New treatments that do not originate from big pharma are quickly rejected. That’s why you will find some cancer treatments producing results in hospitals in Germany that will never even be introduced in the US (and few will even hear about them). America may have once been the leader and innovator in medical care, but I believe those days have passed. And at the same time, medical care costs in the US have skyrocketed to the point that no one, even the very high income earners can afford to pay directly for any kind of medical care in America out of pocket. Some will find fault in my personal report, and will continue to praise American medical care as the best there is, but these people have blinders on that could be shattered by real experience at a premium hospital in Thailand. Without really direct personal comparison, I don’t think a person should rate American medical care over any other place.
  7. Rainy season is now upon us and with that begins an increase in Dengue Fever. Every doctor will warn you that before heading to a tropical destination, there are a few mosquito borne illnesses that strike fear into people worldwide. These often include malaria, Japanese encephalitis and Dengue fever. According to the Public Health Ministry of Thailand, this year is expected to be the worst season in Thailand’s history for haemorrhage dengue fever, also know as “Break-Bone Fever.” Already this year, 39,029 people have been treated for dengue fever and 44 people have died. With those cases expected to peak during the rainy season, the Public Health Ministry expects more than 100,000 cases by the years end and more than 100 deaths. So the question remains, “How do I make it through this rainy season without getting dengue fever?” What is Dengue Fever? In order to avoid a week of misery, its best to first understand where dengue comes from. The simple answer is from a mosquito, specifically the Aedes mosquito. This small, daytime mosquito is distinctive by its black body with white stripes or spots. It often hangs out around clean, still water while looking for blood in order to get the necessary protein to lay eggs. When the mosquito bites a human with dengue fever, the virus incubates in the mosquito for a number of days and then reaches the mosquitoes salivary glands. This allows the virus to be easily transferred to the person who is next bitten by the mosquito. How do I know if I have it? The good news is that 80% of the cases of dengue fever are asymptomatic or the person only shows signs of a mild fever, which means you may never even know you have it and your body will naturally deal with it over the course of a couple weeks. However for approximately 5% of those infected, they will be in for a long week or two. The incubation time, or the time between exposure to the virus and the onset of symptoms can be anywhere from 3 days to as much as two weeks. When symptoms do start, they will often feel very similar to an ordinary fever including raised body temperature, a stuffy nose as well as vomiting or diarrhea. While these symptoms are common and hard to distinguish from any old cold, there are a few tell tale signs that should throw up some warning flags and warrant a trip to the doctor. The first sign is severe headaches. We are talking I-can’t-think-because-my-head-might-explode headaches. The second sign is that you will feel like you have been hit by a truck. Expect joint and muscle pain rivaling that of a seventy year old man. If you think you have somehow thrown your back out while doing no labor harder than eating a bowl of rice, you may need to think about visiting your doctor. Another very common symptom is eye pain. If your eyes suddenly feel like they are three sizes too big for your eye sockets and every time you look left or right it exacerbates your headache, than that is another sign you may have dengue. Finally, if in conjunction with these symptoms you develop a body rash, you should immediately head to the hospital. Another rule of thumb is anytime you have a fever for three days, you should go see the doc for a check up. Once arriving at the doctors it is normal to get the full check up and be questioned about your symptoms. However, if you are really worried about potentially having dengue, do not leave the office until you get a blood test because that is the only way to confirm whether or not you do indeed have dengue. Crap, I have dengue, what can I expect now? Quite simply, a long hospital visit. There is no medicine or vaccine for dengue fever, so once you have it, there is little that can actually be done. However, if the disease gets too advanced, it’s possible you can enter Dengue Shock Syndrome or haemorrhage blood from you intestinal tract. This can lead to other complication like liver failure and possibly death. So listen to your doctor. When he tells you to stay at the hospital a few nights, don’t fight him. You will be hooked up to an IV day and night and given paracetamol or acetaminophen, which is commonly sold as Tylenol. Do not take ibuprofen or aspirin as this can increase your chance of internal bleeding. If your doctor is trying to give you this, sit him down and have a serious conversation with him. I repeat, DO NOT TAKE IBUPROFEN OR ASPIRIN. When the doctor tells you to stay in the hospital, expect to stay for a number of days. Five was my magic number and was corroborated by a few friends who have also had the disease. Every morning you will have blood drawn and a visit from your doctor to update your white blood cell count, blood platelet count and kidney functions. Nurses will check your temperature and blood pressure every four hours and you will eat horrible, horrible hospital food. Typically your doctor will allow you to go home when you have not had a fever for 24 hours and your blood counts are trending towards normal. Congratulations you made it. That sounds horrible, how can I not get this? It is horrible and there are a few things you can do to decrease your chances of acquiring it. The easiest thing to do is to coat your body in mosquito repellent 24/7. It is also important to understand that if the Aedes mosquito bites during the day and is attracted to still, clean water, then you should aim to stay away from those areas or prevent those environments from occurring. There are a number of preventative measures you can take to make your home unattractive breeding grounds for the Aedes mosquito. The most obvious is to get rid of still water in your house or apartment. These mosquitoes love to hang around water holding containers such as water bottles, plant dishes and toilets. Make a concerted effort to throw water bottles away, or at the very least screw the caps on them. Plant dishes should be cleaned every other day and toilet seats should be shut. The idea is to not even let them breed as one of the reasons for this years outbreak is that the mosquitoes are breeding at hiring rates than ever. For more information on preventing Aedes mosquitoes from breeding and other information on dengue fever, check the Singapore National Environment Agency website.
  8. There are loads of information on the internet about how easy it is for Americans to receive Social Security payments while living overseas and to have Medicare protection if you go back home. The web sites — many from the government — make it sound like it is a walk in the park and no different than if you lived in Eastern Oklahoma or Eastern China. Well I am here to tell you that if you never have any questions or changes made or ever get older, it is easy. BUT, if you are a normal person that will have an occasional change or problem, it does notwork smoothly, despite the social security administration telling you it will be. There can be and there are lots of problems that can come up, and you cannot expect much assistance from the bureaucrats and clerks that work in the system. I do not consider social security and US Medicare to be a “benefit”. Since I was 16 years old, I have been paying into that system. It is a very lousy return on my involuntary retirement investment (also sometimes accurately referred to as “confiscation”). I am very sad for those younger than me that are obliged to continue to have their money taken away and are unlikely to get anything in the future. That is WRONG, and it should be stopped. (It will stop in the future one way or another because it cannot be sustained — all Ponzi schemes must end eventually). Right now more than 61 million Americans receive some form of Social Security benefits, and it is climbing. If you can believe it, Medicare is facing unfunded liabilities of more than 38 trillion dollars over the next 75 years. That comes to approximately $328,404 for each and every household in the United States — and that’s just for Medicare. You don’t even want to hear about social security and all the other mandated redistribution schemes that will enslave future generations (unless it collapses). The Social Security system is facing a 134 trillion dollar shortfall over the next 75 years — understand that the total GDP (everything America produces by everybody in the country in a year) is 15 trillion dollars. As an Expat, I am often discriminated by US official decree. Because I am living overseas, I do not have it easy to vote, I have extra tax reporting obligations and my elected representatives care little about us living outside of the country. There is no one in government that is there to help Americans living abroad. I can accept that because I have the benefit of not living with US nanny state overreach into my private life everyday like most living in the 50 States. So I am not complaining much (on this post anyway) about how Expats are short changed in other areas. I have the most simple system possible for my social security. My checks are deposited in my US bank, and I draw out the money as needed from a local ATM. Fortunately, I have one of the very few banks in the world where I get no charge for using an ATM anywhere on Earth, plus has no conversion fee for changing currency (that bank is the Bank of Charles Schwab). I maintain a US address as I still own a home in California. Greg’s Elaborate Saga When Changing Bank Accounts for the Social Security Deposit (a bit of a rambling rant and perhaps boring tale that you may want to skip reading. It’s OK). One day, I had one of my checks that were sent directly from my bank account stolen, and the perpetrator managed to deposit the stolen check. My bank insisted that I change my bank account — same bank, just a different account number and ATM card. The stolen money was returned to my bank account, and it was a fairly routine easy change. But to change my automatic deposit with social security became a bit of nightmare. In the US, it is easy to just pick up the phone and call the toll free number for social security and make the change. If you live in Northern Thailand, social security instructs you to visit your local US consulate, and for me that is very close to my home. Easy. You cannot simply walk in to the consulate. You must make an online appointment, which allows you to come in about a week later. Still no big problem. But in the consulate, they don’t want to very hear much about social security. They just hand you a scrap of paper telling you that you must call the nearest social security office which is in Manila, Philippines. OK, still no big problem. When you call the social security office in Manila as instructed, you automatically get a voice recording saying that they are busy and if I leave name and number they will call me back. I learned that this is just a pacifier, since I have yet to receive a call back after 5 messages. So I sent the Manila social security office an email. No response. And another, and another, and another. Nine emails before I finally got an email response. During this time, I also wrote an email to the social security head office in Baltimore. They replied that they would forward my message to the Manila social security office, my closest SS office who would reply quickly. Ha. So 18 days after starting this, I finally get an email back from a SS agent. She seemed efficient. After taking down all the details over a dozen or so more emails, she assured me that it was all taken care of with the automatic deposit. When my pay date rolled through and I did not get any money, I again tried to reach the Manila SS office. After a few attempts, I got the same helpful agent. She now tells me that it takes two months to get the account switched, and during that period I will not be paid. After letting that sink in, I was a bit furious. That would mean that since the time I had started trying to reach social security to change my bank account number, it would be about two and half months before they could complete that task, and I would get no social security payment during that waiting period. The agent told me that there nothing I can do, and she did her job and that’s it. Me being me, I wrote to the head office in Baltimore, and after getting the name of the director of the Manila SS office, I wrote her a very strong letter, letting her know that I would starve to death during that two and half months but I would be contacting every US congressman and senator about my plight. After several angry emails from me to the Manila office, the director apologized for the problem and had her agent start working on the problem. It is now corrected. It took 30 days and tons of emails and lots of calls. For anyone not able or unwilling to do all this, they would not get their payment. I lost sleep and was aggravated. All just to change my bank account number for my auto deposit. The Medicare Plan B Scam on Expats OK, during the last month I became a bona fide old guy; I passed my 65th birthday. Besides all the other trauma of reaching this age, a person also becomes eligible for Medicare (which most of us having been paying on for decades). Medicare has a plan A for hospital visits (which one gets automatically with age and there are no premiums) and plan B for doctor visits (which has a monthly premium). You cannot use Medicare outside of the US, so if you reside overseas it is not prudent to pay for plan B. The kicker is that Medicare automatically signs you up for Plan B even if you did not sign up for it, and starts deducting the premium each month from your social security check. I was somewhat aware that they did this, so I specifically planned for it. Before turning 65, I wrote to the social security office in Manila and to the head social security office in Baltimore, stating in writing specifically that I do not want to sign up for Plan B of Medicare. Not enough. They deducted for Plan B even though I did not sign up for it and despite my letters specifying that I do not want it. I have learned from an American expat in Japan that you cannot cancel the Plan B Medicare on the phone and that social security requires one to visit the social security office so that we can be consulted about the decision to not participate in this program (which we can’t use) and make premium payments. There is a form that can be completed to cancel the plan, but social security will not mail it outside of the US. So if you work out something, you may be able to have the form sent to your US address or have it go to a friend in the US that will forward the form to you overseas. A very long process. After you complete the form, you mail it back to social security and send it registered (which requires a signature from the person getting it). Here is the kicker: Social Security will not sign for registered mail. Your form will go back to the post office and sit. And there will be no change to your account. So now you must do the whole process again, but this time do not send the form registered or requiring a signature, and after just a few months, they may stop deducting for Plan B from your social security. Here is what I have learned about the government medical system for the retired: Medicare is not a health care guarantee for U.S. citizens. It’s a payment guarantee for the U.S. health care industry. This becomes obvious when you try to take advantage of the lower costs of international health care — and learn that Medicare (which, on paper, should seek to cut costs) doesn’t want to let you. If you start a business in your country of residence while living abroad, and are self-employed, you must pay self-employment taxes in the US (“SECA” contributing to Medicare and Social Security) in addition to those in your country of residence unless the US citizen/green card holder lives or works in a country which has a Totalization Agreement with the US. The self-employment tax rules apply no matter how old you are and even if you are already receiving Social Security. So while you may have to continue to pay taxes for a Medicare program you cannot use, you will also be required to pay a premium for the Medicare insurance that you cannot participate in, unless you go to great lengths (and cost) to stop. Now the US is about ready to embark on a labyrinth medical system euphemistically called Obamacare or the totally ridiculous name of “Affordable Care Act”. The government has done such a marvelous screw job on expats with Medicare, I am sure we will have it easy with this one. Your comments or own story about how good or bad you have had it with social security and/or Medicare would be appreciated. Please share your experience and ensure you get some decent Thailand expat health insurance coverage.
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