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Wednesday, October 29, 2014

Living Legal in Costa Rica - PART II continued

As indicated in my last post under "Living Legal in Costa Rica", both Lance and I now have our carnés (i.e. medicare ID cards) which allow free access to public health care services in Costa Rica. But, it is one thing to have a carné. It is quite another to start using it. To do so, you first have to introduce yourself to the system so that the EBAIS clinic to which you have been assigned by CAJA can meet you, open a file, and start keeping records of who you are and your medical history.

There are many EBAIS clinics located throughout the country. They are at the front line of the public health care system in Costa Rica. They provide basic non-emergent health care services such as quick fixes for minor complaints, prescribing drugs, and generally monitoring and keeping detailed records of each individual’s health. If attention is required which is beyond their capacity to provide, then part of their job is to make initial appointments and/or referrals for more intensive care and attention.

We have now introduced ourselves to the system, but not without some hiccups along the way.

With our new carnés in hand, we first went to the EBAIS clinic in Atenas. After all, this clinic occupies the same complex as the place where we got our carnés and the name "ATENAS" appears on the carnés.

Problem is that the carnés we received did not identify the EBAIS clinic in Atenas. Instead, they identified "A.S. ATENAS EBAIS B. JESUS". As later pointed out to us, this meant the EBAIS clinic in "Barrio Jesus". Arggh!

Note that Atenas (the town/city) is the capital of the canton of Atenas in the province of Alajuela, Costa Rica. Like Atenas (the town/city), Barrio Jesus is a community in the same canton. The name of Atenas as it appears on our carnés is probably a reference to the canton and not the town/city.

Walking into the EBAIS clinic in Atenas, there was a large waiting room, pharmacy windows, an area where you receive your carné, a glassed-in area which I have since found out is where you go to make appointments, a number of hallways and "no admittance" doors.

We were a bit confused about where we should go, so I asked a passing employee as best I could. She looked at our carnés and directed us down a hallway to a separate area - another waiting room with more service windows, doors and hallways. A helpful security guard pointed us to a window where a desk clerk takes your carné, fills out and stamps a form. Our completed forms were placed in a wall file outside a swinging door. In a short time, the forms were picked up. Then we waited.

Eventually my name was called. I went in through the swinging door to a nurse who took my blood pressure. Then I was sent to a doctor's office who coincidentally spoke some English. He first indicated that he worked under supervision and that he was not yet a fully qualified physician. Then he got to the important point - I was in an area where you go for emergencies! Not only that, he looked at my carné and said my EBAIS clinic was in Barrio Jesus, not Atenas.

Lance was up next so I went outside to wait. Not unsurprisingly, he came back with the same information.

Then, like an angel, along comes our friend and neighbor, Vera from Brazil, who speaks four languages that I know of (English, Portuguese, Spanish and German). She said, "What are you doing in emergency?" Don't know! She took me by the arm through the setup in Atenas and showed me where to make an appointment, how to use the pharmacy, where to go for blood tests, etc. Such valuable information - but not knowing that our assigned EBAIS was the clinic in Barrio Jesus.

Turns out that the Barrio Jesus EBAIS clinic is not that far from our house, closer than the Atenas clinic. So, a couple of days later, off we went by taxi to test the waters in Barrio Jesus. It was a very positive experience.

The Barrio Jesus clinic is plain and simple - nothing fancy but the job gets done. It has a waiting room with television, a records office, a doctor's office, a nurse's office, an examination room, and so on. We walked into the waiting room and a housekeeper who was cleaning the floor at the time directed us back to the window of a receptionist at the entrance. The receptionist took our carnés and, in hardly any time, we were cleared to go back to the waiting room. There was one person ahead of us.

My name was soon called and I went into the nurse's office. In my best baby Spanish, I said good morning, how are you, and I apologized for my limited Spanish ("mi español es poco"). Then I handed over a Spanish translation of why I was there. Doing this saves a lot of misunderstanding. She weighed me, measured my height and took my blood pressure and pulse. My very own file was opened.

Back to the waiting room and soon I went in to see the doctor. She outlined a treatment plan for me, she prescribed medications and is arranging for a mammogram, plus I was given a requisition for routine medical lab tests (blood workup, etc.). One note - CAJA does not necessarily use, or is able to access, medications available in Canada and the U.S. It is a socialized medical system and leans towards the use of less costly generic drugs when possible.

My appointment over, the housekeeper gestured me outside the waiting room - or so I thought. Actually, she was gesturing me back to the receptionist to get a follow up appointment with the clinic. Lance eventually came out from the doctor, also with a requisition for lab tests - his appointment likewise finished. We both have appointments in four months on the same day - very convenient. As we now understand the system, when you once visit your assigned EBAIS clinic, they will always provide a future appointment if only for routine monitoring - typically three or four months later.

Our next visit will be a breeze now that we know the procedures and protocol. We have been assigned Hospital San Rafael in Alajuela - that's where I'll go for my mammogram. It's also the next step up on the health care ladder.

All the staff at the Barrio Jesus clinic were women (except for the records clerk). Remarkably, the receptionist, the nurse, and the doctor all spoke at least some English.

A few days later, it was off to the CAJA in Atenas to have our prescriptions filled and to make an appointment for lab tests. At the pharmacy window, we stood in a small line to hand in our prescriptions and, most important, a receipt showing that monthly payments to CAJA were up to date. We were each handed a number and an estimated time when the prescriptions would be ready for pickup.

We then headed to another waiting room for lab tests. The receptionist there seemed to say that we were much too early for lab tests because our next appointments with the Barrio Jesus clinic were not until February and our doctor would want more current results. To make sure we understand, I'm going to ask a friend who uses CAJA.

Decided to go out for cold drinks while our prescriptions were being filled. There is a small soda next to the Cruz Roja (Red Cross) building beside CAJA and we enjoyed iced teas. I was wishing I had not already had breakfast because those cooks were turning out some great things - casadas, corn tortillas, scrambled eggs.

We went back to the CAJA pharmacy about an hour later, took a seat, and our names were called in a very short time. That was it .... prescriptions in hand and the mysteries of the CAJA and EBAIS clinics revealed to us!

Everything new and unfamiliar can seem intimidating at first. My initial instinct is to just jump in and see what happens - that is probably why we ended up in Emergency. Lance is more steady and thoughtful. Living in a foreign country is so interesting - we are always learning something.






Sunday, October 26, 2014

Beach Day - Playa Esterillos Oeste

On Saturday, October 25, 2014, a group of us from Atenas went to Esterillos Oeste, a beach south of Jaco and Playa Hermosa on the Pacific Ocean. Thanks, Tom, for organizing us. We hitched a ride with our friends Diane and John. Esterillos is divided up by rivers into three sections: Esterillos Oeste, Esterillos Centro and Esterillos Este. Each one has well marked entrances, with Esterillos Oeste being the first one.

The beach is made of dark volcanic sand and surf conditions can be quite rough and powerful, dangerous for swimming. This is an area for surfers. There are motel accomodations along the beach, as well as a camp ground, and numerous places to eat. Since we were here in the off season, not everything is open all the time.

The facilities on Esterillos Oeste are not as plentiful as at Playa Doña Ana in Puntarenas, which has shower/change room facilities, picnic benches, BBQ's, and so on. However, for 3,000 colones ($6.00) for the entire day, we got two loungers and an umbrella. The fellow who looks after this service works very hard - he was wearing a shirt that said "lifeguard". He dragged lots of loungers and umbrellas from away down the beach, dug holes to put the umbrellas in and arranged our loungers. Later, when the tide started coming in he moved everything up closer to shore. An incredible deal.

Not long after we were settled in our loungers, a young guy with a cooler came around selling ceviche. It was delicious, the best I've ever had. The fish and shrimp were fresh, lots of cilantro, lime juice and spices and nice and cold. Price - 2 mil ($4.00 - includes a package of crackers!)

We spent an idle, relaxing morning - walking on the beach (I think you could walk all the way to Panama on these beaches), reading and snoozing on the loungers, paddling in the ocean, looking for shells. This is one area where I would not want to swim because of the strong waves and undertows. A nice stroll up the north end of the beach will take you to the mermaid statue, "La Sirena". When the tide comes in, she is almost covered over.

A big thrill for me was seeing four scarlett macaws flying overhead to the almond trees that line the beach. They fly in pairs. Absolutely magnificent. It's the way they were meant to live - not as pets or in cages.

One of the reasons for this Beach Day was to enjoy the first ever Chili Cook Off at Surf Mi Restaurant. Live music was provided by Jim Lajudes and Rodney Paige. We had lunch there and the food was excellent. Between Lance and myself we ordered ice teas, popcorn shrimp and BBQ chicken wings and drumsticks - delicious. I was told the seared sesame crusted tuna is excellent also. Lots of local dogs hang around hoping for a tidbit - they all belong to someone and are in good shape and like being petted. I highly recommend Surf Mi Restaurant. There's a grocery store next door too.

Back to our loungers, a short stroll away. Now that we were safely settled up near the shoreline, we watched the breakers crashing in and admired the surfers. Around three o'clock, we headed home for Atenas, about an hour and half away in the mountains.

There's just something about a day at a Costa Rican beach - I slept like a log that night. The sun, the heat, the ocean, the shifting sands, the good food and friends - priceless.

Speaking of price, here is what a day at this beach cost the two of us (in dollars):

  • Gas share - $20.00
  • Loungers and umbrella - $6.00
  • Ceviche - $4.00
  • Lunch for two - $19.50
  • Road toll - $1.00

Grand total: $50.00.

This is really great value. I'm still amazed at our life here in Costa Rica - over three years later.



Monday, October 20, 2014

Living Legal in Costa Rica - PART II

Part I of this trilogy dealt with the overdue renewal of our cédulas (mandatory ID cards if you want to linger on in Costa Rica for more than 90 days at a time). This part deals with mandatory health insurance and, if you choose, utilizing the medical and other health services provided by CAJA Costarricense de Securo Social - "CAJA" for short.

As used here, CAJA is a reference to Costa Rica's public health care system. The services include not only medical care in the classic sense as provided by medical doctors and nurses but also dental care, providing prescribed pharmaceuticals, prescribing and providing eye glasses, hearing aids, prosthetics, etc. In the case of dental care, our understanding is that the services for adults are limited.

CAJA runs in parallel with various private health care systems which operate in Costa Rica. This is in contrast to some countries, including Canada, where legislators in their supposed wisdom have decided that competition between public and private health care systems is a bad thing.

Some people rely exclusively on private health care in Costa Rica. Others rely exclusively on CAJA. Still others rely on a mixture between the public and private sectors. However, whether or not one chooses to rely on CAJA, enrolment and monthly payments to CAJA are a mandatory component of "living legal" in Costa Rica.

Until recently, we relied exclusively on the private sector. However, two factors have motivated us to try CAJA. Firstly, the amount of our monthly payments to CAJA has increased substantially from when we first started making payments in 2012 (over 70%). Secondly, Sun Life Insurance in Canada has started to deny pharmaceutical claims because receipts provided by pharmacies in Costa Rica somehow do not measure up to indecipherable regulations which Sun Life declines to explain in a clear manner.

My CAJA carné. Stapled to it is a clinic appointment card.

Enrolment in CAJA is typically evidenced by an insurance card referred to as a "carné. There are carné Aseguado Directos for principal insured persons, or direct policy holders, and carné Aseguado Familiars for related family members.

When applying to renew our cédulas through Banco de Costa Rica (see my blog post on October 11, 2014) a question arose as to whether my husband should have his own "carné" We never thought so - and not having one did not impair his cédula renewal. Neverthess, we ultimately decided that he should have his own if only as a matter of convenience.

In the meantime, someone pointed out that my carné had expired. In fact, it had expired in October 2012 just three months after it was issued.

The expiry date is in the upper right hand corner box - "Válido hasta". It's just the card that expires. We were still covered under CAJA - as long as the monthly payments were up to date.

So now it was time to renew my carné and get one for Lance.

We knew we could not do this without the services of a translator and we used Mercedes, a wonderful young lady who lives in the Atenas area and is fluently bilingual.

We first went to the Atenas EBAIS (Equipos Básicos de Atención Integral en Salud), which is the health care clinic located beside Cruz Roja (the Red Cross building). Luis Cruz is the person who issues the carnés. He sits behind a window where all the patient files are kept. There is a bench to sit on and wait your turn at the window. We had Mercedes on my cell phone and she talked to Luis and translated for us. Luis issued me a new carné (expiring in 10 days because we were waiting for our new cédulas to arrive). He gave Lance an appointment for the following Monday at the Seguro Social building around the corner and told us what we needed to bring with us.

The following Monday, we met with Mercedes at the main Social Security office in Atenas and were issued some kind of confirmation number that we then took to Luis, along with the requested documents, and Lance was issued his own carné. Coincidently, that same morning our new cédulas had arrived at the correos so I too was then given a new carné, this time with a more reasonable expiry date of February, 2016 - the same as Lance's carné.

Having Mercedes along with us was invaluable, especially because she also seemed to be a friend of Luis - more to follow.



Monday, October 13, 2014

Canadian Thanksgiving in Costa Rica

October 13, 2014, is Thanksgiving in Canada. Here in Costa Rica, it is just Monday.

Some expats will get together to try to recreate the holidays from their home land. It can be a challenge. Turkeys are not very common here, although once I saw a beautiful tom turkey, turkey hen and chicks running free just outside Atenas. This was the lovely old style tom, with the beautiful feathers and big fan tail. So different from today's sad commercial turkeys that can't stand up because their breasts are too big, because everyone wants to eat turkey breast meat.

You can buy frozen Butterball turkeys in places like PriceSmart but they are quite pricey because they are imported. Imported canned pumpkin puree can also be bought, for a price. I once made a pseudo-pumpkin pie here using canned pejibayes, the fruit of a palm tree species. It tasted pretty good.

So, for our Costa Rican Thanksgiving, we are having sea bass tacos - one of my favorites.

We are at the height of the rainy season now. I've been doing small laundry loads for the last three days, first thing in the morning. I try to get everything out on the line when there is still sun and hopefully wind. All went well until today, when the rain started falling before I expected it. We pulled everything off the line, getting wet in the meantime, and have hung a lot of clothes in the house - over chairs, from hangers, door frames. It is all part of the experience of living in a tropical country.

Although it does not feel very tropical right now. I've been wearing jeans and a long sleeved shirt most of the day. Lance just now put on a t-shirt under a long sleeved shirt to try to keep warm. It will be nice to fall asleep tonight with the sound of tropical rain falling.

Happy Thanksgiving to all my Canadian friends and family!

Saturday, October 11, 2014

Living Legal in Costa Rica - PART I

Foreign nationals like ourselves who wish to live in Costa Rica without having to leave the country every 90 days - or sometimes less - are obliged to have (or to have completed an application for) a government issued ID card commonly referred to as a "cédula" or as a "DIMEX", the latter being an acronym for "Documento de Identidad Migratorio para Extranjeros".

With fanfare, I first wrote about receiving our cédulas in my blog post on July 23, 2012. They had been issued on July 20, 2012. Recently, they were renewed. As indicated in the above snapshot of my own cédula, the headline is "RESIDENTE PENSIONADO COND RESTRINGIDA". This means that our right to live in Costa Rica is subject to conditions. Being in the "pensionado" category, one condition is an assured monthly income of at least $1,000 U.S. Usually, the assurance is in the form of a letter from a competent authority verifying a government pension. Another condition is being able to prove year-to-year that at least $12,000 is being converted from U.S. dollars to Costa Rican colones. When the each year begins and ends is a bit of a mystery. We took it to begin on the date our cédulas were issued - and that seems to have worked.

Coming from Canada, the conversion process is a bit painful not by reason of the amount but because we have to first buy U.S. dollars from a Canadian bank then sell the dollars to a Costa Rican bank, each bank taking its pound of flesh along the way. We figure that we are losing 8‑10% to the banks on foreign exchange, whereas those from the U.S. might be losing half that amount. I suppose those from France, Germany, the U.K., etc., are in the same position as ourselves.

Another condition is to enroll in CAJA, Costa Rica's public medical care system and to make monthly payments to CAJA based on income. Even if one elects not to use the public system and to rely exclusively on private hospital and medical care services which are available, one is still obliged - and rightly so - to contribute to CAJA.

When we received our cédulas in 2012, we cheerfully assumed that they were good for two years from the date of issue - and then would have to be renewed. Two years is a number which we had heard several times. We had in mind that we had until July 20, 2014 to renew.

WRONG! They expired in February. So off we went to our lawyer who advised us we would each need an affidavit explaining why we were late. The affidavits are in Spanish. The cost was $50.00 each.

The actual expiry date of a cedula is indicated on the bottom right of the card - "Vence" - with a date beside it. We never noticed that!

Our lawyer also advised that I then needed to get a new pension letter from my Canadian federal government pension people stating my monthly net income. A phone call to Ottawa started this wheel turning, but it took about three weeks for the actual letter to get into my hands. We then took the letter to the Canadian Embassy in San José for an official translation - only to have it rejected because there was no written signature. Fortunately, however, we were dealing with Michelle in the Consular Section and she was very helpful. We ended up making a conference telephone call from the Embassy to a pension officer in Ottawa and I was able to authorize my pension information to be made available to Michelle. She was then able to prepare a Spanish language letter on Embassy letterhead verifying the pension amount. The Embassy charge for all of this was 22,400 colones (about $41.00 U.S.).

Neither the affidavits nor the new pension letter would have been required had we renewed our cédulas in a timely manner.

The next step was to phone Banco de Costa Rica (BCR) and make an appointment. Their phone number is 900-00-34639. They offer an option to speak to an English speaking employee. We opted to go to the BCR in San Jose because it is easy to get there on a bus. BCR told us to bring along the following:

  • Current passport and a copy of the information inside.
  • Current cédula and copies of the front and back.
  • A letter from our bank verifying the amount converted from U.S. dollars to Costa Rican colones. Special Note: We do not maintain bank accounts in Costa Rica because we have not sensed much need. All we have done is to keep bank teller receipts showing the conversions with my name and cédula number on them. They were organized with checklists for 2012, 2013 and 2014 so that they could be quickly inspected and checked off.
  • Copy of marriage certificate.
  • Current "Carné Asegurado Directo" and a copy. This is the card issued to you when you have joined the CAJA.
  • Current receipt from CAJA showing you are paid up to date.
  • We also had to bring our affidavits and the new pension letter.

The cost for renewal is $123 USD each and this can be paid in colones or U.S. dollars. We also had to pay 3,000 colones for each month we were overdue (for each of us). There was also a 3,500 colone charge (for each of us) for the correos (post office), which is where our new cédulas would be sent and, in our case, this was the correos in Atenas.

There was one glitch: Lance did not have his own carné from the CAJA and this caused some confusion with the BCR people. They seemed to suggest that it would be necessary to get some form of confirmation from CAJA that he was covered by CAJA and that it should be delivered directly to Immigracion and not via BCR. Necessary for what? At the end of our appointment with BCR, we were both told that our new cédulas would be available for pickup at the correos in two or three weeks - and so they were without any followup involving Immigracion.

In the meantime, we were a bit concerned about the situation with CAJA and took steps to obtain Lance’s own carné - but that is a different story.



Saturday, October 4, 2014