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Posted by Mama Max - - 1 comments

After living in Texas for 3 years, I like to think I have embraced the lifestyle! And one thing I have come to appreciate well is the charms of a classic frozen Margarita! I always thought I hated tequila... thanks to awful drinking games with neat cheap tequila back in my student days... but have been won over by this very popular cocktail here in the US. Apparently, the key is to get tequila made from 100% agave as this is the best indication that you are looking at a quality liquor. These spirits were produced using only fermented and distilled agave juice with water, whereas, cheaper tequilas use other sugars in the process. This is really the most important thing to look for - the rest is a matter of opinion. I was told if you stick to 100% agave tequila, you won't get a hangover, but I'm yet to test that theory!!!

The problem is that to recreate a classic frozen Margarita at home requires an ice blender (which I don't possess). It is also difficult to make in large batches, say for a party, unless you invest in a very expensive frozen Margarita machine (which I also don't possess). So, I tried a bit of an experiment and thought I would share the fabulous results!





You will need:

- Blanco Tequila (preferrably 100% agave)
- Tequila mix (either shop bought ready mix as I did, or the ingredients from your favourite Margarita recipe)
- A volume of water equal to the amount of ice (if melted) you would add to the margarita recipe before blending
- A freezer-proof container with a lid







I used a large plastic tub that can hold 7 cups volume (approx 1.65 litres). I then simply created a mix using the following ratios:

- 1 part tequila
- 3 parts tequila mix
- 3 parts water




Then simply put the lid on and stick the tub in the freezer overnight.  Take the tub out of the freezer about an hour before your guests arrive and using a fork mix up the ice and break up any larger chunks (it will have the consistency of quite hard slushy ice).










By the time your guests arrive it will have the perfect slushy consistency and can simply be ladled into your margarita glasses ... garnish with salt on the rims if you like and a fresh squeeze of lime! Store the tub in the fridge and it will stay slushy for several hours!







Super easy and delicious! Enjoy!
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1. Get prepared in advance

Do your research now, while the little blighters are still at school! Look up local attractions and events calendars (try your local newspaper's website, local parks, libraries, cinemas etc...) so that you can plan a schedule of things to do in advance! Use a paper diary/calendar, use your calendar on your smartphone, or create one in Microsoft Publisher. Put together a calendar of events for your family, even if it's only a loose schedule. It gives you things to look forward to and to plan around.

Also, consider putting together a 'Ready To Go' bag! See the blog I wrote on this last summer.




2. Set a routine, and stick to it... sometimes at least

The temptation may be to let things slide. Lay-ins in the morning, late nights, mooching around and skipping chores are a wonderful prospect when you and the kids are exhausted getting towards the end of the school semester, but in my experience, too many unstructured days are a recipe for disaster. Try to have a flexible routine. Perhaps a later start in the morning, but still an expectation to be up, dressed and ready for action by a certain time! You could set aside certain times of the day for specific activities... for example, outdoor activities in the morning before it gets too hot, and then maybe, quiet time activities for an hour after lunch. Also, have set days of the week for certain activities, e.g. Monday is library day, Tuesday is for baking (you can incorporate a trip to the grocery store before hand and get the kids to help with the shopping for ingredients), Wednesday is for playdates, Thursday is Movie Day, etc...! Kids and adults benefit from structure and without it, the 100 days of summer hols become a haze!




3. Home school

Yes. You did read that right! Two and a half months off will undo a lot of the progress your child will have made academically if they don't utilise their little brains. Set aside a 30 minute chunk of the day (maybe at a regular time slot ... see point 2 above) to do some school work. It doesn't have to be dull as dishwater and can be fun! Try educational puzzles and games, video games, online resources and activity packs. Just a little bit of educational activity a day (especially if it revises stuff they have been doing at school) and it will keep their brains limber ready for the start of the new academic year. Just make sure you start as you mean to go on. If it's part of a daily routine established at the start of the school holiday there will be fewer complaints!

Check out these great workbooks and video games.


4. Play dates and reciprocal babysitting

Before the last day of school, exchange contact details with some of your child's classmates' parents. Take the initiative and organise a park play date for the first week off school with a few families and then organise a schedule with the other parents for the weeks ahead! You could even take the play date thing one step further. If you have friends with children a similar age you could set up a weekly play date swap. This enables each parent to have some well-deserved child-free time to run errands or just relax. For example, you could arrange for your children to go to a friend's house for a few hours on a Tuesday and then return the favour looking after their kids on a Thursday. The kids have friend's to play with (and so pester you less) and you get a few hours to yourself each week. Everyone's a winner!




5. Themes & projects

You could set a weekly theme and base all your activities around that theme. For example, you could have a farm theme... visit a farm park with another family, plant some vegetable seeds, bake a carrot cake, do some garden themed literacy/numeracy/art activities and etc... You could get each child to keep a summer holiday scrapbook, keeping photos, mementos and artwork from each week together.

6. Bribery

When all else fails and the kids are driving you crazy, don't feel bad about resorting to bribery! Just be sensible about it. Try using charts where the kids have to work towards getting a reward. Set out your expectations clearly first and agree the reward in advance. Think outside the box when it comes to a reward. You could treat the kids to a frozen yoghurt after a trip to the park on a Friday afternoon for good behaviour throughout the week rather than a monetary amount, candy or material object. Stick to your guns though, and only reward the behaviour that has been asked for! For more ideas check out my earlier post which includes a printable LEGO reward chart I created.

7. Camps

Summer camps can be really expensive, especially if you have more than one child. However, they can be a good option, especially for older kids with specific interests.




8. Low-cost options

If you have more than one child, summer camps can become cumulatively and prohibitively expensive. Short of picking your favourite child and only allowing that one to attend a camp, you could limit them to one week each, or just avoid them completely and come up with your own low-cost activities. This can be especially fun if you join up with other families. Suggestions:

- Use your local library - and not just for borrowing books. Many have free story times and activity classes you can sign up for.

- Local businesses sometimes have free kids' activities: Lowes DIY stores have a free build-and-grow scheme where kids can do building projects, Barnes & Noble hold free story times and etc...

- Parks - are a brilliant option. Many have play equipment, even splash pads, suitable for a wide range of ages. They also often have restrooms and picnic facilities... great for a change of scenery when the kids are driving you crazy, and even better when you meet friends for a play date!

- Museums and galleries sometimes have free days. Do your research ahead of time (see point one)!

- Cinemas often run a summer program of matinees for low cost. They won't be new releases, but you can see family favourites for just a few bucks! Treat the kids to some popcorn to make it a special (low-cost) occasion!

- Visit the dollar store and select some art supplies for a project.

- Get an annual pass to a favourite local attraction. For example, you can buy a family pass a local zoo for about $80 and visit as many times as you like throughout the holidays!

- Create a den or pitch a tent in the backyard (or in the house if the weather is bad)!

- Visit the beach, local nature reserve, woodland or river and get closer to nature!

- Try geo-caching to make walks and bike rides more exciting!

- Volunteer - find a local food bank, nursing home, or animal shelter and spend some of your summer holiday doing something worthwhile with your kids!

9. Remember... it's a holiday!

After a full-on academic year, you and the kids will need some time to relax. Don't try to fill every moment with activities or you will end up exhausted and needing to go back to school for a break. It's okay to have days with nothing planned. Let (insist) the kids play on their own sometimes... it's important that children learn to use their own imaginations and initiative. Trot out that really annoying line that your own parents used: "Only boring people get bored"! It's not true of course, but sometimes a little boredom is unavoidable and you should not feel obliged to entertain the troops continually!

10. Drink...

After a particularly stressful day with the kids... treat yourself to a glass of wine once they've gone to bed and remember the holidays won't last forever!

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While this series is aimed at explaining the US medical care system to expats, I am going to start by giving a brief overview of the government funded insurance programs that exist to support US citizens and legal permanent residents with low incomes. The reason for this is that I was utterly bamboozled by the names being bandied around when I first encountered a healthcare provider in America and so I think it is helpful to get the broader picture.

Back in 2010 when we were relocating to the US from the UK, one of our 18 month old twins ended up with a high fever on the flight from London Heathrow to Houston. Talk about bad timing! A few days later and he had developed a blotchy rash across his torso and I was starting to worry. In the UK, I would probably have called the nurse at our local GPs office for some reassurance, but in an unfamiliar environment and without a regular medical provider I panicked a bit. We called my husband's employer who put us in touch with our employer-sponsored medical insurer to find out what to do... at this point they hadn't even issued us with our policy details! Thankfully, they emailed me details of a paediatrician not too far from our temporary accommodation and I took the Shouty One to get checked out.

This was my first encounter with the forms you have to complete when visiting a healthcare provider in the US. I was surprised they didn't want to know my inseam length and favourite colour on top of all the other information!!! Unfortunately, being in the country for less than 3 days I was still jet lagged and had no idea what most of the questions were about. I didn't have a permanent address, US telephone number and had no idea what SSN# and DL# stood for (social security number and driving licence number, not that I had obtained either at the time)! And I must have looked like a right prat when I asked the receptionist whether she knew if I had Medicaid?

So, even though it probably doesn't apply to most of you reading this article, I AM going to give a quick summary of all types of insurance, including those funded by state and federal government for some US citizens!

NOTE: A glossary of terms is at the bottom of this post.

Another caveat: please remember that this is a high-level overview.  Check the details of your own medical policy carefully as every one is different and specific things may or may not be covered by your own policy.

A - MEDICAID, CHIPS, MEDICARE & MEDIGAP...



Medicaid is a means-tested federal and state funded insurance program. It was expanded in 2010 by the Affordable Care Act (nicknamed "Obamacare") to include individuals and families with incomes under 133% of the poverty threshold. In 2011, this was $29,700 annual income for a family of four. Medicaid beneficiaries receive free treatment for a limited number of healthcare services, but in some states people are required to pay a small co-payment (a set fee collected at time of treatment by the healthcare provider).

CHIPS (Children's Health Insurance Programs) is a supplementary program that provides healthcare to uninsured children under the age of 19 who come from low-income families that don't qualify for Medicaid.

Medicare is also a means-tested state funded plan but it's aim is to assist low-income individuals over the age of 65 and people that are disabled and unable to work. It provides Hospital Insurance (part A) for eligible individuals and covers limited costs incurred by patients requiring hospitalisation as an in-patient... assuming they paid FICA tax (similar to National Insurance contributions in UK) for at least 10 years. Additional coverage must be paid for by the individual if they need Medical Insurance (Part B), e.g. to see a doctor/GP. Further coverage can be purchased to cover extra costs (Part C) & prescriptions (Part D).

Medigap insurance is private insurance that can be purchased by individuals to supplement Medicare.


B - Private Medical Insurance



60% of people in the US participate in an employer sponsored health insurance scheme. This type of insurance is paid for in whole, or in part, by businesses on behalf of their employees as part of an employee benefit package. Although workers are effectively paid less than they would be (because of the cost of insurance premiums to the employer), this type of insurance offers several benefits to workers, notably economies of scale, whereby they qualify for group discounts.

Only 9% of people in the US have individual health insurance that they have purchased directly from the insurer. In this case, the individual pays the entire premium without benefit of an employer contribution. In general, overall out-of-pocket costs for these types of plans are higher than employer-sponsored schemes.

There are many different types of policies, both employer-sponsored and individually purchased.  Below is a summary of some of the common types:

1.  Traditional Indemnity (sometimes called Private Fee-For-Service, PFFS)
This is the most basic type of healthcare insurance available, whereby beneficiaries pay a monthly premium and can submit receipts for their medical expenses to their insurer for re-imbursement, as long as they are services specifically covered by the policy.


2.  HMO (Health Maintenance Organization)
HMOs were historically called pre-paid Health Plans and are still sometimes referred to as these. Key features of an HMO plan:

- Patients are required to choose a primary care physician (PCP), like a GP in the UK. Women can select to have an OB/GYN as their PCP. The PCP will take care of most of an individuals healthcare needs.

- If the individual needs to see a specialist, they must obtain a referral from their PCP first. HMO policies also require beneficiaries to only see approved (in-network) health care providers.

- Expenses usually include the monthly insurance premiums and co-payments (a fixed dollar amount paid every time an individual sees a physician or buys a prescription). The co-payment is paid at the time of service directly to the provider and no further payments required.  This is particularly beneficial to expectant mothers whose policy covers maternity services.  They often only have to pay a co-pay at their first doctors visit and then all subsequent care during the pregnancy is covered.

- HMOs often provide preventive care for a lower co-pay or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services, e.g. immunisations, well-baby checkups, mammograms etc...

- Experimental treatments and elective services that are not medically necessary (such as elective plastic surgery) are almost never covered.


3.  Preferred Provider Organization (PPO)
In the case of a PPO policy, enrollees are encouraged to seek healthcare services from certain 'preferred' healthcare providers that have a negotiated discount with the insurance company.  Key features:

- Patients have greater flexibility.  They do not have to enroll with a Primary Care Physician and do not require a referral from a PCP in order to see a specialist.  They can chose to visit ANY healthcare provider they like rather than just those on an approved list.

- Most PPO policies have a deductible. This is the amount of expenses that must be paid out of pocket before an insurer will pay any expenses. In the UK this is called an excess. Deductibles are typically used to deter enrollees claiming for trivial items. Policy holders are required to pay 100% of all medical expenses they incur until they reach the set deductible for their policy. Some policies have cumulative family deductibles.

- Expenses usually include the monthly insurance premiums, the deductible and a co-insurance amount (a percentage of the cost, shared with the insurer).

- The co-insurance amount varies dependent on whether the patient has chosen to see a provider that is in-network or out-of-network. For example, if a patient visits an in-network doctor's and the total bill is $100, they may be required to pay a 20% coinsurance (they will pay the doctor $20 and the insurer will pay the doctor $80).  For out-of-network doctors there may be a 40%/60% split instead.  This encourages policy enrollees to seek in-network providers only.

- Some healthcare providers will expect the deductible and/or coinsurance to be paid at the time of service.  In this case the patient will be given an itemised invoice and receipt.  Other healthcare providers may send a bill for the deductible and/or coinsurance at a later date.  In both cases, the insurance company will send a statement (for information only) to the patient reflecting these payments.

- Some in-network providers will charge a co-payment instead of the coinsurance for certain limited services on a PPO plan.  For example, a 'Wellness Check' (annual health screening for preventative purposes) or an Emergency Room visit may be included on the policy as a service that carries a set co-payment amount.  In the case of both of these, if any 'treatment' or 'service' is required, the patient will usually also be responsible for the deductible/coinsurance.  For example, a friend of mine attended a Well Woman checkup (covered by a co-pay on her policy).  At the end of the appointment, the Doctor asked if she had any questions and she asked about a health issue of concern.  As this was an issue not strictly covered by the Well Woman Check-up, she was billed for a doctor's visit in addition to the co-pay!

- PPOs have a set out-of-pocket maximum.  This is a cap or limit on the amount that an individual will have to spend in any plan year.  Due to the variability in out‐of‐pockets costs on a PPO plan, out‐of‐pocket maximums help PPO members gauge the total they will pay in any one plan year. Once the out-of-pocket maximum has been reached, the insurance company will pay 100% of the cost of medical services.  The maximums are usually higher for out‐of‐network services and the maximums do not cross accumulate.


3.  Point of Service (POS)
A point of service plan, or POS plan, combines characteristics of traditional indemnity, HMO and PPO plans.

- Individuals with a POS plan only choose which system to use at the time of service. Like an HMO plan, a POS gives lower medical costs in exchange for more limited choice. However, the flexibility of a PPO is there if the patient requires it.

- A patient with a POS plan is required to choose an in-network primary care physician to monitor their health care and to be their "point of service". However, unlike with a traditional HMO, the primary POS physician may then make referrals outside the network if the patient requests it. However, the patient will only receive partial reimbursement by the health insurance company if they choose to take this route.

- For medical visits within the health care network, a co-payment and/or coinsurance is collected and the paperwork is completed for the patient. If the patient chooses to obtain a referral outside the network, it is the patient's responsibility to fill out the forms, send bills in for payment, and keep an accurate account of health care receipts.

----------------------------

I hope the overview of policy types has been helpful.  Please see the other posts in this series for more information.

PART 1: An Expats Guide to Understanding the US Medical System ... an Overview
This article gives an overview of the US Medical System as summarised by this flow diagram.




And coming soon...
PART 3: An Expats Guide to Understanding the US Medical System ... Where to go for healthcare
PART 4: An Expats Guide to Understanding the US Medical System ... Paying the bill


----------------------------

GLOSSARY OF TERMS

CO-PAYMENT (a.k.a. CO-PAY) - A fixed-dollar amount that is paid at the time a health service or treatment is received.

CO-INSURANCE - A percentage of the cost of care that the patient is responsible for paying. For example, if a doctor's visit is $100 and you have a 20% coinsurance, you will pay the doctor $20 and your health plan will pay the doctor $80.

DEDUCTIBLE - A set amount that the patient is responsible for paying before the insurance benefits begin. An excess. For example, if you have a $1000 deductible, you are responsible for paying out $1000 from your pocket before the insurance will start paying for your health services.

IN-NETWORK - Refers to providers or health care facilities with whom the insurance company has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts. Services by out-of-network providers may not be covered, or covered only in part by an individual’s insurance company.

OUT-OF-POCKET MAXIMUM - A predetermined limited amount of money that an individual must pay out of their own pocket, before an insurance company will pay 100%of the individual's health care expenses.

PRIMARY CARE PHYSICIAN (PCP) - A health care professional (usually a physician) who is responsible for monitoring an individual’s overall health care needs. Like a GP.
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Gee whizz... time flies when you're having fun! It's been an absolute age since I blogged on here and I apologise for my tardiness but, frankly, I've been having too much fun elsewhere!!! However, this evening I have been 'abandoned' by Him Indoors who has headed to the pub so I thought I would sit down and spend some time writing.

But what to write about? To be honest, craft projects have been a little thin on the ground of late (see above excuse) and my spare time has been taken up with planning our super duper summer vacation to California. However, a joking comment made by a friend a little while ago has been hanging around in my head. For those of you who haven't followed my blog, I self published a book in January 2013 entitled "The British Expat's Guide to Grocery Shopping in America"... a labour of love based on my 3 years experience of navigating the US grocery stores through the eyes of a Limey expat! Within a week or two of publication I was told by a friend over a glass of wine... "So, you've written about the food shopping, what you should do now is tackle the medical insurance system!" This comment was scoffed at by all in attendance... as no one, I repeat no one, truly understands it all. Even the Americans.

But... it did start the beginnings of an idea deep in my head. There is absolutely no way I am going to try to write a book explaining the US medical insurance system. It is too big, too complicated and I just wouldn't know where to start. The problem is that there are so many different policies out there that are all slightly different that you'd never be able to comprehensively detail all of it. However, that doesn't mean that there isn't the need for a higher level overview... especially one aimed at expats who struggle to understand the terminology let alone the policy intricacies.

So, this is where I come in. Firstly, a caveat. I am a Brit and so have been brought up with the NHS (national health service)... an institution that entitles every British man, woman and child with free healthcare from cradle to grave (if you want it). Obviously, there is the option for private health insurance in the UK in addition to the care available from the NHS but having utilised both, I can honestly say that the care is pretty much the same and usually provided by the same doctors that also work in the NHS (you just get a coffee brought to you by the concierge in the waiting area of a private practise and more convenient appointment times). Obviously, my thoughts on state funded healthcare provision are going to be a little influenced by this background, but I am going to try to refrain from weighing in on the healthcare reform debate ('Obamacare') as I truly don't understand it well enough.





Therefore, this is an overview of the current system and an explanation of terminology (in laymans terms) and usual procedures. Read on to find out more...

OVERVIEW

Healthcare is one of the leading industries in the United States and US hospitals are at the forefront of many medical advancements and cutting edge therapies. I've lost count of the times I've heard local people say here in Houston, "Well, if you're going to get sick, this is the place to do it!" In fact, here in Houston the medical industry rivals the oil & gas industry for dominance. So why is the US falling behind other developed countries in important health indicators such as infant mortality, life expectancy, cardio-vascular diseases, teen pregnancies, disabilities and STDs? The answer is because there is unequal access to healthcare provision. A 2004 Institute of Medicine (IOM) report said: "The United States is among the few industrialized nations in the world that does not guarantee access to health care for its population." Consequently, it is estimated there are 48,000 unnecessary and preventable deaths in the US every year.

This is because nearly all healthcare provision in the US is through private sector businesses. Their objective is to make money. Healthcare is therefore expensive to purchase, and being a big country with a big population, the US government cannot afford to pay for equal access to healthcare for everyone (at least, not with taxation at current levels). Consequently, most individuals in the US opt to have medical insurance to safeguard them against potentially high healthcare costs in the event that they become sick.

BUT... and here's the kicker... private medical insurance is ALSO expensive. The vast majority of people under the age of 65 have to purchase private medical insurance, often sponsored and subsidised by employers as a taxable benefit. The government does what it can and provides state funded or subsidised insurance (Medicaid, CHIPS, Medicare, Medigap etc...) for those in poverty, but for those just above the means tested threshold, often being uninsured and keeping your fingers crossed you don't get sick is the only option. Approximately 16% of the US population is in this position.

One question I often pondered when I first arrived in the US is that surely (having taken the Hippocratic Oath) doctors would/could not turn away a sick or injured person from hospital? And for the uninsured this IS luckily the case thanks to the Emergency Medical Treatment and Active Labor Act enacted by congress in 1986. This act states that hospitals are obliged to treat emergency conditions of ALL patients that present themselves regardless of their citizenship, legal status or ability to pay, until they are stabilised and able to “self-care” following discharge. Note, this does not mean cured. In reality, this means that many uninsured families resort to using the hospital emergency rooms for treating things like ear infections that under 'normal' circumstances would be treated by a GP or primary care physician (who would charge lots of money requiring insurance). Something like 55% of all ER visits now go unpaid, which unfortunately means healthcare providers shift the costs onto those who can pay. A vicious circle indeed.

For those who do purchase medical insurance the levels of coverage vary widely and there are numerous types of policies, the most common types being traditional indemmity (a.k.a. Private Fee For Service, PFFS), Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) and Point of Service (POS) plans. These will be explained in greater detail in Part 2.

The system is huge and very complicated, but for the benefit of a newbie expat trying to understand everything I have summarised the overview above into a flow diagram.





As you would imagine with a topic as BIG as this, there will be a series of posts. Coming soon...

PART 2: An Expats Guide to Understanding the US Medical System ... Types of Insurance
PART 3: An Expats Guide to Understanding the US Medical System ... Where to go for healthcare
PART 4: An Expats Guide to Understanding the US Medical System ... Paying the bill








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