Sep 26 2014

Costa Rica’s Caja: How it Works

PaulCTScan_afterMany people ask us about the Caja because we know it so well. We know it well because we use it extensively. Gloria had surgery in the Caja, and I’ve had a multitude of procedures done within the Caja. Additionally, we use our local clinic (EBAIS) for our basic, everyday health concerns. Consequently, we know how the system works and we’re going to share some of that information now.

If you’re truly interested in CCSS (Caja), watch this video of Paul getting a CT Scan through the Caja. It will show you what’s possible.

Who should use the Caja?

I would say you should use the Caja if:

  • Your funds are limited.
  • You’re paying into it. After all, you are required by Costa Rica law to join the Caja if you become a legal resident, so if you’re paying for it, why not use it?
  • You want to defray some of your prescription costs by getting them through the Caja (generics only are available).
  • You have a medical emergency and need to go to the emergency room (Urgencia).
  • You want to learn the public healthcare system and integrate into the community.

Using the Caja has an extra benefit. I call it “Integration 102.” (You can find out what I’m talking about in this article.)   When you are there, waiting, it will be just you and lots of Ticos. It’s a great way to practice your Spanish – though someone almost always speaks English. Here is our late friend, Jo Stuart’s, take on it:

Waiting to see the doctor at Hospital Mexico
           by Jo Stuart

A nice gentleman gave me his seat, telling me to ‘sit down’ in English. It turned out that he had seen my Trader Joe’s bag and knew I was from the States…He was there with his father-in-law, a handsome man of 84, waiting to have his pacemaker checked. The father-in-law was a Tico, born in the U.S. having returned to Costa Rica…We compared the health services in the U.S. and Costa Rica and agreed that one reason the waiting rooms were so crowded was that no Tico comes alone. They’re accompanied by at least one, and usually more, family members. And given the sympathetic doctors and nurses here, many people take advantage of it and come in with minor ailments. ‘We’re sissies,’ the older gentleman said. I pointed out that life expectancy in Costa Rica has surpassed that in the U.S. and maybe taking care of minor ailments was a form of preventative medicine.”

From Butterfly in the City, page 153-154. Used with permission.

A good acquaintance of mine does everything privately. His advice is to look at your Caja payment as a tax, just for the right to live here. Other expats use it for some of their medications, but go no further than that. And some expat residents don’t use the Caja at all.

If you were to ask 10 expats what they thought about the Caja, 9 would give it a “thumbs down.” They may have heard bad things about it or had a negative experience themselves. But the Caja has been around since 1942 and, obviously, they have done some things right, as the Costa Rican lifespan is one of the highest in the Western Hemisphere.

Like many Ticos, and some expats, we use a combination of the Caja and the private medical care, when necessary. Even though it was rated highly by the World Health Organization, Costa Rica’s Caja is socialized medicine and socialized medicine has its limitations. Still, for many things, it’s more than adequate.

I asked Gloria once why she likes it and here is what she said. “In the States, even though I had health insurance, I always worried that something medically would happen and the insurance company would find a way not to pay. I was afraid of incurring huge medical bills, and that I could lose my house and everything else I owned. Here, in Costa Rica, I don’t have that fear. And neither do the Ticos. It’s just not part of their consciousness.”


My “ladder of referrals”

My Recent Experience

Like in the U.S., as a doctor’s patient, you need to be proactive about your health and ask the doctor questions about your tests, medications, and if you should be referred up the ladder to a specialist.

As you can see by the graphic to the right, I started the process at the local EBAIS and was referred to our local Caja hospital in San Ramon. The specialist I saw referred me to another specialist at Hospital Mexico. At Hospital Mexico, I was told to go to the transplant clinic down the block. The transplant clinic took one look at the referral and said that I needed to see Dr. Moreno at the Caja hospital in Alajuela. Once there, I was referred to Dr. Moreno’s office at Clinica Rodriguez in Alajuela. The whole process took just four months and a lot of running around. Along the way, I accumulated four expedientes (patient files) and, over the next several months, I traveled between the hospital (where all of my tests were done) and Clinica Rodriguez (where I saw Dr. Moreno) in Alajuela. So, not only do you need to be proactive, you need to be persistent and patient!

A few quick tips

  • Expediente means “records.” It’s your file, usually paper, with all of your medical records. You’ll have an expediente  at every hospital or clinic you go to. As you get referred “up the ladder,” each medical facility will create a new expediente  for you. You  start your expediente  at the Afiliación window, which is located at all major hospitals and clinics.
  • Ask for your file and make copies of everything – blood tests and other test results, anything you consider important. You can put the copies in your expedientes  at other clinics and doctor’s offices, to keep them up to date. Plus, it may save you from getting a new test if the results are recent. It’s your health, so be proactive.expediente
  • Your specialist may refer you to other specialists; you don’t need to start over each time at your local EBAIS. Once you get to your final specialist, he will eventually discharge you when the outcome has been reached.
  • Your local EBAIS is where healthcare starts, so go there personally. If you don’t know where it is, ask a neighbor. (You can get preliminary EBAIS location information at this website: Get your first expediente. And get to know the clinic staff as we have. The EBAIS usually has a receptionist, nurse, visiting nurse, pharmacist, and your primary physician. You can’t choose your doctor but you will normally have the same doctor each time you go (with the exception of vacations and personal days).
  • Most districts in Costa Rica’s 81 counties have at least one EBAIS, though this can vary slightly, According to population, some districts have more than one EBAIS. This is how Costa Rica brings health care to the people.
  • The full name of the Caja is “Caja Costarricense de Seguro Social (CCSS).ccss-logo

The Caja is something you can do if you need or want to. If you don’t speak or understand Spanish, look up some key words to describe your symptoms and concerns; you could also bring along a Spanish-speaking friend whom you trust.

When might you NOT use the Caja?

  • When time is a factor. If you’ve been diagnosed and you’ve determined that you must be treated immediately or very soon, it may be better to go privately.
  • If you’ve got plenty of money, you can afford INS, Costa Rica’s private health insurance, or an international health insurance policy. All of the private hospitals and clinics will readily accept it. Some hospitals even have their own medical plans.
  • If you are already using the Caja, have a diagnosis, and they give you a date for non-emergency surgery months or years in advance, you may be forced to go privately if your symptoms are severe.

This is why we say, have a reserve fund for emergencies. Your monthly Social Security or pension may not be enough to cover emergencies, health or otherwise. Also, if you are from the U.S., keep you Medicare B if you can afford to do so. You could get your procedure done on a visit home. You never know what will happen and it’s just one more way to be prepared.

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