Aug 02 2015

Retire for Less in Costa Rica – August 4, 2015 Special Healthcare Issue

Welcome to our Retire For Less In CostaRica Newsletter

Paul and Gloria

In Our Special Healthcare Issue:



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.

All of the reasons above pertain to us, especially #1.

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.

Related Articles:



From the Public Health System to the Private: Our Story

Beavis1by Bob & Linda Beavis

April 26, 2015

It’s isn’t a bruise like we thought…….

Linda fell on a section of very rocky road near our house on Friday and hurt her right shoulder. We thought just soft tissue damage but planned to go to our local Caja hospital clinic today for an X-ray just to be sure.

Well, we ended up in San Juan de Dios Hospital in San Jose. Long story short, she’s broken the arm just below the shoulder joint and has been admitted to hospital. It’s somewhat “elective” surgery so she may have to wait a day or two to get into the operating room to have pin(s) inserted to the break. It’s apparently a clean but total break.

The Emergency Room Entrance at San Juan de Dios Hospital in San Jose

The Emergency Room Entrance at San Juan de Dios Hospital in San Jose

I just got home to retrieve some stuff for her and have to drive back right away to take the things to her. I may be a tad late getting back tonight. Hospital rules are that family can only visit one hour per day (6-7pm). Some of the staff speak a bit of English.

April 30, 2015

Day 5 Update: Went to see Linda today after her messaging this morning that they moved her to a room on a ward. Turned out I was caught in the standard visitation protocol that I could only get in for an hour at 4pm. Stood in line with about 200 other visitors to get in but actually that worked smoothly, other than the guard confiscating the Gringo food I had in my bag for her.

Linda is in a room with 6 other women (1 bed is empty so otherwise it would have been 8 in the the room). All nice ladies and all full Spanish, which is interesting. Linda has gotten to know them all a bit; I introduced myself to them all and had a bit of Spanish chat with them.

Found out I could get a “permisso especial” to visit anytime I want based on Linda’s need for interpretive service plus assistance since she only has one functional arm.

All in all she is doing very well.


Nurse with Linda at San Juan de Dios Hospital in San Jose

May 1, 2015

Visited Linda today with my “permiso especial” for about 4 hours. Got her through the shower routine (minus shampoo/soap – not provided by the hospital & I forgot to take them) and helped her eat lunch.

She continues to manage the situation well and is having some conversations with her Tica roommates. Crossing our fingers for surgery to happen next week. I’ll be heading back down tomorrow to visit.

No system is perfect. Social systems usually make you wait & private systems make you pay. CR does have both systems to give a choice. We’re using the social rather than spending $6000-$8000 to get it done privately.

May 2, 2015

The big news of the day – The doctor told Linda she WILL have her surgery this coming week. Which day, who knows…..

May 5, 2015

Linda got word this morning that her surgery will be “very soon”. We’re suspecting it will happen tomorrow.

May 7, 2015 – Changing hospitals: from Public to Private

Quick update on Linda: She had full shoulder replacement surgery Wednesday night at 10:30pm. Long story short, we concluded we were getting a runaround at the public hospital, moved her 2 blocks to a good private hospital with orthopedic specialty staff.

At Hospital Metropolitano, Linda was received, assessed and in a bed in a private room in less than 3 hours. Just EXCELLENT service! We dealt primarily with the surgeon – very respected young guy – he gave us face to face updates 4 times within the first 90 minutes and a couple more until the last one at 2am after the surgery was finished.


The surprise to us was that the break was NOT below the shoulder, but was actually the right shoulder “ball” itself, broken into about 4 pieces. Hence the full replacement option was taken. Healing should be a bit quicker, but therapy will be involved. Thankfully, we have a great PT close to our home.

The worst of the ordeal is over – finally! Linda should come home Friday.

May 7, 2015

My Gal’s home after a harrowing 14 days. Fantastic hospital service and treatment but it had a significant cost that, hopefully, our U.S. insurance will cover. New shoulder should fully fix the problem. The hospital gave us the pictures.


The shoulder ball was in about 4 pieces, too tough to repair. An artificial implant was put in instead. Surgery at 10:30pm last night, checked out of hospital at 5:30pm tonight.

Word of caution: This type of (“elective”) injury was VERY badly handled by the CAJA hospital. In essence they told Linda (after 12 days), “You’re a Gringo. You should go to a private hospital or you may be waiting 2 months here for this surgery.” We were appalled and immediately moved to get her into a private hospital yesterday.

The fault totally lies with the CAJA doctors who are apparently very arrogant and could care less about Gringo patients. The other hospital staff at the CAJA hospital were generally good service, but a patient is expected to tend to themselves far more than the North American standard.

Much as we are very much not the “Rich Gringos” the doctor implied, we immediately took my wife to Hospital Metropolitano where we received immediate & excellent treatment. My wife had shoulder replacement surgery that night (not ‘a repair’ as she’d been told would be done at San Juan de Dios). We really felt, as Gringos participating in the CAJA, typically at higher premiums than Ticos, we are entitled to equal treatment in the CAJA and were being told we would not.

May 8, 2015

The CAJA system here is not perfect. Some things they do really well. In Linda’s case, the initial triage was excellent. The problem was she was in a long line-up for surgery. In such cases, being able to access private hospitals is an alternative not found in Canada and is hard to do in the U.S.

However, here’s another good example of the public system here, dealing with the sliver I got in my foot 3 months ago while at the beach. I left it for 2 months thinking it would work its way out on its own and it was an annoyance, not really bothering me too much.

I finally went to our local hospital clinic emergency department where they tried to extract the sliver under some mild local anesthetic. The attempt was not successful but I was out of the emergency dept in less than an hour. So they gave me an appointment to come back for minor surgery this week. I went for the appointment, was put into a small surgery room where heavier local anesthetic was administered (ouch!) The ball of my foot was sufficiently frozen that I never felt another thing while the surgeon dug out what was a 3/8 inch, fairly thick sliver of wood.

Total time in hospital: 40 minutes. Total cost: $0.00


Beavis4While we had moments of anxiousness in the public hospital, I came to realize that we simply were in a lineup within an overtaxed surgery slate for “elective” stuff.  As I tried to clarify later, the outer ends of the spectrum have been very good (emergency or scheduled services).

The other point I want to make is the saving graces of holding onto Medical A & B, and signing up for a Medicare Advantage plan for those retaining a home in the U.S. (See below.) The one we found included $50,000 of emergency coverage when out of the U.S. Our final tab at Hospital Metropolitano was $18,000. The reimbursement payment from the insurance came through at about the two month point, paying the claim in full, with no deductibles or co-pays.


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In the Mailbag – Healthcare in Costa Rica

emaildelivery-200pxOur newsletters and posts generate lots of discussion, on our website, in emails, and on facebook. Here’s a glimpse into our mailbag about healthcare in Costa Rica.

From Nel C.:

Last year, my husband, Blue, collapsed in our dining room in the early hours of the morning.  I heard a noise and got up and found him unconscious.  I called 911 and they called Red Cross ambulance.  There was no one at the station and when they did finally get through, they still took about a hour to get to us, even though the station is only about a mile from our house.

We took him to Clinica Biblica first, even though we had no insurance, because they had a file on him and he needed immediate help.  He stayed there until I ran out of money and then we had him transferred to a public hospital, San Juan de Dios.  He spent the first day in the ER and then they shifted him to ICU.  He spent 2 weeks there and then he was moved to a ward.  He spent a total of 2 months in a Caja hospital.

The care he received was impeccable.  The nurses were wonderful, the doctors so good.  At one point, I was told Blue wasn’t going to make it but it almost seemed like the doctor was determined not to let that happen.  I sat with the doctor for half an hour talking about what could be going wrong (no one knows my hubby like I do).  The doctor changed some meds and did some other procedure and lo and behold, he saved Blue’s life.  We were lucky in that we had an English speaking doctor and a couple of nurses who were also pretty good at it!  Between my halting Spanish and their English, we got along just fine.

I cannot say enough about the care he received through the Caja.  Since then, he has been seeing a doctor at the Ebais regularly.  She looks after him and me.  And not a penny to be spent on anything other than the premiums which, to me, are very reasonable!   I’m so glad we took Residency when we did.  This whole thing could have been a financial disaster for us.

By the way… the going rate for Clinica Biblica was about $4,000/day.  Another North American was in San Juan de Dios while Blue was there and he had no Caja.  They were charging him $1,000/day for everything.

From Tom S.:

Thanks for the truthful and honest articles on the CAJA. All systems in all countries have had people with good and bad experiences, good for you to share yours. We have lived here 5 years, have used only CAJA the whole time, and have nothing but good to say about our doctors and treatment. My wife gets her yearly mammograms, goes in for a bone scan this week, I just had an echo-cardiogram, I go to a dermatologist specialist next week for a precancerous spot they found, and I have a visit with my internist and cardiologist every three and six months. I will say that, as with all things here, your experience is directly proportional to the amount of Spanish you speak.

From Diego X.:

I just rushed a Tico neighbor to the local Caja yesterday. It was clear to me that he was suffering from malignant hypertension which was severe enough to cause nosebleeds and angina. The Caja doctor was cavalier and said he had been hit in the nose (when there was no history of that) and not to worry. I warned the family that he was at risk for a stroke or heart attack and that they should go to the hospital. He was admitted last night with a heart attack.

My point? Not that the Caja is terrible. Just that there are always a few bad doctors anywhere. I’ve seen this in the US from time to time, too. Most doctors in most places are sincere and honest and caring. But like any profession, there’s a chance you’ll find a bad apple in the barrel.

From Charlotte L.:

The Caja saved us about $75,000 and most importantly saved my husband’s life. When a U.S. doctor, a few years later, saw the work, he said it was very well done. My Spanish is entertaining (not good) and I get along fine. So don’t let bad Spanish stop you from using the Caja. And too, when I got here I had some health issues that puzzled the U.S. doctors, for years, within just two appointments (private doctors) the problem was solved—-I was extremely allergic to pork and peanuts. Our doctors can see us privately or work with us through the caja—we think this is wonderful!

From Kat. B.:

Well….just had a GREAT experience with the medical services in Costa Rica. I had to have an endoscopy done last night. May I say…I was fairly nervous but my doctor and techs were very calming, gentle, and kind. My doctor was ‘present’. He listened to me, alleviated my fears, then did the procedure. It cost $120.00 U.S — private care and no co-pay. When we receive our residency we’ll contribute to CAJA. In the meantime, we’ll do private. Awesome, quality, personal care. Have I said I love living here?

From Connie S.:

There are some delays using the CAJA, compared to what most have been used to in the USA, but for us, it has been a great blessing. We moved here, in large part, for the health care system and have received excellent care. My husband has had cararact surgery for BOTH eyes, we get our prescriptions and medical visits and lab work done regularly, and also see dentists in the system, all without paying ANYTHING beyond our monthly premium.

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Our Ultimate Healthcare Tour of Costa Rica

Our newest tour is the Ultimate Healthcare Tour of Costa Rica. When asked what he liked best about our healthcare tour, one of our guests wrote, “the wide variety of places we saw, the experts that Paul HCTOUR_030arranged for us to meet and talk with, and an emphasis on all aspects of health, not just doctors and hospitals. Mental health is just as important as physical, if not more so.” HCTOUR_008

We’ve lived in Costa Rica for over five years and have used the Caja, Costa Rica’s public healthcare system extensively, as well as the private system, when needed. We’ve learned the system and have been referred up the ladder to see specialists in the maze that is the Caja system. Gloria’s even had surgery here.

Our blend of personal insights and on-the-ground experience combines to answer your questions about whether or not Costa Rica’s healthcare system could meet your individual needs.


But, while it is focused on healthcare, you will learn a lot more about living and retiring in Costa Rica’s Central Valley. Most of the second day of the tour takes place in the town of San Ramón where we live and use the services. And you will come to our home for lunch that day to listen to two of our featured speakers. Our tour is designed to save you both time and money, packing a lot of information into a short period of time. Our goal is to show you the possibilities and to try to demystify Costa Rica’s healthcare system. Our tour lasts two days and 1 night and includes lodging, transportation, meals and non-alcoholic beverages.

Sample Itinerary

You’ll visit:

  • At least two private hospitals in San Jose area
  • Hospital Mexico, the largest and best public hospital (they even do open heart surgeries there)HospitalMexico
  • An insurance broker for a presentation on the various supplemental health insurance options, including public, private, and international plans
  • A senior living retirement community
  • CPI language school for a presentation about how learning Spanish increases your options for healthcare and some basic medical Spanish.
  • Our local hospital here in San Ramón
  • A local EBAIS (community clinic)
  • A local private medical and dental clinic
  • A local Seguro Social office where you would sign up for the Caja (national healthcare coverage)
  • A pharmacy
  • A health food store (macrobiotica), and more!

EBAISStaffYou’ll learn:

  • If the Costa Rican healthcare system could meet your needsand put your mind to rest, once and for all, about this sensitive subject.
  • About the public system and how it works, about the private healthcare system, and how you can use a combination of both to your advantage.
  • About the EBAIS – where healthcare starts in Costa Rica.
  • Approximately how much you would pay for Caja.
  • About medical tourism in Costa Rica.
  • About home health care in Costa Rica.

Introductory prices: $550 for a couple, $450 for a single.

Please contact us if you are interested in booking this tour. Space is limited.

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