Andorra is a popular destination for many expats, particularly those working in the skiing industry or in finance. Healthcare is of a very high quality: according to some healthcare rankings, it is among the best in the world. But what are your options when it comes to health insurance? Andorra has a two-tier system of both public and private health cover and you will have a number of choices when it comes to arranging health insurance for your stay here.

Public healthcare in Andorra has been in place for over a hundred years. It covers around 92% of Andorran citizens, in the form of the current health insurance scheme, the Caixa Andorrana de Seguretat Social, or CASS. Enrolment is compulsory for salaried employees and will cover them for treatment in Spain, France and Portugal in addition to Andorra itself. If you are registered with this system and are planning to travel over the border it is advised that you contact the CASS before you go.

Your employer will need to register you with CASS and you will pay monthly contributions, which will be deducted from your salary. If you are unemployed, you can register yourself with CASS and will need to pay directly.

Emergency healthcare, for example in the case of accidents, is free for everyone, including people who do not have health insurance. Ongoing healthcare after the critical period has passed may entail a fee, however, so it is advised that you have private cover if you are not eligible to access the Andorran national scheme.

Andorran citizens and salaried employees are entitled to sign up with CASS. Note that residency permits are time-limited, and it is very difficult to become a citizen here. Criteria are very strict and you will need to have been resident in the country for 20 years before you can apply, or 10 years if you have been educated in the Andorran school system. In practice, attaining Andorran citizenship has been described as ‘next to impossible’.

However, there are various forms of residency programs, including passive residency, in which your main source of income lies outside Andorra. Expats often take advantage of this for tax reasons. There is a minimum income cap on this – your income must be at least 300% of the average Andorran annual minimum salary (currently around €12,600 per annum). In addition to this, you will need to make an investment into the Andorran economy, usually by means of buying a special government bond.

If you are intending to apply for passive residency, however, you will not be entitled to access the national healthcare system. You are required by law to demonstrate that you already have coverage for three types of insurance in place:

• incapacity
• old age
• medical

You will thus need to take out private health insurance before you apply for any form of residency in Andorra and if you are applying only for passive residency, you will need to keep your private cover in place, since you will not be entitled to use the national healthcare scheme. The law states that passive residents must “justify and have in force for Andorra coverage and insurance for illness, disability and old age for the applicant and for their dependents or the dependents of their spouse or stable partner for the entire period of validity of the passive residence.”

However, if you are employed in Andorra and are not, for example, funded primarily by investment income outside the state, you can apply for active residency. This is mainly for expat employees and in this case it is compulsory for you to be registered with CASS by your employer. Thus, although you may need to prove that you have private health insurance cover to begin with, you will then be eligible for treatment under the Andorran national scheme.

If you are self employed, you must register yourself as a self-employed worker or autònom with the CASS and you must also register any dependents.

If you have an EHIC card, you will not be able to use this in Andorra.

If you are working, your employer will need to register you with CASS: this is mandatory. You can also register yourself if you are self employed.

Around 75% of your outpatient medical expenses will be covered by CASS, along with 90% of any hospital expenses. The main cause of accidents in Andorra is winter sports and if you are planning on undertaking regular activities such as skiing and snowboarding, it is advisable to take out specialist private cover.

The national scheme includes:

• primary care
• hospital treatment
• specialist treatment (you may need a referral from your GP)
• maternity care
• childhood medicine

Andorran medical institutions usually require upfront payment, so be aware that you may need to pay first and then claim the money back from your insurance provider, so make sure that you have all your receipts. Your doctor should give you a stamped voucher, which you can then submit to CASS. Make sure that your health provider, such as your GP, is registered with CASS if you are entitled to access the public healthcare system.

Note that Andorra, as a small state, has limited facilities: although the country’s single hospital (Hospital Nostra Senyora de Meritxell, or the Centre Hospitalari Andorrà / CHA) provides care of a very high standard, you may find yourself having to seek treatment over the border in France or Spain.

You can retire to Andorra and a number of expats have done so: note that, as above, acquiring citizenship probably will not be an option, but you can still apply for passive residency, in which case you will not be eligible to register with CASS and must take out private health insurance.

If you are intending to study in Andorra you will need to have private health insurance that will cover 100% of any medical costs incurred during your stay.

If you are a passive resident, you will need to take out private healthcare cover for any dependents.

If you are an active resident, then your spouse will only be entitled to access the national healthcare scheme under certain limited forms of residency (Category D). It is advised that you take out comprehensive private cover which includes your dependents.

CASS covers basic check ups and routine care but for any more advanced treatment, you will need to pay out of pocket or have private dental cover.

If you are unemployed, you can register with CASS but will need to make a contribution of between €200-400 per month.

As an employed worker, you will be paying 6-9% of your salary into the system each month, and your employer will contribute 15.5%.

If you are self employed, your fixed-rate payment to CASS will be €453.68 per month. If you set up a new company you may apply for a 50% concession within your first 12 months: thus paying €226.84 per month. Companies with less than €12,000 in profit and €150,000 in turnover in the last financial year can also apply for a 50% concession of €226.84 per month.

If you are a passive resident or a visitor, you will need to take out private health insurance cover.

It is also advisable to take out specialist sports insurance if you are planning on engaging in winter sports. Make sure that your medical insurance covers you for any injuries on the slopes. You should be looking at a minimum of around €3m in medical cover and should also ensure that your policy includes travel back to your home nation if required, plus mountainside rescue. You will also need details of a 24-hour emergency helpline.

Make sure that your policy also contains a personal liability clause: this will cover you against legal action if you injure another person. A minimum of €1 million is advised.

A ‘loss of use’ clause will cover you for any period when you cannot use your ski passes due to bad weather, illness or injury. This will generally take the form of a monetary amount per day lost, so if you are injured, you can factor this loss into your insurance claim.

If you are planning on engaging in any ‘extreme’ winter sports such as heli-skiing, it is advisable to check whether this is also covered by your policy.

Finally, make sure that any private insurance includes reference to any pre-existing conditions.

Average costs for a week’s winter sports coverage are currently in the region of:

• individual in their mid 20s: €9- €95
• couple in their early 30s: €15 – €160
• family of four (children aged eight and 12): €22 – €287
• couple in their early 60s: €29 – €168

Specialist policies can allow you to ski off-piste. Ski Club, for example, offers a policy for €156 annually for a 35 to 69-year-old for up to 45 days’ skiing a year; or €252 for a couple and their children.

Also, make sure that you read your policy thoroughly. Wearing a helmet, for example, is compulsory in some resorts and not doing so may invalidate your insurance. So can drinking alcohol, so check your policy for any invalidation clauses before you set out. There may be age limits, too: some insurers set a cut off date if you are in your 70s.

Private health insurance will cover you for:

• GP visits
• hospital visits and treatment
• advanced dental care such as crowns and bridges
• cosmetic surgery

As so many variables have an effect on the cost of international private medical insurance in Andorra it becomes very difficult to give accurate estimates without knowing the full details of the coverage required. However, as a very rough guide, using a standard profile of a 40 year old British male with no deductibles, no co-insurance, a middle tier plan/product, all modules included and worldwide coverage excluding the US, a ballpark price of around €4,800/$5,200 might be expected.

Some international private insurers cover Andorra including:

• BUPA
• Cigna
• Expatriate Healthcare
• Foyer Global Health
• Globalink
• Pacific Prime

The main language in Andorra is Catalan, and having a basic command of the language will be useful.

Caixa Andorrana de Seguretat Social, or CASS – the Andorran national healthcare scheme

Hospital Nostra Senyora de Meritxell, or the Centre Hospitalari Andorrà / CHA – Andorra’s main hospital