CCSS funds are put into a central pool. The system used to be run by the Ministry of Health, who have now adopted a steering role, and the responsibility for most care is now held by the CCSS itself.

As an expat, you will be eligible to sign up with "La Caja" for a small percentage of your income. It has been mandatory since 2010 to join the scheme if you are a citizen or have residency papers, but you must be a legal resident via an approved scheme such as a Pensionado or Rentista. You will be required to sign up to the Caja as part of your immigration process.

If you are not signed up for residency, but are visiting the country, you will only be entitled to emergency treatment at a state hospital or clinic unless you have private travel insurance.

All citizens, and expats who have residency permits, are eligible for state healthcare insurance.

If you are employed, then your employer will sign you up to the Caja. They will then give you a receipt of registration called the "orden patronal."

If you are self-employed but have residency, you will need to sign up at your nearest regional government office. They will then direct you to an EBAIS (Equipos Básicos de Atención Integral de Salud or Primary Healthcare Provider), your nearest local clinic, who will issue you with a carnet (an insurance card). You may need a utility receipt as proof of residence and you will need to show your residency permit from the Department of Immigration.

Although you need residency status, you do not have to be living in Costa Rica full-time to qualify for the Caja.

The Costa Rican healthcare system has a strong focus on preventative medicine. It provides 100% coverage for:

• doctors\' visits
• medications (including dental and eye-related)
• examinations
• hospitalization
• some pre-existing conditions

As a retired expat, you will be eligible for the state medical scheme but deductions will be made from your pension.

Emergency care is free at the point of delivery to everyone in Costa Rica, but international students should check with the CCSS to assess their eligibility and take out private travel insurance if required, particularly if they are staying in the country for only a short time.

The Caja allows dependants (spouses, parents, and children) to be covered under your health insurance.

Treatment under the CCSS is limited but the INS provides a variety of dental insurance plans. Overall, dental costs are cheaper than in the US, for example, and Costa Rica is a destination for dental tourism.

The system is funded from payroll taxes, and you would expect to pay around 7 - 11% of your income. Payment is calculated on your income, with a minimum monthly income of $1,000 for Pensionado (Retirement) status and $2,500 for Rentista (Income Based). These monthly incomes are the minimum requirement to qualify for these residency categories.

If you are a Pensionado, you will pay around 8% of your monthly pension. If you are, for example, a retired expat with a monthly income of around $1200, you would pay about $96 per month for your health coverage, and this will also cover your spouse and your children.

Investor status (Inversionista) is treated by Caja as analogous to the Rentista category, so if you are an investor in Costa Rica, your health insurance deduction will be calculated on a minimum monthly income of $2,500. If you earn more than this, however, your premiums will be increased.

Residency applications can take up to 18 months to be processed, so it is important to make sure that you have coverage in the interim.

Some expats also prefer to have access to a wider range of healthcare and shorter waiting times. Private hospitals sometimes charge high fees upfront for admittance, so some expats take out private insurance to cover this. Appointments to see specialists, in particular, can have lengthy waiting times.

The two systems work in tandem to some degree. You can, for instance, have diagnostic treatment done in a private clinic and then go back to your state GP for treatment. Prescriptions are covered by the Caja and some private doctors will write prescriptions that can then be claimed under the state scheme.

You might not be eligible for the INS if you have a pre-existing condition.

INS coverage is divided into two forms: INS Seguro de Gastos Medicos and INS Medical Insurance.

INS Seguro de Gastos Medicos is split into two plans:

Plan A:

• medical consultations
• medicines
• examinations
• laboratory costs
• pregnancy

Plan B:

• hospital costs
• ambulance costs
• surgery
• medical assistance for pregnancy
• home healthcare
• medical instruments

INS Medical Insurance covers:

• hospital and ambulance costs
• cancer treatments
• treatment for epidemics
• organ transplants
• prostheses

and is divided into three main plans, including Regional and International, depending on whether clients want coverage for other Central American countries or elsewhere.

Some expats also sign up for discount plans. There is a difference between health insurance and a discount plan: in the case of the latter, some public doctors who have their own private practices allow you to sign up to budget healthcare treatment, including:

• appointments
• blood tests
• x-rays

This is designed for people who have not signed up with the INS but still want access to private healthcare.

You can also sign up with independent providers, in which case your insurance will cover a range of primary and other treatments depending on your policy.

This will depend on your individual needs, but overall health insurance premiums for private coverage in Costa Rica usually cost 30% to 50% of comparable coverage in the United States.

For those seeking international private medical insurance (iPMI) cover for multiple countries including Costa Rica, numerous variables can have an impact on the cost.

The most important variables are:

• age (the higher the more expensive)
• area of cover (i.e. in addition to Costa Rica, which other areas is coverage required in? If those other areas include any of the US, the Caribbean, Singapore, China, Hong Kong or Dubai this can significantly increase the overall price)
• product choice (higher end insurance products are more expensive)

Other variables include:

• deductibles
• co-insurance
• payment frequency
• gender
• nationality
• country of residence

As so many variables have an effect on the cost of international private medical insurance in Costa Rica 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 $5,000/GBP4,000 might be expected. Were coverage to be expanded to include the US then the premium could increase to almost double that amount.

Since the ratification of CAFTA - the Central American Free Trade Agreement - also known as the Tratado de Libre Comercio (TLC), a wider range of private companies now operate in Costa Rica, although the INS is still in place. They include:

• Cigna Global
• MAPRE
• Blue Cross
• BMI Insurance

Caja Costarricense de Seguro Social (CCSS) - The Costa Rican Social Security Fund

Equipos Básicos de Atención Integral de Salud - Primary Healthcare Provider

Instituto Seguro Nacional (INS) - the national insurance scheme