From the print edition
The Caja is short for the Costa Rican Social Security System, a government-run health care and pension provider for all Costa Rican residents. The Caja operates health clinics throughout the country that provide primary health care for residents, as well public hospitals that provide advanced medical services. All foreign residents who have applied for or have obtained residency status are required to affiliate with this government agency.
So how do residents register with the public health care system?
Under Caja regulations, a person registering under the status of pensionado (retiree) or rentista (a person not yet of retirement age who has a substantial enough income or savings on which to live) is required to show a cédula, an ID that shows a visa has been granted, or an approval notice from the Immigration Administration. Foreign nationals who have only filed for temporary residency are technically not allowed to enroll in the Caja.
What are the levels of enrollment?
There are four levels of enrollment, of which only three are applicable to most expats residing in Costa Rica.
1. Salaried and professional workers: This level includes people employed by businesses and whose employers deduct monthly Caja payments from salaries.
2. Independent workers: These are usually freelance or self-employed workers who do not have an organization employing them, such as independent contract employees or street vendors.
3. Voluntary: This category is designed for retirees, students, homemakers and the unemployed. It provides only the medical portion of the plan on the assumption that the enrollee is either not currently employed (but may work and contribute to the pension plan in the future) or is elderly and will not work the requisite number of years to be eligible for the pension part of the program.
How much does it cost?
The cost of the first two categories of enrollment ranges from $30-$150 per month, with the final amount being determined using a base figure of 13 percent of stated income minus allowable deductions. The monthly payment covers not only the medical part of the system, but also includes a contribution to the retirement pension portion of the Caja.
The Voluntary program is probably the best-suited for most expats; its monthly rates are individually calculated based on a variety of factors including age, employment, income, number of dependents and other criteria. The cost of this category generally is a relatively small, fixed amount. Enrolling under this plan provides only Caja medical services. It does, however, entitle members to use any of the Caja facilities anywhere in the country.
Retirees who have no Costa Rica-based income and are members of the Association of Residents of Costa Rica (ARCR, www.arcr.net) can join the Voluntary classification through the ARCR, and the association has negotiated a fixed monthly rate – currently $49 per month. This amount includes health coverage for a spouse and all legal family members under 18.
Regardless of which plan you enroll in, you must make the appropriate monthly payment before the 8th of each month to be issued a payment receipt for the current month. The receipt is a two-inch-wide strip of paper that is the equivalent of an ID.
If you like standing in line, you will be given a new carné, or ID, when you make your monthly payment at the local Caja office. If you prefer to avoid lines, the payment can be made online, and a carné can be printed out from the website. ARCR members who have arranged for their payments to be made automatically via credit card can receive their carnés either in person at the Casa Canada offices or have them automatically mailed to local addresses via the Costa Rican postal service.
Whichever payment method you choose, timely payment is important, because without a carné for the current month, no regular, nonemergency, services will be provided at the clinics.
Where do I enroll?
Joining the Caja is not a difficult process and can be accomplished at many locations. One is at the main Caja offices on Ave. 2 in San José, (on the south side of the avenue, across from the Plaza de la Cultura). Enrollees also can visit one of the outlying Caja offices in communities around the country. If you are not fluent in Spanish, it is a good idea to bring someone who can answer questions and help you learn the Caja system. Otherwise, the language barrier may become a source of frustration.
What should I bring?
As with all things bureaucratic, changes may occur or different offices may have different procedures. Be prepared for variations. Bring with you:
1. The original and a copy of your electric bill. (Another utility bill showing your residence address may suffice.)
2. If your residency application has been accepted and is in process, bring the originals and copies of your passport and a letter stating that your residency application is en trámite (being processed). If you already have residency and a cédula (DIMEX card), bring it and a photocopy of it showing both sides of the card.
What happens next?
Be prepared to answer personal questions. You will be interviewed and asked to provide information on such things as your age, employment status, income (amount and source), birth date, address, marital status and cost of living. This information will be entered into a computer and printed out for you to sign as a sworn statement.
Based on the above, you will be assigned a monthly payment amount. The first month’s payment is required up front. You will receive a copy of the document and a receipt for the payment.
After completing the enrollment process, you will then need to visit your local clinic with all the Caja paperwork. You also can familiarize yourself with the clinic layout and schedule an initial appointment. You will be assigned a doctor at that time.
During your first appointment with the doctor, it is a good idea to provide copies of any medical records and recent lab reports you have, plus a list of all medications you take (including dosage.) The doctor will appreciate it and include the information in your file. One of the nice things about the Caja system is that they do not discriminate against “pre-existing conditions” like many commercial insurers do, so there is no reason to hide anything.
What else should I know?
When the time comes that you need to utilize the Caja’s services, start at your local clinic. If you want an appointment for the same day, plan to arrive at the clinic early (around 5 a.m.) and be prepared to stand in line. Later arrivals may find the day’s appointments already filled.
When you see the doctor, be specific and detailed about your complaints – like doctors everywhere, they can do a much better job if they have more information than “I don’t feel well.” If you can describe the problem with details about location, symptoms, etc., you will get better care.
The Costa Rican health care system is predicated on the concept of preventive medicine. Therefore, enrollees are advised to have an annual lab test, blood pressure and weight checks, and updated information included in medical files at each new appointment.
There are many horror stories floating about regarding the services rendered and drugs provided by the Caja system. However, there are many more patients who report excellent care and treatment. Like any health care system anywhere, services can vary between local facilities.