Ecuador Health Insurance: Private vs. Public IESS – EXPLAINED (2021)

Health insurance in Ecuador can be complicated and confusing, so we were very fortunate to have Carlos Ramírez from Blue Box Insurance stop by to explain it to us.

Blue Box is an insurance broker representing several health, auto and home insurance companies in Ecuador. They have an office in Cuenca, and they will be opening an office in Manta in April 2021.

We are not being compensated for this article, other than the time Carlos donated for the interview and for answering our questions about health insurance and healthcare in Ecuador.

Health Insurance in Ecuador Explained

Ecuador Health Insurance

Universal participation has provided Ecuador with an excellent healthcare system. Medical procedures are a fraction of the cost in the US, and the quality of care is high.

Health Insurance in Ecuador is a bit different than the United States. You have the option of getting Private Health Insurance with one of Ecuador’s many health insurance companies.

Or, you can sign up for the Public IESS Health Insurance, which is Ecuador’s version of Universal Healthcare (Medicare/Medicaid). You’ll need your Temporary Residency Visa AND your cédula before you can apply for this plan.

Or, you can get both Private AND Public Health Insurance to make sure ALL your bases are covered. Since the cost of healthcare and health insurance in Ecuador is so much more affordable than in the United States, this is a viable option for many people.

The decision then comes down to a few significant distinctions: price, flexibility, and treatment of pre-existing conditions. Here’s what you can expect regarding each of those considerations for private insurance and the IESS. Hopefully, this information will help you choose which option or combination might work best for you.

Private Health Insurance in Ecuador

In Ecuador, there are 28 private health insurance companies to choose from. They provide health insurance that allows you to visit any private doctor and receive any treatment in Ecuador at private hospitals. Some plans even cover treatments outside of Ecuador.

Monthly premiums are generally affordable but can vary according to your current health factors (age, smoking, pre-existing conditions, etc.), coverage maximums, and the deductible that you choose. There are no network limitations like you’ll encounter using the public IESS plan.

For private insurance, in addition to the monthly premium, you can expect to pay a deductible on an annual or per-incident basis. You’ll also be responsible for a small co-pay for each doctor’s visit or prescription.

Ninety percent of in-network healthcare costs are covered, and 80% of costs out-of-network are covered by private insurance companies. Submit a claim, and the insurance company will reimburse you.

The government mandates coverage of pre-existing conditions, but there is a two-year waiting period before those treatments must be covered by private insurance. You’ll also have to secure private insurance before you go through the residency requirements of obtaining your cédula (Ecuadorian National Resident ID card).

Ecuador Public IESS Health Insurance

IESS Hospital in Manta Ecuador

Once you have received your cédula, you can sign up for the public IESS health insurance plan. The IESS is the national social security healthcare system that all Ecuadorians must pay into unless they obtain private coverage.

Under the IESS coverage, expect no co-pays or deductible and all medical costs are covered at 100%. However, you will be restricted to the doctors, hospitals, and pharmacies within the IESS network unless you are referred elsewhere after seeking treatment from an IESS facility.

All pre-existing conditions are fully covered after a 3-month waiting period, which is often why expats choose to have both IESS and private coverage at the same time.

Health Insurance Deductibles in Ecuador

Private health insurance providers in Ecuador offer both low and high deductible plans. A plan with a low $100 annual deductible will cost more than a plan with a high $5,000 annual deductible.

You’ll have to pay up to this amount before your private insurance coverage kicks in, but you can also purchase additional gap insurance for as little as $40/month to cover the deductible.

Your premium will depend on the maximum major medical coverage level you choose and how high you’d like your deductible to be. The higher your deductible, the lower your premium will be. There are plenty of coverage levels to fit most budgets, as you can see in the examples below.

Health Insurance Prices in Ecuador

Overall, both health insurance and healthcare are very affordable in Ecuador, especially compared to the United States.

Ecuador Private Health Insurance Cost

Here are some examples of current private insurance rates for an average 65-year-old.

Total Coverage Annual Deductible Monthly Premium
$100,000 per incident $180 $220-$230
$500,000 annual $5,000 $70
Up to $6,000 (Vida Buena) $39.20

For some, combining private plans makes the most sense. Combining the Vida Buena plan for about $40 per month with a plan that covers up to $500,000 per year with a high deductible will cost about $110.

Effectively, by paying for both, you’ll avoid paying the high deductible and have substantial coverage in place for major medical emergencies.

Ecuador Public IESS Health Insurance Cost

Ecuadorian nationals pay a percentage of their claimed income into the IESS system as their monthly premium.

Expats who choose IESS insurance are permitted to pay a voluntary amount based on the minimum wage, which is about $72 per month.

Again, there are no deductibles or copays and all medical care is covered at 100%. You just have to pay the monthly premium to access services in the IESS network.

Health Insurance Claims Reimbursement in Ecuador

Claims Reimbursement

With the IESS, you won’t need to do anything other than pay your premium to access national healthcare services.

Filing Claims with Private Health Insurance

Private insurance companies require that you to pay for healthcare services out-of-pocket before you can submit claims for each visit, procedure, or prescription that you’d like to have reimbursed.

You have three months (90 days) to submit each bill using a reimbursement claims form. Don’t wait too long to submit the paperwork in case additional documentation is required. Try to submit medical bills with the accompanying claims forms as soon as possible. Your insurance broker can assist you with preparing these claims forms and submitting them correctly.

If your insurance provider initially denies your claim for any reason, you can appeal the decision to the Superintendencia de Companias, who will review the request and make a final decision. If your paperwork is in order for a valid claim, the insurance company will likely be ordered to reimburse you. Otherwise, your claim can be denied.

This appeal process can take 3-5 months for a final decision, but it is free for you to apply. You have the option to file with the Superintendencia on your own, with the help of an insurance agent who’s familiar with the process, or through the free services of a public defender in Ecuador.

What if I can’t afford to pay for expensive medical services out-of-pocket?

Ecuador Health Insurance Filing Claims

Even though healthcare in Ecuador is far less expensive than it is in the United States, complicated treatments can still cost $20,000 or even more.

With private health insurance in Ecuador, you are normally required to pay for the services out-of-pocket and then file a claim to be reimbursed. However, what happens if you need expensive services like heart surgery or cancer treatment and you can’t afford to pay the entire hospital bill while you wait to be reimbursed?

If your treatment is NOT an emergency, you can get pre-approval from your insurance company and then you would only be responsible for paying the regular copays and deductibles.

If your treatment is the result of an emergency, such as an expensive surgery following a car accident, then you will only be required to cover the copay and deductible as long as you go to an in-network hospital. If you go to an out-of-network hospital, you will need to pay for all the services rendered before leaving the hospital.

However, if your emergency treatment is at an out-of-network hospital and you cannot afford to pay the entire bill, it is possible to submit a letter of commitment to pay to the hospital, which will mean you are legally required to pay the hospital even if the insurance company denies your claim.

This is another reason why it’s a good idea to work with an insurance broker like Carlos at Blue Box Insurance to help you negotiate this process.

If you do not have health insurance, you will be required to pay the entire amount before leaving the hospital.

Conclusion

The insurance framework in Ecuador makes it easy for residents to secure affordable coverage. Your best bet is to go through the options available and choose what will best meet your needs. An insurance agent can help you find what you’re looking for and secure that coverage.

There are plenty of significant differences between private and public health insurance and benefits to carrying one type or the other, or even both at the same time. Regardless of your decision, there are plenty of coverage variations for you to find quality, affordable health insurance solutions in Ecuador for your needs.

If you have more questions about health insurance or healthcare in Ecuador, we recommend contacting a health insurance agent/broker directly for more detailed or specific answers. To get in touch with Carlos and his team at Blue Box Insurance, please visit their website at BlueBoxInsurance.com and be sure to tell them you saw this video on Live Abroad Now.

You might also be interested in our article about the Cost of Living in Ecuador: A Guide for Expat Budgeting.


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