Experience with the Updated Healthcare System in Costa Rica - Should You Retain a Translator?

As I have previously indicated in this blog, the healthcare system in Costa Rica is quite unique. The country has its own government run public sector system which provides coverage for all medical procedures, prescription drugs and other benefits. This is provided to citizens and ex-pats alike, the latter of whom have been in the country long enough to acquire legal residency status. There are a number of public hospitals and a network of public "Ebais" clinics throughout the country. Overall, the public system is commonly referred to as "CAJA" which is short for "Caja Costarricense de Seguro Social".

As well, the country has a private system which is also able to provide high quality healthcare services. Many doctors in this sector speak English and have received training in the United States, Canada or Europe. There are four major private sector hospitals in Costa Rica.

Some private sector doctors are also affiliated with CAJA. They work part of their time in private practice and the remaining part for CAJA. If you find a doctor in CAJA who also has a private practice, it sometimes may be helpful to consult that doctor in his or her private practice. If you meet them once in CAJA and are happy with the experience, there is no assurance that you will ever meet them again in a routine appointment in CAJA.

Over the time we have lived in Costa Rica, Lance and I have relied on both the public and private healthcare systems - whichever seemed most convenient or expedient at the time. But, it can be a challenge to navigate the public system if you are not fluent in Spanish. Some CAJA doctors are fluent in English or speak at least some English but many are not. The same is true of nurses and administrative staff. Unlike the private system, you are unable to choose your doctor in the public CAJA system and you may be met with different doctors at different times.

Recently, Lance got fed up with a persistent bad back problem which can act up whenever he twists himself the wrong way or lifts something too heavy using his back instead of his arms. He decided to get an appointment at our local CAJA Ebais clinic in Puente de Piedra (less than a 5 minute drive from our house). Today, if one is able, this is done by having the EDUS app on your computer or phone. EDUS stands for Expediente Digital Unico en Salud (unique digital health record) and this is where you make clinic appointments, see your medical history, drugs, vaccinations, etc. You look at a calendar for available dates and select a convenient date and time. CAJA then responds with an email which confirms the date and time.

After getting the appointment, we decided to engage a translator ("Minor Villalobos" - see his contact information below) to be present during the appointment. Our understanding of Spanish is limited to day-to-day stuff and does not include technical medical terminology. He is fully conversant in English and Spanish. He has a paramedic background and is familiar with medical terminology. 

The appointment went seamlessly. The Ebais doctor decided that some lower back x-rays were in order. But, they had to be taken at the local hospital in Grecia (not the Ebais clinic). The doctor provided a requisition to get a hospital appointment to facilitate that purpose. 

Normally, without the translator, we would have had to drive to the hospital, find somewhere to park, and navigate to the right location in the hospital to submit the requisition. We speculated that this could be a real chore. Minor said he would do it. With the requisition in hand he drove off to the hospital and we drove home. About 1 hour later he arrived at our home with the x-ray appointment.

The x-ray appointment was on one morning at 8 a.m. We decided that we did not need Minor for this purpose because we had a good idea of where to go and the x-ray technician would simply follow the Spanish language instructions in the Ebais requisition. We were right. Shortly after arriving at the hospital and knowing where we had to go, we left with the x-rays.

We surmised that we should deliver the x-rays to our Ebais clinic. This was wrong. The receptionist at the clinic indicated that we needed to get another appointment (going online, etc.) and hand them over to the doctor at that appointment. We left the clinic with the x-rays went home, and once again went online to get an appointment.

Lance got an appointment. We then contacted Minor to determine whether he could attend. As it turned out, he could not. He had a previous commitment. So we went online, cancelled the appointment and got a new appointment which worked for both Minor and ourselves. In cancelling the appointment, we were asked to provide an explanation and said that we were doing so because our translator was unavailable at the scheduled time. That turned out to be good enough. There was no problem getting a later appointment.

With the latest appointment, Lance and Minor once again attended our Ebais clinic. The doctor (who was not the doctor that prescribed x-rays) reviewed the x-rays and decided (a) that there was nothing particularly urgent and (b) nevertheless, the attention of a specialist was in order. There were two bone spurs at or near the lower spine which the doctor indicated should be controlled and that a specialist should be consulted for that purpose.

As a result, the doctor issued a requisition for an appointment with a CAJA specialist. Minor is currently handling that. By reason of non-urgency, it may be a few weeks before we get any feedback including an appointment with a specialist.

The above is in contrast to how a medical issue might be handled within the private healthcare system in Costa Rica. Whether urgent or non-urgent, whatever issue you might have may be handled much more promptly in the private sector. Lance is laid back. He does not care very much except when his back acts up.

Despite the bureaucracy of CAJA, we remain convinced that the healthcare system in Costa Rica is second to none throughout the world. The bureaucracy and the available options are designed to serve both the poor and the rich, and those in between, and so it should be.

For those who may be interested, the contact information we have for Minor is:

Should you retain a translator in dealing with CAJA? In our experience, a competent translator like Minor can be very helpful. So, the answer is "yes".

Interesting Stuff That Happens To Us

We are quite fortunate because Costa Ricas always seem to be helping us out when we get stuck. I think it is in their very nature to be kind and helpful.

Recently I received a parking ticket. Parking in our town of Grecia is a system called elPark. You pull into a numbered parking spot, pull up the elPark app on your phone, enter the stall number, the minutes/hours you want to park for, and pay for the time on the phone (using a preauthorized credit card number). Then I get an email from elPark with my parking details.

The ticket was incorrect and I had the emails to prove it so off we went to City Hall. The guard at the front gave me a ticket to see an agent and I guess it was a ticket for old people because I went right to the front of the line in a crowded room of folks waiting to see an agent. The agent looked through my paperwork then directed us out of the room and down somewhere else. We couldn’t find “somewhere else” in the building. In consultation with the building guards, a Costa Rican came to our rescue! 

This shaven haired, very muscular and tall man indicated we should follow him. We walked and walked - I whispered to Lance that we were following a complete stranger to who knows where. Into the Mercado Municipal de Grecia we went (a huge indoor market in the middle of town). Past all the fruit, vegetable and meat venders to a set of stairs. Up we went - turns out it was the office of elPark so our stranger knew exactly where to take us. We thanked him and my ticket got sorted out.

Another example: we recently renewed our cedulas (residency ID cards, everybody has one) and had to wait for them to arrive - they expired on March 29. Since our association with the CCSS (socialized medical system here - if you have residency you must join) expired on the same date, we had to reassociate with the CCSS. This meant taking our new cedulas and all associated paperwork to the affiliation wicket in the CCSS medical clinic building in Grecia. You sit (or stand if there are no chairs) at the end of the line and wait. On this day, we waited three hours but I’ve heard of longer and shorter wait times. Finally our turn came but it quickly became apparent that we were totally at sea what with the ambient noise around us and the rapid fire Spanish from the clerk.

To our rescue! Costa Ricans! One lady in the lineup saw our predicament and sent her husband over to help us. He was bilingual so thanks to him we got through it all. It’s nerve wracking because you never know if you have all the correct paperwork and if you don’t, away you go to get it and come back and line up again. We were asked if we were married and thankfully I had our Costa Rican marriage license with us. There’s a reason why we remarried in Costa Rica. I won’t go into it here but I did a blog post on it a few years ago.

Turns out our rescuers are also our neighbours - they live not far from us in the same complex. They rescued us a second time, the very next day. Now that we were reassociated with the CCSS, we went to our newly assigned Puente de Piedra Ebais so I could make a doctor appointment. We had been told to be there at 0800 but the receptionist was telling everyone to come back at 0900 the same day. Our angels somehow talked the receptionist into giving me an appointment for the next day right then and there.

The next day, back at our Ebais clinic and waiting to be called by the nurse and then the doctor. The Costa Rican lady next to me started to chat, in English! She showed me photos of her husband and children. We traded names and phone numbers and it turns out she lives not far from us. She even went into the nurse’s office when my name was called, saying “venga, venga” to me (“come on, come on”) like they do when calling little kids. She stayed and translated for me which was a blessing because there were lots of questions about my medical history. We had some good laughs when none of us could make ourselves understood - pointing at private parts and so on. You will always see a nurse first before the doctor - they take your height, weight and blood pressure. Everything is entered into the computer system and the doctor pulls the same info up on his computer.

Fortunately, the doctor was bilingual.

The Puente de Piedra Ebais clinic is much larger and more modern then the Barrio Jesus clinic we were assigned to when we lived in Atenas. The nurse and doctor offices are large and the nurse has an electronic blood pressure machine and electronic scales, not what they have in B. Jesus. It’s also very close to our house - a five minute drive. Grecia has its own hospital - Hospital San Francisco de Asis. 

Navigating the Public Medical Care System (CAJA) at the San Rafael Hospital

I apologize for the length of this post, but I wanted to give as much detail as possible to help others who find themselves in the same position.

I recently wrote a post about how we joined MediSmart and the specialist I went to see. This was regarding a reddish patch of skin on my lower back which I had been living with for several years - first in Canada, then ongoing in Costa Rica.

In Canada, a doctor I had at the time (before 2011) took a look and basically said that it was just a sign of aging. After about four years in Costa Rica with the patch still there, I decided to have our CAJA doctor (a general practitioner) take a look (then 2015). She thought it might be some kind of fungus and directed skin scrapings to be taken and analyzed. When nothing of particular concern was indicated by the analysis, she prescribed a popular skin cream called "Crema de Rosas" and Betametasona (a steroid medication).  I used both for over two years, but the patch lingered on. However, when a new CAJA doctor arrived on the scene (also a general practitioner), I pointed out to him that the treatment did not seem to be doing anything and expressed maybe I should see a dermatologist. He agreed.

Then, the only question was whether to get an appointment with a dermatologist in CAJA or a dermatologist in the private system. I elected for the private system (in this case MediSmart) because first time appointments with a specialist in CAJA can sometimes be long delayed.

Five days after I saw the MediSmart doctor (October 30), he emailed his diagnosis and lab report to me. It was a non-malignant skin cancer confined to the top layer of the skin. He said that it could be removed with minor day surgery - that he could do it under MediSmart or that I could also have it done through CAJA. I decided to check how long it would take CAJA to move forward given the head start report provided by the MediSmart doctor. Not long.

On November 1st, I had an appointment with my regular CAJA doctor, showed him the Medismart diagnosis, and who then issued me a referral for a dermatologist at the hospital assigned to us when we first joined CAJA - the Hospital San Rafael  in Alajuela.

Here is where the fun begins:

In the CAJA system, a "referral" is not an "appointment". It merely opens the door to get an appointment. On November 3rd, I took the referral to the hospital, the purpose being to have a dermatologist assigned to my case and an appointment with that doctor. At the main door of the hospital, a guard looked at the referral and directed us (Lance and I) to reception on the 4th floor. There, there were three reception windows with three clerks and long line ups at each.

It was by no means clear which window was appropriate. But, a prominent sign in front of the third window (as you walk in) listing "Dermatología" and a number of other specialities suggested that window was the right one. A similar sign listing still more specialities was in front of the first window. No signage was in front of the second window.

Logic dictated that we should be in the third window line up.  But, after dwelling in that line up for a period of time, a really nice lady thinking - and rightly so - that we might not understand the system looked at my referral, determined that I was in the wrong line up, and directed us to the second window line up. So we moved from the middle of the third window line up to the end of the second window line up. Once at the second window, I presented my referral and was quickly assigned to a dermatologist and given an appointment with that doctor for four days later (November 7th).

We subsequently learned that the line up at the first window was a line up for able bodied people to get an appointment; the line up at the second window was a line up for preferred service to get an appointment (pregnant, disabled, mothers with babies, and seniors like myself); and the line up at the third window was a line up for people showing up on the day of their appointment. 

With the appointment in hand, was I all set? Not on your life - there was another line up to come. This was a new case, so the case had to be opened and a file had to be created. With a first appointment in hand, this requires the patient to retreat to the main floor of the hospital and get in the appropriate line up at the "Plataforma de Servicios" (Services Platform). There, a clerk reviews the appointment, checks out information on a computer (e.g. are you up to date with CAJA payments) and enters new information. If everything is in order, he or she opens a file and puts a number of print outs in a file folder. Unfortunately, we did not know any of this on the day I got my first appointment for November 7th. We simply went home with the appointment.

For my first appointment, we were told to be at the 4th floor reception area at 1030 for an 1100 appointment. The hospital is about a 50 to 60 minute bus ride from Atenas so we opted to catch the 0800 bus from Atenas. At the Alajuela bus depot it was a short taxi ride to the hospital. We arrived at reception an hour early. My appointment paperwork was processed quite quickly, BUT I did not have a file! We were sent down to the Plataforma to get a file.

At the Plataforma, I grabbed a number from a ticket machine and we sat and waited. The numbers were not moving very fast. I got the bright idea to get a special number for the preferred service line up. Mistake! It must have been new baby registration day because there were several babies and it took ages to create files for them. I should have stayed in the regular line. The numbers you get for the preferred line are not the same as those from the ticket machine which are flashed out on a wall screen. They are obtained by walking up to one of the clerks and asking for a preferred number card. Apparently, it seems OK to interrupt and do that when the clerk is trying to deal with somebody else. With the card in hand, you then have to listen very carefully for the number to be called (and obviously have to recognize the number when spoken in Spanish). 

By the time my number was called, my 1100 am appointment was long gone. But, my file was eventually created and we headed back up to the 4th floor. The reception clerk saw me, waved me in ahead of others, put the file in order and directed me to a waiting area elsewhere on the 4th floor. It didn’t take long to see the doctor (in Spanish "doctora" as it turned out).

Events may have unfolded differently had I tried to get the file opened on the same day that I got the first appointment. I don't know which, but I expect that the file either would have been handed to me with instructions to deliver it up to 4th floor reception before leaving the hospital or would have been kept and routinely delivered by some internal office procedure.

The doctora set an appointment for the next day for what I thought was going to be a minor procedure to confirm the MediSmart diagnosis. I started to have my doubts about this when I was told to put on a gown, booties and a head covering and directed to an operating room where my doctora and two nurses waited. About an hour and a half later, the reddish patch was gone and I was on my way with stitches and a dressing on my back. I had several prescriptions to fill at the hospital farmacia but was told it would take two hours so we left them there and opted to take a taxi home instead of a bus.

Which meant we had to return the next day to pick them up! In hindsight, I should have tried to have them filled at our Atenas clinic farmacia. Live and learn.

My next appointment was scheduled for five days later. This turned into a bit of a fuster-cluck because my file was placed in the wrong consulting office. After patiently waiting (no pun intended) about five hours, we finally told a reception lady that there was no doctor. She was on the phone immediately, we were given a different room number to go to and I saw the doctora right away.

I have two more appointments the last week of November.

Hospital San Rafael is large and modern. The medical staff are excellent, but the administrative system might be deserving of some scrutiny. Go there with a lot of patience as there are lineups for everything. If you have never been there before, it might be a good idea to bring somebody with you who not only knows Spanish but also knows the CAJA system. Parking is very limited. So, if you are going to drive to Alajuela instead of taking a bus, I suggest parking at the Juan Santamaria International Airport or at the City Mall Shopping Center, and taxing to the hospital - it’s not very far from either place. 

At every visit, Costa Ricans helped us out when we were stuck - wonderful people.

I expect that the system is not much different at other CAJA hospitals.

______________________________________

the San Rafael Hospital 

Medical Care in Costa Rica

We recently signed up for MediSmart, a prepaid discount medical plan. At a low yearly cost of $173 USD for the both of us, we have access to quality private health care. Specialists, x-rays, lab work, hospital rooms and operating room times offer us 40% to 80% savings on medical services. There are no exclusions for age or pre-existing conditions.

My ID card - note the mixed up names!

We also belong to Costa Rica’s socialized medical system, known as Caja (which I’ve discussed in earlier posts). We use it regularly. However, there are times when we want to see a specialist without having to wait. Last week, we went to our first appointment with MediSmart. I had made the appointment on line. The web site has an English version so very easy to navigate. I indicated which specialty I wanted and up popped a list of the appropriate doctors with their bios and photos. You can indicate which time of day you want your appointment for, if you want to see a particular doctor and if you want Spanish or English speaking. The next day I received an email with a selected doctor’s name, the date of the appointment and two appointment times I could select from. I just had to select the time I wanted and send back an email.

We took the bus to the Coca Cola bus terminal in San José, planning to take a taxi from there to Hospital Metropolitano, where MediSmart is located. It was pouring rain when we got off the bus and we did not have an umbrella. We were right in front of the Mercado Central, San José’s largest indoor market, established in 1880. We were going to go in and look for umbrellas when, lo and behold, our Water Guy appeared. He’s the fellow that has sodas, water, and snacks for sale at the bus station. He will also make sure you get on the correct bus, load your purchases into the bus cargo bay, and find you a good seat on the bus. He speaks Spanish, English and (I think) French.

We told him we needed an umbrella and he said, “Follow me”. Into the market we went, and he took us to a stall where we purchased an excellent quality paraguas. Then off we went to Hospital Metropolitano. My doctor was on the third floor and I didn’t have to wait long to see him. Total cost for a consultation with a specialist, a bit of minor surgery and lab work was 90,000 colones, about $180 USD. He will also be emailing me the lab work results. If anything further needs to be done, I can take his paperwork to my Caja doctor and have it done through Caja or go back to the MediSmart doctor.

For us, we like having two medical care options. MediSmart is worth looking into.

Living Legal in Costa Rica - Part III

When we arrived in Costa Rica, we had valid driver's licenses from British Columbia, Canada. To obtain Costa Rica licenses, all we had to do was present our unexpired foreign licenses and some papers (passports and verification that we had applied for residency status), pass low threshold medical and eye examinations, and pay the piper within 90 days from our date of arrival. Fortunately, we did so in a timely manner because the law changed a short time later.

Now, the rule seems to be that you must have residency status in Costa Rica before you can obtain a Costa Rica driver's license based upon a foreign driver's license. The problem is that it often can take upwards of a year or more to have a residency application approved. In the meantime, your foreign license will be recognized for only 90 days from your latest date of entry into Costa Rica as it appears stamped in your passport. So, for those caught by the new law and wanting to drive in Costa Rica, it may be necessary to periodically leave the country (to Nicaragua, Panama or wherever) and return the next day (or whenever) merely to get a new latest date of entry into Costa Rica – and then to be good for up to another 90 days. Or, you may choose to rely on the bus system and taxis.

Recently, the time came when our original Costa Rican drivers' licenses had to be renewed. In fact, they had expired but expiry has no effect on renewal. The only consequence is the obvious one – you cannot or you had better not drive. You certainly will not be able to rent a car as we do from time to time.

The first step in the renewal process was for each of us to obtain a medical exam and "dictamen médico digital" (digital medical opinion). For this, we went to Dra. F. Elena Arias (tel. no. 8336-6475) who has a private practice in Atenas – the town where we live.

The exams were little more than taking blood pressure, measuring height and weight and heart rate, and asking a few questions (any drugs, etc.?). We were in and out within a half hour. A good part of the doctor's time was spent entering our identities and exam results into a computer and transmitting the information to a database (SEDIMEC) which appears to be operated under the umbrella of the College of Physicians and Surgeons of Costa Rica ("Colegio de Médicos y Cirujanos de Costa Rica"). Although Dra. Arias said we probably would not need them, she provided us with printouts headed "Comprobante Dictamen Médico" (Medical Opinion Proof), each containing an important code number so that authorities down the road could easily locate our information on the database if any question arose.

Costa Rica law requires that we be enrolled in the public medicare system (CAJA) and we are. Whether we might have obtained "dictamenes médico digital" through CAJA, I do not know. But, I seriously doubt it. Nevertheless, not being inclined to address the issue, we turned to the private system. The total cost for the two of us was ₡30000 (about USD $60.00).

The next step should have been to go to the Banco de Costa Rica, pay for the license renewals (₡5000 or about USD $10.00 each), and get receipts confirming the payments. But, early one morning, we instead went directly to "COSEVI" - the agency in Costa Rica which handles the issuance of drivers' licenses and license renewals.

COSEVI is an acronym for "Consejo de Seguridad Vial" or roughly "Road Safety Council" in English. In addition to its headquarters in La Uruca, it has several regional offices throughout the country where renewals can be obtained. The locations of these offices can be found here or, with Google Translate from Spanish to English, here. We chose the COSEVI location in Alajuela which is identified on the maps below.

From where we live in Atenas, Alajuela is a comfortable ride by bus on highway 3 to the interurban bus station "1" shown on the right hand map. Depending on traffic, the trip takes about 45 to 60 minutes. From the bus station, it is a 10 minute ride by taxi to COSEVI. By car from Atenas on highway 3, one should exit right on Calle 24 in Alajuela.

When we stepped out from our taxi at COSEVI, we were approached by a friendly traffic guide wearing road safety clothing. He spoke some English and basically asked if he could help. He then guided us to a guard at the main entry gate to COSEVI only to be informed by the guard that the "jefe" (pronounced hef-eh or "head" or "boss" in English) would not be there that day. He was needed in order to properly process renewal applications that needed to be linked to a cedula and not a passport. "Come back tomorrow at 8:00 a.m." was the message. Both the guard and the traffic guide looked truly sorry, but that's the way it was. So back to Atenas we went.

We returned at 8:00 a.m. the next day and were met by the same traffic guide who took us over to the same guard. We were then were told that unfortunately the "jefe" would not be available until at least 9:30. Again, both the traffic guide and the guard looked sorry. The traffic guide then asked if we would like a coffee. When we said sure, he walked us across the street to a nondescript shop offering coffee and various bottled beverages and seemingly nothing more – but there was more as we subsequently discovered. We left the shop after about 45 minutes and then marked time in the shade at the side of the street for another 45 minutes. The traffic guide gave us chairs to sit on.

It was about 10:00 a.m. before we sat down in front of the "jefe". He wanted to see our existing licenses and cédulas (ID cards) and he wanted to know our current residence. For the latter purpose, we simply gave him a copy of the latest electric bill. Although we had them with us, he did not ask to see our Medical Opinion Proof – so he obviously had no difficulty getting the required medical information from the SEDIMEC database. He asked some questions including whether we agreed to be organ donors. He spent a lot of time at his computer typing and producing a lot of documents each of which required signatures and dating and some of which also required hand printed full names and cédula numbers. I think we each had 7 documents to deal with – more than required to get our original drivers' licenses.

When we were done with the "jefe", we were directed to another office to have our photographs taken. Here we encountered a minor embarrassment. The lady in charge wanted to see receipts confirming that we had paid the required license renewal fees. Well, we had not and we had to leave – nothing more could be done. We had immediate visions of having to taxi to a Banco de Costa Rica branch in downtown Alajuela, then back, just to pay the fees – and who knows how long it might take to get a teller in the bank. When we went outside, we asked the friendly traffic guide for directions. He smiled, pointed across the street, and walked us back to the nondescript shop where we had had coffee earlier in the day. He spoke to the proprietor who then stood at a computer terminal, did a bit typing, and produced two receipts. Total cost: ₡5500 colones each - ₡5000 for the license fee plus a ₡500 colone commission.

We were back at the photographer's office within 10 minutes of having left. In another 15 minutes or so we were done with renewed driver's licenses in hand and good for the next 5 years.

By the way, the friendly traffic guide never asked or hinted, but we did give him a gratuity for his time and assistance. He also has cars on hand that can be rented to take a driver's test and, if you don't have the required safety equipment in the trunk of your car, he can rent you those items too.

 

 

 

 

 

 

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Using the CAJA on an Urgent Basis

CAJA = Costarricense de Seguro Social (aka Costa Rican Social Security)

EBAIS = Equipos Básicos de Atención Integral en Salud (Basic Teams of Global Healthcare)

Recently I had the misfortune of pinching a nerve in my lower back. Anyone who has experienced this knows how painful it can be. I put up with it for a few days before deciding it was time to see a doctor.

We taxied to the EBAIS clinic in Barrio Jesus. This is the clinic we were assigned to by the CAJA. It is the first step in the ladder of treatment.

If your Spanish is weak like ours, at least for dealing with medical problems, a good idea is to translate your problem from English into Spanish and print it out. Hand it to the receptionist and then the doctor - although our doctor speaks English.

I must have appeared to be in some significant pain because I was seen almost right away. The doctor wrote down my problem in my file and prescribed a pain relieving injection, muscle relaxants and anti-inflamatories - all STAT.

Another taxi ride into Atenas to the EBAIS clinic there to hand in the scripts at the prescription counter. You will need to show your carnet (medical card), proof that your CAJA is paid up to date (receipt) and your cedula (ID card). Then you sit and wait until your name is called to pick up the drugs. In the case of scripts for injections, these are filled at the prescription area and a nurse comes by regularly to pick them up. Your name will be called and you head into a small room for the shot. Neither Lance or myself heard my name being called but a young lady came to get me and I don't know how she knew who I was. Or maybe it was obvious - I guess we stand out because anyone can tell we are not Ticos.

So now we know how injections are dealt with and where we have to go. Every visit we learn something new. Although things seem confusing at first, it becomes clear that there is a smooth running system in place.

 

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Living Legal in Costa Rica - PART II continued

As indicated in my last post under "Living Legal in Costa Rica", both Lance and I now have our carnés (i.e. medicare ID cards) which allow free access to public health care services in Costa Rica. But, it is one thing to have a carné. It is quite another to start using it. To do so, you first have to introduce yourself to the system so that the EBAIS clinic to which you have been assigned by CAJA can meet you, open a file, and start keeping records of who you are and your medical history.

There are many EBAIS clinics located throughout the country. They are at the front line of the public health care system in Costa Rica. They provide basic non-emergent health care services such as quick fixes for minor complaints, prescribing drugs, and generally monitoring and keeping detailed records of each individual’s health. If attention is required which is beyond their capacity to provide, then part of their job is to make initial appointments and/or referrals for more intensive care and attention.

We have now introduced ourselves to the system, but not without some hiccups along the way.

With our new carnés in hand, we first went to the EBAIS clinic in Atenas. After all, this clinic occupies the same complex as the place where we got our carnés and the name "ATENAS" appears on the carnés.

Problem is that the carnés we received did not identify the EBAIS clinic in Atenas. Instead, they identified "A.S. ATENAS EBAIS B. JESUS". As later pointed out to us, this meant the EBAIS clinic in "Barrio Jesus". Arggh!

Note that Atenas (the town/city) is the capital of the canton of Atenas in the province of Alajuela, Costa Rica. Like Atenas (the town/city), Barrio Jesus is a community in the same canton. The name of Atenas as it appears on our carnés is probably a reference to the canton and not the town/city.

Walking into the EBAIS clinic in Atenas, there was a large waiting room, pharmacy windows, an area where you receive your carné, a glassed-in area which I have since found out is where you go to make appointments, a number of hallways and "no admittance" doors.

We were a bit confused about where we should go, so I asked a passing employee as best I could. She looked at our carnés and directed us down a hallway to a separate area - another waiting room with more service windows, doors and hallways. A helpful security guard pointed us to a window where a desk clerk takes your carné, fills out and stamps a form. Our completed forms were placed in a wall file outside a swinging door. In a short time, the forms were picked up. Then we waited.

Eventually my name was called. I went in through the swinging door to a nurse who took my blood pressure. Then I was sent to a doctor's office who coincidentally spoke some English. He first indicated that he worked under supervision and that he was not yet a fully qualified physician. Then he got to the important point - I was in an area where you go for emergencies! Not only that, he looked at my carné and said my EBAIS clinic was in Barrio Jesus, not Atenas.

Lance was up next so I went outside to wait. Not unsurprisingly, he came back with the same information.

Then, like an angel, along comes our friend and neighbor, Vera from Brazil, who speaks four languages that I know of (English, Portuguese, Spanish and German). She said, "What are you doing in emergency?" Don't know! She took me by the arm through the setup in Atenas and showed me where to make an appointment, how to use the pharmacy, where to go for blood tests, etc. Such valuable information - but not knowing that our assigned EBAIS was the clinic in Barrio Jesus.

Turns out that the Barrio Jesus EBAIS clinic is not that far from our house, closer than the Atenas clinic. So, a couple of days later, off we went by taxi to test the waters in Barrio Jesus. It was a very positive experience.

The Barrio Jesus clinic is plain and simple - nothing fancy but the job gets done. It has a waiting room with television, a records office, a doctor's office, a nurse's office, an examination room, and so on. We walked into the waiting room and a housekeeper who was cleaning the floor at the time directed us back to the window of a receptionist at the entrance. The receptionist took our carnés and, in hardly any time, we were cleared to go back to the waiting room. There was one person ahead of us.

My name was soon called and I went into the nurse's office. In my best baby Spanish, I said good morning, how are you, and I apologized for my limited Spanish ("mi español es poco"). Then I handed over a Spanish translation of why I was there. Doing this saves a lot of misunderstanding. She weighed me, measured my height and took my blood pressure and pulse. My very own file was opened.

Back to the waiting room and soon I went in to see the doctor. She outlined a treatment plan for me, she prescribed medications and is arranging for a mammogram, plus I was given a requisition for routine medical lab tests (blood workup, etc.). One note - CAJA does not necessarily use, or is able to access, medications available in Canada and the U.S. It is a socialized medical system and leans towards the use of less costly generic drugs when possible.

My appointment over, the housekeeper gestured me outside the waiting room - or so I thought. Actually, she was gesturing me back to the receptionist to get a follow up appointment with the clinic. Lance eventually came out from the doctor, also with a requisition for lab tests - his appointment likewise finished. We both have appointments in four months on the same day - very convenient. As we now understand the system, when you once visit your assigned EBAIS clinic, they will always provide a future appointment if only for routine monitoring - typically three or four months later.

Our next visit will be a breeze now that we know the procedures and protocol. We have been assigned Hospital San Rafael in Alajuela - that's where I'll go for my mammogram. It's also the next step up on the health care ladder.

All the staff at the Barrio Jesus clinic were women (except for the records clerk). Remarkably, the receptionist, the nurse, and the doctor all spoke at least some English.

A few days later, it was off to the CAJA in Atenas to have our prescriptions filled and to make an appointment for lab tests. At the pharmacy window, we stood in a small line to hand in our prescriptions and, most important, a receipt showing that monthly payments to CAJA were up to date. We were each handed a number and an estimated time when the prescriptions would be ready for pickup.

We then headed to another waiting room for lab tests. The receptionist there seemed to say that we were much too early for lab tests because our next appointments with the Barrio Jesus clinic were not until February and our doctor would want more current results. To make sure we understand, I'm going to ask a friend who uses CAJA.

Decided to go out for cold drinks while our prescriptions were being filled. There is a small soda next to the Cruz Roja (Red Cross) building beside CAJA and we enjoyed iced teas. I was wishing I had not already had breakfast because those cooks were turning out some great things - casadas, corn tortillas, scrambled eggs.

We went back to the CAJA pharmacy about an hour later, took a seat, and our names were called in a very short time. That was it .... prescriptions in hand and the mysteries of the CAJA and EBAIS clinics revealed to us!

Everything new and unfamiliar can seem intimidating at first. My initial instinct is to just jump in and see what happens - that is probably why we ended up in Emergency. Lance is more steady and thoughtful. Living in a foreign country is so interesting - we are always learning something.

 

 

 

 

 

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Living Legal in Costa Rica - PART II

Part I of this trilogy dealt with the overdue renewal of our cédulas (mandatory ID cards if you want to linger on in Costa Rica for more than 90 days at a time). This part deals with mandatory health insurance and, if you choose, utilizing the medical and other health services provided by CAJA Costarricense de Securo Social - "CAJA" for short.

As used here, CAJA is a reference to Costa Rica's public health care system. The services include not only medical care in the classic sense as provided by medical doctors and nurses but also dental care, providing prescribed pharmaceuticals, prescribing and providing eye glasses, hearing aids, prosthetics, etc. In the case of dental care, our understanding is that the services for adults are limited.

CAJA runs in parallel with various private health care systems which operate in Costa Rica. This is in contrast to some countries, including Canada, where legislators in their supposed wisdom have decided that competition between public and private health care systems is a bad thing.

Some people rely exclusively on private health care in Costa Rica. Others rely exclusively on CAJA. Still others rely on a mixture between the public and private sectors. However, whether or not one chooses to rely on CAJA, enrolment and monthly payments to CAJA are a mandatory component of "living legal" in Costa Rica.

Until recently, we relied exclusively on the private sector. However, two factors have motivated us to try CAJA. Firstly, the amount of our monthly payments to CAJA has increased substantially from when we first started making payments in 2012 (over 70%). Secondly, Sun Life Insurance in Canada has started to deny pharmaceutical claims because receipts provided by pharmacies in Costa Rica somehow do not measure up to indecipherable regulations which Sun Life declines to explain in a clear manner.

My CAJA carné. Stapled to it is a clinic appointment card.

Enrolment in CAJA is typically evidenced by an insurance card referred to as a "carné. There are carné Aseguado Directos for principal insured persons, or direct policy holders, and carné Aseguado Familiars for related family members.

When applying to renew our cédulas through Banco de Costa Rica (see my blog post on October 11, 2014) a question arose as to whether my husband should have his own "carné" We never thought so - and not having one did not impair his cédula renewal. Neverthess, we ultimately decided that he should have his own if only as a matter of convenience.

In the meantime, someone pointed out that my carné had expired. In fact, it had expired in October 2012 just three months after it was issued.

The expiry date is in the upper right hand corner box - "Válido hasta". It's just the card that expires. We were still covered under CAJA - as long as the monthly payments were up to date.

So now it was time to renew my carné and get one for Lance.

We knew we could not do this without the services of a translator and we used Mercedes, a wonderful young lady who lives in the Atenas area and is fluently bilingual.

We first went to the Atenas EBAIS (Equipos Básicos de Atención Integral en Salud), which is the health care clinic located beside Cruz Roja (the Red Cross building). Luis Cruz is the person who issues the carnés. He sits behind a window where all the patient files are kept. There is a bench to sit on and wait your turn at the window. We had Mercedes on my cell phone and she talked to Luis and translated for us. Luis issued me a new carné (expiring in 10 days because we were waiting for our new cédulas to arrive). He gave Lance an appointment for the following Monday at the Seguro Social building around the corner and told us what we needed to bring with us.

The following Monday, we met with Mercedes at the main Social Security office in Atenas and were issued some kind of confirmation number that we then took to Luis, along with the requested documents, and Lance was issued his own carné. Coincidently, that same morning our new cédulas had arrived at the correos so I too was then given a new carné, this time with a more reasonable expiry date of February, 2016 - the same as Lance's carné.

Having Mercedes along with us was invaluable, especially because she also seemed to be a friend of Luis - more to follow.

 

 

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Living Legal in Costa Rica - PART I

Foreign nationals like ourselves who wish to live in Costa Rica without having to leave the country every 90 days - or sometimes less - are obliged to have (or to have completed an application for) a government issued ID card commonly referred to as a "cédula" or as a "DIMEX", the latter being an acronym for "Documento de Identidad Migratorio para Extranjeros".

With fanfare, I first wrote about receiving our cédulas in my blog post on July 23, 2012. They had been issued on July 20, 2012. Recently, they were renewed. As indicated in the above snapshot of my own cédula, the headline is "RESIDENTE PENSIONADO COND RESTRINGIDA". This means that our right to live in Costa Rica is subject to conditions. Being in the "pensionado" category, one condition is an assured monthly income of at least $1,000 U.S. Usually, the assurance is in the form of a letter from a competent authority verifying a government pension. Another condition is being able to prove year-to-year that at least $12,000 is being converted from U.S. dollars to Costa Rican colones. When the each year begins and ends is a bit of a mystery. We took it to begin on the date our cédulas were issued - and that seems to have worked.

Coming from Canada, the conversion process is a bit painful not by reason of the amount but because we have to first buy U.S. dollars from a Canadian bank then sell the dollars to a Costa Rican bank, each bank taking its pound of flesh along the way. We figure that we are losing 8‑10% to the banks on foreign exchange, whereas those from the U.S. might be losing half that amount. I suppose those from France, Germany, the U.K., etc., are in the same position as ourselves.

Another condition is to enroll in CAJA, Costa Rica's public medical care system and to make monthly payments to CAJA based on income. Even if one elects not to use the public system and to rely exclusively on private hospital and medical care services which are available, one is still obliged - and rightly so - to contribute to CAJA.

When we received our cédulas in 2012, we cheerfully assumed that they were good for two years from the date of issue - and then would have to be renewed. Two years is a number which we had heard several times. We had in mind that we had until July 20, 2014 to renew.

WRONG! They expired in February. So off we went to our lawyer who advised us we would each need an affidavit explaining why we were late. The affidavits are in Spanish. The cost was $50.00 each.

The actual expiry date of a cedula is indicated on the bottom right of the card - "Vence" - with a date beside it. We never noticed that!

Our lawyer also advised that I then needed to get a new pension letter from my Canadian federal government pension people stating my monthly net income. A phone call to Ottawa started this wheel turning, but it took about three weeks for the actual letter to get into my hands. We then took the letter to the Canadian Embassy in San José for an official translation - only to have it rejected because there was no written signature. Fortunately, however, we were dealing with Michelle in the Consular Section and she was very helpful. We ended up making a conference telephone call from the Embassy to a pension officer in Ottawa and I was able to authorize my pension information to be made available to Michelle. She was then able to prepare a Spanish language letter on Embassy letterhead verifying the pension amount. The Embassy charge for all of this was 22,400 colones (about $41.00 U.S.).

Neither the affidavits nor the new pension letter would have been required had we renewed our cédulas in a timely manner.

The next step was to phone Banco de Costa Rica (BCR) and make an appointment. Their phone number is 900-00-34639. They offer an option to speak to an English speaking employee. We opted to go to the BCR in San Jose because it is easy to get there on a bus. BCR told us to bring along the following:

• Current passport and a copy of the information inside.
• Current cédula and copies of the front and back.
• A letter from our bank verifying the amount converted from U.S. dollars to Costa Rican colones. Special Note: We do not maintain bank accounts in Costa Rica because we have not sensed much need. All we have done is to keep bank teller receipts showing the conversions with my name and cédula number on them. They were organized with checklists for 2012, 2013 and 2014 so that they could be quickly inspected and checked off.
• Copy of marriage certificate.
• Current "Carné Asegurado Directo" and a copy. This is the card issued to you when you have joined the CAJA.
• Current receipt from CAJA showing you are paid up to date.
• We also had to bring our affidavits and the new pension letter.

The cost for renewal is $123 USD each and this can be paid in colones or U.S. dollars. We also had to pay 3,000 colones for each month we were overdue (for each of us). There was also a 3,500 colone charge (for each of us) for the correos (post office), which is where our new cédulas would be sent and, in our case, this was the correos in Atenas.

There was one glitch: Lance did not have his own carné from the CAJA and this caused some confusion with the BCR people. They seemed to suggest that it would be necessary to get some form of confirmation from CAJA that he was covered by CAJA and that it should be delivered directly to Immigracion and not via BCR. Necessary for what? At the end of our appointment with BCR, we were both told that our new cédulas would be available for pickup at the correos in two or three weeks - and so they were without any followup involving Immigracion.

In the meantime, we were a bit concerned about the situation with CAJA and took steps to obtain Lance’s own carné - but that is a different story.

 

 

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