IESS vs Private Health Insurance in Ecuador: An Honest Guide

Healthcare in Ecuador is affordable. Choosing the right coverage is the hard part.

We've been helping expats navigate Ecuador's healthcare system for over 25 years. The most common question we get - after visa questions - is about health insurance. And the honest answer is that there's no single right choice. It depends on your age, your budget, your risk tolerance, and how much Spanish you speak.

Here's what we tell our clients.

Option 1: IESS (Ecuador's Public Social Security System)

IESS - the Instituto Ecuatoriano de Seguridad Social - is Ecuador's public healthcare system. As a legal resident, you can enroll through voluntary affiliation.

What It Costs

IESS contributions are 17.6% of your declared income. Based on the 2026 minimum base salary of $482, the minimum monthly contribution is roughly $84.83. But here's the catch: if your residency visa was granted based on a declared income of, say, $1,500/month, IESS may calculate your contribution on that figure - putting you at $264/month.

Adding a spouse costs an additional 3.41% of the contribution base.

What You Get

On paper, IESS coverage is generous:

• No copays, no deductibles. Medical costs covered at 100% within the IESS network.
• Pre-existing conditions covered after a 3-month waiting period.
• Dental care included.
• Prescription medications included (when available - more on that below).
• Hospitalization, surgery, and specialist care within the network.

What You Need to Enroll

• A cedula (Ecuadorian identity card), which means you need your residency visa first.
• No outstanding debts with IESS.
• Must be at least 18 years old.

The Problems - And We Need to Be Honest About These

IESS is in financial trouble. The institution has accumulated significant debts to hospitals and suppliers across the country. What that means in practice:

• Medication shortages are real. The IESS pharmacy regularly runs out of medications. You may be told to come back next week, or buy the medicine yourself at a private pharmacy. For ongoing prescriptions, this is a serious problem.
• Wait times are long. Specialist appointments can take weeks or months. Emergency room waits of 4 to 8 hours are reported regularly.
• Appointments get cancelled. Expats report that scheduled appointments are rescheduled without notice because of system problems or staffing shortages.
• The prescription cycle is frustrating. If your doctor needs to approve a refill but your appointment gets cancelled, you may wait months without access to your medication through IESS.
• Most IESS doctors speak only Spanish. If your Spanish is limited, miscommunication is a real risk in a medical setting.
• Policy changes hit without warning. IESS has changed contribution rates and rules for voluntary affiliates in the past, including recalculating fees based on visa-declared income rather than minimum wage. These changes tend to come suddenly.

None of this means IESS is useless. For catastrophic coverage - a major surgery, a long hospitalization, cancer treatment - having IESS as a backstop is valuable precisely because it has no coverage caps for care within its network. But relying on it as your only healthcare option is a gamble we don't recommend.

Option 2: Ecuadorian Private Insurance

Several domestic private insurance companies operate in Ecuador and are popular with expats.

Major Providers

• Saludsa (Salud S.A.) - Latin America's largest health insurer. Typically covers 80% of doctor visits, 60% of medications, and 100% of hospitalization.
• Ecuasanitas - Operates its own network of clinics. Popular for its predictable costs and clinic access.
• BMI - Approved by the government for visa applications. Their intermediate plan offers up to $100,000 in coverage, with deductibles ranging from $140 to $2,000.

What It Costs

Costs vary significantly by age, coverage tier, and deductible:

• Basic plans: Starting around $50-$80/month for younger enrollees.
• Mid-range plans: $100-$200/month for comprehensive coverage with moderate deductibles.
• Premium plans: $200-$300+/month for older enrollees or low-deductible plans.

A 60-year-old couple should budget $200-$400/month combined for decent private coverage.

Why Expats Like Private Insurance

• Same-day or next-day appointments at private clinics.
• Choose your own doctor. No referral chain required.
• English-speaking physicians are available at major private hospitals in Cuenca, including Hospital del Rio, Hospital Santa Ines, and Hospital Monte Sinai.
• Private clinic visits cost $25-$50 out of pocket, even without insurance. With insurance, your copay is often less.
• Medication is available. Private pharmacies are well-stocked.

What to Watch Out For

• Pre-existing condition exclusions. Unlike IESS, most private policies exclude pre-existing conditions or impose long waiting periods.
• Coverage caps. Many plans cap annual or lifetime benefits at $50,000-$100,000. A serious illness can exceed those limits.
• Age limits. Some providers won't issue new policies to applicants over 65 or 70.
• Annual increases. Premiums go up every year, and the increases can be steep as you age.

Option 3: International Insurance

If you want coverage that travels with you, international insurers are an option.

Providers to Look At

• Cigna Global - Plans starting around $150/month for basic coverage, averaging $460/month for comprehensive plans. Tiered options (Silver, Gold, Platinum) with optional add-ons.
• Pacific Prime - Broker that compares plans from multiple international insurers. Good for getting quotes.
• GeoBlue, Aetna International, Now Health - Other options worth comparing.

Pros and Cons

International plans give you worldwide coverage, which matters if you travel frequently or split time between countries. They often have higher coverage limits than Ecuadorian domestic plans. But they are significantly more expensive, and costs increase steeply with age. A comprehensive international plan for a 65-year-old can easily exceed $500-$800/month.

For most expats living full-time in Ecuador, domestic private insurance offers better value. International plans make more sense if you're a frequent traveler or if you want the option to seek treatment in the US or Europe.

The Combo Strategy: What Most Smart Expats Do

After 25 years of advising clients, here's what we see working best for most people:

IESS + a domestic private plan.

• Use IESS as your catastrophic safety net. If you're diagnosed with cancer, need major heart surgery, or face a long hospitalization, IESS covers it within its network with no caps, copays, or deductibles. That alone is worth the $85/month minimum.
• Use private insurance for everyday care. Doctor visits, specialist appointments, routine tests, prescriptions. You get seen quickly, you choose your doctor, and communication is easier.

This combination typically runs $150-$350/month total and gives you the best of both systems.

Why Not Just Private?

Because private plans have coverage caps. A $100,000 cap sounds like a lot until you need extended cancer treatment or a complex surgery with complications. IESS has no such cap for in-network care.

Why Not Just IESS?

Because when you need to see a doctor next week - not next month - and you need your prescription filled today, you need private access. Quality of life matters.

The Visa Requirement You Need to Know

Ecuador now requires proof of health insurance at the visa application stage. This applies to temporary and permanent residency visas, retirement visas, and even tourist visa extensions.

You can satisfy this requirement with:

• A domestic private insurance policy (BMI, Saludsa, and others are accepted).
• IESS affiliation (though you need a cedula first, creating a chicken-and-egg problem for new applicants - we help clients navigate this).
• An international health insurance policy with coverage in Ecuador.

This requirement is relatively new and enforcement varies. We handle the insurance documentation as part of our visa process so clients don't get tripped up.

What We Recommend for New Arrivals

1. Start with a domestic private policy before you arrive. BMI and Saludsa can issue policies that satisfy the visa requirement.
2. Enroll in IESS once you have your cedula. It takes a few months after visa approval. Start the process early.
3. Keep both for at least the first year. See how IESS works for you in practice. Some people find it works fine; others find the wait times unacceptable.
4. Budget $150-$300/month for healthcare between insurance premiums, copays, and out-of-pocket costs. That's still a fraction of what you'd pay in the US.

Costs Without Any Insurance

Even without insurance, Ecuador's private healthcare is affordable by North American standards:

• Doctor visit: $25-$50
• Specialist consultation: $40-$60
• Hospital room (semi-private): $30-$50/night
• Most procedures: 10-20% of equivalent US costs

Some expats - particularly healthy younger ones - choose to self-insure for routine care and carry only a catastrophic policy. That's a valid approach if you have savings to cover unexpected costs.

Bottom Line

There's no perfect health insurance option in Ecuador. IESS is cheap and comprehensive but slow and unreliable. Private insurance is fast and comfortable but has coverage limits and gets expensive with age. International insurance is the most robust but costs the most.

Most of our clients end up with IESS plus a domestic private plan. It's the best balance of cost, access, and protection.

The important thing is to make this decision with good information, not based on what someone in an expat Facebook group said six months ago. The rules change. The costs change. We keep up with all of it.

Keep reading:

• Health Insurance as a Visa Requirement in Ecuador
• Cuenca Cost of Living 2026
• Guide to Ecuador Residency

Have questions about health insurance options in Ecuador? Schedule a consultation or call 651-621-3652.