Healthcare Reimbursement in Ecuador: Who Reimburses What, Depending on Your Situation

CLEISS publishes sheets for the countries bound to France by a social security agreement: Ecuador does not appear among them. In practice, France and Ecuador do not coordinate their schemes: no card giving access to care in both countries, no totalisation of insurance periods, no cross-coverage. ameli.fr (the Assurance Maladie website) reminds readers that a worker expatriated outside the European Union necessarily comes under the scheme of the country of work, which reimburses their medical costs, and that they are advised to find out about the local system and, depending on the likely care, to take out a specific contract.

Four players can come into play: the Ecuadorian scheme (IESS), the French scheme kept in place (secondment outside an agreement), the CFE and international health insurance. The notions of reimbursement base and out-of-pocket cost help you compare. The local organisation is described on the page on the healthcare system in Ecuador.

Employee on a local contract. They are affiliated to the IESS by their employer, with a contribution of 20.60% in total, of which 9.45% is payable by them. They become entitled to care after three months of continuous contributions, work accidents being covered from the first day. Their dependants are their children under 18 and their spouse or partner. See the notion of a local contract.

Seconded employee. In a country without an agreement, the seconded employee remains affiliated to the French scheme for three years, renewable once. They are covered up to the benefits they would have received for the same care in France: they send their fund the paid invoices with form S 3125c, their dependants who accompany them follow the same procedure, and those who stayed in France turn to the affiliation fund. A sick-leave certificate must be declared within 48 hours. Supplementary cover can be taken out if care is expensive locally. See seconded worker.

Self-employed. A resident self-employed person holding a visa can affiliate voluntarily to the IESS with their RUC, for the same sickness and maternity benefits as compulsory members, or join the CFE (which covers sickness-maternity for a self-employed person) or take out international insurance.

Retiree. The S1 form, reserved for residents of the European Union, the EEA, Switzerland and the United Kingdom, does not apply. The retiree residence visa requires national or foreign health insurance valid for the duration of the visa and covering Ecuador; the retiree chooses between voluntary affiliation to the IESS, the CFE and international insurance. During a temporary stay in France, they are reimbursed for their care if they draw a pension from a basic scheme based on at least 15 years of insurance and have no activity; the spouse who accompanies them is not covered (CLEISS).

Student. In the absence of an agreement, CLEISS indicates that, for a stay of under six months, the French fund may reimburse unforeseen care on a flat-rate basis, on an optional basis and after the costs have been advanced. Beyond six months, a student over 20 is no longer covered by French health insurance and takes out cover locally, with the CFE or a private insurer. See student insurance abroad.

Spouse and children. They are IESS dependants (children under 18; spouse with a 3.41% premium under voluntary affiliation) or remain under the French scheme if they accompany a seconded worker. See expat family insurance.

Tourist (90 days over twelve months). France Diplomatie strongly recommends assistance or insurance covering all medical costs, private hospitalisation being very expensive; any insurance requirement for the Galápagos should be checked with the archipelago’s authorities before departure.

The CFE offers its main offer (aged 30 and over), its youth offer (under 30) and a retiree offer, each with a contribution that depends on age and the plan chosen, with no health questionnaire. Cover is immediate if you join before departure or within three months of settling; otherwise the waiting period is three months before age 44 and six months beyond age 45. Abroad, reimbursement depends on the country of care and the procedure, with a rate or a flat amount applied to the actual expense; maternity requires conception after joining. See CFE contributions.

First-euro insurance reimburses actual costs within the contract’s ceilings, with direct payment to the establishment possible, which limits the advance of the required deposit; excesses, waiting periods and exclusions determine the out-of-pocket cost. See first euro.

Return to France. A CFE member with no activity in France keeps their rights for up to three months after returning; they affiliate to the CPAM of their place of residence with form S1106. An employee taking up a contract in France has rights from the start. In the absence of an agreement with Ecuador, the lifting of the waiting period cannot rely on an agreement; it is confirmed with the CPAM. See return-to-France insurance.

• Consultation: covered by the IESS for a member; payable by the patient in the private sector unless covered by a contract; reimbursed under French legislation within the limit of benefits for a seconded worker; according to the CFE’s country scale.
• Hospitalisation: IESS network for a member; in the private sector, a deposit is always required on admission (France Diplomatie), which makes direct payment useful.
• Medicines: according to the list and availability of the local scheme for a member; reimbursed according to the CFE’s scales or the ceilings of an international contract.
• Dental: the extent of IESS cover is checked with the institute; the CFE and international contracts apply their own ceilings.
• Optical: mainly a matter for international contracts, with ceilings per period to be read in the benefits table.
• Maternity: covered by the IESS for members, including under voluntary affiliation; the CFE requires conception after joining; international contracts generally apply a waiting period.

The reimbursement guide and the page on expat health insurance give benchmarks; Expavy helps you weigh these options against your situation.