Expat Health Insurance in Ecuador — Comparing Every Option So You Don't Overpay

Health insurance in Ecuador is one of those topics where every expat has a strong opinion, and half of them are based on outdated information. The landscape has genuinely changed in the last few years — IESS has improved in some ways and gotten worse in others, new private plans have entered the market, and international insurers have adjusted their Ecuador offerings.

This guide lays out every option available to you, with real prices, honest trade-offs, and the strategy most long-term expats end up using after they've been here a while.

The Four Approaches

Broadly, expats in Ecuador handle health insurance in one of four ways:

1. IESS only — Ecuador's public system
2. Ecuadorian private insurance — Local plans with local networks
3. International insurance — Global plans from big carriers
4. Self-pay (no insurance) — Pay cash for everything

Most experienced expats end up with a hybrid of options 1 and 4, or 1 and 2. We'll get to why.

Option 1: IESS (Instituto Ecuatoriano de Seguridad Social)

IESS is Ecuador's public social security system, and enrollment is mandatory for all visa holders. Even if you buy private insurance, you're still required to pay into IESS. So you might as well understand what you're getting.

Monthly cost: Approximately $85–$90/month (17.6% of the minimum wage, declared as a voluntary affiliate). You can declare higher income to increase contributions if you want, but most expats declare the minimum.

What it covers:

• General consultations
• Specialist visits (cardiology, orthopedics, oncology, etc.)
• Hospitalization and surgery
• Prescriptions (dispensed at IESS pharmacies)
• Lab work and imaging (X-rays, MRIs, CT scans, ultrasounds)
• Emergency care
• Pre-existing conditions — from day one after the waiting period
• Dental (basic — cleanings, extractions, fillings)
• Mental health (limited)

The waiting period: Coverage activates after your first three monthly payments. During those 90 days, you're paying in but can't use services. Emergency care is the exception — IESS hospitals will treat genuine emergencies regardless of contribution status.

The honest downsides:

• Wait times for non-emergency care are brutal. Getting a specialist appointment can take 2–6 months. An MRI might be scheduled 3–4 months out. If you need a non-urgent surgery, the wait can be 6–12 months.
• The system runs in Spanish. Doctors, nurses, receptionists, forms — everything is in Spanish. Some doctors in Quito and Cuenca speak some English, but don't count on it.
• You don't choose your doctor. IESS assigns you to a centro de salud (health center) based on your address. You see whoever is available. Want a specific specialist? You need a referral from your assigned general practitioner first, and then you get whoever has an opening.
• Bureaucracy is real. Lost paperwork, rescheduled appointments, confusing processes — this is government healthcare in a developing country. It works, but it tests your patience.

The honest upsides:

• Pre-existing conditions are covered. This alone makes IESS invaluable for expats with chronic conditions, cancer history, or other pre-existing issues that private insurers exclude or surcharge.
• Catastrophic coverage. If you're diagnosed with cancer, need open-heart surgery, or face any major medical event, IESS covers it at zero out-of-pocket cost. A cancer treatment that costs $200,000+ in the US is fully covered.
• Prescriptions are free when dispensed through IESS pharmacies. For expensive chronic medications (blood pressure, diabetes, thyroid), this saves hundreds per month.
• It never cancels. No lifetime limits, no age-out, no dropped coverage for making claims.

Best for: Retirees, anyone with pre-existing conditions, anyone who wants catastrophic coverage at a low fixed cost, and anyone who can tolerate the wait times for non-urgent care.

Option 2: Ecuadorian Private Insurance

These are local insurance companies with networks of Ecuadorian hospitals and clinics. They're significantly cheaper than international plans but limit you to care within Ecuador (and sometimes specific networks within Ecuador).

Ecuasanitas

Structure: HMO-style. You must use Ecuasanitas clinics and affiliated providers.

Monthly cost: $80–$150/month depending on age, plan tier, and deductible. A 45-year-old can expect $100–$130/month for a mid-tier plan.

Pros: Cheapest private option. Ecuasanitas has its own clinics in Quito, Guayaquil, Cuenca, and other major cities, which means shorter wait times than IESS and integrated record-keeping. Good for routine care — you can usually get a specialist appointment within 1–2 weeks.

Cons: Network is limited. If you're in a smaller city or rural area, access drops off. The Ecuasanitas clinics are functional, not luxurious. Pre-existing conditions have a 24-month waiting period on most plans. No coverage outside Ecuador.

Best for: Budget-conscious expats in major cities who want faster access than IESS for routine care.

Salud SA

Structure: PPO-style. Larger network of affiliated hospitals and clinics. You have more choice in providers.

Monthly cost: $150–$350/month depending on age and plan. A 50-year-old typically pays $180–$250/month for a comprehensive plan.

Pros: The most popular private option among expats, and for good reason. Wide network that includes most of the best private hospitals in Ecuador — Hospital Metropolitano and Hospital de los Valles in Quito, Clínica Santa Inés and Hospital Monte Sinaí in Cuenca, Hospital Clínica Alcívar in Guayaquil. Solid coverage for hospitalization, surgery, and specialist care. Wait times for specialists are typically 1–2 weeks.

Cons: Gets expensive as you age — premiums jump significantly at 60 and again at 65. Pre-existing conditions have waiting periods (12–24 months depending on the condition). Deductibles vary by plan ($200–$1,000).

Best for: Expats under 60 who want reliable private coverage with good hospital access and are willing to pay for it.

BMI (formerly BlueMedical)

Structure: Premium PPO. Access to the best hospitals in Ecuador plus coordination services.

Monthly cost: $180–$400/month. Higher than Salud SA, but the service level matches.

Pros: English-speaking coordinators who will help you navigate the system (huge for non-Spanish speakers). Access to top-tier hospitals. Some plans include limited international coverage for travel. Faster claims processing than most local insurers.

Cons: The most expensive local option. Still won't cover you internationally in any meaningful way. Premium increases with age are steep.

Best for: Expats who want premium local coverage with hand-holding in English.

Humana (SALUDSA)

Structure: PPO-style with multiple plan tiers.

Monthly cost: $120–$300/month depending on age and tier.

Pros: Well-established insurer. Competitive pricing in the mid-range. Good network in Quito and Guayaquil. Responsive customer service.

Cons: Network is thinner in Cuenca and smaller cities compared to Salud SA. Not as well-known in the expat community, so fewer English-speaking resources.

Best for: Expats in Quito or Guayaquil looking for mid-range private coverage.

Option 3: International Insurance

These are global health insurance plans from major international carriers. They cover you in Ecuador and in other countries. Premiums are significantly higher than local plans.

SafetyWing Nomad Insurance

Monthly cost: $45–$85/month depending on age.

What it is: Travel medical insurance designed for digital nomads and remote workers. It's technically travel insurance with health benefits, not a comprehensive health plan.

Pros: Cheapest international option. Easy online signup. Good for short-to-medium-term stays. Covers you in the US and other countries when traveling.

Cons: This is NOT a replacement for proper health insurance if you're living in Ecuador long-term. Coverage limits are relatively low ($250,000 lifetime). It doesn't cover routine care — only accidents and acute illness. Pre-existing conditions are excluded. It's designed for healthy people who are moving around, not settled residents.

Best for: Digital nomads passing through Ecuador for a few months, or as supplemental coverage for international travel alongside a local plan.

Cigna Global

Monthly cost: $200–$500/month depending on age, plan tier, and whether you include US coverage. Excluding US coverage drops the price significantly.

Pros: One of the most respected international health insurers. Comprehensive coverage worldwide. Large provider network. Excellent for expats who travel frequently or split time between countries. High coverage limits ($1M+).

Cons: Expensive. Claims process can be slow. You may need to pay out of pocket and get reimbursed rather than having direct billing at Ecuadorian hospitals.

Best for: Expats who travel internationally frequently, split time between Ecuador and another country, or want the security of a global insurer with high coverage limits.

GeoBlue (Xplorer plan)

Monthly cost: $150–$400/month depending on age and coverage level.

Pros: Backed by Blue Cross Blue Shield, which makes it particularly appealing for Americans. Good US network when visiting home. Strong coverage for evacuations and repatriation.

Cons: Similar to Cigna — expensive, potentially slow reimbursements for Ecuadorian care, may not have direct billing agreements with local hospitals.

Best for: American expats who visit the US regularly and want seamless coverage in both countries.

Option 4: Self-Pay (The "Go Naked" Approach)

A surprising number of long-term expats in Ecuador carry no private insurance at all. They rely on IESS for catastrophic coverage and pay cash for everything else. Given Ecuador's healthcare prices, this is more viable than it sounds.

Typical cash-pay costs in Ecuador:

Service	Cost
General doctor visit	$25–$50
Specialist visit	$40–$80
Blood panel (basic)	$15–$30
MRI	$150–$250
CT scan	$100–$200
X-ray	$15–$30
Dental cleaning	$25–$40
Dental crown	$150–$300
Knee replacement	$6,000–$12,000
Appendectomy	$2,000–$4,000
Normal childbirth (private hospital)	$1,500–$3,000
C-section (private hospital)	$2,500–$5,000

Compare those prices to what you'd pay in the US — even with insurance — and you start to understand why some expats skip private coverage.

The math: If you're 50 years old and healthy, private insurance costs $150–$300/month ($1,800–$3,600/year). If you average $500–$1,000/year in actual medical expenses paying cash, you're spending less than half what insurance costs. Even if you have a $5,000 emergency, you're still ahead over a few years.

The risk: The scenario where self-pay fails is a genuine catastrophe — cancer, a major accident, organ failure. A complex cancer treatment can run $50,000–$100,000+ even in Ecuador. This is exactly where IESS saves you. As long as you're enrolled in IESS and your contributions are current, catastrophic events are covered.

Best for: Healthy expats under 65 who are enrolled in IESS, have $10,000+ in accessible savings for medical emergencies, and are comfortable with the risk.

The Combo Strategy — What Most Long-Term Expats Actually Do

After a year or two in Ecuador, most expats land on some version of this:

IESS + Cash Pay for routine care = Best value for most people.

Here's the logic:

1. You're paying IESS regardless — it's mandatory. So the $85/month is already spent.
2. IESS handles catastrophic coverage — cancer, major surgery, hospitalization. This is where insurance actually matters, and IESS covers it.
3. Cash-pay handles routine care — A $40 doctor visit and $20 blood test are cheaper and faster than navigating IESS for non-urgent care, and dramatically cheaper than private insurance premiums.
4. IESS covers prescriptions — For chronic medications (blood pressure, thyroid, diabetes), IESS pharmacy dispensing saves $100–$400/month compared to paying retail.
5. No age penalty — Private insurance premiums skyrocket after 65. IESS stays at the same rate regardless of age.

The upgrade: If you're under 60 and want faster access to specialists and private hospitals without paying cash for everything, add a mid-tier Salud SA plan. The combo of IESS (catastrophic/prescriptions) + Salud SA (everything else) gives you comprehensive coverage for $250–$350/month total.

Pre-Existing Conditions — The Deciding Factor

If you have pre-existing conditions, this single factor may determine your entire strategy:

• IESS: Covers pre-existing conditions after the 90-day waiting period. No exclusions, no surcharges.
• Ecuadorian private insurance: Most plans exclude pre-existing conditions for 12–24 months. Some won't cover them at all. Diabetes, heart disease, cancer history — expect exclusions or waiting periods.
• International insurance: Varies by carrier. Some exclude pre-existing conditions entirely. Others cover them after a 12-month waiting period. Premiums may be significantly higher.
• Self-pay: You can always pay cash, but managing a chronic condition out of pocket adds up fast.

If you have a serious pre-existing condition, IESS is not just your best option — it may be your only realistic option for comprehensive coverage.

The Visa Angle

Most visa applications require proof of health insurance or IESS enrollment. This is a practical concern if you're in the application process:

• IESS enrollment satisfies the insurance requirement for all visa types.
• Private Ecuadorian insurance also satisfies it.
• International insurance is generally accepted but check with your visa advisor — some consulates want to see a policy with specific Ecuador coverage language.

If you're applying for a visa through EcuaPass, they'll advise on exactly which insurance documentation you need for your specific visa type.

Making Your Decision

Here's the quick decision tree:

You're under 50, healthy, no pre-existing conditions: IESS (mandatory) + cash pay for routine care. Consider Salud SA if you want peace of mind.

You're 50–65, some health concerns: IESS + Salud SA or BMI. The private plan handles the routine care and specialist access you'll increasingly need. IESS backstops catastrophic events.

You're over 65: IESS is your anchor. Private insurance premiums at this age are steep ($300–$500+/month) and rising annually. IESS + cash pay is the most sustainable long-term strategy. Supplement with Ecuasanitas if you want a safety net for non-IESS care.

You have serious pre-existing conditions (any age): IESS is critical. Make it your primary coverage. Supplement with cash pay or a private plan for convenience, but IESS is your lifeline for the conditions private insurers won't touch.

You travel internationally frequently: Add Cigna Global or GeoBlue on top of IESS. The international plan covers you abroad; IESS covers you at home.

You're a nomad/short-term: SafetyWing for now, but switch to a local strategy if you stay past 6 months.

Final Notes

Don't overthink this. Healthcare in Ecuador is genuinely affordable, and between IESS and cash-pay, you're covered for the vast majority of medical situations at a fraction of what you'd spend in the US. The insurance decision is about comfort level with risk, not about access to care. You'll have access regardless. The question is just who pays the bill.

Start with IESS — you have to anyway. Evaluate your actual medical usage after 6 months. Then decide if a private plan is worth the premium. Most people find it isn't.