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To get the visa "D", which you need before you can apply for residency, you must purchase health insurance. My lawyer arranged it. Once I got the visa "D" and began the current process of applying for residency, I extended the coverage (through my lawyer) to run through the end of the one-year residency period for which I am applying. I haven't had occasion to use it yet. I believe you can also pay providers directly.

Before I got on the Bulgarian healthcare system I simply paid privately. I got the lowest healthcare insurance possible for the visa/residence permit (which is only extreme emergency coverage and expatriation of remains... basically not worth using) and paid out of pocket. A visit to the GP is generally 20 lev, a specialist 30-50 lev. Since I was in general good health, I did not find that overly much to pay. Dental I also paid out of pocket as it is not too expensive.

I had my first child here privately (at a private hospital and without insurance) and it cost 700 lev for the prenatal visits (including all screenings and ultrasound) then 1500 lev for the birth and four nights in the hospital (including an epidural and a private room with my husband staying).

So in short, until I got on the Bulgarian system, I paid everything out of pocket and did not find it overly expensive.

Thanks for the valuable information.