How does the state health insurance system work?
Around 90% of Spanish citizens are currently registered with the public healthcare system, which is considered to be of a high standard. The Ministry of Health oversees the whole healthcare system, which is devolved into regions. Spain currently spends around 9% of its GDP on healthcare.
Spanish citizens and permanent residents pay into the scheme through payroll deductions, if they are in employment. If you are self-employed, you can make your own contributions into the system: check with your local Social Security Office (Instituto Nacional de la Seguridad Social / INSS).
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Who is eligible for state healthcare?
The INSS is open to:
- anyone employed by another person, or self-employed workers who are affiliated and registered
- pensioners who are registered with the Social Security system
- recipients of any other periodic Social Security benefit, including unemployment benefit or allowance
- unemployed persons who have exhausted unemployment benefits and others of a similar nature, who do not have insured status on any other grounds, and who reside in Spain
- individuals who do not have mandatory health insurance by some other means and who may be vulnerable (check with the INSS to see if this applies to you)
- children in state care
- residents in Spain who are recently divorced or separated from a partner who is registered with social security
- children who are resident in Spain
- pregnant people who are resident in Spain
- anyone who is under 26 and studying in Spain
If you are an expat employed by a Spanish company, you will be automatically registered with the Spanish national health insurance scheme.
If you are from outside the EU, check to see if your home nation has a reciprocal healthcare agreement with Spain.
How do you apply to join the state health insurance system?
If you are coming in from the UK, you will need an S1 form, which you then need to present at your local INSS office, who will give you an accreditation letter. If you are unemployed, you will need to take your Spanish National Health System card with you to appointments, or provide documentary proof of your right to health cover by the British authorities.
You will need to register initially with Spanish social security (Dirección General de la Tesorería General de la Seguridad Social or TGSS), in order to obtain a social security number. To do this, you will need:
- your passport or ID
- your proof of residency
- proof that you have registered your address at your local town hall
Once you have registered your address, you will be given a certificate of registration (empadronamiento). You can then take your documents – including your social security number – to your local medical centre and they will sign you up. You will then be sent a health insurance card (tarjeta sanitaria individual or TSI). Note that you can choose your own GP and medical centre.
If you are British, not working, and not yet 65 (for example, if you are an early retiree) you may not be entitled to state healthcare and should take out private cover. Speak to the INSS to see if it is still possible to register you, however. For example, if you have been resident in Spain prior to April 2012 and earn below €100,000 per year, you will be entitled to public healthcare.
You can use an EHIC card up until the point where you gain residency, but not after this.
If you do not have an EHIC card, have been resident in Spain for at least a year, and are not covered by reciprocal benefits between Spain and the UK, you may be eligible in some regions of Spain for the government’s new pay-in discount scheme, Convenio Especial, which is aimed at low-income earners and which will allow you to access the state healthcare system for a monthly payment: €60 if you are under the age of 65 and €157 for those aged over 65. After 5 years you may be able to apply for permanent residency if you have been registered as a resident, and this will entail that you are entitled to national healthcare.
If you are self-employed (autónomo), and you earn above the Spanish minimum wage (€10,303 per year), you will need to make contributions into the system yourself: there is a state scheme specifically for the self-employed (régimen especial trabajadores autonómos). You will need to contact your local social security office about registration and subsequent contributions.
The entitlement to healthcare for both the insured person and their dependents begins on the day you sign up with the Social Security System and becomes activated on the day after you apply for active contributor status in the appropriate scheme.
What is covered by the state health insurance system?
Currently the INSS covers:
- Basic care services: prevention, diagnosis, rehabilitation and emergency health care. These are fully funded by public funds and are thus free at the point of delivery.
- Supplementary care services: outpatient care such as pharmaceuticals, orthotics and prosthetics, health products and non-emergency health transport. These are subject to a co-pay contribution by the user.
- Ancillary services: these are not classed as benefits and are considered as extra support for improving pathologies. These are subject to a contribution and/or reimbursement by the user.
Note that the INSS may also cover home visits by your GP, if you are disabled or elderly.
The Convenio covers a similar range of healthcare to the main scheme, including pre-existing conditions, but does not cover prescriptions. Under the INSS, you may have to make a co-payment for your prescriptions and this will depend on your income.
The INSS will cover around 40-60% of prescription costs (typically, if you are working, it is a 50-50 split). Pensioners pay around 10% of their medication costs and prescription costs are capped for pensioners at around €8-18 per month depending on their income. Medication tends overall to be cheaper in Spain, however, so you should not pay a great deal in out-of-pocket costs.
You will be able to claim sick pay benefits for up to a year (longer if your GP agrees), due to accident or illness, if you have been making contributions into the system for 180 days over the previous five years. You are entitled to 60% of the monthly contribution base for 20 days and 75% after this.
If you are pregnant and an employee or self-employed, and have been making contributions, you will be eligible for maternity pay (Permiso de la Maternidad). This will cover 100% of your average daily salary for 16 consecutive weeks up to the month when your maternity cover starts. Generally, you will need to have made 180 days’ worth of contributions in the past 7 years if you are over 26, but the amount varies depending on your age. Paternity cover on a similar basis is also available.
Note that you will need to make some co-payments even if you are covered by the national scheme. You may also choose to make out-of-pocket payments. The average cost of an emergency room visit is around €200 and the average cost of a doctor’s visit is around €100. An appointment with a specialist is around €150.
Are retirees covered by state medical insurance?
If you are over 65 and making contributions, or are covered by a reciprocal healthcare agreement between Spain and your home country, you will be covered under the state system. Note that the UK currently has such an agreement and this should continue after Brexit.
Are students covered by state medical insurance?
EU students will be covered by their EHIC cards. You may also be able to apply for a Spanish-issued EHIC, called a Tarjeta Sanitaria Europea (TSE).
If you are a UK citizen studying for a postgraduate degree, or an ERASMUS student in Spain, you will be covered under the reciprocal healthcare arrangement between the UK and Spain. This will be unaffected by Brexit.
If you are from outside the EU, you may need to have private health insurance before enrolling with your educational provider. Check with your university to see what level of insurance they require, and whether they recommend any specific providers.
Will your family be covered by your insurance?
Yes, your dependents will also be covered if you are registered with the Spanish national scheme. Your dependents include:
- spouse or life partner
- children of 26 years of age or under
- family members of any age who are disabled, provided that they are dependent on you and live with you
- your siblings
Is dental treatment covered by state health insurance?
The national scheme does not cover dental care except in emergencies, and you will either need to make out-of-pocket payments or take out dental insurance. Premiums for dental treatments can be as low as €10-20 per month.
What are the contribution rates for state health insurance?
Currently the contribution rates for overall social security are set at around 36%, the bulk of which is paid by employers: 6.35% for employees, dependent on the type of contract, and 29.90% for employers.
The levels of your contribution rate will depend on the type of work in which you are engaged: senior management, for instance, will have a monthly contribution base of around €1,153, whereas if you are at a lower administrative level, the base on which contribution percentages are calculated will be around €823. The maximum base on which contribution percentages are calculated is around €3,751 per month.
Note that only part of your contributions are put towards healthcare: they will also entitle you to a pension, injury or sickness benefit, and maternity cover.
Why buy private health insurance?
Most Spanish citizens use the public system, but some expats choose to take out private cover in order to access a quicker route to treatment and better facilities.
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What is covered by private health insurance?
Private health insurance will cover the full range of primary and secondary cover extended by the public health system, as well as more advanced dental treatment and elective surgery.
How much does private health insurance cost?
Numerous variables can have an impact on the cost of private health insurance in Spain.
The most important variables are:
- Age (the higher the more expensive)
- Area of cover (i.e. just Spain or other areas too? If those other areas include any of the US, the Caribbean, Singapore, China, Hong Kong or Dubai this can significantly increase the overall price)
- Product choice (higher end insurance products are more expensive)
Other variables include:
- Payment frequency
- Country of residence
As so many variables have an effect on the cost of international private medical insurance in Spain, it becomes very difficult to give accurate estimates without knowing the full details of the coverage required. However, as a very rough guide, using a standard profile of a 40-year-old British male with no deductibles, no co-insurance, a middle-tier plan, all modules included and worldwide coverage excluding the US, a ballpark price of around £4,000/$5,000 might be expected. Were coverage to be expanded to include the US then the premium could increase to almost double that amount.
Which companies offer private health insurance?
The main international providers cover Spain and if you are dividing your time between Spain and your host country (for example, the UK) and are not retired, you may wish to consider private insurance that covers both countries:
- Aetna Global
- ACA PPP
- Bupa Global
- Helicopteros Sanitarias (a local provider on the Costa del Sol who can arrange packages for international residents)
- Cigna Global
- Pacific Prime
Always request quotes from as many insurance providers as possible.
Glossary of health insurance terms
asistencia sanitaria pública - public healthcare
Convenio Especial - the government’s new pay-in discount scheme
Permiso de la Maternidad - maternity pay
privado - private cover
régimen especial trabajadores autonómos - a state scheme specifically for the self-employed
seguridad social/SNS - National Health System
tarjeta sanitaria individual / TSI - health insurance card