Getting health insurance in Spain: A complete guide

Healthcare isn’t usually straightforward and when you add insurance into the mix, it gets even more complicated. When you’re headed to a new country, there are going to be new rules, new regulations and new forms to fill out before you can receive treatment.

If you’re headed to Spain, you’re in luck: they have one of the best public healthcare systems in the world. But just because they have a strong public health system doesn’t mean you can’t or shouldn’t get insurance. Whether you’re packing up to move or have already settled in, this article will help you understand how to access and use health insurance while living in Spain.

What kind of healthcare system does Spain have?

Spain is known for having one of the top healthcare systems in the world. The country has a universal healthcare system and also offers private insurance options for those who want to expand their coverage. The overwhelming majority of Spaniards and expats use the public Spanish National Health System (SNS, which stands for Sistema Nacional de Salud)

SNS doesn’t cover every health expense though. For example, ambulances, dentists and pharmacy costs are additional out-of-pocket expenses, where individual payments are used to supplement the full price of the services.

Private insurance can be an alternative to cover these added expenses, but it's good to keep in mind that the insurance company will often limit the list of services that are available and also have a list of prefered care providers you can visit. Make sure to check with your insurance company about this before you visit a specialist.

People sometimes turn to private insurers because there's some concern about the lengthy wait times to see public health providers. Still, by all accounts and comparisons, the public Spanish healthcare system is robust and high-quality. This are some average wait times for procedures in Spain:

Procedure	Average wait time in Spain
Seeing a specialist	65 days
Undergoing a special treatment (e.g., prostatectomy)	62 days
Hip replacement	123 days

Who needs to be covered by health insurance, by how much, and what’s actually covered?

Spain’s universal healthcare system, SNS, ensures that no citizen or long-term resident goes uninsured. Spain’s constitution actually requires that the state provides medical care for all basic and preventative care.

For European travelers, the European Health Insurance Card (EHIC) will enable you to access the necessary SNS healthcare in Spain at a reduced cost, or sometimes for free if you’re on a temporary stay. Once you plan on staying in Spain for a long-term basis, you should register for their SNS coverage or purchase private insurance.

If you’re a visitor, remember that all non-EU or UK travelers (US and Canada) should already have valid health insurance coverage prior to obtaining a residency visa.

How long can I be uncovered by health insurance?

Because Spain’s health insurance system is considered universal, there are no citizens or long-term residents without access to emergency health care. All foreigners and citizens have a right to be served for emergency or urgent treatment in Spanish hospitals, no matter your insurance coverage or whether or not you have a general practitioner.

EU residents can have free healthcare for the first three months under their EHIC. After that, you’ll need to look into either private insurance or registering for the public option. You can register into the public option by starting to contribute to the social security system.

Cautious travelers are always welcome to purchase travel insurance. Having travel insurance will protect you in the event of an emergency. These plans can be tailored to your needs, so if you’re just visiting for school or vacation, they may work out to be your cheapest and most risk-free option.

Are there any penalties for not being covered by medical insurance?

While there's always access to healthcare for all Spanish citizens and residents, not having the right coverage can cause some delays in needed services. For example, some providers may not serve long-term stay foreigners who have yet to transition from their EHIC coverage to Spain’s universal SNS coverage. Additionally, there's a distinction between private doctors and health centres versus public facilities. Only the public facilities will provide free care; the private providers will add extra fees if you don’t have the correct insurance.

Private or public health insurance, which should I choose?

Private insurance

Because of Spain’s widely recognised free and universal healthcare coverage, not many citizens or long-term residents use private insurance. However, the coverage can be helpful for those with special health needs, to aid in additional coverage with prescription drugs, for dental care, or for expats who don’t qualify for the public healthcare (for instance when you don’t work or haven’t reached the retirement age yet).

The largest providers are called Sanitas, Adeslas, and Asisa. If you have a job in Spain, they might offer you access to a private insurance scheme as a benefit. If not, you can always purchase private insurance as a top-up to the public scheme. With private insurance, you need to be careful that you’re using doctors and medical centres that are approved by the insurance company; otherwise, your insurance won’t be accepted.

Universal public insurance

All Spaniards have access to the country’s universal healthcare system, called the Spanish National Health System (SNS). The SNS covers most healthcare free of charge, or at least for a low cost. The system is nationally mandated, but each of Spain’s 17 regions or comunidades autonomas implements and executes the system on a local level.

Foreigners also have the right to access SNS services if they're working in Spain, are a visiting student under 26 from the EU, or over the retirement age.If you’re coming from a country that has universal healthcare, your country will sometimes pay Spain to cover you. For those over 60 from the UK, for example, you can fill out a Form E121 to facilitate this process.

HMOs

In Spain, you'd only have an HMO plan if you have foreign health insurance, and if you’re from a country that offers international HMO plans. With an HMO plan, your healthcare services are coordinated between yourself and a primary care physician.

What’s the average cost of health insurance?

Here are some plans and their expected costs:

Name / Type	Average Cost
Sanitas private health plan for an individual	€100 - €200 per month
Adeslas private health plan for individual	€164 per month
Asisa Integral private health plan for individual	€51.30 per month
Convenio Especial, pay-in public insurance (SNS)	€60 up to the age of 65, €157 for 65+

Private insurance is widely available and can be purchased easily online. Monthly premiums will depend on age, gender, and health needs. Spain also offers a special pay-in public insurance, Convenio Especial, for those ineligible for the free SNS coverage. This plan provides access to the state healthcare system for a monthly payment, and it covers all pre-existing medical conditions but does not cover prescriptions.

If you need to start paying for coverage before you arrive, you should consider signing up for a Wise borderless multi-currency account, which helps you receive and organise your money without crazy fees or exchange rates. There’s just a small fee charged when your money moves between currencies. You can send money to over 50 countries, and hold and manage money in 27 different currencies, including euros. This lets you avoid exchange rate movements and prep for future transfers. And from the beginning of 2018 you can even get a debit card connected to your borderless account as well.

Do I need to choose a family doctor / GP?

You can register as a resident at the local town hall with your social security number. Expect the paperwork to be in Spanish, so if you're not fluent you should bring along someone who is. Then, you'll be assigned a GP based on your location. It’s important to keep in mind that your registration must be three months old before you can be assigned a GP.

You won’t have a choice of GPs unless you have private insurance; then you’re free to choose a GP that falls under your network. Your GP will refer you to specialists if you need specialised treatment.

What about pre-existing conditions, are they covered?

Healthcare is a constitutional right in Spain, so you can’t be excluded from medical care based on pre-existing conditions. However, for major operations, there have been instances where people have been refused emergency treatment because the wait time for complex procedures is usually some months.

To make extra sure your pre-existing conditions will always be treated, it’s best to sign up for supplemental health insurance. Private medical companies vary in whether they choose to treat a pre-existing condition, just like in any country, so it’s a good idea to shop around for the best rates and plan for you.

If you aren’t covered by the state’s healthcare through your job or your residency, you can join the convenio especial. You’ll pay on a monthly basis for public healthcare access, regardless of any pre-existing conditions. The scheme will be managed according to the autonomous region where you’re living.

Are there any deductions I can make for medical expenses in my Spanish taxes?

In general, medical expenses aren't deducted from Spanish taxes. Pension contributions from work income are deductible for income taxes and you can eventually use those contributions on medical expenses. However, there’s no outright process for deducting medical procedures on Spanish taxes. Usually, your medical expenses will be inexpensive anyway.

How do I sign up for medical insurance?

To sign up for Spain’s public insurance, first you should register with social security at the Tesorería General de la Seguridad Social (TGSS). They have offices throughout Spain. Then, here are the steps you'll take:

• Gather your passport, residency certificate, proof of address and a completed application form to register for a doctor
• Take these documents to the TGSS and submit your application to receive a national insurance number
• Take your certificate, passport and national insurance number to a local health centre
• Register for the GP at your health centre
• Apply for your health card (tarjeta sanitaria individual or TSI)

The health card

You can receive your public health card, or TSI, by applying at your closest state health centre. It should arrive in the post a few business days after you applied for it. You’ll use it every time you visit a clinic or hospital, or pick up a prescription. Your TSI is valid for four years at a time.

Which insurance company should I choose?

Sanitas is the largest private health insurer in Spain. The following are prevalent insurance companies that you’ll find there:

• Sanitas Health Insurance in Spain
• Adeslas Insurance
• Asisa Insurance
• Expatriate Healthcare
• AXA PPP International Healthcare

You can also use the following websites to learn basic facts about your private health insurance options in Spain. These will help you make an educated decision about which company to go with:

• Spain made simple
• Acierto

How do I submit a claim to my insurance company?

In Spain, if you’re using private international insurance, your expenses are reimbursed according to Spanish rules. The claims submission process will vary based on your insurance and your treatment. If you’re going in for unplanned treatment, you may be asked to pay all costs upfront, and then claim reimbursement from your insurance company once you get home.

If your treatment is planned, you might pay a copay upfront and then be covered for the rest of your treatment. You also might receive an additional bill in the post, after the fact. Usually, you’re only allowed reimbursement for treatments that you’d be entitled to receive at home under your plan. Also, private insurance companies tend to reimburse only the cost of what the treatment would be in your home country. Often, claim submissions require triangulation between the hospital or medical centre, the insurance company, and yourself. Expect to spend some time on the phone with the insurance company to figure these things out.

Whether you’re an expat relocating to Spain or just visiting for a holiday, it’s always important to know how to access your health insurance. If a sudden emergency happens, thanks to Spain’s extensive universal coverage, you’ll always be able to receive quality care. Keep this guide in mind as you travel through Spain so you can have fun and stay healthy.