US citizen getting Health Insurance
and Healthcare in Spain

Payment

• National health cost coverage: Get a healthcare card (Tarjeta Sanitaria Individual; TSI).
  
  AKA "SIP card" (sistema de informacion poblacional, conselleria de sanitat).
  
  Only for workers or Spanish citizens or EU citizens, or those dependent or married or pareja de hecho with such a person. Have to have paid into an EU SS system to get SIP card. Must have a Spanish Social Security number (or SSN from another EU country). Must be on padron also, and have residency or DNI.
  
  July 2018: a big change to this, apparently. Everyone covered, no need to pay for Convenio Especial even if you're not a worker.
  Myra Cecilia Azzopardi's "Approval of Universal Healthcare July 27 2018"
  Myra Cecilia Azzopardi's "New Universal Healthcare Law July 27 2018 FAQs"
  BOE's "Real Decreto-ley 7/2018, de 27 de julio, sobre el acceso universal al Sistema Nacional de Salud"
  
  Entitles you to free healthcare. Does not cover dental (does cover emergency dental, tooth extractions, and children age 6-15 ?) or vision care or esthetics or provide hearing aids. Prescription coverage percentage depends on your income level. Does provide loaner wheelchairs.
  
  AngloINFO's "Healthcare Benefits and Health Cards"
  AngloINFO's "Health Insurance and Social Security"
  Love From Andalucia's "Tarjeta sanitaria"
  Benidorm Seriously's "The Spanish Health Care System"
  
  Expatica's "Going to the dentist in Spain"
  SpainMadeSimple's "Find Dentists In Spain - How Does Spanish Dental Care Work?"
  Tumbit's "How to Choose a Dentist in Spain"
  Richelle de Wit's "Dental Care Spanish Nhs For Pensioners?"
  Richelle de Wit's "Is There Free Dental Care For Children In Spain?"
  
  Tarjeta Sanitaria Europea (TSE):
  
  
  AKA European Health Insurance Card (EHIC).
  
  This is a temporary card that covers TSI-holders when they travel to other countries in Europe. Coverage varies a bit by country.
  
  If you are buying into the Spanish NHS through Convenio Especial, you have "second level" coverage and can't get a TSE.
  
  Apply online at INSS. In "Tipo de solicitud" section, you will choose if you need card only for the worker, for the worker plus their beneficiaries, or only for their beneficiaries. If doing worker plus beneficiaries, the "cuantos" field is the number of beneficiaries. You need to know the SS number for the worker, as well as their DNI or NIE. Card will come in the mail in a week or more. Card is valid for one or two years, maybe depending on region ?
  
  If you forgot to apply in time to receive the physical card before starting your travel, apply anyway and then the web page will allow you to download and print a provisional certificate which is good for up to 90 days.
  
  If you forgot to apply before starting your travel, and then fell ill in the other country, maybe you still could apply online and download and print a provisional certificate, and use it immediately.
  
  Spanish-Living's "Living in Spain and visiting abroad? - You need the TSE - Tarjeta Sanitaria Europea"
  Spanish Solutions' "EHICs - European Health Insurance Card in Spain"
  Smart Expat's "European Health Insurance Card (EHIC)"
  
  
  'Convenio especial' buy-in to public health system:
  
  

  • New circa 2014.
  • Up and running only in certain regions; 7 regions as of mid-2015.
  • Available after you've been resident for 1 year. Can't apply until the 1-year date. [But: it may take months to renew your residency card at the 1-year mark, so being able to apply for Convenio Especial right at the 1-year mark is unlikely. Although you might be able to use passport as ID.]
  • You pay a monthly fee to get access to the govt healthcare system.
  • No coverage for prescriptions.
  • No coverage when you travel to other European countries (no Tarjeta Sanitaria Europea, aka TSE).
  • Pre-existing conditions don't matter. This is a MAJOR advantage for some people, who can't get private insurance at a reasonable cost, or at all.
  • Age doesn't matter. This is a key point for some people, who can't get private insurance because they're over age 70 or some similar limit.
  • Not sure if you register with TGSS or INSS. One source says file Form TA-0040 with TGSS.
  • Full name of program is "convenio especial para asistencia sanitaria"; royal decree 576/2013. There is another "convenio especial" which is only for ex-workers or the disabled to keep contributing to the pension part of social security.

  
  From someone on "Expats in Spain" Facebook group 9/2014:

  > can buy into system for €250/month or something ?
  
  The €250 a month is what self-employed people pay (actually it's more than that), and goes for healthcare and towards a pension. In some areas there is the buy-in 'convenio especial', which is available after you've been a registered resident for 12 months and afaik is for all such residents regardless of nationality. It's currently €60 a month under 65 years of age and €157 over 65. It is planned to eventually be nationally available.

  
  Application form and application procedure are specific to each region; find the right form and instructions for your region.
  Myra Azzopardi Swainson's "How and Where Can I Apply to Purchase Healthcare ? (Convenio Especial)"
  
  Summarized from Servicio Andaluz de Salud's "Convenio Especial Para la Prestacion de Asistencia Sanitaria - Procedimiento - 03/09/2014":

  
  Requisitos:
  
  Must satisfy three requirements: resident for one year, on the padron, and not covered by another health system.
  
  Prestaciones:
  
  Convenio Especial grants a "cartera comun basica", which covers pre-existing conditions, prevention, diagnosis, treatment, rehabilitation, and urgent transport, to the same levels as the general public gets.
  
  It excludes "cartera comun suplementaria", which also would cover pharmacy, orthoprosthetics, dietetics, and non-urgent transport. Those things are covered (at various levels) for the general public.
  
  [I think neither plan covers dental (does cover check-ups and tooth extractions ?) or vision or hearing-aids.]
  
  Tramitacion:
  
  You apply at an administrative health center (probably not your local Centro de Salud).
  
  You supply three documents: ID, document showing residency for one year, and padron. In case of an EU citizen or Swiss citizen or citizen of a country with a bilateral Social Security treaty with Spain, you also provide certification that your home-country health system is not covering you.
  
  When you apply, your documents are reviewed. If some are lacking, you still can submit the application, and must submit the fixed documents within 10 days.
  
  After application and all documents are verified, the health service will respond within 30 days. If they don't respond, it is understood that you have been accepted, and the agreement is in effect.
  
  After you have been approved, you have to sign a form accepting the agreement. Then within 3 months, you must start paying the monthly fee, and send them a copy of the payment form for the first month. If you don't start paying, the agreement is terminated. [And I read somewhere: then you have to wait a year before you can re-apply.]
  
  Monthly fee is €60 if under 65 years old, or €157 if 65 years or older.
  
  The monthly fee is paid to a special health service bank account (IBAN is given in document). Your name must be specified with each payment.
  
  Health coverage starts from the day you make the first payment, not the day you signed.
  
  [From another document: the agreement is terminated if you fail to pay the first month, if you fail to pay any two months in a row, or if you fail to pay any three months alternating (miss 3 out of 6). And I read somewhere: then you have to wait a year before you can re-apply.]

  
  Eyeonspain's "New Healthcare Option for Those Without Cover"
  Myra Azzopardi Swainson's "How and Where Can I Apply to Purchase Healthcare ? (Convenio Especial)"
  Tamara Essex's "Back in the Arms of a Health Service"
  Learn-Aprender's "The Convenio Especial"
  Seguridad Social's "Normativa: Real Decreto 576/2013, de 26 de julio, por el que se establecen los requisitos basicos del convenio especial de prestacion de asistencia sanitaria ..."
  
  Trying to find out if this is available in Barcelona:
  El Pais's "Sanidad exige 710 euros al ano a los sin papeles por ser atendidos"
  Ajuntament de Barcelona's "Nueva Normativa Para El Acceso Al Sistema Publico De Salud" (PDF)
  
  I was planning to apply in Catalunya:

  Can't apply until date that you've had residence for 1 year.
  
  With application, submit copy of residency card, padron certificate, proof of actual residence in Spain for a minimum continuous period of one year immediately preceding the application (does that mean not even a single short trip out of Spain ?), INSS document saying you don't have health coverage, SEPA CORE debit form.
  
  Get an appointment, then submit application to Catsalut
  
  Within 30 days, get response from regional manager.
  
  If approved, sign agreement, pay first month, and coverage starts as of month in which agreement was signed.
  
  A medical card valid throughout Spain will be mailed to you.
  
  Coverage includes prevention programs, primary care, specialized care, urgent care, psychiatric care, geriatric care, emergency medical transport, rehabilitation, transplants. But not prescriptions, dental (does cover check-ups and tooth extractions ?), vision.

  
  I moved to Andalucia, and will apply there:

  
  Went to local health center with convenio especial application form and instructions (from CAB (PDF)). Asked (in my broken Spanish) what kind of document is needed to satisfy the "Documento que acredite la residencia efectiva en España por un periodo continuado de un año" requirement in the instructions. They didn't really know what document would satisfy this requirement. So I asked will they accept a simple written statement by me, or accept a copy of my residency card showing it started more than a year ago ? The "copy of residency card" idea seemed to get a good reception. I think I'll go back later with my Spanish-speaking partner and ask again.
  
  But: 1-year renewal of my residency card is taking months (3.5 and counting). I don't think I can apply for Convenio Especial until I have the new card.
  
  Finally decided to try applying while residency card is being renewed. Doesn't seem to be a way to get a cita without first having a TSI, so I'll go to office without a cita. Filled out the application form from CAB (PDF). Made copies of my residency card and padron and the form showing that my residency card is in renewal (renovacion). Printed a PDF from INSS stating my Spanish Social Security number. Wrote a little one-page letter in Spanish saying "I have resided in Spain since [date]." ("He residido en España desde el 15 de [date].") to satisfy the "Documento que acredite la residencia ..." requirement on the form (section 5).
  
  1/17: went to local Centro Salud, handed my stack of documents to the guy. He seemed to focus mostly on my Social Security number document, and passport. Typed into the computer for a while. Then said a bunch of stuff along the lines of "you're not alta on Social Security, you have to go to INSS, Convenio Especial is for EU people only, you have to stay on private insurance, etc". I think he's wrong about most of that, but I'll try going to INSS and see what they say.
  
  1/25: went to INSS office with cita. First official didn't know what convenio especial is, another knew a little about convenio especial, said it was not for Americans, but we have to go to TGSS anyway, it's not an INSS thing.
  
  So, off to TGSS. Man there tried to say it wasn't for Americans, consulted with someone else, then I showed him the royal decree number (576/2013) listed on a Salud form. He printed out the decree, and highlighted a part which says we have to apply at Salud, not TGSS. We've been there already, a week ago, and Salud said I have to get "alta" with INSS or TGSS first, and anyway convenio especial is not for Americans. But they're all wrong about that; the decree he just printed shows it's for anyone who is resident, on padron, and not covered by another SS system. I satisfy all three requirements. And the decree says nothing about what country you're from. This man also says you can't apply while your residency card is being renewed (even if you show the renovacion form), and your padron has to be dated within last 3 months.
  
  Back to Centro de Salud. Lady there again tried to say it's not for me, but we showed her the royal decree. Then she said there's no way to pay for it here. I said fine, we'll pay at TGSS or something, once I get on it. Then she said I have to go apply at the central hospital, not here. So I gave up for today, we'll have to go to the central hospital.
  
  Then online I found Servicio Andaluz de Salud's "Convenio Especial Para la Prestacion de Asistencia Sanitaria - Procedimiento - 03/09/2014". Which seems to say I have to apply at a special health administrative center, so I guess the lady at the Centro de Salud was right about that. And it says money is paid into a special bank account, not through INSS or TGSS, so that's why they didn't understand it. Progress !
  
  Called the administrative center at the main hospital, they've heard of Convenio Especial, aren't too clear on it, think I should go back to TGSS to get a number (SS number ?) and pay there.
  
  4/4: With freshly-renewed residency card and padron in hand, I went to the registry center at the main hospital. Gave the Convenio Especial application form to the receptionist, and he found someone to handle me. I speak little Spanish, and she spoke no English. But I had my documents all set, and laid them out in front of her:

  • Convenio Especial application form.
  • Residency card and photocopy.
  • Passport and photocopy of ID page.
  • Padron (copy, not original).
  • Paper from INSS stating my SS number.
  • One-line letter I wrote, saying I've been residing in Spain since date X, about 1.5 years ago.

  
  The first problem was the SS number; she said something like I'm not in the Salud system, but I pointed to the SS document again and said I'm in the INSS system. She said something like I'm not "alta", and I said yes, I don't work, so I'm not "alta".
  
  Then a question about whether I'd ever been in their system, did I have insurance, etc. I showed my private insurance info, but I don't think that answered the question.
  
  Then the resident-for-1-year proof. My letter did not satisfy her, although she kept it with the bundle of application documents. She seemed to be saying that the Jerez padron did not show one year of residence, but the padron never shows your starting date anyway. I dredged up an old Barcelona padron application that was dated and officially stamped, and the two padrons together seemed to suffice. She copied the Barcelona document, and kept the copy (not original) Jerez padron. At one point she pointed to the stamp on the Jerez padron, and said something about it being a copy, and I held up the original to show her a real stamp, but she kept the copy and didn't take the original.
  
  She was working from handwritten instructions, and consulting someone in a back room, so I think this is not a common procedure. Lots of typing on the computer, too.
  
  Eventually done, and she gave me a stamped copy of the first page of my Convenio Especial application form, and another stamped page certifying my base data in the Salud system, I think. Mainly it gives an NUSS / NUHSA number. The application is sent off to Sevilla, and they will respond to me.
  
  4/5: The Jerez office called and spoke to my partner, who speaks Spanish. My proof of being resident for a year is not sufficient; they want to see some official document stamped March of last year. But I have no such document; I wasn't moving or renewing residency or anything at that time, I was just living quietly in Barcelona. The back of my residency card shows that I've passed the 1-year renewal, so should be proof that I've resided in Spain for more than 1 year, but that's not good enough for them. My partner says there may be a document called a "padron historical", but we don't know if I can get it, and I'd have to get it from Barcelona.
  
  Online, I found there IS a "certificado historico de empadronamiento", and for Barcelona I can request it: portaltramits. I tried doing that online, using a digital certificate, and found that the page (AFTER entering all the info) requires that latest version of Java be installed. And I don't think it works with Firefox browser, so I switched to IE. Multiple updates of Java, and still it insists I need to update. Wiped out older versions of Java and Java SDK, restarted. Fixed Control Panel problems using a Microsoft utility. Installed the Java update again, restarted, tried again, no go. Gave up.
  
  But they do give a way to fill out a PDF, print it, and postal-mail it. So I'll do that.
  
  In the form, I put my current address in the address fields. And for "Exposicion de hechos y razones", I put:

  Necesito "Certificado Historico de Empadronamiento" anterior en OLDADDRESS, desde STARTINGDATE.
  
  Actualmente empadronado en NEWCITY, empadronado el NEWSTARTINGDATE.
  
  Estoy tramitando la atencion a la Seguridad Social / Salud / Convenio Especial para Asistencia Sanitaria. Me piden constancia de empadronamiento que certifique que estoy viviendo en España mas de 1 año.

  For "Peticion":

  Solicito: "Certificado Historico de Empadronamiento" que conste que estuve empadronado en Barcelona desde STARTINGDATE hasta ENDINGDATE, fecha en que me empadrone en NEWCITY.
  
  Envieme el documento a la direccion actual: NEWADDRESS.

  4/6: Mailed the document request to Barcelona, then went to hospital again. They accepted a copy of my old/first residency card, but weren't interested in anything else I offered. They will wait for the historical padron document.
  
  5/2: Gave them the padron historico (they wanted the original). They said now everything goes to Sevilla, and I'll be notified.
  
  5/16: Received certified letter saying I'm approved for Convenio Especial !
  
  5/18: Paid €60 at bank and got a "pago" confirmation. Signed and dated both copies of convenio agreement (5-page "Convenio Especial para la Prestacion de Asistencia Sanitaria"). Made copies of the pago and agreement. Certified-mailed the three documents (originals of the pago and agreements) to address specified in first, stamped page of letter.
  
  Next step should be: I get one copy of signed agreement, and a certificado saying I'm covered, in the mail.
  
  Then: Take the certificate, SS number document, and residency card to local health centre. Register with a doctor and apply for a health card (tarjeta sanitaria individual or TSI). This will be sent to you in the post, or you will be asked to pick it up personally.
  
  Once you have TSI, log in to ClicSalud+.
  
  But: 5/25, without having TSI, just using digital certificate, I was able to connect to ClicSalud+ and see that I have been assigned to some centro salud, I have to pay 100% of any farmacia costs, I have been assigned to a family doctor, etc. I think this is just default stuff as my registration is happening.
  
  5/26: Received certified letter containing signed agreement and a page saying I'm registered in the system as of 5/24. Went to local health center to register and get a doctor and get a TSI, but the not-very-friendly guy said I have to go to the salud centro, which is a different health center. Maybe that's the only place they issue TSIs ? But it's not in the central hospital, where I applied for convenio especial.
  
  5/28: Online, I see that my TSI was "emitida" 5/25, so maybe it's in the mail to me. I guess I'll wait until I receive it.
  
  5/29: My TSI arrived in the mail !
  
  5/30: Went to the centro salud where I'm registered. They said the way to change centers is to go to the new center, as I tried. Maybe I was rejected because I didn't have a TSI. They don't know if or which doctors at their center speak any English.
  
  I'm confused about when to pay for convenio especial each month. I paid on 5/18 to start coverage. Do I have to pay for the next month on 6/1, or 6/18, or when ? By paying on the 18th to start, did I stupidly pay a whole month's payment to get coverage for only 12 days ? I wasn't registered until the 24th. Maybe I paid for a month to get coverage for 1 week.
  
  6/1: My lady called salud in Sevilla, and they said since I started first payment on 18th, my next payment is due 18th of next month. But it sounds like you can pay ANY time during the month. Which means I got screwed by starting near the end of a month. Should have tried to start near the start of a month.
  
  6/16: To the local Centro Salud; I want to change from my initially-assigned center to this one, which is nearer my home. But they say I have to wait 3 months since starting on the NHS, before I can change centers. But but: somehow they calculate the end of 3 months to be June 24, a week from now. That's 1 month since I got onto the NHS.
  
  6/26: Back to the local Centro Salud; I want to change from my initially-assigned center to this one. Much confusion among the staff. Finally they say that technically I have to wait 3 months since starting on the NHS, before I can change centers, but the boss will make an exception. So they do the change for me. Nice !
  
  7/5: First appointment with doctor, and he's good. My lady went with me, she speaks Spanish. Got in right on time, maybe a couple of minutes early. I handed a three-page document (in Spanish) to the doctor, giving my family history and some procedures or diagnosis I want. Got an order for laboratory tests. Took it downstairs in the health center, and scheduled that.

  
  From someone on "Expats in Spain" Facebook group 1/2017:

  
  I applied in Andalucia in 2015. ... There is a Conserjeria de Salud admin office in Malaga if you are in that area - this is where I applied.
  
  Your residency is proven by the residence card. I didn't have to apply for an SS number.
  
  I submitted passport, padron, NIE, residence card, completed application form, proof that I had set up a monthly payment, and proof that I didn't have healthcare in my home country.
  
  I took originals and copies with me. They inspected the copies against the originals then accepted them and the completed form.
  
  You don't have to set up the payment prior to sending the forms as they will send you a direct debit form to complete along with the second set of docs they send you to sign.

  
  Six months after starting Convenio Especial in Andalucia, I moved to Catalunya:

  
  Local health center and local INSS (on phone) both told me same thing: Convenio Especial is a national program, no need to change anything, keep paying into same IBAN I've been paying into.
  
  Went to local INSS for something else, and they said for questions about Convenio Especial, I have to go to TGSS.
  
  Went to local TGSS and asked if I keep paying into same IBAN as I did in Andalucia. At first they said "go to central medical administration and ask". Then they changed to "yes, we think you keep paying to same IBAN".
  
  Went to central medical administration (Balmes 22) and they said no change needed, no paperwork needed, just keep paying to the same IBAN.

  
  A couple of people said they were able to get on Convenio Especial healthcare just before their first renewal of residency card (so I guess they avoided committing to another 6 or 12 months of private insurance):

  You can apply for residency renewal up to 90 days after your residency card "expires". So shortly after their card expired, they were able to show they'd been resident and on padron for a year, and thus were able to apply for Convenio Especial. They received the approval letter and NHS health card quickly, and then showed those as proof of medical coverage when applying for residency renewal.

  
  Once you're on Convenio Especial:

  • I think you're supposed to communicate any changes to the original govt body where you got onto Convenio Especial, even if you've moved to somewhere else.
    
    
  • I think you're supposed to keep them updated every time you move to a new address.
    
    
  • I think you're supposed to inform them by letter when you want to terminate Convenio Especial.
    
    

  
  
  
  
  
  
• Private health cost coverage: private medical insurance.
  
  From someone on British Expats forum:
  If you take out private health insurance to cover your first year, there will be qualifying periods before the company will pay for various kinds of treatment. When we took ours out, emergency treatment and visits to doctors/specialists were covered immediately, for all further forms of treatment the qualifying periods ranged from 3 months to 12 months (although the 12 months applied to obstetric and maternity care, probably not something most early retirees will be worried about!). ...
  
  ... if you have private medical insurance that normally covers the cost of medication prescribed during a hospital stay but not anything prescribed for use at home ...
  
  Apparently some people who are covered by the NHS choose to have private insurance also:
  From postings on Andalucia.com forum:

  
  I don't think there is anything wrong with the Spanish health care system but private health care gives you more choice and control.
  
  ...
  
  The health service is fine, but like the UK it is understaffed and subject to budget cuts.
  
  We have private insurance and are also in the state system. The advantage to us is the ability to get much quicker treatment for minor conditions. Also, you tend to get more tests very much quicker. For example, a CAT or MRI scan can usually be arranged within a few days, even it it is not a life-threatening condition.
  
  You can usually go straight to see a specialist without consulting your GP first.
  
  The downside is that you have to pay for your prescriptions, but assuming you are registered on the state system, you can usually get the drugs prescribed so long as your doctor agrees.
  
  ...
  
  There are very short waiting times in the private system. ... As ever, you get what you pay for.
  
  ...
  
  ... Most private medical insurance will not cover pre-existing conditions, so as soon as we can get onto the Spanish healthcare system we will. ...
  
  ...
  
  [We are now in the state system, but] We are keeping our Sanitas policy going, just in case. The Spanish health system has similar problems to the NHS in UK with waiting lists etc, whereas in the private system [with brain tumour] I was 7 days from diagnosis to operating table, with part of those 7 days spent receiving treatment to reduce swelling so op could go ahead. There are some excellent doctors in the private sector and some equally good ones in the state sector, often because it is the same doctor!
  
  The state system is good and so is the private sector.
  
  ...
  
  Can I suggest that you investigate carefully the availability of doctors and hospital care in any private health care scheme you may be considering IN YOUR AREA. We have found in our area in Huelva Province that private doctors and hospitals available on private schemes are few and far between.
  
  ...
  
  One more thing to mention is that prescriptions are not free in Spain for anybody, even if you are covered under the state health system, or for pensioners. The costs depend on your level of income and whether this can be proved by means of having made resident tax declarations.

  
  Simple Care is one such add-on insurance, not intended as your primary insurance, and doesn't satisfy the visa application requirement for medical insurance.
  
  From Sanitas - HealthPlanSpain:
  
  [Rates are lower if you pay one annual payment, higher if you pay monthly. I'm showing annual numbers.]
  
  "Basic" plan:
  Not suitable for visa and residencia applications; intended as supplement to NHS.
  
  "Classic" plan:
  Suitable for visa and residencia applications.
  Has co-pays.
  Does not cover travel outside Spain.
  Does not cover Dental.
  Quote 9/2014 for "Classic" plan for 56-year-old male with no health problems to live in Barcelona: €1120.
  Add Worldwide coverage out-of-network with €150K annual limit (has 8-month waiting period, and upper age limit of 64): €235.
  Add full Dental coverage: €125.
  
  "Complete" plan:
  Suitable for visa and residencia applications.
  No co-pays.
  Does not cover travel outside Spain plus one other EU country.
  "Medical assistance in the USA via United Health Care, using their network of hospitals and doctors and with 100% of medical costs covered (when authorised by Sanitas)"
  Partial coverage for Dental.
  Quote 9/2014 for "Complete" plan for 56-year-old male with no health problems to live in Barcelona: €3290.
  Add Worldwide coverage out-of-network with €150K annual limit (has 8-month waiting period, and upper age limit of 64): €235.
  Add full Dental coverage: €125.
  
  From people on "Expats in Spain" Facebook group:
  

  Trying to cancel Sanitas is really terrible. They ignore and try to block attempts at cancellation. I try to not do business with companies that have these kinds of terrible business practices.
  
  ...
  
  They tried the same with me, just send them an email as early as you can then cancel the direct debit. That's what I did, they whinged and moaned and threatened me with legal action, but what they do is illegal and they know it.

  
  
  
  From SOS Insurance:
  
  Policies actually are with Caser Seguros.
  If you currently don't have health insurance, these policies have a 6-month waiting period before you're covered for specialist treatments (no waiting period for emergency/accident).
  Policy does NOT include repatriation. For that, you need separate Lloyds policy, which limits coverage to 90 days per trip, maybe more per year. If you want 12-month repatriation coverage, sorry, find that elsewhere.
  Policies do not have deductibles, and no per-treatment or per-day limits.
  "We would have to ask if the underwriting company would allow contracting with a passport number and not an NIE."
  
  "Activa" plan:
  Has co-pays.
  Does not cover travel outside Spain.
  Basic Dental coverage.
  Quote 9/2014 for "Activa" plan for 56-year-old male with no health problems to live in Barcelona: €709. Same quote again 6/2015.
  
  "Integral" plan:
  Has co-pays.
  Does not cover travel outside Spain.
  Basic Dental coverage.
  Quote 9/2014 for "Interal" plan for 56-year-old male with no health problems to live in Barcelona: €1286.
  
  It's unclear to me if the SOS Insurance policies will be acceptable for visa and residencia applications.
  
  From IMG:
  
  Quote 6/2015: GlobalFusion Bronze plan, Europe only, $1000 deductible, $50K evacuation/repatriation, one annual payment, 57-year-old male with no health problems: $753/year.
  
  Very easy to apply and pay online, then print ID card and visa letter.
  
  From Insubuy:
  A broker. Very much oriented toward insurance that satisfies the Schengen visa requirements; not sure if that means appropriate for long-stay visa. Web site offers links to various plans written by other companies. Some plans are travel insurance rather than primary medical insurance. Many plans have maximum duration of 187 days, so you have to renew frequently.
  
  Quote 6/2015 for 57-year-old male with no health problems to live in Barcelona, $0 deductible, $1M maximum payout: plans start at €1600/year.
  Changing to $250 deductible changes that to €1300/year.
  
  
  From people on "Expats in Spain" Facebook group:
  You have to give 2 months notice if you want to cancel out of your health insurance plan. The plan also has to give you 2 months notice before the end of the term, before renewal, telling you the new rate for the next year. Suggestion: always give them 2 months notice that you are going to cancel at end of term; they will come back with a better rate.
  
  I ended up choosing IMG.
  
  If you have a Spanish bank account, medical or dental insurance may be available through your bank.
  
  Maria Cecilia Tacchi's "Questions To Ask before Taking Out Private Insurance" (PDF)
  Turner Insurance's "Your Step by Step guide to health insurance"
  
  MAPFRE (no English on web site)
  SwissCare
  Catalana Occidente Seguros (no English on web site)
  Prevision Medica
  Adeslas (no English on web site)
  
  
  
• Cash (no insurance).
  
  Not allowed when applying for visa; must show proof of medical insurance. Maybe feasible later ?
  
  From someone on "American Expats in Spain" Facebook group 6/2015:
  For anyone who has to visit the hospital etc during emergency room hours without insurance, it's 140 euros, and they mail you a certified envelope about a week or 2 later telling you how to pay (direct deposit at any bank) ...
  
  Quora's "Can I use HSA funds for medical expenses abroad?"
  
  
  

Early retirement

I asked:

Spanish worker: lose NHS if retire early ?

We live in Spain. My wife has a salaried job in Spain. She is "alta" in Social Security. She has NHS, and her son and I get NHS through her. I'm a US citizen resident in Spain. I'm on Tarjeta Comunitaria. I don't work.

If my wife retires early (stops working), say at age 60, I know she can't collect pension until age 65 or more, and the pension is reduced.

But if she retires early (stops working), what happens to her NHS coverage, and son's and mine ? I assume she goes "baja" on SS, but what does that mean for NHS ? Do we all still have coverage ? Is the coverage reduced (I seem to remember there are two levels of NHS coverage) ?

I assume she could pay autonomo for those years from 60 to 65+. Would that make her "alta" in SS, and give NHS for all three of us ?

A response:

According to the official website:

Your wife has insured status if she is working, a pensioner or receives any other Seguridad Social benefits.

You can only get beneficiary status while she has insured status.

As I understand, she will get "emergency beneficiary cover" as she is a Spaniard and lives in Spain, but you would lose coverage thourgh her. Her son, if he has a Spanish nationality, he can get the ame "emergency beneficiary cover", being a Spaniard himself. You would lose coverage, I think.

You could do the autonomo trick and keep on getting healthcare through her.

Autonomo now comes with huge discounts and depending on where you live, it could even be for free the first 1 or 2 years. After that, expect to pay the minimum, so 250 eur a month or less. (= I say "or less", because the minimum is supposedly going down every year from now on.)

Also, consider private healthcare.

But according to that site, my wife would be an insured individual (because "Having exhausted unemployment benefits and others of a similar nature, being unemployed, not having insured status on any other grounds and residing in Spain. ... Having Spanish nationality and residing in Spanish territory."). And I would be her beneficiary (because "Being the spouse of the insured individual ..."). And son would be a beneficiary too (because "descendant").

Care

• State healthcare providers / NHS facilities.
  
  My understanding of the NHS facilities:
  • Medical center (in Barcelona, called a "CAP"): local in your neighborhood, you'll be assigned a family doctor there, you need an appointment, they can do only the very simplest treatments (vaccinations, nursing care). They also should have an "urgent" section for people who can't wait for an appointment with their family doctor, but even there you'll get only simple treatments and then prescriptions.
  • Primary care clinic (in Barcelona, called a "CUAP"): bigger and fewer, they handle people who walk in sick or moderately injured, no appointment needed. May do X-rays. Probably would set an easy simple fracture.
  • Hospital: probably one per city or district, they handle serious emergencies such as car crashes, heart attack, do surgery, etc. Have X-ray, MRI, etc.
  
  They must treat any emergency or serious acute illness, regardless of your ability to pay or form of payment.
  
  From someone on "American Expats in Spain" Facebook group 9/2014:
  "The public system doesn't accept private insurance ..."
  
  From Sanitas web site:
  > Will Sanitas cover me in any Spanish
  > Social Security Hospital as well ?
  
  Only when you are admitted to a Social Security Hospital as an Emergency. Sanitas must be advised within 72 hours of your admission so that they can settle your bill and then transfer you to a private hospital if clinically possible.
  
  From someone on belegal.com forum:
  "Those holding a private medical insurance will only be able to attend the hospitals / doctors which are authorised by the insurance company. The national health service hospitals are not included in this coverage."
  
  My friend is a doctor in Barcelona. She says [2014] that almost all of the medical facilities in Catalunya are privately owned, and they handle both private and NHS patients. Only two of the hospitals in all of Catalunya are 100% govt-owned.
  
  One key thing that a family doctor in a govt facility can do that a private facility can't do: for a worker, they can give them a "baja" that gives them paid days off work.
  
  Rob Horgan's "Waiting times increase in Spain's hospitals for non-urgent procedures"
  
  My opinion:
  
  Limited experience in Spain so far, but it seems to me that the Spanish NHS is very good if you have an obvious acute problem. You'll get treatment pronto.
  
  But if your condition is less urgent, or chronic, you'll get a referral to another doctor, wait weeks, get examined, wait a week for a test, a week later back to doctor to have test result evaluated, wait weeks for treatment, etc. In that kind of situation, private healthcare (Sanitas, for example) is far faster.
  
  My lady and I had a bad experience with the health system in late 2017:
  
  Background:

  My lady is a family doctor in Spain, has worked in family doctor role and also in Emergency Room, had lots of similar experience in Peru before moving to Spain.
  
  She has a tendency to self-medicate and take lots of pills.
  
  Her sister also is a doctor, a gynecological surgeon.
  
  We lived in Andalucia, but were planning to move (back) to Barcelona.

  
  The accident:

  We went to Peru for 4 weeks, had a stressful trip, both us got sick, she was very sick on the flight back and got mad at the lack of help from the aircrew. We came back and went to her sister's townhouse, and stayed the night there with her family.
  
  In the middle of the night, she got up and went out of the bedroom, thought she was still in Peru (in a one-floor piso), and walked right off the top step of the stone/marble stairs down to the first floor. She landed on her back on the stairs, screamed in pain, her mother and sister were there immediately.
  
  I was sound asleep until she screamed, didn't realize something so serious had happened, and no one told me; I went back to sleep. I assumed she had stubbed a toe on the cabinets in the hallway or something.
  
  I think she immediately started taking painkillers and corticosteroids.

  
  The next morning, she went to her NHS family doctor. They'd butted heads before, and now they had a huge argument. He didn't even examine her, just said "you look okay, you're walking okay". Wouldn't prescribe anything, wouldn't order an MRI.
  
  She said she was moving to Barcelona, send my records there, I'll get treated there. So he agreed to send the records.
  
  She had bad bruising on her lower back, in the middle and both sides above the hips. She went to the local ER, they diagnosed a hematoma, but said just rest and take painkillers, I think.
  
  We were scheduled to start a 10-day trip to Vienna the next day. It was a big trip, to a medical congress, whole family going along to celebrate son's 21st birthday there, we've always wanted to see Vienna. So, with a 1-day delay to try to do INEM paperwork, she went on the trip.
  
  I know she was taking painkillers during the whole trip, and I think corticosteroids too. Even so, her back was painful, you couldn't touch her lower back.
  
  Back home to Andalucia, and apparently she stopped taking the corticosteroids, and within several days she had no sensation in the front half of one foot, her pain was worse, she walked badly and couldn't lift things without pain.
  
  She went to the main hospital in town, and they wouldn't do anything for her. An MRI might be done in weeks or a month. She was frantic that she had spinal cord damage and it would progress and she'd end up in a wheelchair.
  
  Hospital:

  So she went back to the neighboring town where her sister lived, and got admitted to the hospital where her sister works.
  
  She butted heads there with the nurses, who said she looked okay, was walking around, must be faking. She criticized the way they were treating her, her forearms were covered with bruises from bad IV attempts, etc. But after a couple of days, she was seen by a traumatology doctor, who took one look at the way she was walking and said "spinal damage". Ordered an MRI, but then she had to wait 5 days for it. Meanwhile, the nurses were missing scheduled times to give her medicines, not testing her blood pressure, etc.
  
  Finally she got the MRI, and it showed a displaced disc. But not conclusive proof that it was caused by the accident, and apparently her family doctor had written "chronic and not work-related", which would greatly reduce any disability payments she would get.
  
  After the MRI, the doctor wanted to do an echo-doppler to test her legs for thrombosis, but she said her legs were swollen from laying in bed for a week. She left the hospital, and two days later we went to Barcelona. She was still in pain and walking badly, taking painkillers and oral corticosteroids. But now that she was walking regularly, the swelling in her legs did go down almost completely in about 2 days, and completely in a week or so.

  
  In Barcelona, we went to the Emergency Room and then to a family doctor, with little joy. At least in the ER they actually examined her back and foot, and did an X-ray. But they wouldn't write any prescriptions, just said go to a family doctor.
  
  The family doctor wouldn't even examine her, wouldn't touch her, wouldn't write any prescriptions. And the whole situation is complicated by being in the middle of a move from Andalucia to Barcelona, and probably what the family doctor wrote in Andalucia is following her and poisoning the situation.
  
  She ran out of corticosteroids, and the oral painkillers were becoming less effective. She was waking up at 1 AM each night in pain, and unable to sleep. She can't carry anything heavier than a phone, not even her purse.
  
  Another visit to the ER, we had to beg them to eventually give her a pain shot after more than 3 hours of waiting in a not-busy ER. They refuse to write prescriptions for painkillers and corticosteroids, saying a family doctor has to do that, telling her not to come back to the ER.
  
  Then she revived her Sanitas insurance policy, which she had let lapse a couple of years ago, and started going to their clinic and hospital in Barcelona. In no time, she was seeing doctors, having MRI and other tests, getting new/different prescriptions. Her condition improved slowly, the different medicines worked much better to control her pain.
  
  She's on dual tracks now, doing both NHS and private. The NHS track is very slow, months behind the private track.
  
  My lady had another bad experience with the health system in mid-2019:
  
  She was having pain, and blood in the urine. Went family doctor, got a referral for an echography and scheduled it. Then somehow the appointment disappeared and had to be started again. Meanwhile, she was in pain.
  
  Finally she went to the private Sanitas hospital, covered by our private insurance. In the first day, she saw about 4 doctors including a urologist, who was amazed the NHS hadn't done blood and urine tests right away. An echography and then an X-ray showed a large stone that had shifted down a little below the kidney. Scheduled for shockwave lithotripsy 2 days later.
  
  More tests over the next day or so, most related to other complaints such as persistent bad cough.
  
  
  
  
• Private healthcare providers.
  
  Private urgent-care facilities also must treat any emergency or serious acute illness, regardless of your ability to pay or form of payment.
  
  All dentists and vision-care providers are private; no dental or vision coverage or care in the national system. When choosing private dental or vision insurance, check with local providers to see if they accept that insurance.
  
  

Nursing home / residencial long-term care / Retirement Home / care home / hospice

Public patients in residence homes, relevant to my family

• If someone is a Spanish citizen with NO pension and no savings, and they go into a residence home as a public-paid patient, do they have to pay anything ? What if their children have salaries or savings, do the children have to pay ?
  
  
• If someone is on NHS but NOT a Spanish citizen and they have savings, and they go into a residence home as a public-paid patient, what do they have to pay ?
  
  
• At what point can one apply to get on the waiting-list for a residence home as a public-paid patient ? Do they have to be a certain age ? Do they have to need to move in right away ? What happens if they apply now, a room becomes available, and they decide not to move in, they want to stay on the list until later ?
  
  
• Can a couple apply together, to live in a room together ?
  
  
• Does one apply and get on a waiting-list for a specific facility, or do you apply and get on a waiting list for anywhere in a whole city or province ?
  
  

Some responses from people:
Each region or district tends to have different requirements.
You can get moved up the waiting list for health reasons.
Usually you have to be at least 65 years old.
Not everyone (with a pension) pays the same; it depends on several things and the residents have the right to retain a small part (20% ?) of their pension for living expenses.
Another response:

Variable by Region. I'm a UK qualified social worker in Alicante/Murcia. All statutory services start with social work assessment which at the moment is around 18 to 24 months waiting time for assessment. Services are means-tested with most services being excluded if you have more than 800 euros income. All Care homes are private provision with reduced cost if you are responsible of region. Murcia/Alicante/Valencia have social services web pages [ Murcia, Alicante, Valencia ].

Also see "Caring Costa Blanca" Facebook group

6/2018: My wife, who is a family doctor in Barcelona, says the wait for a woman who wants to move into a residence home as a public-paid patient in Barcelona is 5 years.

6/2018: I looked up (on Consorci de Serveis Socials de Barcelona's "Persones amb Dependencia i Gent gran") the residence home right next to our apartment building in Barcelona. They have 88 public residents, 0 private residents, and a waiting-list of 422.

Private facilities

Domus Vi
Ballesol
Orpea Residencias (they acquired Sanyres)
Casaverde
Angels Nursing Group
Residencia Rojales (in Alicante)

SmartExpat's "Retirement Care in Andalusia"
Plusesmas's "Residencias de ancianos"

Pensium's "Precios de las residencias de tercera edad en España"

Health-care directive

Funeral

My wife died 15 months ago. The funeral directors took care of everything. No need of a funeral plan as a cremation here is very cheap, and as I said the funeral directors took care of everything.

...

My husband died suddenly at home. The doctor telephoned the funeral directors who are based and own the crematorium local to where I live. After that it was seamless. They took care of everything there is no need for a funeral plan. The insurance companies just call the funeral directors who then take over. They spoke English asked me what I wanted and that was that. When I hear how much people pay for these funeral plans this is the reason I speak out. There is no need for them. Go to your local crematorium. They have offices there and they will answer all your questions.

...

I'm not sure that I would recommend giving 4000+ Euros to a company who promise to pay for your funeral one day in the future. Google some of these funeral companies like Avelon before you do anything. Better put your money into your own savings account. Check out local funeral directors and see what they suggest. Funerals or cremations usually take place within a couple of days of death unless a PM is needed.

...

My husband died 6 months ago went to local funeral directors they asked me what I wanted done even flowers funeral 2 days later then cremation had his ashes in a week they were really good company

...

In most areas on the Costa Blanca a funeral plan is not necessary. If the person dies in hospital the administrative staff liase directly with a funeral director. If the person dies at home unexpectedly a call to the Guardia Civil is made to confirm death and they will liaise with a funeral director. Cremation is the easiest to arrange. The crematorium staff speak most European Languages and can arrange all types of religious and humanist services including flowers, equivalent of lying in chapel of rest and urn for ashes. They arrange issue of death certificates and give advice on what needs to be done. If placing the body in a niche at a cemetery is preferred following a religious service the funeral director will arrange this. However, a niche should be reserved in advance through the local town hall. Funerals usually take place within 24 - 36 hours after death but for foreigners it is allowable to request up to 5 days delay to allow family and friends to make travel arrangements. It is easy to arrange a funeral. However, one needs to be aware that bank accounts can be frozen or partially frozen if a joint account. Ask your bank what their process is. Also investigate how death duties / taxes will be applied to the estate.

I would be stressed with or without a so-called funeral plan in this situation! The crematoriums are happy to provide quotes for their range of services so its easy to get a ballpark figure. I would prefer to keep the amount in my savings account and hand over my credit card at the time rather than have a third party profit from it. But that is my personal preference.

...

My partner died in Andalusia very suddenly, he died on the Sunday afternoon, we had no funeral plan, the morgue in the hospital phoned Collfer a local funeral in hurcal overa he was cremated on the Tuesday and his ashes and all the paperwork completed on the Wednesday, total cost €2500.

...

My condolences, I had the same and paid more, but yes just hide the money away because the bank will freeze the money as soon as you give the death certificate.

...

You can get a plan from the tanatorio itself cheaper it's basic but it's cheaper

...

Funeral plans in my experience are expensive in the long run whereas shopping around the better funeral directors is often much cheaper. Certainly a lot cheaper than UK. My wife passed away 3 years ago and the final costs were much cheaper than the original funeral plan we had cancelled earlier and had to pay a huge penalty for 'admin' costs.

...

they have crematoriums and usually a body has to be buried within 72 hours unless you pay for storage. usually the undertaker wants the cost of the funeral before the burial ...

...

My elderly neighbour passed suddenly leaving his wife behind ... they had no funeral plans ... because he died at home the ambulance took his body to the hospital to confirm his death and release his death certificate and within 4 hours his body was transferred to the crematorium. I took his wife to the crematorium who were so very helpful, we literally there and then chose the basic coffin and urn and booked the time, which was just about 24 hours later from appointment. She paid €3200 which had to be part cash part card, we attended the service the very next day and within 24 hours of his cremation to which we didn't attend we were able to return to collect his ashes. It was done very quickly but the crematorium were very professional and very good to his late wife.

I did ask this question for interest, you can store the said person at a cost of €300 a day to allow family to arrive and suspend the service till later.

Repatriation Help
Anubis

7/2018: Quote through Repatriation Help for funeral director services plus transport of body from Barcelona to Lima Peru, not including mortuary or hospital charges: about €6200.

They died from COVID in a public hospital in Barcelona, with no insurance. Procedures may vary elsewhere.

Because of COVID, no public viewing or funeral.

If you have insurance (seguro de decesos) you need to contact that company and they will take care of all, asking you about your preferences. But we had no insurance.

Finding a funeral home:
Cofune (but nothing for cremation in Barcelona)

Apparently Barcelona has only two funeral homes in 2021. A law was proposed in 2017 to create a municipal service, but it was defeated.

We went to the hospital (Vall D'Hebron). There are two funeral-home offices on the grounds, right next to each other. Went into one and they quoted us €3500 for the simplest cremation. Went into the other and they quoted €1800, so we went with that one. I think the second was including fewer extras, and the real difference in the basic service part was €1800 versus €2100.

No chance for a viewing at the hospital, since this is a COVID case.

We were able to reclaim our relative's clothing right away, but the Security office held the only valuable thing (mobile phone) until we came back another day with a document showing power of attorney.

Two days later we went to the mortuary at Montjuic cemetery, and were able to view the closed coffin with the body inside. The cremation took place after that, probably very soon.

Not sure when we'll get the actual urn with the ashes. Funeral home is supposed to be arranging the death certificate, but that could take a couple of months.

Miscellaneous

Medicare

Medicare, with a few exceptions, does not cover expenses outside the USA. And if you stop paying for Medicare part B while outside USA, and later go back to USA and resume Medicare part B, your premiums will be higher because of the gap.
Medicare.gov's "Get started with Medicare"
Medicare.gov's "Part B late enrollment penalty"
Medicare.gov's "Sign up for Medicare"

From someone on "Expats in Spain" Facebook group:

I am a contract analyst for the largest medical insurance company in the US. What I might suggest is at the very least getting a Medicare Advantage plan rather than straight Medicare when you retire. Medicare does not cover out of the country, but many of the Advantage plans will cover for any kind of emergency while you are out of the US. You do not want to give up or waive your Medicare benefits (even though they cost you) because if you come back to the US there are large penalties and a waiting period to get Medicare started for you. The penalties get bigger and bigger every year for Medicare.

... I have noticed that when retirees get a lot older and need added care, they move back to the US, and then Medicare gives them a ton of trouble trying to get their benefits back.

When you start collecting US SS benefits, make sure they don't take Medicare payments out of them ?

I'm told USA medicare (SSA) online system will not let you log in from an IP address outside of the USA; use a VPN. But 6/2023 I was able to log in from an IP address in Spain.

Elder Law's "Getting Medicare While Traveling or Living Overseas"