Discover our special file on health insurance in Spain:
In Spain, health coverage is available to all permanent residents. Whether you are an employee, self-employed, retired or a student, Spanish social security covers you for public sector healthcare, and you do not have to pay in advance for services. Do you want to have your choice of practitioners and places of care, shorter waiting times and a high level of reimbursement in the private sector, while continuing to be covered in your country of origin? If so, expatriate health insurance is your best choice.
|Health care expenditure per capita||3 453€|
|Annual indexing of health care expenses||10.7%|
|CFE hospitalization reimbursement rate||42 %|
|Number of insurance companies providing services||15|
|Cost of hospital coverage for people 30 years old/year||804€|
|Cost of hospital coverage for people 50 years old/year||1 435€|
Spanish health coverage is based on two health systems that operate independently of each other: the universal public system and the private system.
Although weakened by a decade-long economic crisis that has led to severe budget cuts (since 2008), the Spanish health system is among the best in the world; it was ranked 7th by the WHO and 8th by CEOWorld in 2021. This good rating is accompanied by one of the highest life expectancies in the world (83 years). Spain is a good place to live, where medicine is based on prevention, does not encourage over-medication, and is accessible to all.
Spain's universal healthcare system allows all its citizens and all residents to receive low-cost care (with limited out-of-pocket expenses) or even free care, depending on the type of expenses, and the status and resources of the insured. The WHO has commended Spain for the health measures it has taken for citizens and residents. Residency determines access to the national health system, there is a wide range of health services and adequate geographical distribution, there are little or no out-of-pocket expenses for consultations, tests, diagnoses and hospital care, and there are measures to protect the most vulnerable.
While the public system covers the above-mentioned health expenses free of charge, it is preferable to use the private system for better coverage of preventive medicine, drugs and optical/dental expenses, and to avoid excessive waiting times.
One feature of the Spanish health system is that you can use private insurance to compensate for the limitations mentioned above, but the benefits offered by these insurance companies only apply in the private sector and within a specific network. These benefits are not supplementary to the public sytem (for drugs, for example). If you have private insurance, you will have to make a choice when you incur your healthcare costs.
The quality of healthcare and infrastructure in Spain is well known. The country has a very good reputation at the European level, most notably due to a strong balance of financial accessibility and services provided. The infrastructure and the training of practitioners meet international standards.
Although the lack of financial resources in health was felt at the beginning of the COVID crisis in 2020, when there was a shortage of personal protective equipment in hospitals, Spain still holds 22nd place in the World Index of Healthcare Innovation, ahead of France at 25th place or even Canada at 23rd; which is evidence of the quality of public healthcare in Spain.
The quality of care is very similar in both the public and private networks. However, being privately affiliated allows you to obtain better waiting times, appointments/treatment by the doctors of your choice (French-speaking doctors, for example), access to a private or semi-private room during hospitalization, reimbursement for drugs, as well as dental care, optical care and alternative medicine.
The weak points of the public sector are the long waiting for consultations and surgery, as well as the lack of coverage for dental and optical expenses.
If you have public health coverage, you will have to choose a general practitioner in the area where you live (if they have availability), or a doctor will be assigned to you by your local health center (centro de salud).
The general practitioner (primary care physician) will coordinate all your healthcare. You will need to go through this doctor to be referred to a specialist or to a public/conventional institution in your area, when you are scheduling a hospitalization. Compliance with the care pathway is the sine qua non condition for free healthcare in the public sector.
If you are privately affiliated with a local insurance company, you can consult the doctor of your choice from the list of practitioners in your insurance company's network. If you go to a doctor who is not in the network, you may only receive a partial reimbursement (e.g., 80%) or may be reimbursed at all. The network allows you to benefit from direct payment. Finally, some insurance companies have deductibles: for example, there may be a €3 to €7 out-of-pocket expense for a general practitioner consultation.
With international insurance, you can select the doctor of your choice in the private sector, without having to select from a list or being limited to your area of residence. A consultation with a general practitioner will cost up to €60, while a consultation with a specialist will cost between €70 and €110 on average, and may be more, depending on the practitioner's reputation and pricing (open window pricing). You will have to pay for your consultation, and in order to be properly reimbursed, you will need to ask for a detailed invoice which lists all the procedures that were performed and their rates. The invoice can be sent by mobile app or via an online customer portal.
Medicines are free of charge for some disabilities and chronic illnesses (under certain conditions), for unemployed persons who no longer receive unemployment benefits, certain categories of retired persons, and for workplace injuries and diseases. In all other cases, you will have to pay for at least part of the cost of your medication.
For prescription drugs, the out-of-pocket expenses depend on the income level of the insured. Out-of-pocket expenses are generally between 40% and 50%, and can be as much as 60% for those who earn more than €100,000/year. For retired persons, out-of-pocket expenses are standardized at 10% and capped (except for those who earn more than €100,000/year). It should be noted that there is a cap on the out-of-pocket expenses for common drugs used to treat certain chronic diseases.
Pharmacies are private or hospital institutions and their number and geographical distribution are regulated. Aspirin (or other common drugs of this type) can only be obtained from pharmacies, and depending on the dosage, you may need a prescription (known as a "receta").
Private insurance provides access to better drug reimbursement for anyone who is not retired or dependent on a specific category of care.
For hospitalization, admission to a hospital requires a medical prescription; except, of course, for emergencies! The cost of hospitalization in a non-private room in public and approved institutions is covered by the health insurance. If you value your privacy, you will need to pull out your wallet to get a private room. Hospitalization in the public sector costs on average €700/day according to a 2014-2015 estimate by the Ministry of Health; and a little more than €1,000 for outpatient hospitalization
The public health system does not cover optical and dental expenses, or covers very little. Most dental offices are private. They offer very good quality care and have modern equipment.
Even if the prices are more moderate in Spain than in France (excluding no out-of-pocket expenses) or in other European countries, the cost of certain types of dental work can be quite high. A temporary crown costs on average €50, while a ceramic crown on an implant will cost €350, an implant about €800 and a panoramic X-ray €40.
When choosing a dental office, make sure it is registered with the Consejo Dentista de Colegios de Odontologos y Estamologos. If you have purchased a comprehensive plan, expatriate insurance will cover your dental and optical expenses.
Maternity expenses are covered by social security (if you are a beneficiary) for care received in the public sector. Your referring physician will designate the hospital, depending on where you live, and you will most likely have to share a room with another insured. During the pregnancy, the same midwife (comadrona) usually accompanies you through the entire process, the pregnancy follow-up is quite basic (less advanced than in France), and, depending on the region you are in, is not very personalized. Finally, on the day of the birth, the gynecologist on duty will take care of you.
In the private sector, a delivery will cost between €2,500 and €7,000 depending on the place of care and the services chosen. Pregnancy follow-up is more comprehensive than in the public sector. And you will be able to have the same gynecologist who has assisted you throughout your pregnancy. The private room can be one of the benefits included in your private (local or international) insurance policy.
Spanish doctors have been known to resort to Caesarean sections even if the baby is in the ideal position for a conventional delivery. This tendency to resort to a Caesarean section may not be appropriate for all women and it is best to discuss this option with your doctor at the beginning of care. Finally, a hospital stay in Spain is rarely longer than 48 hours when everything goes well for the mother and the child.
In the public sector, support can be particularly limited and not very informative, and new mothers can easily feel abandoned, as the medical profession relies heavily on maternal instinct. Choosing care in the private sector will allow you to have more personalized, higher quality support. You will need private insurance to cover these costs.
Expatriate insurance will allow you to cover three of the main deficiencies of public coverage: private rooms, pharmacies and optical/dental coverage, without being limited by location and without being required to select from the local insurance company's network.
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In Spain, healthcare is decentralized and managed by each region, which is responsible for the roles of insurer, purchaser and provider of care for the local population. The National Ministry of Health and Social Policy has limited powers. It legislates on pharmaceuticals and ensures the equitable provision of health services by defining the basic need basket, quality of care and performance monitoring.
The Spanish Social Security system is divided into many insurance branches. These branches cover sickness/maternity, disability, old age, death/survivors and unemployment insurance. You can find more information on each of these aspects on the CLEISS website.
To obtain universal health insurance, you must be registered as a resident and/or able to pay taxes as an employee or a self-employed person, or be retired with a Spanish pension or a jobseeker (and must have previously worked in Spain). Since the process of becoming a resident requires proof of health insurance, expatriates often use private insurance when applying for residency.
A resident is any person who resides in Spain for more than 183 days of the year. To begin the process of enrolling in the National Health System (SNS), register at your local town hall (Padron) to obtain your NIE (foreign identity number), and then go to your nearest "centro de salud." You can present the S1 form (if you are French or European) to the medical representative, along with your valid identity card, your Padron certificate of less than 3 months and your NIE, and complete the administrative file. It takes about three months to get your social security number and to receive your permanent SIP card.
The general scheme covers employees in the industry and services sector, the schemes attached to the general scheme and the special schemes, such as RETA for the self-employed (and agricultural workers), seamen or mine and coal industry workers. The INSS (Instituto National de Seguridad Social) manages the payment of cash benefits for all insured persons.
If you do not pay enough contributions to receive contributory social benefits, there is a non-contributory scheme, which provides minimum coverage (means-tested). This scheme is for unemployed persons, retired persons aged 65 and over (with 10 years of residence), retired persons with disabilities (between 18 and 65 years of age with a 65% disability and five years of residence), or recipients of the minimum living wage.
The Spanish health care system is divided into three main areas: doctors, medicines and hospitalization. These coverage areas are divided into six categories:
- Public health: management of epidemics, prevention and health promotion in general.
- Primary care: this includes scheduled or emergency healthcare (you can see a doctor as often as you need to), prescriptions, basic rehabilitation, mandatory vaccinations, or specific psychiatric, palliative or supportive care.
- Specialized outpatient or inpatient care: for outpatient consultations and outpatient services prescribed by your primary care physician; performed in general hospitals, regional hospitals, referral centers or private hospitals/clinics under agreement.
- Emergency care: always prescribed by the physician, for emergency medical and nursing care, provided in primary care centers, polyclinics, hospitals or at home. It also includes telephone assistance and emergency medical transportation, and other services.
- Pharmacy: private or hospital pharmacy, by prescription only.
- Long-term care: these benefits are linked to citizenship, and are subject to means testing and degree of dependence.
To be eligible for cash sickness benefits, the employee must have contributed for at least 180 days in the last five years. There is a three-day waiting period for non-occupational diseases and injuries, and benefits are generally paid up to a maximum of 365 days (+180 days for imminent recovery).
Workplace injury and occupational disease coverage is acquired in the same way as employee health insurance or private accident insurance. The employer makes the contributions.
There is no requirement for a previous contribution period. The only requirement is that the person is employed at the time of the workplace injury or disease.
Occupational diseases are eligible for compensation if they are on the list established by the Spanish Ministry of Labor.
The benefits depend on the type of disability, and the calculation criteria and payment will be slightly different if you are an employee or you are self-employed.
Self-employed people enroll in the same organization that provides temporary disability. Workers who have not included professional risks in their insurance will be compensated in the same way as for non-occupational injuries.
Death and survivors insurance is subject to prior contribution requirements: 500 days during the five years preceding death (except in specific cases).
The conditions are the same for employees and self-employed persons affiliated with the RETA.
Death insurance provides different types of pension benefits for survivors (reversionary, temporary widowhood, orphan's pension, etc.) and a death allowance for the person who paid the burial expenses.
Insured persons with a reduction in work capacity of at least 33% are eligible for a disability pension. Retired persons with a contributory old age pension are not eligible.
The conditions of compensation differ according to the insured's status, age, type of disability and whether or not the disability is the result of an occupational injury.
There are four levels of recognized disability:
For the self-employed, if the incapacity is the result of a workplace injury or an occupational disease, it will only be covered if they have workplace injury and occupational disease insurance.
To be eligible, a person must have contributed for at least 15 years in Spain, including two years during the 15 years prior to retirement.
In general, eligibility for retirement benefits depends on the insured's year of birth and the total amount of contributions paid.
For example, in 2022, the legal age is 65 for people who have contributed for at least 37 years and six months.
There is also a non-compulsory supplementary pension system (individual or collective).
These are social security insurance companies or funded pension funds and plans.
To receive unemployment insurance benefits, employees must have paid at least 360 days of contributions during the last six years. They must be totally unemployed or have had their working hours reduced by 10% to 70%, be actively seeking work, and be registered with the employment services.
The Prestacion Contributiva por Desempleo will be paid for a period of four months or two years (depending on the amount of contributions). The first 180 days are compensated at 70% of the average salary (excluding overtime), and then at 50% after 180 days.
Self-employed workers can take out unemployment insurance with an insurance company, in order to receive benefits in event of cessation of activity if the following conditions have been met: if they are not receiving a contributory old-age pension, if they have contributed for the last 12 months without interruption, or if their activity has ceased for a specific reason (economic, force majeure, technical. etc.).
The duration of the compensation depends on the contributions paid in the 48 months preceding the cessation of activity. The amount of compensation depends on the average of the contribution bases received in the last 12 months: 70% of the regulatory base, according to a minimum and maximum amount.
The Subsidio por Desempleo is available to:
- insured persons who are no longer eligible for unemployment insurance,
- who have monthly resources of less than 75% of the minimum wage (i.e., €723.75/month in 2021),
- who have contributed to the unemployment insurance for at least six months (or three months if they are the head of a family) and
- are registered with the employment services and are actively seeking employment (reasons must be given for rejecting job offers).
*In 2021, the SMI (minimum wage) was €965/month.
Family and maternity cash benefits are also provided. For more detailed information on these social benefits, please visit the CLEISS website, which offers extensive documentation.
Since 2020, the Ingreso Minimo Vital has been available to anyone who has resided for more than 12 months in Spain, and who is between 23 and 65 years old.
This allowance is paid monthly, without means testing, if applicants can prove that they have previously applied for all the social benefits for which they are eligible.
The application is made directly online. In 2021, the allowance was €469.93/month for a single adult receiving no other assistance.
Sickness/maternity insurance (e.g., maternity leave), old-age insurance, and disability and survivors insurance are financed by what is known as the general contribution. As of January 1, 2022, for employees, the general contribution is 23.6% for the employer's share and 4.7% for the employee's share.
The base for calculating the general contribution varies according to the worker's professional category, and it will also be capped accordingly. For example, for engineers and graduates, it is a maximum of €4,139.40 per month.
The unemployment contribution for an employee with an open-ended contract is 5.5% for the employer and 1.55% for the employee. The employer is responsible for the workplace injury and disease contributions only.
All these social benefits are administered by the INSS (Instituto National de la Seguridad Social).
How are the healthcare services provided by public healthcare institutions paid for? These services are financed almost exclusively by taxes, as are family benefits.
Regarding the contributions of self-employed persons covered by the general scheme, via the special RETA scheme: they pay an overall contribution for social insurance. This is calculated on a monthly base that varies, depending on their choice, between a minimum of €960.60 and a maximum of €4,139.40 per month (the contribution base can be changed four time per year). Caps are set depending on the different situations. The overall contribution rate is 28.30%.
In addition, the workplace injury and occupational disease contribution is set at 1.30% of the calculation base, while the contribution to the protection scheme against termination of employment amounts to 0.90%.
Finally, 0.10% of the contribution base is deducted to finance professional training.
As previously mentioned, there is no public/private cross-over coverage in Spain.
The local insurance (or health assistance) does not supplement social security reimbursement, but does allow access to a private health network. It is important to remember that the care pathway which will be initiated outside of public services must be performed in its entirety in the private sector.
Local insurers include Sanitas, Adelsa, Mafre Salud and Aegon Salud. Companies frequently offer these policies by these insurers. They provide a parallel network to the public sector, in which the insured can receive care at no additional cost. The level of benefits is determine by the amount of contributions!
Please note, these plans cover the costs of doctors and hospitals, but the insured often has to pay 100% of the pharmacy costs. In addition, although the insurance company may approve the hospital, it may not approve all the specialists who offer services at the hospital. Before selecting your health assistance plan, it is important to learn about the coverage limits, the network of doctors and places of care, and the type of expenses covered.
You can find insurance for hospitalization plans, doctors or for dental coverage only (these health costs are not covered elsewhere).
Finally, there is so-called private medicine, which is practiced outside the insurance networks and the public sector. The rates charged for private medicine are not regulated, and there is no private/public cross-over coverage. Expatriates often use private medicine because it removes the limitations imposed by health insurance companies and social security. In this case, it is essential to take out an expatriate health insurance policy in order to be reimbursed for your healthcare costs.
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Health insurance is mandatory when applying for a residence permit and a visa for Spain. Not all health care costs are covered in the public sector and private insurance is often necessary to cover these costs.
Even if you have to pay for private insurance, an expatriate insurance policy will give you great freedom of choice, a good level of reimbursement for all the benefits you want to cover (including pharmacy, optical/dental, alternative medicine, private rooms and more), and the peace of mind knowing that you are covered in your home country if you keep certain doctors and procedures there.
You can take out expatriate insurance at any time, whether you are departing within three months, have just arrived or have been a resident for several years.
International insurance offers are flexible, and you can choose only the options that interest you. The benefits are similar to those you are familiar with, which avoids uncertainties about how local reimbursements work. In terms of your budget, expatriate insurance will be a little higher than local Spanish private insurance, but it will also offer more advantages and greater flexibility.
In addition to the benefits mentioned above, your expatriate insurance policy also guarantees emergency international health coverage for your personal or professional travel.
Expatriate insurance is also complementary to the Caisse des Français de l'Etranger, the social security fund for French nationals and European citizens living abroad. If you choose to join, the CFE's health coverage is only a first basis for reimbursement. With expatriate insurance, you get reimbursement rates that are in line with the rates available in your host country.
Finally, travel insurance is not enough: many expatriates think they can save money on expatriate health insurance by using their travel insurance/CB or the European Health Insurance Card (EHIC).
However, in the event of a problem, the travel insurance company will ask you to provide proof of your travel conditions, return ticket, type of accommodation and Social Security reimbursement. If they find out that you are staying for more than 90 days, and are not on a short trip, they will deny coverage.
In Europe, the EHIC allows European citizens to benefit from their local coverage in UE countries, for emergency expenses during temporary travel, and not for expatriation/residence abroad; and not for scheduled care. The reimbursement basis will be the local basis if you are covered directly by the local health insurance. You may also be reimbursed on the basis of your own EU country basis, if you are not covered directly by the local health insurance. This basis will sometimes be lower than the rates charged in Spain. You may be surprised by the amount of out-of-pocket expenses you have to pay.
The procedures for enrolling in expatriate coverage are more complex than for traditional insurance, so it is recommended that you enroll at least 30 days before your departure.
All expatriate insurance companies require you to complete a health questionnaire. Depending on your medical history, discussions with the medical department may take some time. You may need to gather additional documents, consider a specific proposal, or have your doctor complete a specific questionnaire.
Our website allows you to get quotes online and to compare coverage.
An advisor will be available to help you review the proposals, assist you in choosing a policy and accompany you through the enrollment process.
Your advisor can also verify that the plan you have selected has been accepted/recognized by the administration.
Because universal health coverage is available to all residents (employed or self-employed), the biggest risks will be covered locally by the public sector (hospitalization and doctors).
If you wish to benefit from private sector healthcare services and to be able to select the doctors and medical facilities you prefer, you should choose an expatriate hospitalization and medical plan.
This type of coverage will allow you to consult your usual doctors when you are in France, and will cover any health expenses that you would prefer to continue to incur there.
If you can afford to spend more on your health budget, and if you have a regular need for it, choose a plan that also reimburses optical/dental expenses; although quite accessible, you are generally responsible for these healthcare costs.
If you are insured with the Spanish social security system, you do not have to pay for consultations, hospitalization and certain primary healthcare services. However, for example, you will have out-of-pocket pharmacy expenses.
With local private insurance, the costs can be paid for medicine and hospitalization, only within the network (approved institutions and doctors). It is recommended that you confirm any procedures with your insurer, especially for hospitalization.
With expatriate insurance, for hospitalization of more than 24 hours, the insurer organizes the payment with the hospital/clinic. You must pay in advance for routine medical and optical/dental expenses.
Nowadays, reimbursements can easily be requested online (no more sending requests by mail); insurers all offer customer portals or mobile apps for submitting your reimbursement requests and tracking them.
In general, invoices up to €1,000 can be transmitted digitally. Invoices for amounts over €1,000 (which is more rare) must still be sent by mail.
The quality of care and the local facilities mean that there is little risk that you will have to be repatriated for health reasons. However, repatriation assistance may be useful abroad in the event of an accident or illness that occurs during a trip/vacation or business trip (depending on how often you travel and for how long).
It also offers services that can be considered as "comfort" but which will be welcome in the event of a serious problem, such as paying for the trip of a relative to come to your bedside, arranging for the care or transport of children, receiving medical advice and guidance, repatriation of the body in case of death, etc.