What Does Health Insurance Consist Of And How Can I Accredit It?

In this blog post, we are going to talk about health insurance, a frequent requirement in some immigration authorisations that can be accredited through various ways. Let's get to it!

The applicants for the following authorisations must prove that they have health insurance as a requirement for their granting: 

• Temporary non-profit residence

• Studies

• Job-seeker residence

• Certificate of registration of EU citizens (students, non-workers and their accomplices)

• EU citizen family card (in cases where the citizen who reunites with their family does not work)

• Visa for digital nomads (except if the country of origin has a Social Security agreement with Spain)

• Residence for entrepreneurs

The main reason for this requirement is to protect the financial sustainability of the Welfare State. We could summarise it with the following premise: “those who do not contribute to the system should not consume its resources.” Spain's Immigration Law has as its fundamental pillar that foreign residents do not become a burden on social assistance in Spain. By requiring private insurance, the State ensures that if something happens to a foreigner, who has not contributed to the national Social Security system, the bill will be paid by a private company, the insurer, and not the Spanish taxpayer.

This principle applies not only in Spain but throughout Europe, under the Directive 2004/38/EC, concerning the rights of Union citizens and their family members to move and reside freely in the territory of the Member States. It distinguishes between active citizens, who have social rights by contributing, and inactive citizens, who must have the right to reside only if they demonstrate that they have sufficient resources so as not to destabilise the budgets of the host country. This is why it is a requirement that is asked of citizens from the Union, European Economic Area, and Switzerland when they come to reside in Spain without working.

Healthcare coverage in Spain can be demonstrated in various ways, making it important to distinguish between public and private health insurance. The way to demonstrate healthcare coverage entirely depends on whether you access the system through the public network, that is, Social Security, or through a private entity. There are 4 main types of insurance, and below we will see what they are.

⚕️ Private Health Insurance 

Who needs to prove it?

This is the catch-all category. It is the most common route for non-EU citizens and those who do not work. You can opt to take out a private health insurance policy with a Spanish insurance company or one authorised to operate in Spain that provides complete coverage in Spain.

What companies are there?

The most common insurance entities are Sanitas, Adeslas, Mapfre, Asisa, among others… In any case, make sure, by searching the following link, that your insurance entity is listed in the Register of Insurance and Reinsurance Entities of the Directorate General of Insurance and Pension Funds (DGSPF).

Our recommendation is that, if necessary, always take out insurance with a recognised and reputable insurer, with a wide presence and track record in Spain. Taking out cheap insurance online, just to meet the Immigration Authorities' requirement, may be convenient, but when the time comes it can be costly and overwhelming. If you have a healthcare need during your stay in Spain, it is better to be well supported with a wide and recognised network of centres and doctors throughout the country.

What should the policy include?

Make sure that the insurance has the following characteristics: 

1. It is full-time.

2. With benefits similar to those provided by the basic common portfolio of health care services of the National Health System. That is, the care activities for prevention, diagnosis, treatment and rehabilitation carried out in health or social health centres, as well as emergency medical transport, which are normally fully covered by public funding.

3. It is exempt from copayments, reimbursements and waiting periods.

4. If the policy has limited coverage to a specific amount, this shall not be less than €30,000.

5. The insurance contract must be maintained for the duration of the authorisation period.

🏥 The Spanish Public Healthcare System (Social Security) 

For many foreigners, the simplest way to prove healthcare coverage is through the public system. In Spain, the right to health is intrinsically linked to contribution to the system or family ties with a contributor. This is certified by the certificate from the National Institute of Social Security (INSS).

Who are entitled to the right?

All those who actively contribute to Social Security are entitled. This includes:

• Wage earners (employees).

• Self-employed workers (freelancers).

• Pensioners in the Social Security system.

• Recipients of periodic benefits (such as unemployment benefits, commonly known as “paro”, or the minimum vital income). 

• Unemployed: People who have exhausted their unemployment benefits and remain registered as job seekers. 

• People with insufficient economic resources (who do not fit into the previous groups but reside legally). 

If you come to Spain as a wage earner and/or self-employed, you do not need to prove that you have health insurance, since Immigration Authorities understands that, by registering with Social Security based on the contributions that will be generated through your work, you will have guaranteed public healthcare assistance financed by State funds. By working, you will be contributing to the system and, likewise, you will be able to benefit from it.

There is an exceptional modality for joining Social Security by paying a monthly fee, known as the special agreement for the provision of healthcare assistance, which we will discuss below.

Who can be beneficiaries?

The right holder (the worker) can "extend" their healthcare coverage to their direct family members, who will acquire the status of beneficiaries, as long as the requirements of cohabitation and economic dependence are met.

The family members who can be included are:

• Spouse or partner (duly registered in the corresponding registry).

• Ex-spouse or person legally separated, if they are dependent on the holder and receive a compensatory pension.

• Children/grandchildren/siblings under 26 years of age.

• Children/grandchildren/siblings over 26 years of age with a recognised disability of 65% or more.

The Key Document: the INSS Certificate

Being employed is not enough for Immigration Authorities to know that you or your family is covered based on being the right holder or beneficiary. You must demonstrate it through the “Document certifying the right to public healthcare assistance,” in this case, the INSS certificate. Without this paper, it is very likely that you will be required to have private insurance subsidiarily.

How is it requested?

The holder must carry out the procedure for "Inclusion of beneficiaries" before the National Institute of Social Security (INSS). This can be done in person by appointment or electronically through the Electronic Headquarters of Social Security (with a digital certificate or Cl@ve).

Once approved, the system generates a document listing the holder and all their associated beneficiaries with their respective identification codes.

Other Requirements

For the INSS to accept a family member as a beneficiary, three fundamental conditions must be met:

1. Residence: It must be legal and habitual in Spain.

2. No personal coverage: They cannot be insured by any other means (for example, because they already work).

3. Economic dependence: The family member must not have personal income exceeding the legal limit.

🇪🇺 European Agreements

This option is specific for citizens of the European Union (EU), the European Economic Area (Iceland, Liechtenstein and Norway), Switzerland, or the United Kingdom. It is the legal mechanism that allows "exporting" the right to healthcare from your country of origin to Spain, all through the well-known S-1 form.

What is the S-1 form? 

The S-1 form (replacement for the former models E-121, E-106, E-109, and E-120) is a certificate that certifies your right to receive healthcare assistance in a European Union country when the person is insured in another EU/EEA/Switzerland/UK Member State.

Its operation is simple but powerful; by registering this document in Spain, the country that pays your pension or benefit legally commits to reimburse Spain for the medical expenses you need. For Immigration purposes, the S-1 form is equivalent to having complete public insurance and is the preferred route for EU/EEA/Switzerland/UK citizens moving to Spain.

Who can submit the S-1 form? 

The most common cases that can use this route are:

• Pensioners (retirees): people receiving a retirement or disability pension in their country of origin. 

• Posted workers: People sent by their company to work temporarily in Spain but who continue contributing in their country.

• Cross-border workers: People who work in one country but reside in another (and return home regularly).

In addition, the dependants are also eligible as long as they reside with them in Spain.

How does the process work?

The S-1 form itself, issued by the Social Security management body in the country of origin, is sufficient to certify healthcare assistance before Immigration Authorities. However, for it to take effect, it is not enough just to have the paper in hand; it must be validated in Spain:

1. Request in origin: You must request the S-1 Form from your country’s social security institution (before coming to Spain).

2. Registration at the INSS: Once in Spain, you must go to the National Institute of Social Security (INSS) to register the form.

3. Issuance of the Spanish certificate: The INSS will provide you with a document certifying that you are already integrated into the Spanish public system “charged to another Member State” and with your Social Security number in Spain.

⚠️ Attention! ⚠️

Although it is sufficient to present the S-1 form to Immigration Authorities, it is important to go to an office of the National Institute of Social Security (INSS) in Spain to validate and register it to ensure your inclusion in the national Social Security system. In addition, you will need your Social Security number to register in your Autonomous Community for the issuance of your health card. Not doing so may lead to bureaucratic problems and generate debts with the National Health System if you receive healthcare assistance while residing in Spain. All of this, on top of not being able to benefit from the right to healthcare if you are not active in the database of the Spanish Social Security.

🪪 European Health Insurance Card (EHIC)

The European Health Insurance Card is a personal and non-transferable document that certifies the right to receive necessary healthcare benefits, from a medical point of view, during a temporary stay in Spain. It is issued by the social security body of the country where you contribute or receive a pension, or where you are a beneficiary.

Who can use it as accreditation?

This route is exclusive to citizens of the European Union, European Economic Area (Iceland, Liechtenstein, Norway), Switzerland, and the United Kingdom in very specific cases.

It is the ideal option for:

• European students: Students coming to Spain for an Erasmus, a degree or a master's, or a training course for a determined period.

• Tourists or visitors: Citizens who do not intend to reside permanently but need to demonstrate or wish to receive healthcare coverage while in Spain.

What does it really cover?

It is vital to understand that the EHIC is not an "all-risk insurance". It covers necessary medical assistance (emergencies, unforeseen illnesses, chronic illnesses, childbirth, etc…) so that the citizen can receive the required attention without having to return to their country prematurely. Additionally, it gives you the right to receive assistance under the same conditions as if you were another resident of that country; if it costs citizens some service or there is a copayment, you will also have to face that cost. This is also not valid when the purpose of the trip is to receive medical treatment. Unlike the S-1 Form, the EHIC is not intended for scheduled recurring treatments or for people who transfer their residence permanently to Spain.

🩺 Health Insurance For People In An Irregular Situation (Undocumented)

It is very common to confuse the right to health with the fulfilment of immigration requirements. Spain is a country with universal healthcare, but for the "undocumented", the rules change. If you find yourself in an irregular situation, you have the right to receive healthcare assistance thanks to the Royal Decree-Law 7/2018. This decree guarantees that health is a right of all people, regardless of their administrative situation.

To access this right, in general, you must follow the following steps. However, local competencies related to health are delegated to Autonomous Communities, so the criteria and documents required may vary based on your locality of residence:

• Register in the municipal register: This is the first and most important step. Being registered (empadronado) is the official proof that you reside in a Spanish municipality.

• Prove a minimum stay (+90 days): Generally, the system requires you to demonstrate that you have been in Spain for more than 3 months (the municipal register serves for this). If you have been there for less time, you will only have coverage for emergencies, pregnancy, childbirth, and care for minors.

• Request the healthcare assistance document: You must go to the Health Centre (outpatient clinic) assigned to your address and request registration for persons without legal residency. It will be essential to present your passport/NIE and the certificate of registration to carry out the procedure.

Certain vulnerable groups, who are protected due to their condition, may benefit from complete healthcare without conditions, such as minors, pregnant women, etc…

⚠️ Attention! ⚠️

This healthcare procedure allows you to go to the doctor "for free", meaning, at the expense of public funds, but is not valid as health insurance for Immigration purposes. If you present this card to apply for a residency that requires you to have “private or public health insurance,” it will be denied as it is considered a "public burden" for the State. Moreover, it may not cover all the service portfolio offered by the National Health System and may be limited to certain situations, such as emergencies.

🩹 The Special Agreement for the Provision of Healthcare Assistance from Social Security

There is a little-known but very interesting option for those who have been living in Spain for some time, do not work, and due to age or previous health conditions, have difficulty taking out private insurance. We are talking about paying for public healthcare, the special healthcare assistance agreement from Social Security. For a monthly fee, similar to an insurance premium, you have access to the services of the basic common portfolio of healthcare services offered by the National Health System, with some specific exclusions and without coverage of subsidised pharmaceutical benefits.

Who can subscribe to it and how much does it cost?

It is designed for people who already reside in Spain but do not have the status of insured or beneficiaries of the National Health System. To access it, you must meet two requirements:

• Effective residence: Prove that you have resided in Spain for at least one continuous year immediately prior to the application.

• Registration: Be registered in some Spanish municipality at the time of application submission.

• No other access route: Not having the right to healthcare assistance by any other national route or international agreement.

There is a flat monthly rate, which varies depending on age:

• Under 65 years old: €60 per month.

• Over 65 years old: €157 per month.

Is it valid for Immigration purposes?

Yes, the special agreement of Social Security is totally valid for Immigration purposes. As a regulated access to the public system, Immigration Authorities accept it as proof of health insurance, equivalent to complete private insurance.

This is an ideal option at the time of renewing the residence authorisation for older individuals or those with pre-existing conditions, as private insurers often reject these groups, and those who prefer the public system over the private one.

🚋 At Traam, we help you manage the immigration procedures you wish to undertake, and part of our work is to verify that the method and documentation for access to healthcare during your residence in Spain is correct, validating it and providing you assistance before submission in case of doubts. What are you waiting to obtain your residence in Spain? Come and get on board with Traam!