Health Provision and Insurance in Spain

Healthcare in Murcia

The question of whether we are entitled to receive healthcare in Spain is a complicated one, as it very much depends on the age and residency status of an individual.

This attempts to clarify the system and help you to make sure that you have fully protected yourself by taking the appropriate measures and help to avoid some of the situations in which unwary ex-pats find themselves every year.

   Contents.

• Quick links to useful websites
• The difference between Spanish and English healthcare systems
• EHIC cards for UK visitors to Spain
• Moving to Spain permanently and what constitutes a Spanish resident
• 1 - 7 Specific situations

  If you are searching for information about a specific form, Please use the links below.

• Obtaining an EHIC card in the UK
• E121
• E106
• TSE card ( For Spanish residents wishing to travel abroad)
• NHS Website
• British Consul Website 

  Spanish and English Health systems

In the UK, the mere fact that you are resident in the UK gives you an entitlement to free healthcare. This style of provision is called "residence based "healthcare.

In Spain, the system is "contribution based" so you can be living in Spain, but have no entitlement to health care unless you are making contributions to the Spanish system or your country of residence has a reciprocal arrangement with Spain.

Only State Pensioners living here full time, and those working legally in Spain are entitled to Spanish State Health Care, but there are many UK citizens who do not fall into either category and are putting themselves in a situation whereby they could face severe financial penalties should they encounter a medical problem. 

Many of the problems experienced by ex-pats are to do with money.

The Spanish government will only take responsibility for its own citizens and will not pay for the healthcare of anyone else.

If you need healthcare whilst in Spain, it costs money and either this government, the UK government or an insurance company will have to pay for the care you receive, and it is your own responsibility to ensure that you have either followed the correct procedures and acquired the appropriate documentation, in accordance with the laws of your country of residence, or taken appropriate health or travel insurance.

There have been several well documented cases of UK citizens having to pay thousands of euros for health emergencies and repatriation to the UK for treatment because they have not obtained correct documentation or appropriate insurance

It all boils down to money, with nobody willing to pay for the healthcare of residents from other countries.

The same applies to ex-pats who have left the UK and are now resident in Spain. The UK government will respond in exactly the same way if you need healthcare whilst on a visit to the UK- as a Spanish resident you are not in their care any more and they will not pay the bill for emergency treatment if you have not obtained the correct documentation to cover your UK visit.

  Important Information For UK Residents Travelling From The UK

Anyone travelling out of the UK, either on holiday, visiting Spain for less than 6 months of the year, or on an extended visit with a view to settling here, must carry an EHIC, which is a European Health Insurance Card, entitling them to emergency cover should they need medical help whilst in any EU state. These are valid for 3-5 years,  and are free from the Department of Health.

• By phone 0845 606 2030 or 0044 191 203 5555(If outside the UK)
• By Post. EHIC Applications, PO Box 1115, Newcastle Upon Tyne, NE991SW 

We cannot stress enough how important it is to obtain an EHIC before leaving the UK, as it will take time to process all your Spanish documentation once in Spain, and without this temporary cover, you have NO MEDICAL COVER ENTITLEMENT unless you have private insurance. 

IF YOU ARE PLANNING TO MOVE TO SPAIN PERMANENTLY we would strongly advise consulting the British Consulate website and the NHS website for their full advice. For the sake of clarifying points raised below, all State Registered pensioners should obtain an E121 before leaving the UK if they are intending to re-locate here. See above for links and refer to the websites mentioned above for detailed information. 

Before we look at individual situations, lets just clarify what actually constitutes a resident of Spain.

  What constitutes A Spanish Resident? 

If you live here more than 6 months of the year, you are RESIDENT IN SPAIN.

There is no point trying to pretend that you only popped over here for a couple of weeks should you be caught trying to trick the system. There are cases at the moment whereby household bills, car registration documents and phone bills are being called as evidence to prove that people are fraudulently trying to pretend they were not here when they were.

In this electronic age, BIG BROTHER IS WATCHING YOU!!!! 

Healthcare can be a fairly complicated subject, and whether you are entitled to healthcare here or not depends on your individual circumstances. Look at the list below and select which applies most accurately to your own situation, then scroll down to the appropriate information.. 

1.I am not resident in Spain as I am here for less than 6 months of the year.

2. I am a UK State Pensioner and are resident in Spain permanently.

3.I have taken early retirement and live here, but neither my partner nor myself is yet entitled to a state pension.

4.I have taken early retirement, live here permanently and my partner receives a UK state pension.

5. I am legally employed , or am a posted worker.

6. I am self employed and am a legal worker.

7. I am working here illegally. 

  1. I am not resident in Spain as I am here for less than 6 months of the year 

You own UK property, in which you are registered as living. You own or rent in Spain for prolonged periods of time, but spend MORE THAN 6 MONTHS A YEAR IN THE UK.

You are registered in the UK for your health cover, and providing you hold an EHIC card are entitled to receive state cover in Spain for the time you are here.

Anyone travelling out of the UK, even for a weekend away, must carry an EHIC, which is a European Health Insurance Card ,  entitling them to emergency cover should they need medical help whilst in any EU state. These are valid for 3-5 years and are intended to be used for short periods of time only, and are free from the Department of Health.

• Online www.ehic.org.uk/internet/home.do
• By phone 0845 606 2030 or 0044 191 203 5555(If outside the UK)
• By Post. EHIC Applications, PO Box 1115, Newcastle Upon Tyne, NE991SW

The UK has notified all European member states that from 1 April 2008, their citizens will be expected to show an EHIC in order to access necessary hospital treatment without charge.

The EHIC is NOT an alternative to travel insurance. It will not cover any private medical healthcare or the cost of things such as mountain rescue in ski resorts, repatriation to the UK or lost or stolen property.

For these reasons and others, it is important to have both an EHIC and a valid private travel insurance policy, or private medical insurance. When choosing a policy, ensure that it allows cover for all medical conditions in Spain and covers costs of repatriation. Some insurers now insist you hold an EHIC and many will waive the excess if you have one.

  Treatment covered by the EHIC

In Spain, the EHIC covers:

• all medical care that becomes necessary during a temporary stay;
• oxygen and dialysis treatment, as well as treatment for chronic diseases or a pre-existing illness. NB, You should inform healthcare authorities at your destination in Spain before you travel, to ensure that supplies are available;
• routine maternity care;

• 60% off prescriptions, and free prescriptions for pensioners (you may need to prove your pensioner status to get free prescriptions - see below).

  Treatment not covered by the EHIC

The EHIC wont cover you:

• if getting treatment is the main purpose of your trip. In this case you need to get permission from your UK local healthcare trust who will issue you with form E112;
• for long term, routine or planned treatment;

• for private sector healthcare providers. You must use the State Health System;

  Getting free prescriptions if you are a pensioner  

Additional documentation is often requested as proof of pensioner status to get free prescriptions when on holiday. If you provide proof of pensioner status and that is not accepted by the local health authorities, you can apply for a refund when you return to the UK. Send your receipts, along with a covering letter to:

DWP International Pension Centre
Overseas Healthcare Team
The Pension Service
Tyneview Park
Newcastle upon Tyne
NE98 1BA
United Kingdom

Alternatively, your nearest British Consulate can issue a certificate, valid for 3 months, confirming that you are a pensioner. For this you will need: 

• UK EHIC;
• recent DWP correspondence, addressed to your UK address, regarding payment of pension.

The consular fee for this certificate is £34, charged at the consulate rate of exchange.

  2. I am a UK State Pensioner and am resident in Spain permanently.

Before you leave the UK to move here permanently, ask the International Pension Centre (IPC) in Newcastle for an E121 form, and make sure all dependants are registered on it before you leave. This entitles you, and your dependants to health cover under the Spanish system, but once you are here, you are here, so this will not give you any entitlement to be repatriated back in the UK in case of severe illness or receive any treatment in the UK. It also does not cover any private care you may wish to receive or many things we take for granted in the UK such as social care and even nursing in hospitals.

Even private insurance will not give you these, if you need nursing help, provision should be budgeted for as you will not receive this assistance from the Spanish authorities, as the family are expected to fulfil this role and private health care will only be available if you take out private medical insurance. 

If you are a UK State Pensioner and are living here, there are a series of stages to becoming a resident, which include obtaining an NIE number and registering your presence with the local police authorities and Town Hall (Empadronamiento.)

This is done for a variety of reasons, one of the main ones being that the regional government can ask for money from the central government pool allocated for healthcare. Regions receive money based on the number of legal residents they have, and this money builds hospitals and pays for ambulances as well as paying for the right number of medical personnel, so it is very important that you register.

Once these initial processes are completed, you should register with the Spanish Health authorities and a local health centre.

To do this, your E121 should be taken along to the nearest INSS Office to where you live, together with other essential documents.

So, you need to take:

• E121 form
• Certificado de Empadronamiento, your certificate of residency which is obtained from local town halls.
• Numero de Identificacion Extranjero(NIE)/ Certificado de residencia. Your proof of Spanish residency, available from the nearest police station 

An INSS Office is the Spanish equivalent of the Social Security office in the UK.(CLICK HERE for a list of INSS Offices in Murcia) 

They will keep both copies of your E121 and issue you with a document that entitles you to full access to the Spanish State System. This is called a Documento acreditivo del derecho a la asistencia sanitaria.

As soon as you have this piece of paper you are fully covered, but you then need to register with the local health centre, so take the acreditivo to the nearest centre and they will issue you with a plastic card, the Tarjeta Sanitaria Individualizada Nacional.

This may take a few months and will not be posted to you, so you will need to call in at the centre again to see if it has arrived. Allow 3 months, then call in again. In the mean time you will be given a written version that you can use when accessing  medical care. 

Bear in mind that once you are registered as living in Spain that you will need to get what is known as a TSE, A Tarjeta Sanitaria Europea if you travel out of Spain, even popping back to the UK for a weekend, otherwise you will NOT BE COVERED in the event of needing medical attention anywhere other than Spain.

This can also be obtained from your nearest INSS office. This is a very quick process and is done on the spot, unbelievable in the land of mountainous bureaucracy, but true. 

Please bear in mind that you are vulnerable until you have registered your  E121 with the INSS. Although you will be covered for a short time when you first arrive, providing you have an EHIC card, if you do not have a UK address any more, you are technically living in Spain. Whilst it is understandable that it will take a short time to obtain all the necessary paperwork to register the E121, if you had an accident and were hospitalized you could find yourself liable to pay the medical costs involved.

So the long and short of it is:

If you are receiving a UK Pension and are moving permanently to Spain,

• Get an EHIC CARD to give short term travel cover
• Get an E121 before leaving the UK
• Make sure you have an NIE number in advance so you can obtain certificate of residency and empadronamiento quickly.
• REGISTER the E121 as quickly as possible. 

  3. I have taken early retirement and live here, but neither my partner nor

      myself is yet entitled to a state pension.

Early retirees who have relocated to Spain are amongst the most vulnerable to issues caused by  lack of health care provision, as they often end up in a situation where neither Spain or the UK has responsibility for their healthcare.

The decision to live permanently in Spain for more than 6 months of the year means that they will only be entitled to health care if they start to make payments to the Spanish system until they qualify for UK pension payments.

The move from the UK to relocate permanently to Spain, means that they are no longer entitled to UK healthcare once they have been in Spain for 6 months.

Form E106, which has actually been designed to give cover to contracted short-term workers on temporary assignment in Spain will give short-term cover to early retirees, but the cover term is limited, and will NOT cover a period of years, the cover being limited to months

BEFORE leaving the UK, obtain an E106 form. These are issued by

DWP International Pension Centre
Room TC001. Tyneview Park. Whitley Road
Newcastle upon Tyne NE98 1BA, UK
Tel: +44 191 218 1999

  Registering with the Spanish authorities

In order to register your E106 you need to get the following in this order:

i) Certificate of Residence in Spain (Certificado de Residencia/Numero de Identificacion Extranjero) - available from your nearest National Police station.
ii) Certificate as a Local Resident (Certificado de Empadronamiento) - available from the Local Town Hall (at the Padrón Office).

Once you have your certificates, take them, along with both copies of your E106, to the local Instituto Nacional de la Seguridad Social (INSS) office. They will keep one copy and return the other copy signed and stamped. This copy can now be used in order to access the healthcare system.

You dont need to register with a local GP but be aware this may mean that youre not seen by the same doctor every time.

The E106 is valid until the expiry date shown on the document and you may be treated as a private patient if the form has expired and you havent got any other right to Spanish State healthcare. If there isnt an end date, the document is valid until the International Pension Centre (IPC) tells Spain that the cover has to end. When visiting the UK, you will still be able to access NHS services under the normal rules. E106 holders should continue to use their UK-issued EHIC when visiting a third EU Member State.

  Where to get more information

If you have any queries about form E106 or health care cover, call +44 191 218 1999 (Monday to Friday: 8am - 5pm, UK time). For general information and enquiries regarding healthcare abroad, check www.dh.gov.uk/travellers.

There have been many instances of early retirees becoming seriously ill , unaware that the E106 has expired and not realising that they have no entitlement to state health care. Medical treatment in these instances has to be funded privately, and early retirees should ensure that medical insurance is contracted to cover them for the years in which they have no entitlement to Spanish state treatment .

There have been several well documented cases in ex-pat newspapers of residents needing medical treatment for severe illnesses, such as cancer, who have no entitlement to state care in either the UK or Spain, having fallen into this gap and facing huge medical bills.

Please be aware how vulnerable you are if this is your position and take adequate provisions, which basically means contracting private medical insurance. 

   4.I have taken early retirement, live here permanently and my partner

      receives a UK state pension.

Providing one of you is receiving a UK State Pension and you are registered with the Spanish authorities, you are entitled to state medical cover. Please see section 1 for details of exactly what you are covered for.

   5. I am legally employed, or I am a posted worker.

POSTED WORKER

(Employee of UK based business, with contributions being paid in the UK.)

To obtain healthcare, these workers need to obtain an E106. These are issued by:

HM Revenue and Customs CAR - Residency
Room BP1301. Benton Park View
Newcastle upon Tyne NE98 1ZZ, UK
Tel: 0845 915 4811
From outside the UK: +44 191 203 7010

Registering with the Spanish authorities

In order to register your E106 you need to get the following in this order:

• i) Certificate of Residence in Spain (Certificado de Residencia/Numero de Identificacion Extranjero) - available from your nearest National Police station.
  ii) Certificate as a Local Resident (Certificado de Empadronamiento) - available from the Local Town Hall (at the Padrón Office).
• ii)
  Once you have your certificates, take them, along with both copies of your E106, to the local Instituto Nacional de la Seguridad Social (INSS)office. They will keep one copy and return the other copy signed and stamped. This copy can now be used in order to access the healthcare system.

You dont need to register with a local GP but be aware this may mean that youre not seen by the same doctor every time.

The E106 is valid until the expiry date shown on the document and you may be treated as a private patient if the form has expired and you havent got any other right to Spanish State healthcare. If there isnt an end date, the document is valid until the International Pension Centre (IPC) tells Spain that the cover has to end. When visiting the UK, you will still be able to access NHS services under the normal rules. E106 holders should continue to use their UK-issued EHIC when visiting a third EU Member State.

Where to get more information

If you have any queries about form E106 or health care cover, call +44 191 218 1999 (Monday to Friday: 8am - 5pm, UK time). For general information and enquiries regarding healthcare abroad, check www.dh.gov.uk/travellers.

Working legally- your employer should be paying your contributions which entitle you and your dependants to healthcare under the Spanish system.

  6. I am self - employed, working legally.

If you are fully legal you will pay contributions of around 240 euros a month, which entitle you and your dependants to State Heathcare as long as you continue to pay your contributions. If work is erratic and you are unable to make your payments regularly, you should maintain a private healthcare policy.

  7. I am working illegally and am below retirement age.

If you have been in Spain for a few months only, an E106 will offer short term medical cover.

If you are here for more than 6 months consecutively, you become a Spanish resident, and have no further entitlement to UK health cover.

If you do not start making contributions into the Spanish system, you have no health cover with either country.

If youre one of these people, do something about it, because one slip off a ladder can lead to financial ruin should the worst happen, particularly if you have a family to support.

Either take out private medical insurance or register as self-employed and start to make minimum payments of 240 euros a month to the social system which will protect you and your dependants.