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Accessing Public Health Care In Catalunya

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In Spain, there is a public, universal health-care system that is available to all Spaniards funded by taxes. But, did you know that if you are an expat you can also be covered by this health-care system?

If you’ve lived in Spain for more than ten years, you probably know that this was the case up until April 20, 2012 as well. However, on that date the conservative government of Mariano Rajoy limited coverage for undocumented residents with the Real Decreto-ley 16/2012, de 20 de abril. This law virtually cut off health-care access to adults who were not legal residents of Spain, providing them with only the most basic emergency services. But when PSOE took the reigns again in June 2018, one of the laws passed early on was Real Decreto-ley 7/2018, de 27 de julio which once again provided access to the public health-care system to all in Spain regardless of legal status. This law remains in effect, and as long as the coalition of left-leaning parties remains in power, it is unlikely to change. 

One thing that is important to remember about the Spanish health-care system is that it  is decentralized, so the way system works in each of Spain’s 17 communities varies, and coverage can vary too, with some regions—such as Catalunya—offering even more services than legally mandated. Each community has its own health-care card (targeta sanitària individual (TSI)) and health-care management system, so coverage will vary, depending on where you live.

It’s also important to remember that while in principle health care in Spain is “universal” your access may be limited by your legal status (certain types of visas preclude access). Additionally, your country of origin—EU nationals vs. third-country (non-EU) nationals—will determine how and what you can access as well. More on that later.

How CatSalut Works

The Catalan Department of Health contracts with the organization CatSalut to provide health care services in Catalunya. In essence, CatSalut is an insurance company in a single payer system that contracts with public and private health-care delivery organizations to provide health services. The public organization Institut Català de la Salut (ICS) provides 80% of the services. Another 10% is provided by other public entities, and just 10% of the services are provided by private businesses. In some cases, local governments form collaborations or consortium with provider organizations to cost share. There are close to 300 clinics throughout Catalunya and the patient has free choice as to where to receive primary and specialty care.

There Are Six Different Levels of Coverage in the CatSalut System:

  1. Department of Health, health interest program (programes d'interès sanitari Departament de Salut)
  2. General health coverage (cobertura sanitària general)
  3. General health coverage except pharmaceuticals (cobertura sanitària general excepte farmàcia)
  4. CatSalut second level access (accés CatSalut segon nivell)
  5. Coverage based on special agreement, Royal Decree 576/2013 (cobertura conveni especial Reial decret 576/2013)
  6. PMO health coverage (cobertura sanitària PMO) and EMBL health coverage (cobertura sanitària EMBL)

The majority of the Spanish population enjoys general health coverage (#2 above), providing access to all benefits. What is available to foreigners can be determined by many factors. 

If you are a foreigner who is a  legal resident with permission to work, you can also enjoy the same level of access as Spanish citizens, and can access full health-care coverage throughout all of Spain; this is true for EU and third-country nationals alike. While on the other end of the spectrum, some visas—such as the non-lucrative visa—designate the holder as a legal resident, but do not allow access to the public health-care system. In fact, proof of complete, private health-care coverage is required in order to be eligible for some visas. There are many designations that fall between those two examples; we’ll just touch on the ones that affect most foreigners. 

Third-country nationals residing in Catalunya who are not legal residents are eligible for CatSalut second level access (#4 above), however being empadronat (registered) is a requirement. So, yes, even if you are living in Catalunya “under the radar” you do have access to public health care. But, because this level of coverage goes beyond what is required by the national law, this level of care is only available in Catalunya and not the rest of Spain. 

EU, EEA and Swiss nationals who have reached retirement age in their home country are entitled to access the national health-care system in Spain. In order to qualify they must obtain an S1 form from their country of residence. 

What Is (and Isn’t) Covered

For most people who qualify for the CatSalut card, almost all health care services are covered at no cost to the patient and there are no exclusions for pre-existing conditions. Coverage generally includes primary care, specialized care, mental health care, medical transport, some degree of pharmaceutical coverage, physical therapy, support for chronic illnesses and palliative care.

However, there are some services that are not covered. Notably, dental care coverage is very limited. This seems out of place from a public policy perspective in such a progressive single payer universal health-care system, as dental health is critical to overall health. Dentistry services are covered for children, diabetics and pregnant women. For the rest of the population, dental services are limited to emergency extractions and injuries, but not more invasive and expensive interventions. 

Another large excluded service is medical services for aesthetic purposes only. For example, breast reconstruction after mastectomy is covered, however breast implant surgery for appearance only is considered elective surgery and is not covered. 

There are no outright limits on diagnostic tests, procedures, imaging etc., but physicians do follow science-based practice guidelines to determine what tests and frequency of testing are necessary so as to avoid driving up costs. Additionally, podiatry is not covered, with the exception of people with diabetes, who are permitted up to three preventive check-ups annually.

Pharmaceuticals

The only charges to patients in the national health-care system are for medications, which have only recently been implemented nationwide to reduce waste and abuse. Coverage rules are determined at the national level, not at the regional level.

For those who receive general health coverage (#2 above), seniors pay just 10% of the retail price, with a cap on payout based on income. For the employed, individuals will pay from 40% to 60% of the retail price, again, based on income.

For those who receive CatSalut second level access (#4 above), the cost of medications prescribed in primary care is just 40% of the retail price. In both cases, there is no requirement to use generics when they are available and there is no cost for pharmaceuticals administered when an individual is admitted to a health center within the public health network.

Even if you aren’t eligible for the reduction of costs as described above, the vast majority of medications in Spain are remarkably inexpensive as compared to the retail prices in the US.

Additional Services

There is a wide range of mental-health and substance-abuse addiction services. Remarkably, residential detox and rehabilitation programs, such as for alcohol and opiate addiction, are from 12 to 18 months as compared to the 30-day norm in the US.

Beyond the normal range of health-care services, CatSalut also covers some services that some private health-care insurance in and outside of Spain do not, such as:

Private Insurance

There is a completely separate private health-care system, paid for by employers and their employees or by private individuals. The advantages of the private system are often seen most in terms of significantly reduced waiting times for procedures and in the more upscale facilities. There may be other reasons people choose to have private insurance in addition to CatSalut, such as clinician preference or convenience. Many people with private insurance see their private physician for care but maintain a relationship with a CatSalut physician for prescriptions to enjoy the discounted drug costs, because in the CatSalut plan you must present an official CatSalut prescription to the pharmacy to get the discounted rates 

As mentioned earlier, if you are a third-country national, you may be required to get private insurance in order to qualify for certain types of visas, and, come renewal time, you will have to submit proof of your private insurance coverage again. Your private insurance must provide coverage equivalent to the coverage provided by the national health-care system and have no additional co-pays or deductibles. In this scenario, you can forget about getting the cheapest private plan and then relying on CatSalut to cover you.

How to Register for Public Health Care

To enroll in the national health-care system here in Catalunya, you must go to the centre d'atenció primària (CAP) in your district in person with the following documents:

Your CatSalut card will be mailed to you free of charge to the address at which you are registered.

Electronic Access

The medical records of CatSalut and private insurance are not shared unless specifically requested. Participants in CatSalut can access their records online through the La Meva Salut. Appointments can also be made online as well as arranging for video visits.

The single payer universal health-care system provided by CatSalut has much to be admired. You have to decide if you want to or need to enroll. There may be some distinct advantages given your personal situation, but you cannot forget your obligations for health-care coverage based on your immigration status.

Punished January 22, 2020, updated July 14, 2023.

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