Spain's public healthcare for Americans: convenio

Spain's public health system is good and cheap, but it isn't automatic for Americans. You get in through a job, or, after a year of living here, by paying a fixed monthly fee under the convenio especial. Until then, private insurance is your ticket.

The short version

If you work in Spain and are registered with Social Security, you and your dependents are covered by the public system, which in Madrid is the SERMAS (Servicio Madrileño de Salud) [1].
If you don't work (non-lucrative visa holders, retirees, many remote workers), you can join through the convenio especial after one year of continuous residence, registered on the padrón [2][3].
The fee is EUR 60 (about USD 67) a month under 65 and EUR 157 (about USD 175) a month at 65 and over, per the Ministry of Health and Comunidad de Madrid pages when we checked in November 2026 [2][3].
It covers doctors, specialists and hospital care with no copays or waiting periods, but not prescriptions, which you pay 100% [2].
For your first-year visa, Spain requires private insurance from an insurer authorized in Spain, with no copays, no deductible and no waiting periods [4].

USD conversions use the Federal Reserve H.10 rate of October 30, 2026 (EUR 1 = USD 1.1163), rounded.

Three ways into healthcare in Madrid

Route	Who it fits	Cost	Covers prescriptions?
Work (Social Security)	Employees of Spanish companies, registered self-employed (autónomos), their spouses and kids	Paid through payroll or self-employed contributions	Yes, with the standard copay [1]
Convenio especial	Residents with one year on the padrón and no other public cover	EUR 60 or EUR 157 a month [2][3]	No, 100% paid by you [2]
Private insurance	Everyone in year one; anyone wanting shorter waits or English-speaking doctors	Varies by age and plan	Depends on the policy

Back in the States, losing your job can mean losing your insurance. In Spain the public system is tied to residence and contributions rather than an employer's plan, and it doesn't bill you after a hospital stay. No surprise ER bill in the mail.

Coverage through work

If you're hired by a Spanish company, your employer registers you with the Social Security system (you're afiliado en alta). Self-employed autónomos register themselves. Either way, you become an asegurado (insured person) [1].

Your spouse or registered partner and your children under 26 who depend on you can be added as beneficiarios [1]. The process:

Your right to care is recognized by the INSS (Instituto Nacional de la Seguridad Social). You can check it and download the certificate on the Social Security Sede Electrónica [1].
Take that document to your local health center (centro de salud) and ask for the tarjeta sanitaria individual.
You're assigned a family doctor (médico de cabecera), who refers you to specialists.

That Social Security explainer dates from 2020, but the basic categories it describes still apply [1].

Remote workers on Spain's digital nomad visa who stay on a US payroll usually aren't in the Spanish system this way. They rely on private insurance and can look at the convenio after a year.

The convenio especial, step by step

The convenio especial de prestación de asistencia sanitaria is a pay-in deal for people who live in Spain but have no other route into the public system. It's set by Real Decreto 576/2013 [2].

Who's eligible

To apply in Madrid, you must [2][3]:

live in the Comunidad de Madrid
prove at least one continuous year of actual residence immediately before you apply (time in another EU country, the EEA, Switzerland or the UK counts)
be registered on the padrón of a Madrid municipality when you apply
have no access to public health cover any other way

That last point rules out workers, who are covered anyway, and EU citizens whose home country covers them.

What it costs

The Ministry of Health and the Comunidad de Madrid both list EUR 60 a month under 65 and EUR 157 a month for 65 and over [2][3]. That's about USD 800 a year or USD 2,100 a year. Neither page states which year these amounts apply to; they're set in the 2013 decree, and they hadn't changed when we checked in November 2026. Confirm on the Madrid page before budgeting.

For an American retiree used to Medicare premiums plus a Medigap plan, that's sticker shock in the good direction.

What it covers, and what it doesn't

The convenio gives you the basic common portfolio of the national health system: prevention, diagnosis, treatment and rehab, primary and specialist care, outpatient and inpatient, plus urgent ambulance transport, with no copays and no waiting period [2].

It does not include the supplementary portfolio. Outpatient prescriptions, orthopedic devices, special dietary products and non-urgent ambulance trips are 100% on you [2][3]. If you take expensive maintenance meds, price them at a Madrid pharmacy before you count on the convenio alone.

In Madrid, you don't get the usual health card. You get a Documento para Asistencia Sanitaria, which you show with your ID at public health centers [3].

How to apply in Madrid

Get a historical padrón certificate (volante or certificado de empadronamiento histórico) showing at least one year. It must be issued within 90 days of your application [3].
Gather the rest: a full copy of every page of your passport, and your NIE (the region can check it electronically) [3].
Apply online or in person. Each family member files separately. There's no application fee [3].
Wait about a month for the decision. Fix any missing documents within 15 days of being asked, or the file is closed [3].
Sign the convenio in person on the date you're given, and get the instructions for monthly bank payments [3].

Don't miss a payment

The convenio ends if you skip the first payment, two months in a row, or three months in total. If it ends, you can't sign a new one for a year [3]. Set up a reminder the way you would for a car payment back home. Help line: 012 within Madrid [3].

Private insurance for your visa

None of this helps on day one, because the convenio needs a year of residence. That's why Spain's consulates require private cover for the non-lucrative visa: a policy from an insurer authorized to operate in Spain, valid for a year, covering the risks the public system covers, with no deductible, no copayment, no waiting period and no coverage limit. Travel insurance doesn't count [4].

That's very different from a typical high-deductible US plan. Check the fine print against the consulate's wording before you buy. Many Americans keep private cover even after joining the convenio, for faster specialist appointments and English-speaking doctors.

What about Medicare?

Medicare generally doesn't pay for care outside the US. If you're 65 or older and moving to Madrid, you'll need a decision on Part B: keeping it means paying premiums for coverage you'll mostly use only on trips home, while dropping it can mean late-enrollment penalties if you return. Our Medicare guide walks through the trade-off.

Wondering which private policies other Americans used for their visa? Ask in our community group for Americans in Spain.

Spanish public healthcare for Americans: work, the convenio especial and private cover