Spain's Convenio Especial for Americans: Paying Into Public Healthcare

The convenio especial is a contract with your region’s health service that buys access to Spain’s public health system when you have no right to it by any other route. Real Decreto 576/2013 sets the fee at 60 euros a month under 65 and 157 euros at 65 or over. For an American on a non-lucrative permit, a flat public fee is tempting, but the convenio opens only after a year in Spain, leaves prescriptions at your cost, and no immigration page says it satisfies a permit. This article is for informational purposes only and is not medical, legal or tax advice; verify current requirements with the relevant Spanish authority or a licensed professional.

Can the convenio especial replace your private insurance?

Not at the start, and at renewal only if the immigration office accepts it, which no official page confirms.

Article 3 of Ley 16/2003, in the wording that Real Decreto-ley 7/2018 gave it from July 31, 2018, grants publicly funded care to a foreigner with legal and habitual residence only if that person is not obliged to prove health cover by another route. A non-lucrative resident is obliged: the immigration regulation, Real Decreto 1155/2024, asks for “un seguro de enfermedad”, a health insurance, without saying public or private. The same article 3 lets people without the right obtain care by paying the fee of a convenio especial. Three rules then decide it for an American.

• The first year. Article 3 of Real Decreto 576/2013 requires at least one continuous year of effective residence in Spain immediately before you apply. The Ministry of Health also counts residence in other EU or EEA states, Switzerland or the UK; the United States is not on that list. Arriving from the U.S., you need private insurance for at least your first year.
• The visa. For the initial visa, the Consulate General of Spain in Washington asks for public or private insurance from an insurer authorized to operate in Spain, with no copayment or coverage limit, valid for 1 year. Its page does not mention the convenio.
• The renewal. Hoja 7, the immigration ministry’s renewal sheet updated in May 2025, and article 64 of Real Decreto 1155/2024 require that you kept a health insurance throughout the permit and continue it. Neither says whether a convenio especial qualifies.

The Ministry of Health’s convenio page describes the convenio as aimed at economically inactive foreigners who need health insurance to reside in Spain, but it ties that to Real Decreto 557/2011, which Real Decreto 1155/2024 replaced on May 20, 2025. The same page says outpatient drugs under the convenio are paid 100 percent by the patient, while the consulate asks for insurance without copayment; no official page says how an immigration office weighs the two. Treat acceptance at renewal as unconfirmed: ask the Oficina de Extranjería, the provincial immigration office handling your file, before you cancel private cover, and keep the policy until it answers. The non-lucrative visa guide covers the rest of the renewal file.

The convenio region by region in 2026

The royal decree sets the common rules; each region runs the file.

Comunidad de Madrid

The regional page, updated on December 9, 2024, measures the year through a historical padrón certificate (certificado de empadronamiento histórico, which shows your past registrations) from Madrid, plus one from other Spanish towns when your Madrid history covers less than a year, so the year it can see starts when you first register in Spain. A Director General decides within one month and gives you a signing date; in exceptional cases you can ask to move it, but you must sign within 3 months of being notified of the decision. Madrid’s list of rules still cites Real Decreto 1192/2012, whose convenio provision Real Decreto 180/2026 repealed from March 13, 2026; that 2026 decree deals with foreigners without legal residence and leaves Real Decreto 576/2013 unchanged.

Catalonia

Tràmits Gencat, the Generalitat’s procedures portal, updated on March 18, 2024, asks for the application in person, by appointment, although article 4 of the royal decree allows any public registry. The CatSalut formalization page, updated on February 27, 2024, has you pay the current month’s fee before signing, with coverage from the signing date.

Catalonia also has its own route. Ley 9/2017 opens publicly funded care through CatSalut to residents of Catalonia with no National Health System status and no other public coverage. After a 2018 Constitutional Court suspension and the withdrawal of the appeal, its articles read as they did on October 23, 2018; Ley 5/2020 later added a provision on transplants. An older CatSalut page, dated January 11, 2017, before that law, describes an earlier route: 3 months of padrón in Catalonia, a household income below the threshold it calls renda bàsica, and limited first-level care in the first year. No current page says whether a legal resident who must hold private insurance can use the Ley 9/2017 route: treat it as closed to you unless CatSalut confirms.

Valencian Community

Procedure 17044 applies Decret 190/2013 of December 20, the regional regulation named on the Conselleria de Sanitat page. The 157 euro fee applies from the first day of the month after your 65th birthday. Fees go by direct debit within the first 10 days of each month, with form 046 only as an exception. The 30 working days can be suspended under Ley 39/2015, the common administrative procedure law. Neither Valencian page shows an update date.

Andalusia

The Servicio Andaluz de Salud page, updated on May 22, 2026, is the most recent regional page read and gives 60 and 157 euros as the current fees, for applicants of any nationality. Once the SAS approves the application, it mails the convenio to your home for signature, and you return it with proof of the first payment.

Who can sign: the year, the padrón and no other cover

Article 3 of Real Decreto 576/2013 opens the convenio to people who reside in Spain, are neither insured nor beneficiaries of the National Health System, and meet three requirements:

1. One continuous year of effective residence in Spain immediately before the application.
2. Registration on the padrón, the municipal register, in a municipality of the region at the moment you apply. The decree sets no minimum padrón period; the year applies to residence.
3. No access to public health protection by any other title: Spanish law, EU regulations or a bilateral social security agreement.

The decree says “en España”. The Ministry of Health, the Comunidad de Madrid, the CatSalut formalization page, the Valencian procedure and the SAS also accept residence in other EU or EEA states, Switzerland or the UK, while the CatSalut coverage page, updated on June 2, 2025, mentions only Spain. For an American coming from the U.S. the result is the same: plan on a full year in Spain. The Ministry accepts a police residence certificate or a padrón certificate as proof, and Madrid asks for the padrón history, which is why registering on the padrón in your first days matters.

On the third requirement, the Ministry of Health requires a certificate of non-export of coverage only from people coming from countries under the EU regulations, the UK, Andorra or Chile; the United States is not on the list. Catalonia still lists an INSS (Instituto Nacional de la Seguridad Social) document proving no access for every applicant, and Andalusia a certificate of no access without naming the issuer; Madrid lists neither. In those two regions, ask which office issues it before your appointment. How the INSS itself recognizes a right to public care is in the public healthcare guide.

The decree’s preamble describes the convenio as strictly individual. A spouse or child who joined you through family reunification needs a convenio of their own, and Madrid asks for one application per family member.

What the convenio covers, and what stays at your cost

Article 2 of the decree gives access to the common basic portfolio of the National Health System, with the same guarantees as insured people. Under article 8 bis of Ley 16/2003, that portfolio covers prevention, diagnosis, treatment and rehabilitation in health or social care centers, plus urgent medical transport. The Ministry of Health adds that there are no copays and no waiting period. A region may charge more only when it adds services from its complementary portfolio.

Article 8 ter puts pharmacy, orthoprosthetics, dietary products and non-urgent transport in the supplementary portfolio, outside the convenio; the Ministry says the patient pays them 100 percent, and Madrid, the Valencian Community and Andalusia list the same exclusion, while CatSalut covers the drugs tied to its public health programs, such as HIV or tuberculosis care. Medicare does not fill that gap: Medicare.gov says Medicare usually does not cover care outside the U.S. and that Medicare drug plans do not cover prescriptions bought abroad.

The CatSalut formalization page lists primary, specialist and urgent care, mental health, social health care, urgent transport, rehabilitation, transplants and public health programs; its coverage page of June 2, 2025 does not mention transplants. If that item matters to you, ask CatSalut.

On a temporary stay in another region, the decree’s first additional provision gives you the common basic portfolio there, and CatSalut says its access document is valid throughout Spain; the Valencian procedure describes access within the Comunitat Valenciana while the convenio is in force. After a move to another region, the old convenio can stay valid on request for up to 3 months while you sign a new one.

A card or a document

The decree’s preamble and Madrid say no individual health card is issued: Madrid gives a “Documento para Asistencia Sanitaria-Convenio Especial RD 576/2013” instead, and CatSalut an access document. The Ministry of Health speaks of an individual health card, physical or virtual. Plan on the document your region names.

Fees, the decision and how the convenio ends

Article 6 of the decree sets 60 and 157 euros and provides for revision by ministerial order after agreement of the Consejo Interterritorial, the National Health System’s Interterritorial Council. The BOE’s consolidated text shows every article unchanged since July 27, 2013, and no revising order was found on the BOE, so confirm the amount on your region’s page before you sign. The four regional pages read in September 2026 all state 60 and 157 euros.

Under article 4, the region decides and notifies within 30 days, and without an answer the application counts as approved. You then have 3 months to sign, and coverage starts that day.

Article 7 ends the convenio on death, on losing a requirement, becoming insured or leaving the region’s padrón, on your documented decision, on a breach of its conditions, or on non-payment of the first fee, of two consecutive months or of three alternate ones. A voluntary cancellation takes effect the day after you notify under the decree, on receipt of your written request in Madrid, and after 2 months’ notice in Catalonia. After a voluntary exit, non-payment or breach, the decree bars a new convenio for one year; Madrid’s page applies that wait after any ending of a convenio.

Your next step: start the residence year the week you land

Register on the padrón in your first week and keep the certificate, because the year the convenio needs is the year you can prove. Keep the private policy your visa required for that whole year, then, around the first anniversary of your registration, gather your region’s documents and ask the Oficina de Extranjería handling your permit whether it accepts the convenio at renewal. The pre-move checklist puts the padrón and the insurance in order with the rest of the move.

You can file the application alone: online in Madrid, Valencia and Andalusia, and in person by appointment in Catalonia, as its procedures portal asks. Get help from a lawyer or a gestor, a professional who handles administrative filings, when part of your year was spent outside Spain, when you are between permits, or when the immigration office’s answer on the convenio is unclear.

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