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

The convenio especial is a contract you sign with your region’s health service, and it buys you access to Spain’s public health system when no other route gives you that right. Real Decreto 576/2013 sets the fee at 60 euros a month under 65 and 157 euros at 65 or over. On a non-lucrative permit, a flat public fee can look tempting, but the convenio opens only after a year in Spain, leaves your prescriptions at your cost, and the only immigration text found that accepts it covers telework permits alone. 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?

In your first year, no, and at renewal only if the immigration office accepts it, which no official page confirms for the non-lucrative permit. The single immigration text found that does accept it is a 2023 joint instruction on telework permits, which lets a teleworker prove public insurance with a convenio signed with the region of their padrón.

Here is why the question arises at all. Article 3 of Ley 16/2003, in the wording 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. As a non-lucrative resident, you are 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. For an American, three rules then settle it.

• 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, but the United States is not on that list. Coming from the U.S., you need private insurance for at least your first year.
• The visa. For your 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 says nothing about 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 one 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 you pay 100 percent of outpatient drugs under the convenio, while the consulate asks for insurance without copayment, and no official page says how an immigration office weighs the two. Treat acceptance at renewal as unconfirmed. Before you cancel your private cover, ask the Oficina de Extranjería, the provincial immigration office handling your file, 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, and your region runs the file.

Comunidad de Madrid

In Madrid, the regional page, updated on December 9, 2024, measures your 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. The year it can see therefore 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

In Catalonia, Tràmits Gencat, the Generalitat’s procedures portal, updated on March 18, 2024, asks you to apply in person, by appointment, although article 4 of the royal decree allows any public registry. On the CatSalut formalization page, updated on February 27, 2024, you pay the current month’s fee before signing, and coverage runs from the signing date.

Catalonia also has a route of its own. 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, so treat it as closed to you unless CatSalut confirms.

Valencian Community

In the 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 starts on the first day of the month after your 65th birthday. Your 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

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

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

You can sign if you reside in Spain, are neither insured nor a beneficiary of the National Health System, and meet the three requirements of Article 3 of Real Decreto 576/2013:

1. One continuous year of effective residence in Spain, right before your application.
2. Registration on the padrón, the town’s list of residents, 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, whether through Spanish law, EU regulations or a bilateral social security agreement.

The decree says “en España”, in Spain. 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. Coming from the U.S., you land in the same place either way: 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, and the United States is not on that list. Catalonia still lists an INSS (Instituto Nacional de la Seguridad Social, the national social security institute) document proving no access for every applicant, and Andalusia a certificate of no access without naming who issues it; Madrid lists neither. If you live in one of those two regions, ask which office issues it before your appointment. How the INSS itself recognizes a right to public care is explained 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

Once you have signed, Article 2 of the decree gives you 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. Here is the good news: 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.

Some things stay outside. Article 8 ter puts pharmacy, orthoprosthetics, dietary products and non-urgent transport in the supplementary portfolio, beyond the convenio’s reach, and the Ministry says you as the patient pay them 100 percent. 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 its 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, but 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. If you 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

What you will carry depends on the page you read. The decree’s preamble and Madrid say no individual health card is issued: Madrid gives you 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

Your fee comes from Article 6 of the decree, which 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 if no answer comes, the application counts as approved. You then have 3 months to sign, and your 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. If you choose to cancel, the decree makes it effective the day after you notify, Madrid on receipt of your written request, and Catalonia after 2 months’ notice. After a voluntary exit, non-payment or breach, the decree bars a new convenio for one year, and 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 somewhere safe, 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 sets the padrón and the insurance in order with the rest of the move.

You can file the application yourself: online in Madrid, Valencia and Andalusia, and in person by appointment in Catalonia, as its procedures portal asks. Turn to 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.

The Spain Navigator puts every step of your move to Spain in order, from the visa to settling in.