Healthcare in Spain for expats.

In our research we were surprised to find that several countries around the world ranked higher than the US in quality of health care.  In most cases, the cost of health care in these countries is significantly less than in the US.   We have purchased our insurance in Spain through Sanitas, which is the largest insurance network in the country.  At the time Spain ranked 8^th in quality of care and the US ranked 24th in one of many reports that we read.

Our plan looks like a regular US PPO plan that includes doctor visits, lab work, hospitalization and up to 60 days and 20,000 euros per person in travel insurance coverage including travel within the US.  We were able to purchase it by working with an English speaking agent completely by email(see complete info below).  We filled out the required two forms she needed, scanned and sent them back and had coverage start the day we arrived in Spain.

How has it worked out?  Well, for starters, we had some trouble obtaining our insurance cards because Sanitas had an incorrect address for us.  This took two months to iron out but in the meantime we had a toll free number for the providers to call if we required health care and an email which included our policy numbers and anything else that we would need to verify that we did have coverage.

Sanitas has a web site where we could look up the doctors that were in our city and participated in the private insurance plan.  We could sort them by location and by the ability to speak English.  Since we had almost no Spanish at all when we arrived in Spain this was an important factor for us.  The web site is in Spanish but the auto-translate in Google Chrome worked just fine for figuring it out.

Marilyn had a nasty cold or flu bug when we first arrived in Spain (caught it in the Canaries) and we walked into a pharmacy.  Farmacias are wonderful things in Spain.  Pharmacists are all doctors, they are diagnosticians and can prescribe most non-narcotic, non-chemotherapy drugs including antibiotics.  The pharmacist gave her a decongestant and cough syrup and told her the problems would be gone in three days.  It was.  How convenient!  Total cost 9 euros.

10 days later Mike was having a problem.  He started to experience severe stomach pain and cramping and did not get out of bed for most of one rainy day in Marbella.  Marilyn decided something needed to be done and walked down to the nearest Farmacia.  After describing the symptoms to the pharmacist, it was determined that he was suffering from stomach spasms and an anti-spasmodic was handed to Marilyn.  She was told this should eliminate the problem in 1 or 2 days.  It did.  Total cost 5 euros.

So now we had been indoctrinated into the first level of health care intervention in Spain, the Farmacia.  Inexpensive, convenient, and it worked.  No appointments, no prescriptions, and if the pharmacist thinks you need a doctor they will send you to one.  In Spain, at least one farmacia must be open 24 hours every day in a specific area and the location of the nearest farmacia, that will be open after hours for each day of the week are posted on the door of every farmacia.

After we were settled in Granada, Mike noticed a mole that seemed to be growing and become worried about it.  We made an appointment, with an English speaking dermatologist, in Granada from the health plan network on the Sanitas website.  It took us a couple of weeks to contact the office because it was August and the office was closed for vacation.  When we made the appointment it was on a Friday at 6:30 p.m.

When we asked our friends about the odd time they told us it was because we were “private” patients.  Turns out that the doctors usually work in the clinics in the mornings until 2pm, then take the usual Spanish long lunch break along with the rest of the population from 2-5pm and then see their private patients in their offices from 5-8 in the evenings.

Arriving at the doctor’s office, we were buzzed into the building and again, buzzed into the office.  There was very little traffic in this office building and the only person in the waiting room was the medical assistant.  We were shown to a waiting room that would rival the lobby of many prestigious law firms and we gave the medical assistant our health insurance card. 

The card was returned and we were shown into the doctor’s consultation room, where the doctor himself took a medical history quickly and efficiently.  The physician spoke with us about the problem and took Mike into his examination room which was attached to his office.  After determining that the mole wasn’t dangerous we asked him if he would remove it anyway.  He agreed but explained that we would have to get an authorization from the insurance company for them to cover the 80 to 90 euro procedure.  We scheduled an appointment for two weeks hence and left with the information needed to obtain the necessary authorization. 

Obtaining the authorization was relatively easy, done on the Sanitas website (we really needed our Spanish for this) and the mole was removed.  The doctor gave us the removed mole in a bottle of liquid with the name of a pathologist and an authorization note and told us that if we wished, we could have the pathologist evaluate the tissue…just to be sure.  He was positive that the tissue was not problematic but wanted me to have the choice.  I chose not to.  Total cost 12 euros, each visit – the copay for the office visit.

There is a limitation of coverage in the public health service, for example, one of our friends, a Spanish citizen, needed to have oral surgery to remove a small benign tumor.  This surgery included the removal one of his upper teeth.  He was scheduled for surgery about three months after the problem was diagnosed.  The surgery is covered in full but a bridge or implant after the surgery is not.  He will be out of pocket about 600 euros to fix his teeth.  This is still cheaper than in the US, but a lot of money here in Spain.  He has contacted the University to find out if he would be eligible to have the dental students do the reconstruction work, if so, it will cost about half the normal fees.

Under a private insurance plan the dental work after the procedure would be covered at 50%.  Interesting.

Jumping ahead six months; after we got our final invitation to serve in the Peace Corps it included the need for an updated medical check-up.  Since our insurance coverage was in Spain, with the approval of the Peace Corps we went to the web site, for an English speaking family practitioner and scheduled an appointment for what we in America would call an annual checkup.  Our Spanish was much better but for medical situations we were still more comfortable in English. 

The appointment was scheduled for two days out, we went together.  The doctor was great.  Once she understood what we needed (apparently annual exams are not normal in Spain) she examined us both and wrote out the orders for a complete blood work up.  Then she told us where to go to get the document that is the Spanish equivalent of a “Certificate of Good Health” for her report needed by the Peace Corps (in Spain you must purchase all the forms that are required by the government).  These particular forms cost 3 euros each and the doctor shared a laugh with us when she told us that, believe it or not, you buy them at the estanco (tobacco shop).  Irony at its finest.

We found a lab in the insurance network and were told to come anytime between 8:30am and 1pm on a weekday – no appointment necessary.  We went on a Thursday morning and, after hilariously learning a new Spanish word “orina” (urine – funny, never needed that word before this) we were in and out in less than 30 minutes, with the results to be picked up on Monday.  No cost, it was included in our insurance.  Back to the doctor with our reports in hand, in and out with our certificates signed and a hand written translation done and signed by the doctor in no time at all.

So far, we have to say that our experience with the Spanish health care system has been absolutely fabulous and worth the total monthly cost of about $190 in premium plus co-pays for both of us together.  

Our Insurance agent info:

Susan Warner

http://www.healthinsurance-spain.com/

and new email info@healthinsurance-spain.com

Sanitas Agent 17517

telephone: 951 272 124

Mobile: 615655348

Fax:951239211

A quick stop in Marbellla

Friday morning we awoke to, what else, a driving rain so we dallied over breakfast and packed our bags.  There was a taxi stand in front of our hotel but they were all small and we were traveling with four large, heavy duffel bags plus our backpacks so we asked the front desk to call a larger taxi for us, which they did.  When the taxi arrived it wasn’t any larger than those out front of the hotel.  Joder!  We were out of time so we packed three bags in the back, one in the front seat and held onto our backpacks for the short, five minute drive to the bus station.

After successfully purchasing our tickets to Marbella we immediately boarded the bus which was ready to leave.  The estimated time of travel was four and a half hours, the same as Malaga to Cadiz, although we were only going as far as Marbella.  We soon found out why.

This bus stopped three times and picked up passengers before leaving Puerta Tierra.  The main road curving around the Atlantic coast in Spain and turning toward Algeciras and Gilbralter on the Mediterranean coast runs a few miles inland the entire way.  Along this route, but right on the shore are several small Spanish towns (pueblos) which our bus turned and visited.  Every single one!

It took three and a half hours to travel the distance to Algeciras which had taken us less than two on the way to Cadiz and we were becoming worried that we would be late for our date with our friends in Marbella.  No worries, however, the bus then drove directly to Marbella from Algeciras arriving on time.  We had just learned the meaning of “semi-directo”. 

Dragging our bags to the front of the Marbella bus station we hailed a cab; at this point not caring what size it was (another lesson learned). The hotel was located on an awkward corner less than two blocks from the beach, we hauled the bags up the stairs to the lobby and checked in.  We needed two trips in the tiny elevator but were absolutely astounded at the large, modern corner room we had been given.  Our hotel, the Hotel Lima is a two-star hotel, with great ratings on Trip Advisor; that cost less than $100 per night booked through booking.com (hard to find in the Costa del Sol, Marbella in particular).  It was spotlessly clean, we had a balcony that over looked the main drag right down to the beach!  

A short note may be in order here.  For those of you that are unfamiliar with the Costa del Sol and the cities along this beautiful coast of Spain; it has been referred to as Spain’s answer to the French Riviera.  It is beautiful and expensive.

Although it was threatening rain we met our friends Ash from our TEFL class in 2010 and his lovely lady Donna, at a sidewalk café in the Plaza de Naranjas and enjoyed an evening of tapas with them and some other friends at Tapas and Tintos, a nice corner café located in a tiny cul-de-sac in the old town.

 What a lovely evening.

I awoke the following day with a very painful stomach condition that worsened throughout the day.  It was raining heavily so we didn’t explore Marbella figuring that we could do that another time.  In early afternoon, a worried Marilyn ventured out to the Farmacia and after some discussion with the Farmacista returned home with some anti-gastrospasmodic medicine for me.  These were not over-the-counter drugs and we were impressed that potential solutions could be found this quickly and cheaply without the need of a physician.

Still feeling poorly we met our friends at a café on the beach where we had a quick refresco and were joined by a couple more delightful friends. We finished our evening with a long relaxing dinner in an Argentinian restaurant called Tangitos enjoying the marvelous food and quality wines. 

We called it an early night because I was still a little uncomfortable and we returned to the hotel after saying goodbye to our friends.

Amazingly, I was feeling much better in the morning and of course, since we were leaving, the weather was perfect.  This time we felt prepared and decided that we would simply purchase our tickets at the bus station for the “directo” to Granada.  We arrived at the bus station a half hour prior to the scheduled departure and found that the bus we wanted was sold out and that there wouldn’t be another for three hours; and it only had a few seats left.  Decisions.

The lessons were coming hard and fast for us now as we unhappily evaluated our options.  Revisiting the ticket counter the clerk suggested that we catch a bus to Malaga and travel to Granada from there.  After learning that there were buses to Granada leaving Malaga every half hour and that the combined price would be similar to the directo from Marbella (about 15 euro) Marilyn took a 50 euro bill and got in the suddenly long line at the ticket counter while I stood with the large pile of our luggage.

Twenty minutes later she returned with our tickets but she blanched when I asked for the change from the 12 euro purchase.  We looked with dismay at the line at the counter and Marilyn urgently returned to wait in line yet again.  No problems; the ticket agent remembered her and had set her change aside knowing she would return.  We ran for the bus.

The rest of our trip to Granada was uneventful.  We arrived in Malaga, used the station restroom, bought our tickets and boarded the bus five minutes before it departed.  We knew exactly where to go in Granada, having been there before and after a quick stop in Centro we arrived at the Residencia and found our room ready for us.  We made a quick trip to the nearest mini-mart, ran a load of laundry and turned in early in anticipation of our first Spanish language class at 9:30 the following morning. 

International Health Insurance is an issue if you are planning to live abroad.

We are both over 50 years old and in relative good health.  This is a problem age for self-employed individuals and early retirees because private insurance plans are expensive at this age and Medicare does not kick in until one turns 65.  Pure catastrophic health insurance is ridiculously priced or is simply unavailable.  Further, private plans have limited coverage while traveling and Medicare does not pay for health care costs outside of the US.

In our research we were surprised to find that several countries around the world ranked higher than the US in quality of health care.  In most cases, the cost of health care in these countries is significantly less than in the US. Since we hadn’t yet decided if we wanted to obtain residency in another country the option of utilizing a national health plan wouldn’t be available to us.

Health care and insurance work differently in every country.  First we needed to figure out how to obtain coverage (and health care) in Spain. Spain ranks very high internationally in the quality of health care, in fact, much higher than the US.  Spain has a national social security system which provides public health services to its residents for free or at extremely reduced cost.  Our perception of public health care was that you might wait for hours to see a doctor or wait days or weeks for an appointment but it will not cost you anything out of pocket. 

In all the countries we have researched there is also a limitation of coverage in the public health service, for example, one might be covered for a specific surgery, but reconstruction or cosmetic procedures that would be normal in the US might not be covered in other places.  However, the cost of these additional procedures in other places can be a fraction of the cost in the US.  

What should we do?  A requirement for an extended visa or residency in almost all countries is that the applicant has made provisions for health care coverage.  You can purchase international coverage that will cover you in most places if you are planning to be in several countries.  International health care coverage generally excludes coverage in the very high cost countries (including the US) so it is not an alternative if you are planning to spend significant time inside the US, the UK, or a few other countries. 

A country specific insurance plan is less expensive and has the advantage of being tailored to work within that particular country’s existing healthcare system.  Most plans we found both international and country specific can be purchased month to month or at least quarterly so there is no long term commitment to a specific plan.  However, the old pre-existing condition thing can creep into coverage anywhere so staying within one insurance company’s plans can have the benefit of getting you past any waiting period that might exist for coverage of a specific problem.  By purchasing from a large international insurer, like BUPA your time under contract begins when you purchase your first policy and continues as long as you are insured with them, even if you were to change your country of residence and plan several times under their umbrella.

We looked at many plans and found some great service providers that offer English speaking agents so that communication is not difficult.  Everything can be handled over the internet with applications or health questionnaires signed and scanned.  We were actually surprised at the ease of obtaining quotes and descriptions of coverage   

For us, we chose a BUPA plan for Spain.  The Bupa program in Spain is called Sanitas and it is offered for purchase through agents. It is Spain’s largest private insurance plan and offered the most options for us at a very reasonable cost.  The plan covers us for regular doctor visits, lab work and hospitalization within Spain and also covers us for up to 60 days of travel time outside of Spain for accidents or injury (including the US).   If we were traveling in the US and had an accident the BUPA network in the US is United Health Care.

A one page application and a one page statement of health was emailed to us, we filled them out, signed them and scanned them back.  Assuming we would get long questionnaires about previous health histories and adjustments to the basic premium quoted we were amazed when the following day we received an email simply asking what credit card we wanted to have our premiums charged to each month and when we wanted our coverage to begin.

Copays and deductibles work a little different than in the US but you can generally modify your coverage and out of pocket costs to arrive at an insurance premium that works for you.  Compared to US health insurance plans, coverage may seem to have lower maximum reimbursement but remember, health care costs a lot less in most other countries.

Our plan looks like a regular US PPO plan with no deductible.  Our copay for doctor visits is 12 euros and for a hospitalization it is 24 euros, all lab work ordered by a physician is included.  Prescription drugs are not covered simply because they are so affordable in Spain that coverage is not necessary.  Dental care, on the whole, is very good in Spain and significantly (40% to 50%) less expensive than in the US but dental coverage is relatively expensive so we decided to exclude it.

This plan was very similar to a private plan we had in the US that cost approximately $2,000 per month (for both of us).  There was very little medical information requested (mostly surgeries in the past 10 years and any chronic conditions) and the company did not blink at any of our historical medical information.  This plan costs us 140 euros or about $185 per month for the both of us together.

Wow, suddenly our monthly budget for designing a life overseas became much more reasonable and we started to seriously think that we might just be able to continue to live elsewhere around the world before or after our Peace Corps Service.  We were beginning to get the idea that even on our very limited budget we might really be able to afford it now instead of waiting for that ever elusive “retirement” age.