Provider network (cuadro médico) or reimbursement (reembolso) policy: which type?

Terms used

• Cuadro médico — The cuadro médico is the insurer's list of doctors, clinics and hospitals where your policy covers care.
• Reembolso — Reembolso is a policy type where you pay the provider yourself and the insurer repays part of the cost.
• Copago — A copago is a fixed amount you pay for each visit or test, on top of your premium.
• Baremo — The baremo is the insurer's tariff scale, setting the most it repays for each medical act.

Key rules

• Reimbursement share: Reembolso policies typically repay 80% to 90% of the eligible cost, up to the tariff scale and annual limits.
• Upfront payment: With a closed network you pay nothing at the visit; with reembolso you pay first and claim back.
• Authorisation: Hospital stays, surgery and advanced scans usually need the insurer's prior authorisation, or you may be billed.
• Premium: Network plans cost least, hybrid plans sit in the middle and reimbursement plans cost most.

The short answer

If you are happy to use the insurer's list of doctors and want the lowest premium, take a closed network (cuadro médico). If you want to pick any doctor or hospital, including abroad, and accept paying first, take reimbursement (reembolso). If you want both, a hybrid plan gives you the network for everyday care and reimbursement when you go outside it.

The side-by-side table and the decision tool below set the three out together. This page helps you match them to your habits.

Closed network: lowest cost, least choice

You show the insurer's card or app and pay nothing at the visit. The doctor or hospital bills the insurer directly. Cover applies only to providers on the insurer's list.

• Cost: the premium, plus a copayment (copago) if your policy has one. That is a fixed sum per visit or test. Network plans cost less than reimbursement plans of similar scope, and copago versions cost less again.
• Authorisation: family doctors and paediatricians usually need none. Specialists are normally direct, though some insurers ask for a referral. Hospital stays, surgery, advanced scans (MRI, CT, PET) and many treatments need the insurer's prior authorisation. The provider or the app usually requests it. Without it, you may be billed.
• Best for: people who already use, or are happy to switch to, doctors on the list, and who want no upfront payments.

Reimbursement: most freedom, more paperwork

You can choose any doctor or hospital within the policy territory, in Spain or abroad. You pay in full at the time, then claim the money back.

• Claim: send the original itemised invoice, which must show the provider's tax ID, the service and the date. Insurers often also want a medical report or prescription. You upload it in the app or send a claim form. Repayment usually arrives by bank transfer within a few weeks.
• How much comes back: reembolso policies typically repay 80% to 90% of the eligible cost, up to the policy's tariff scale and annual limits. Some products pay 70% to 100% depending on the service, for example more for hospital care than for outpatient visits. The percentage applies to the actual cost or the tariff scale, whichever is lower.
• The gap: the tariff scale (baremo) sets the most the insurer repays for each act. If your doctor charges more, you pay the difference. Many policies also have annual limits, and sub-limits for dental, psychology or physiotherapy. These are in the policy schedule.
• Cost: premiums are higher than for network-only plans and rise sharply with age.
• Hospital stays often still need notification or authorisation first.
• Best for: people with a doctor they will not give up, people who travel or split their time abroad, and people who can carry upfront bills and keep tidy records.

Hybrid: a middle route

A hybrid plan combines a network with a reimbursement option in one policy. In-network care is billed directly to the insurer. Care outside the network is paid upfront and partly repaid. Premiums sit between the other two types.

Many reembolso products also include the insurer's network. You then choose visit by visit: network with no payment, or any other provider with upfront payment. Some pure reembolso policies have no network, so check. Network use can still need prior authorisation for hospital and costly care.

Names and structures change from one insurer to another, so ask exactly how the product works before you sign.

How to decide

• You rarely see a doctor and want the cheapest cover: closed network.
• You have specialists you trust, or you want to choose freely: reimbursement, or a hybrid that includes the network.
• You dislike paying upfront or chasing claims: closed network, or a hybrid you mostly use in-network.
• You are older or expect heavy use: compare premiums carefully, because reimbursement premiums climb fastest with age.

Before you buy, run through the checklist below. The FAQ answers common follow-up questions.

Choosing between options

Which type of policy suits the way you use healthcare?

• Closed network (cuadro médico): You are happy to use the insurer's listed doctors and hospitals, want nothing to pay upfront and want the lowest premium.

• Reimbursement (reembolso): You want to pick any doctor or hospital, in Spain or abroad, and accept paying upfront, filing claims and a higher premium.

• Hybrid plan: You want direct billing for everyday care in the network, but also the option to see outside doctors and be partly repaid. The price sits between the other two.

If your doctors are in the network and you dislike paperwork, choose a network policy. If freedom of choice matters most and you can afford the higher premium, choose reembolso. If you want both, choose a hybrid plan.

Network, reimbursement and hybrid plans side by side

Network plans cost least and are the simplest to use, but you are limited to the insurer's providers. Reimbursement plans give you full freedom and cost the most. Hybrid plans sit in between on both.

What a reimbursement claim involves

You send the insurer these documents through its app, website or a branch:

• the original itemised invoice
• the medical report or prescription
• proof of payment
• the insurer's claim form

The insurer then refunds a percentage of the cost. The refund never goes above the policy's tariff for that service or its annual caps. Some insurers also offer direct billing with partner providers on reimbursement plans, so ask whether yours does.

Other points to compare before you choose

The plan type is only part of the picture. Check these on any policy you consider:

• Network size and quality in your area. A cheap network plan is little use if few providers are near you.
• Co-payments per visit. They lower the premium but add a cost each time you go.
• Refund percentages and annual caps. These decide how much of a reimbursement bill you really get back.
• Waiting periods and exclusions. They vary between policies of the same type.
• Coverage abroad. Not every plan includes it.
• Language support. Ask whether you can get service in English.

Checklist

• List the doctors and hospitals you use now, and check each one is in the insurer's network if you are considering a closed-network policy.

• Ask whether the policy has a copayment (copago) and how much you would pay for each visit or test.

• Ask the insurer for the tariff scale (baremo) and the annual limits if you are considering reembolso.

• Check that you can keep itemised invoices showing the provider's tax ID, the service and the date, and that you can pay each bill upfront.

• Ask whether a reembolso product also gives you the insurer's network with direct billing.

• Confirm with the insurer how a hybrid plan is structured, since product names and terms change.

Frequently asked questions

Can I use a reembolso policy without paying upfront?

Yes, many reembolso products also include the insurer's network, so you can choose per visit between direct billing and paying upfront. Some pure reembolso policies have no network at all. Even in the network, hospital stays and costly services may still need prior authorisation.

What happens if my doctor charges more than the insurer's tariff scale?

You pay the difference yourself, because reimbursement is capped by the tariff scale (baremo) for each act. Many policies also set annual limits per type of service, with lower sub-limits for dental, psychology or physiotherapy. Look at the policy's schedule of benefits before you choose.

How do hybrid plans compare in price with the other two types?

Hybrid plans usually cost more than network-only plans and less than pure reembolso plans of similar scope. Reembolso premiums also rise sharply with age, so check how the price changes as you get older.

Do network policies ever need a referral for a specialist?

Usually not, since specialist visits are normally direct, but some insurers want a referral first. Hospital admissions, surgery and scans such as MRI or CT need prior authorisation, which the provider or the app normally requests. Without it you may be billed.