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Additional Portfolio of Services of the Autonomous Communities (CCAA):

The Autonomous Communities (CCAA), within the scope of their powers, will be able to approve their respective portfolios of services, which at the very least will include the portfolio of common services of the SNS (basic care services, supplementary and ancillary services), which must be guaranteed to all SNS users.

The CCAA may include, in their portfolios of services, techniques, technologies or procedures that are not included in the portfolio of common services of the SNS. In order to do so they must provide the necessary additional resources.

Under no circumstances will these additional services be included in the general funding of SNS benefits. The CCAA will assume, payable by their own budgets, all costs for implementing the additional portfolio of services for persons with insured status and their beneficiaries.

The public health benefit is a set of initiatives organised by the government to preserve, protect and promote the health of the public. It is a combination of sciences, skills and activities aimed at maintaining and improving the health of all people through collective or social action.

Public health benefits are provided entirely through the public health structures of civil service departments and the SNS primary care infrastructure.

The public health benefit includes the following activities:

• Providing information and monitoring relating to public health, epidemic warning systems and rapid response systems in the event of public health emergencies.
• Protecting the goals and objectives of public health, which is a combination of individual and social activities aimed at getting political commitments, support for health policies, social acceptance and support for specific health programmes and objectives.
• Promoting health, through cross-sector and cross-cutting programmes.
• Preventing illnesses, disabilities and injuries.
• Protecting health, by preventing the negative effects that various environmental elements can have on people´s health and well-being.
• Protecting and promoting environmental health.
• Protecting and promoting food safety.
• Protecting and promoting occupational health.
• Evaluating the impact on health.
• Monitoring and controlling potential health risks arising from the import, export or transportation of goods and the international movement of travellers.
• Early prevention and detection of rare diseases, as well as support for people who contract these illnesses and their families.
• The provision of public health will also include all specific actions or special measures that, in the field of public health, need to be adopted by the health authorities or the various civil service departments, within their sphere of responsibility, when they are required due to special health circumstances or situations of particular urgency or need and the available scientific evidence provides justification for them.

Primary care is the initial and basic level of care, which guarantees the comprehensive nature and continuity of care throughout a patient's life, acting as a case manager and coordinator and a flow regulator. It shall include health promotion, health education, disease prevention, health care, maintenance and recovery, as well as physical rehabilitation and social work.

Primary care, which includes tackling health problems, risk factors and risk behaviour, includes the following services:

• On demand, planned and emergency health care, both through consultations and at the patient's home.
• Recommendation, prescription and implementation, as applicable, of diagnostic and therapeutic procedures.
• Prevention, health promotion, family support and community care activities.
• Health protection monitoring and information activities.
• Basic rehabilitation.
• Specific support and services for women (which will specifically include the detection and treatment of situations of gender-based violence), children, teenagers, adults, the elderly, risk groups and the chronically ill.
• Palliative care for the terminally ill.
• Mental health care in coordination with specialist care services.
• Dental and oral health care.

Specialist care includes support, diagnosis, therapy, rehabilitation and care, as well as health promotion, health education and disease prevention, the nature of which means that implementation at this level is advisable. Specialist care guarantees continuity in a patient's overall care, once the possibilities of primary care have been exhausted and until the patient is able to return to said level.

Specialist care is provided through external consultations and day care hospitals, as long as the condition of the patient so permits. It includes:

• Specialist care through consultations.
• Specialist care provided through day care, medical and surgical hospitals.
• Admission into hospital.
• Primary health care support for early hospital discharge and, where appropriate, home hospitalisation.
• Recommendation, prescription and implementation, as applicable, of diagnostic and therapeutic procedures.
• Palliative care for the terminally ill.
• Mental health care.
• Rehabilitation of patients with recoverable functional deficit.

Emergency care is the care provided to a patient in cases where their medical condition is such that it requires immediate medical attention. It will be dispensed both at health centres and other locations, including the patient's home address and on-site, 24 hours-a-day, by means of medical attention and nursing care, in collaboration with other professionals.

The portfolio of common services for the provision of emergency care includes:

• The provision of telephone support through emergency care coordination centres. This includes medical control of the demand for care by assigning the most appropriate response to each medical emergency (information, guidance or health advice).
• The initial and immediate assessment of patients to determine the risks to their health and life and, where necessary, classifying these patients to prioritise the medical attention they require. The assessment can be completed by directing patients to a health centre, where necessary, to conduct the examinations and diagnostic procedures required to determine the nature and scope of the process and decide the immediate actions to be implemented in order to deal with the emergency situation.
• The conducting of the diagnostic procedures and medical-surgical therapeutic procedures required to appropriately deal with each emergency situation.
• The monitoring, observation and reassessment of patients, when their condition so requires.
• The provision of land, air and maritime health transport, with or without on-board medical care, according to the medical requirements of patients, in the cases in which it is required to suitably transfer them to the health centre that is best able to deal with the emergency situation.
• The provision of information and advice to patients or, where applicable, their support person, on the care provided and the subsequent aftercare measures to be adopted, in accordance with current legislation.
• Once the emergency situation has been dealt with, the discharge or placement of patients at the most appropriate level of medical care and, when the seriousness of the situation so requires, their admission to hospital, with the necessary medical reports to guarantee the continuity of care.
• The reporting of situations that need to be reported to the competent authorities, especially in cases of suspected gender-based violence or abuse of children, the elderly and people with disabilities.
  

Contribution of beneficiaries to the outpatient pharmacy benefit:

An outpatient pharmacy benefit is one by which the patient receives drug prescriptions or hospital dispensing orders through pharmacy offices or services.

The outpatient pharmacy benefit will be subject to a user contribution. This must be paid at the time the medicine or health care product is dispensed and will be proportional to the level of income, which will be updated at least every year.

In general, the user's contribution percentage will be as follows:

1. 60% of the RRP for users and their beneficiaries, whose income is greater than or equal to 100,000 euros, as entered in the general tax base and savings box on the Personal Income Tax (IRPF) declaration.
2. 50% of the RRP for working people with insured status and their beneficiaries, whose income is greater than or equal to 18,000 and less than 100,000 euros entered in the general payable base and savings box in the IRPF declaration.
3. 40% for working people who have insured status and their beneficiaries, who are not included in the foregoing sections a. or b.
4. 10% of the RRP for working people who have insured status as Social Security pensioners, except for people included in section a.

In order to guarantee the continuity of treatment for chronic illnesses and ensure a high degree of equality for pensioners receiving long-term treatment, the general percentages will be subject to maximum contribution limits in the following circumstances:

1. 10% of the RRP for medicines belonging to the ATC reduced contribution groups (appendix III of |R.D. 1348/2003, of 31 October), with a maximum contribution of 4.24 euros per box, from 01-01-2015. This maximum contribution will be automatically updated every January according to changes in CPI.
   
   As of 01/10/2013, medicines included in appendix 1 of the Resolution dated 10/09/2013 are considered as reduced contribution drugs, and may only be dispensed to outpatients from hospital chemist services. The reduced contribution shall be as established in the preceding paragraph; however, where the medicines are not dispensed by hospital pharmacy services in the commercial packaging, the contribution shall be calculated to be proportionate to the amount of medicine dispensed, based on the relevant contribution.
   
2. For individuals with insured status as Social Security pensioners and their beneficiaries, whose income is less than 18,000 euros, as entered in the general tax base and savings box on the IRPF declaration or who are not included in the following sections c. or d., up to a maximum monthly contribution limit of 8.23 euros, from 01-01-2015.
3. For individuals with insured status as Social Security pensioners and their beneficiaries, whose income is greater than or equal to 18,000 and less than 100,000 euros, as entered in the general tax base and savings box on the IRPF declaration, up to a maximum monthly contribution limit of 18.52 euros, from 01-01-2015.
4. For individuals with insured status as Social Security pensioners and their beneficiaries, whose income is greater than 100,000 euros, as entered in the general tax base and savings box on the IRPF declaration, up to a maximum monthly contribution limit of 61.75 euros, from 01-01-2015.

Any contributions exceeding these amounts will be reimbursed by the corresponding autonomous community at least every half year.

Users and their beneficiaries belonging to one of the following categories shall be exempt from making contributions:

1. People affected by toxic shock syndrome and people with disabilities in the cases provided for in their specific regulations.
2. People receiving social integration income.
3. People receiving non-contributory benefits.
4. Unemployed people who are no longer entitled to receive unemployment benefits, for as long as their situation continues.
5. Financial benefits for work-related injuries and occupational diseases.
6. Persons benefiting from the minimum vital income.
7. Minors with a recognised degree of disability greater than or equal to 33%.
8. Persons receiving economic benefits from the Social Security for a dependent child or minor in permanent foster care or under pre-adoption guardianship
9. Social Security pensioners whose annual income is less than 5,635 euros entered in the general and savings tax base box of the Personal Income Tax return, and those who, if they are not obliged to file this return, receive an annual income of less than 11,200 euros.
   

The contribution level for members of mutual societies and the passive classes of the General Mutual Society for Civil Servants, the Social Institute for the Armed Forces and the General Legal Mutual Society will be 30%.

The orthotics and prosthetics benefit consists of the use of implantable and non-implantable medical devices, with the aim of totally or partially replacing a body part, or modifying, correcting or aiding its function. It shall include the elements required to improve a patient's quality of life and autonomy.

This benefit will be provided by the |SPS or will give rise to financial aid, in those cases and in compliance with the legally established regulations by the competent health authorities.

The orthotics and prosthetics benefit includes surgical implants, external prosthetics, wheelchairs, orthotics and special orthotics and prosthetics.

User Contributions:

1. In general, the supplementary portfolio for orthodontics and prosthetics benefit is subject to user contributions, with a scheme similar to that of the pharmaceutical benefit, taking the product Supply price as the basis for the calculation. 
2. The contribution percentage for the user will be governed by the same rules that regulate the pharmaceutical benefit  and, without applying the same amount limit to this contribution,  it will be as follows:
   
   1. 60% of the product Supply price for users and their beneficiaries whose income entered in the assessed tax and savings base in the IRPF return is equal to or higher than 100,000 euros.
   2. 50% of the product Offer price for working people with insured status and their beneficiaries, whose income is greater than or equal to 18,000 and less than 100,000 euros entered in the general payable base and savings box in the IRPF declaration.
   3. 40% of the product Offer price for working people who have insured status and their beneficiaries, who are not included in sections a) or b).
   4. 10% of the product Offer price for working people who have insured status as Social Security pensioners and their beneficiaries, except for people included in section a).
   5. 10% of the product Offer price on products included in the reduced contribution subgroups that are listed in the appendix of RD 1506/2012, of 2 November.
      
3. An order from the Minister of Health, Social Services and Equality, subject to a prior report from the Interterritorial Council, will establish the maximum contribution limit to be paid by the users referred to in sections b), c), d) and e) above.
   
4. Users and their beneficiaries belonging to one of the following categories at the time of dispensing shall be exempt from making contributions:
   
   1. People affected by toxic shock syndrome.
   2. People with disabilities that are beneficiaries of the special system of social and economic benefits, outlined in article 12 of Law 13/1982, of 7 April, for social integration of people with disabilities, and other people with disabilities who are likewise in situations of exemption included in their specific regulations.
   3. People receiving social integration income.
   4. People receiving non-contributory benefits.
   5. Unemployed people who are no longer entitled to receive unemployment benefits, for as long as their situation continues.
   6. Persons requiring treatment resulting from work-related injuries or occupational diseases, whether funded by the corresponding Social Security Mutual Society Partner, the INSS or the ISM. 
      
5. Right holders or beneficiaries of the special Social Security schemes managed by the mutual societies for civil servants will contribute 30% up to the limit established for users in section 2. c), except for the products included in the reduced contribution subgroups, in which section 2. e) shall apply, and for treatments deriving from injury in the line of service or occupational disease, which will be exempt from contribution.
   

The dietary supplements benefit includes the dispensing of dietary-therapeutic treatments to persons suffering from certain congenital metabolic disorders and home enteral nutrition for patients who, as a result of their medical condition, are not able to meet their nutritional requirements with normal food consumption.

This benefit will be provided by the health services or will give rise to financial grants, as applicable, in accordance with current regulations.

Health transport, which must be accessible to people with disabilities, consists of the transfer of patients for exclusively medical reasons when their condition prevents them from being transferred via ordinary means of transport. This benefit will be provided:

• If the medical transport is urgent, it will be covered completely by public financing.
• If it is not urgent , it will be subject to doctor's orders, for clinical reasons, and with a level of user contribution in accordance with that determined for the pharmaceutical benefit. 

The portfolio of common services for health transport includes transport without on-board medical care, which is designed for the special transportation of patients or victims of accidents that require technical health care en route.


Transfer of patients between |CCAA:

When an Autonomous Community decides to transfer a patient to another Autonomous Community in order to provide them with medical care that they are not able to provide with their own resources, the patient will be provided with the appropriate health transport, both for their transfer to the health centre and for their journey home, if the reasons for needing this benefit persist. When air or maritime transport is being used, the Autonomous Community receiving the patient will be responsible for the transfer of the patient from the airport, heliport or port to the health centre, as well as their return to the airport, heliport or port if the reasons for needing the health transport persist.

When patients are receiving periodic treatment, such as dialysis or rehabilitation, and they are transferred to another Autonomous Community for a certain length of time, it is this Autonomous Community which, by applying the criteria used to authorise the use of health transport in their region, is responsible for providing the benefit to receive this treatment to patients (who require this treatment for strictly medical reasons).

When a patient who has been temporarily transferred to another Autonomous Community has received emergency medical care, the Autonomous Community where the patient came from is responsible for the health transport (that they require for strictly medical reasons) to transfer them back to this Autonomous Community, either to their home address or another health centre.

Persons who receive benefits from the portfolio of common services, shall be entitled to information and documentation on health care and support, in accordance with Law 41/2002 of 14 November, regulating Patient Autonomy and Rights and Obligations regarding Clinical Documentation and Information, and Organic Law 15/1999, of 13 December, on Personal Data Protection.

Users of SNS will also be entitled to:

• Information and, where appropriate, paperwork on the administrative procedures required to guarantee continuity of health care.

• The issuing of sick leave, sick leave confirmation and medical discharge certificates, as well as any other reports and documents required for the assessment of disability or other purposes.

• Documentation or medical certification of birth, death and other cases for the Civil Registry.

In the event of occupational contingencies, maximum health benefits will be provided and they will have the same content as those arising from non-occupational contingencies and, alsoart.  11 Decree 2766/1967, of 16 November):

• Supply and renewal of the necessary prosthetic and orthopaedic devices and vehicles for disabled persons.
• Appropriate repair and plastic surgery, when after the wounds arising from work-related injuries have healed there are deformities or mutilations that have caused a significant alteration in the physical appearance of the injured party or hinder their functional recovery for their previous job.
• During the health care period and as a part of this health care, the necessary rehabilitation should be carried out to achieve a more complete recovery in the shortest possible time or to achieve an improved capacity to carry out their job.
• This treatment may also be performed after medical discharge with or without sequelae, and as long as it enables a more complete recovery of their capacity to work in relation to the relevant Social Services.
• Pharmaceutical benefits are provided free of charge.
• Supply companies with first aid kits to provide first aid materials in the event of work-related injuries, as long as they are responsible for providing their workers with protection for occupational contingencies.

When occupational contingencies are covered by the INSS , this Institute must pay the Public Health Services of the Autonomous Communities for the health care, pharmaceutical and recovery benefits arising from occupational contingencies suffered by affiliates with coverage for said contingencies at this Managing Body (59th Additional Provision of Law 30/2005, of December 29, of the 2006 General State Budget, implemented by TAS  Order 131/2006, of 26 January).