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HEALTHCARE

Who can register for national healthcare in Italy?

Who is entitled to free registration with Italy's national service health service, and what are the options for people who aren't? Here's a guide to the basics.

Who can register for national healthcare in Italy?
Registering for public healthcare in Italy will allow you to get medication at a subsidised rate. Photo: Andreas Solaro/AFP

The Italian National Health Service (SSN – Servizio Sanitario Nazionale) is open to anyone living in Italy, and registering with it guarantees foreign residents all the same care available to Italian nationals at the same cost.

But that process is more straightforward – and cheaper – for some than for others.

Here’s what you need to know about registering with Italy’s public healthcare system.

Who can register for free?

Certain people are entitled to iscrizione obbligatoria, ‘mandatory registration’ or ‘registration by right’, in the national health service.

That means you can register with the SSN for free.

Iscrizione obbligatoria applies to the following categories:

  • Immediate family members of an Italian citizen living in Italy
  • People with a valid work contract from an employer in Italy
  • Self-employed people with a partita IVA (VAT number)
  • People who previously worked in Italy but are currently unemployed and registered on the unemployment lists (liste di collocamento)
  • People who have a residence permit expressly for the purpose of applying for citizenship, fostering or adopting children, or because they are pregnant or have given birth in the past six months
  • Asylum seekers, refugees and others under international protection

People in these categories are also allowed to register their spouse, children or other dependents under the same conditions, with the exception of elderly parents.

READ ALSO: Tessera sanitaria: How do you apply for or renew your Italian health card?


Photo: Filippo Monteforte/AFP

Who else can register?

If you don’t fall into any of these categories, you can also opt in to the Italian health service (iscrizione volontaria or ‘voluntary registration’).

It involves paying an annual registration fee in order to access public healthcare.

Once registered, you’ll pay the exact same for the care you receive as people who enrolled for free.

ITALIAN BUREAUCRACY EXPLAINED: 

Voluntary registration is open to anyone legally resident in Italy who doesn’t qualify for free registration, notably non-working elective residents, students, diplomats, volunteers, people aged 65 or over who have moved Italy to be with their children, or anyone else who doesn’t pay social security contributions.

The only condition is that you must be staying in Italy for more than three months – unless you are a student or an au pair, in which case you are still allowed to register for healthcare during a short stay at a reduced fee.

You can also extend voluntary registration to your dependent family members.

How much does it cost?

The fee for voluntary registration is calculated by your local health authority (ASL – Azienda Sanitaria Locale) according to your means. It therefore varies depending on where you live in Italy and your financial circumstances.

The minimum annual fee is €387.34, rising to a maximum of €2,788.86. One fee also covers any dependents you’re registering at the same time.

Students and au pairs can benefit from fixed fees of around €150 and €220 respectively, though this will not allow you to register any dependents (you can do so by opting to pay the full fee instead).

NB: the fee is fixed for the calendar year, so you’ll pay the same amount whether you register in January or November. If it’s late in the year, it might work out better value to wait and if necessary use private healthcare for a month or two before registering.

How do you register?

You register directly with your nearest ASL. Find a list here

You will need:

  • Your passport
  • Your certificate of residence (for EU citizens and Brits) or permesso di soggiorno (for non-EU citizens), or an official receipt to show you have applied for it
  • Your codice fiscale, or tax code
  • For iscrizione obbligatoria: a work contract, payslip, declaration from an employer, VAT registration, UK S1 form, or any other document that shows your entitlement to free registration.
  • For iscrizione volontaria: evidence of your previous year’s income, such as a tax return.
  • If registering dependents: birth or marriage certificates that document your relationship, as well as evidence of family members’ income.
  • If registering as a student or au pair: proof of enrolment in a study programme or a contract with a family.

Ask your ASL exactly which documents you require for your particular circumstances.

If you’re registering voluntarily, you’ll also need to have your ASL calculate your annual fee, which you have to go to the nearest Post Office to pay by postal order (bollettino postale). You’ll then return to the ASL office to show receipt of payment and complete your registration.

Either way, be prepared for multiple consultations – in person – before the process is complete.

And since registration is annual, you can expect to repeat it all over again the following year.

READ ALSO: How do you renew your Italian health card?

The following video explains the process for British nationals and may be applicable to others too:

What are you entitled to once you register?

The benefits of registering are that you’ll be able to access the Italian public healthcare system for free or at a subsidised rate.

Once registered, you’ll receive a tessera sanitaria or health card that shows you’re entitled to public healthcare. You can also register with a GP (medico di base) and register your children with a paediatrician, whom you can consult without charge.

Other forms of care may require you to pay part of the cost (a co-pay known in Italian as the ticket), but the amount will be subsidised by the national health service.

READ ALSO: 

Registering can also help you secure residency in Italy: proving you have healthcare is a condition of being granted a residency permit, in many cases, so if you’ve registered with the SSN (or can at least show you’re in the process of doing so), that will meet the requirement.

However, since residency is a condition of registering it can be a Catch-22 situation. You may be able to persuade officials to accept provisional documents, but there are no guarantees.

You might find it more expedient to take out private health insurance in the short term to allow you to secure the residency permit you need to register with the SSN; or if you prefer, you can opt to skip the public health system altogether and pay for private care throughout your time in Italy.

Member comments

  1. Just FYI, your codice fiscale needs to have your address in Italy. I got a codice when I moved here before finding a house and realised I had to change the address when I applied for the health card.

  2. “f you prefer, you can opt to skip the public health system altogether and pay for private care throughout your time in Italy”. It is true that proving that you have a private health care insurance policy helps. But (and it is a BIG BUT), you might find (as we did after having paid out thousands of euros in premiums for 3 years) that you cannot access your private insurance benefits without having a tessera sanitaria and going through your local public medico.

    1. Oh my god, that’s awful! I have private insurance for this year 2021 but how do I see a doctor? Can I go to any doctor? Wouldn’t I have to register first? I ask this because when I went to register with a doctor, I was told by the ASL (and the doctor I’d chosen in my village), that I couldn’t see her because I wasn’t registered with the health service! It seemed like a catch 22 situation.

      1. You should be able to pay privately to see a GP, as tourists do. You can also get a private appointment at one of the many clinics you’ll find in most towns, which have visiting specialists.

        You don’t need a referral from a GP to do that and it’s not anything like as expensive as private consultations are in the UK. You may prefer to pay out of pocket if you have a specific short-term health issue or want advice, rather than go through the hassle of claiming on your insurance.

        When you go to get your tessera sanitaria next January, you’ll be shown a list of GPs who you can register with.

  3. Just a comment about the article – after you’ve been legally resident for 5 years, you no longer have to pay for your tessera sanitaria. I don’t know if that only applies to people who’ve paid in from the start of their official period of residency, or whether people who have had private heath insurance can “claim” their card when they become permanently resident. I also assume this will only apply to those of us who are here on pre-Brexit terms.

    We’re retired in Marche and currently pay around €2,700 a year (for two of us), as we have a combined household income of over €50,000 per annum (the top band in our region) and aren’t of UK state pension age.

    1. I thought that the tesserae sanitary was free after 5 years but was told it did not become free until after you receive Italian citizenship. Which is hard to do unless you study Italian and get the appropriate language certificate from the University or College

      1. I think you’ve possibly been given incorrect information. I know a lot of people here who aren’t Italian citizens and get their Tessera free (they’re not pensioners, either).

        I’ve been told by our local health office that we’ll get our cards free when we have 5 years of residency.

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For members

BUREAUCRACY

EXPLAINED: What is Italy’s new digital invoicing rule for freelancers?

Italy is bringing in new rules from July that mean changes for freelancers on the 'flat tax' rate. Here’s what you need to know about the new ‘fatturazione elettronica’, or digital invoicing system.

EXPLAINED: What is Italy’s new digital invoicing rule for freelancers?

Italy has been slowly moving more of its bureaucratic systems online in recent years, and in many cases this has made it quicker and easier for residents to access services and get their considerable amounts of Italian life admin in order.

It was hoped that the new electronic invoicing rule would do the same for freelancers on Italy’s flat-tax regime, by doing away with the existing need to print out invoices and affix tax stamps by hand.

READ ALSO: Beat the queues: 19 bits of Italian bureaucracy you can do online

But a close look at the details of the new rules shows that it probably won’t make life easier for those on the flat tax rate, who have so far been spared the bulk of that infamous Italian red tape – but now need to get to grips with a new online system.

Known as the ‘regime forfettario‘, Italy’s flat-rate tax scheme for individuals and small businesses was introduced in 2015 to encourage more commercial activity by slashing tax rates and simplifying bureaucracy.

New freelancers who choose this tax system generally pay somewhere between just five and 15 percent tax on earnings, regardless of overheads.

READ ALSO: The pros and cons of Italy’s five percent flat tax for freelancers

Little has changed since its inception seven years ago, but freelancers using the scheme now need to be aware of new rules coming into force from July 1st, 2022.

How you invoice – how you send, receive and store receipts, therefore – is due to move from analogue to digital, bringing new requirements and know-how on digital invoicing software.

Here’s what’s changing for freelancers with the so-called ‘fattura elettronica‘.

Who is required to send electronic invoices?

While this was already a requirement for the self-employed on other tax regimes, those on the flat tax rate will now be included from July 1st.

They were previously exempt, but that changed under the PNRR (National recovery and resilience plan or piano nazionale di ripresa e resilienza) – the Italian government’s plan for using EU funding for post-pandemic economic recovery.

Digital invoicing is intended to fight Italy’s major problem with tax evasion, as well as to further automate accounting processes.

For now, not all freelancers under this tax scheme need to move to digital accounting – only those who received an income in excess of €25,000 in the previous year are required to comply with the new rule.

It will then extend to all freelancers using the flat-rate scheme from January 1st, 2024.

From that date, everyone subscribed to the ‘regime forfettario’ will have to switch to electronic invoicing and there are hefty penalties in place for those who don’t.

How will electronic invoices work?

Italy’s tax authority has defined a couple of notable differences between the digital or electronic invoice (fattura elettronica) and a paper invoice (fattura di carta) in its updated guidelines.

Firstly, the digital invoice has to be created using a digital device (a computer, tablet or smartphone), and secondly it has to be sent to the client via an ‘Interchange System’, the so-called Sistema di Interscambio (SdI).

READ ALSO: ‘Smart working’? Here’s what you need to know about going self-employed in Italy

Italy’s flat-rate tax scheme is going digital. Photo by Christian Dubovan on Unsplash

This electronic postal system checks whether the invoice contains the required data for tax purposes, as well as checking the verified e-address (or the so-called PEC address) of the recipient.

In doing so, the electronic invoice automatically checks that the VAT number (partita IVA), or the tax code (codice fiscale) depending on who you send the invoice to, really exist.

Once the checks are completed, the system sends the invoice to the client, which will trigger an alert to the freelancer with a delivery receipt, showing the date and time the document was delivered.

How can you send an e-invoice?

There are a few accounting software options on the market if you’re now faced with having to send electronic invoices.

Some charge a fee of around €1-€4 per month or come at a cost per transaction.

Platforms such as ‘Aruba‘ or ‘Fatture in Cloud‘, are competitive and may offer you a free trial before you deciding to buy.

The Italian revenue agency (Agenzie delle Entrate) has also created free-of-charge services to help send and receive e-invoices. These include websites as well as apps for completing the required steps, which are detailed in their guide here.

You can access their Invoices and Receipts (‘Fatture e Corrispettivi‘) portal to benefit from these free services.

You’ll either need a Spid ID (‘Sistema Pubblico dell’Identità Digitale‘), a Carta Nazionale dei Servizi (CNS) or accounting credentials known as Fisconline/Entrate, which are issued by the Agenzie delle Entrate.

You can also delegate this task to an intermediary, such as an accountant (commercialista) who would do this on your behalf, the revenue agency stipulates 

What about the Italian tax stamp?

Until now, freelancers issuing invoices under the ‘regime forfettario‘ have had to attach a €2 stamp, called a ‘marca da bollo’, to every invoice over the value of €77,47.

So what happens when e-receipts go digital and you can’t physically stick a stamp on a document? Well, that goes digital too and the Inland Revenue has issued a 16-page guide on how you need to go about it.

It seems the previously attractive ‘light’ accounting of this regime is about to get bogged down by time-consuming bureaucracy too.

Authorities will systematically check that the fee has been paid each quarter for all the invoices that require it.

As a general rule, you can see if there are any discrepancies by the 15th day of the first month following each quarter on their Invoices and Receipts portal.

You or your intermediary have until the end of that month to fix any accounting errors, but make sure to check with an accountant if you have any difficulties or need specific advice for your personal circumstances.

Once you receive your final stamp duty bill for each quarter, you can pay either via IBAN, which you set up on the portal, or by filling out an electronic F24 form – details of how to do that are included in the guide.

For further information and FAQ’s, see Italy’s Inland Revenue Agency website on the electronic invoice here.

Please note The Local cannot advise on personal cases and seeking expert financial advice is recommended.

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