# Health insurance



## sparrow777

We are contemplating moving from USA to Italy. We are 78 and 68 (husband/wife). Appreciate info on how to obtain health insurance. thanks


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## BBCWatcher

We need a bit more information. Do either one of you possess Italian citizenship? Or an EU/EEA citizenship? Or will you be moving after obtaining Elective Residence visas? How frequently and for how long will you be returning to the United States?


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## sparrow777

Thank you. We do not passes Italian or EU/EEA citizenship. We'd like to move after we get elective residence visas. As of now, we would return to USA once every two years or so for a period between one to three months.


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## BBCWatcher

OK, it's a bit tricky then, but I'll provide some recommendations....

1. In order to qualify for ER visas you'll need to prove that you have at least "Schengen minimum" medical insurance valid in Italy. There are many companies that sell visa-compliant insurance, so just shop around. Schengen minimum insurance isn't really insurance, frankly, but it's a visa checklist item, to make sure the Italian government doesn't get stuck with the _whole_ bill if you become ill.

2. If you have a "Medigap" or Medicare Advantage plan in the U.S. it's possible your insurance carrier provides coverage for emergency and urgent care in Italy (and elsewhere outside the U.S.) Medigap plan types C, D, E, F, G, H, I, J, M, or N offer some international coverage, for example. However, these plans are not sufficient for Italian visa purposes since they only provide coverage for a limited period of time (60 days, usually) as you travel. So you'll still need at least Schengen minimum/visa-compliant medical insurance to get your visas, but your Medigap or Medicare Advantage plan should still be quite useful as the "real" insurance during the first couple months after you arrive.

3. I wouldn't terminate Medicare until you're well established on the Italian system, and perhaps not even then. (See below.) After you arrive and get properly registered as residents you'll be able to enroll in the Italian public medical system so that you shouldn't have a coverage break between your 60 days (for example) of Medigap/Medicare Advantage emergency/urgent coverage and the start of your Italian public coverage. You'll have to pay to enroll, and the fee will be based on your income. Sometimes you get lucky when the local ASL office charges you only the minimum no matter what your income is. If that happens, I wouldn't complain! (But don't lie.) Coverage is calendar year based, so whether you enroll in January or December you pay the same fee, then you have to pay again for the next year. Consequently a very good time to enroll is January (and a very good time to move would be, say, around or just after Thanksgiving in November) in order to get the most coverage from your first enrollment fee. If you can time your move accordingly, fantastic. Your Italian medical card also gives you European Health Insurance Card (EHIC) coverage in most of Europe and in a couple other places, notably in Australia, when you're visiting those countries. However, check the details on what is and is not covered via EHIC -- there are some limits. For example, EHIC isn't supposed to cover sports-related injuries.

There are no preexisting condition or age limitations to enroll in the Italian public system. No matter what you're charged it's a very good value, at least by U.S. standards.

4. Notably EHIC does not cover the U.S., and there's a bit of a problem there. Fortunately you both presumably will have at least free Medicare Part A no matter what you do. However, Part A doesn't cover much if you have an emergency in the U.S. It doesn't cover doctors' fees or prescription drugs, as notable examples. One option would be to stay enrolled in Medicare (with Medigap or Medicare Advantage, probably), but perhaps choose a less expensive plan that offers a level of coverage more suitable to your temporary visits to the U.S. For example, maybe you can choose a Medicare Advantage plan that has a more limited provider network since obviously you're not going to be visiting a particular doctor in the U.S. with any regularity. You have to remain a U.S. "resident" for Medicare purposes -- keep a U.S. mailing address on file, basically -- but you don't necessarily have to be physically present in the U.S. That could be a reasonable approach and costs as little as $104.90 per month assuming your income isn't too high and assuming you enroll in one of the more affordable Advantage plans. It could also be useful "emergency" coverage if for whatever reason you're not happy with medical coverage in Italy and want to fly to the U.S. for treatment. For example, Italy has some age limits on certain medical procedures: the public system simply won't pay for, say, a particular organ transplant once you reach a certain age. If Medicare would, and if you want that particular procedure, then you'd have another option (assuming you're able to travel in the circumstances).

If you choose to discontinue Part B and Part D then, if/when you decide to re-enroll, the Part B and D premiums will be higher. How much higher depends on how long you stayed out of Medicare. Just be aware of that premium increase if you decide not to continue your U.S. Medicare coverage.

5. Another potential option for your U.S. coverage needs is travel medical insurance. The difficulty, though, is that decent medical insurance (the only appropriate kind for the U.S.) is quite expensive at your wise ages and not getting any less expensive. Moreover, only a couple companies sell travel medical insurance for U.S. citizens (I presume you both are) visiting their own country. On top of that, they tend to have enrollment age limits and exclude coverage for preexisting conditions.

So I think for your U.S. coverage you might need to stick with Medicare (and Medigap or Medicare Advantage), either with continuous coverage or hopping on/off -- alternating years, for example -- depending on how often you visit the U.S. and how much you value having U.S. insurance coverage to "backstop" your Italian coverage. If you hop on/off just be aware your hopping is limited, and your premium will increase (above inflation).

Note that medical insurance is not the same thing as long-term care insurance. Both Medicare and the Italian public system provide limited coverage for long-term care -- either residential or at-home. You may already have LTC insurance, or you may want to look into it. Many U.S. LTC insurance policies pay benefits even if you're in Italy since they're basically simple contingent annuities, but that's something to check. Unfortunately the LTC insurance market isn't functioning very well right now since insurance carriers didn't estimate their risks well, so you may find that the cost of LTC insurance is quite high.

As far as I know Italy does not provide public long-term care assistance to Elective Residents, and if it did a prerequisite would be destitution (or near destitution). Medicaid in the U.S. does under the same basic principle (near destitution, i.e. exhaustion of the household financial means to pay for long-term care). Another problem is how to transport somebody who needs long-term care from Italy to the U.S., for example.

There's a bit of a "radical," emerging approach to long-term care: international export/import of long-term care patients. There are a few countries specializing in that practice now. In Europe Hungary, the Czech Republic, and to a lesser extent Spain and Greece have been popular destinations for foreigners seeking nursing home care. In Asia Thailand and the Philippines are attracting foreign nursing home patients. It seems a bit odd, but there you go.


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## sparrow777

Dear BBCWatcher:

Thank so much!!!!!

You've outlined very clearly not only the answer to my initial question, but very useful information re LTC, nursing homes etc. 

During my research on moving to Europe, many articles on the web said obtaining a visa to France compared to Italy would be easier (health care being the same). Is this accurate? If possible, please confirm.

Again, thank so much for your prompt and very detailed information!


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## BBCWatcher

I'm not too familiar with France's visa policies, but I don't think Italy is _particularly_ difficult provided you easily meet the ER income thresholds (or wealth equivalents).


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## sparrow777

Thank you so much for your help.


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## Bevdeforges

I've been away over the weekend and am only catching this thread now.

Be very careful here. The medical systems in France and Italy actually vary greatly - at least as concerns your eligibility for the national health care system.

As I understand it, in Italy, the system is somewhat like the NHS system in the UK. Eligibility is based on residence. But until you establish residence in Italy, you may need to carry private coverage.

In France, health coverage is only available to those who have paid into the "cotisation" system (basically social insurances) for a certain minimum period of time through employment. Pensioners are entitled to state health coverage only if they receive a French state pension. To move to France as an "inactif" (i.e. non-working, for any reason) you must show that you have private health care coverage. 

Over on the French forum here, the EU nationals advise that there is a "fall back" coverage available called the CMU, however this is generally only available to EU nationals (in part because of the private insurance cover required as a condition of obtaining a visa/residence permit).

If you need private health cover, you may want to look at the coverage available through AARO, an American expat association based in Paris. It is pretty much designed to meet the visa requirements throughout Europe and many other countries. You have to be a member of the association to take the insurance, but that's actually a pretty good deal for those with ties to the US. https://aaro.org/medical-insurance
Cheers,
Bev


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## sparrow777

Hi Bev,

Many thanks for providing valuable information. I will check aaro.org and hope on of these days I can look back from the other side of the pond!
Cheers


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## BBCWatcher

Italy is OK, Bev. Once they apply for their PdSes (residence permits) ERs are allowed to enroll in the Italian public system (at the income-dependent fee rate rather than free rate -- so-called "Voluntary Registration"). Provided there's emergency/urgent care coverage as part of the plan, Medigap or Medicare Advantage should provide adequate "bridge" coverage, as mentioned.

This official guide (in English!) provides more information.

AARO's medical insurance is _way_ more expensive than simply maintaining enrollment in a reasonable U.S. Medicare Advantage plan plus Italian/EHIC public coverage, so I don't think it's going to be so attractive. It's also somewhat weak on U.S. coverage compared to what a typical Medicare Advantage plan would cover. So I'm not wild about that idea in these circumstances.


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## rsetzer99

Follow up question to this thread. I have been having trouble finding resources that give a cost range for voluntary registration in the Italian SSN for non-EU retired persons. The cost for students seems easily found, but they typically don't take the next step and discuss fees for other classifications. I found one that may have suggested 7.5% of income, but they were also discussion reunification in the same paragraph, which does not apply to me. If that is a valid number and if it is for all members of a family, then that would seem pretty reasonable. 

I assume that many people in the Italian SSN also carry some kind of supplemental insurance as well. But since our plans for moving to Italy are still 4 years in the future, I'm happy to just learn the details of one subject at a time.


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## Bevdeforges

Look up thread a bit - BBCWatcher has posted a link to some information on the voluntary system that might be useful to you. (Message #10)
Cheers,
Bev


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## BBCWatcher

At last report the calendar year annual enrollment fee for voluntary registration (_iscrizione volontaria_) ranges from €219.49 minimum to €2788.87 maximum, depending on income (and also on whether the local ASL office wants to bother with asking about income). Don't lie, but if your ASL office charges you only €219.49, smile and say "grazie."

So-called mandatory registration (_iscrizione obbligatoria_) is free. Citizens are among those who qualify for mandatory registration, and you can apply for citizenship as you approach 10 years of continuous legal residence. (Applications open after you reach the 8 year mark, and approvals are permitted as early as the exact day you hit the 10 year mark.) You'll probably want to do that as the years go by. Ask a follow-up question if you're interested in that option.

Note that if you have a parent or grandparent that was born as an Italian citizen (or could have been recognized as such), the waiting period falls from 10 years to 3 years.


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## rsetzer99

After following this, and a few other threads on opting into the Italian Healthcare System, I 'think' have have gained a pretty good understanding of the process, but I wanted to get few items understood better.

We currently are planning to retire to Italy in 3 years. We are US citizens. I will be 63 and my wife 60. We will follow all regulations and rules for long term visas. I'm a CPA, so while I find random bureaucratic procedure to be as annoying as anyone else, I am comfortable navigating in that environment. 

We will be officially retired. We will have combined passive income from Social Security, Private Pension, and 401K of $5000 per month. We can go higher or lower as need dictates, but this is just a figure I budgeted that we can maintain in perpetuity. 

From reading threads, my understanding is that we will be eligible to opt into the Italian Healthcare system after 3 months of residency. We will of course carry adequate private coverage until all enrollments are complete.

I find the figures of 4% of the first $20,658 and 4% of amounts over that to $52K Euro (rounded)

I am led to understand that Husband and Wife pay separate yearly fees. 

Will our fees be calculated based on the individual amounts each of us contribute to the yearly income? Or is there likely to be another method? 

Final followup question. I'm guessing that many people in Italy also may carry a separate supplemental insurance policy. If any readers have, or know of examples. I would find even general anecdotes helpful.


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## BBCWatcher

rsetzer99 said:


> We will have combined passive income from Social Security, Private Pension, and 401K of $5000 per month. We can go higher or lower as need dictates, but this is just a figure I budgeted that we can maintain in perpetuity.


I'd recommend going lower on U.S. Social Security, i.e. deferring collection, unless you're expecting to have a shorter than usual lifespan (e.g. you're in relatively poor health). You take a serious hit if you start collecting early -- before age 66 for the 63 year old, I believe.



> From reading threads, my understanding is that we will be eligible to opt into the Italian Healthcare system after 3 months of residency.


I'm not sure where you got the 3 months requirement. That's only a reasonable "worst case" estimate, I'd say, for completing PdS, residence registration, and enrollment formalities.

Note that you'd be well advised to time your move if you can so that you arrive, say, in November. Then you should be ready to enroll in the public medical system in January. Your premium is for one calendar year of coverage and is not pro-rated, so it makes sense to enroll in January and much less sense to enroll in December.



> Will our fees be calculated based on the individual amounts each of us contribute to the yearly income? Or is there likely to be another method?


Another possible method is that the ASL office will simply charge you the minimum premium. Tell the truth, but if that happens I wouldn't complain.



> Final followup question. I'm guessing that many people in Italy also may carry a separate supplemental insurance policy.


Maybe, but the more important consideration for most expatriates is coverage for those occasions when you're outside Italy, e.g. when visiting the United States. For sure you should both enroll in free Medicare Part A when you're eligible, assuming you're eligible -- that's a no brainer. Beyond that "it depends."


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## Bevdeforges

I would check the website of your local Italian Consulate and see what they list as the requirements for an "Elective Residence" visa. I took a look at the Boston consulate and found among the other requirements the following:



> Proof of overseas health insurance covering 100% of all medical expenses;


source: Consolato Generale d'Italia a Boston

It may be possible to get into the national health care system, but for Americans (since there is no reciprocal health care system in the US), they very often have to carry private insurance - at least for the first year or so in an EU country. 

For an idea of what an acceptable policy might cost, you can take a look at the AARO health coverage for their members: https://aaro.org/medical-insurance Not pushing that one in particular, but it's designed to meet visa requirements (at least for Europe) and it's one of the few plans that publishes their current rate sheet online for general viewing.
Cheers,
Bev


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## BBCWatcher

Bev, indeed there are visa requirements but then there are the options you have after entering Italy. They're separate issues, really, much like visas and residence permits themselves. The first thing gets you into Italy (and covered during that entry process), and the other is for staying in Italy (and coverage for that stay).

Rsetzer99 wrote this: "We will follow all regulations and rules for long term visas." I don't think there's any confusion here, and indeed the consulate will not issue an ER visa without proof of visa-compliant medical insurance.

That said, Rsetzer99's questions were specific to what happens after entry and the Italian public medical system. Legal Elective Residents have the option/right to enroll in the public medical system as soon as they've completed registration formalities in Italy provided they pay the assessed premiums to their ASL office. Whereupon they can maintain their first visa-compliant coverage if they wish or terminate it, as they deem appropriate for their coverage needs. There is no legal requirement to maintain the coverage used to secure the visa once enrolled in the public medical system.


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## rsetzer99

Thank you for the replies. I clearly misread something somewhere regarding a waiting period.

Also have seen it posted a number of times that the ASL office may, at their whim, simply charge you the minimum. Its only prudent however, for my budgeting scenarios, that I calculate the maximum. Which, unless I miss the mark, appears to be a max of 2799EU per year for my wife and I to enroll in the Italian system. And of course we will carry an expat focused policy that provides better than minimum coverage until such time as we are formally established on the Italian system. And, as has been mentioned as well, we will take the yearly timing issue into consideration. 

As for advice to wait on Social Security, as an Accountant I have a spreadsheet full of options with all the early, late, register and suspend, spousal benefit....(Social Security strategies can get complex), and to make it even more fun, I have similar options to my wife's pension for early accelerated payments or waiting. And finally I include calculations of 401k depletion/growth using future value formulas. Our plan to retire and move early is simply....because we can.  

This forum is a valuable resource for helping to understand the process. I'm also fortunate that we have friends in Italy that work in the Accounting and Legal fields, and they will be able to provide help navigating a new bureaucracy.


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## BBCWatcher

Yes indeed, and there are also some tax considerations (Italy and U.S.) to factor into when to withdraw retirement funds and which ones first. Good luck!


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