# Cost of Italian healthcare system



## joshuamac

Hi all,

I'm looking for help about opting-in to the Italian healthcare system. I'm a U.S. citizen living in Rome with my wife (also a U.S. citizen). We both have permessi di soggiorno through my work as a journalist, and have our residence in Rome registered at the anagrafe as well as our marriage.

I visited the ASL office yesterday, got the necessary forms and feel ready to go but have one question. If I list my wife as my dependent on the form (even though she makes income in the U.S. working remotely) do we both have to pay the opt-in fee for the system, or do we pay one opt-in fee based on my income?

I also am registered as someone seeking Italian citizenship through ancestry (I filed the documents with Rome's central office, and am waiting for a reply) but I don't think that's pertinent.

Does anyone know if we pay one or two opt-in fees? Thanks so much for any help.


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## accbgb

I do hate to bring this up, but feel I must - if only for your own protection.

If your wife is performing work while in Italy, regardless of the "remote" nature of it, then she should be reporting that income on her Italian income tax return and paying the appropriate taxes. Failure to do so could lead to all sorts of problems.


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## joshuamac

Hi,

Thanks for helping with the reply. We just moved here six months ago (last August) and we've never filed taxes here yet. I don't know how to do that.. maybe that's a whole different (and lengthy) process to become familiar with?

But on healthcare, my understanding was that since we don't get paid in Italy (and therefore don't pay Italian taxes on our salaries), we have to pay ASL to opt into the health care system. I'm just not sure if I list my wife as a dependent if I have to pay two opt-in fees. Thanks for any help.


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## accbgb

joshuamac said:


> Hi,
> 
> Thanks for helping with the reply. We just moved here six months ago (last August) and we've never filed taxes here yet. I don't know how to do that.. maybe that's a whole different (and lengthy) process to become familiar with?
> 
> But on healthcare, _*my understanding was that since we don't get paid in Italy (and therefore don't pay Italian taxes on our salaries*_), we have to pay ASL to opt into the health care system. I'm just not sure if I list my wife as a dependent if I have to pay two opt-in fees. Thanks for any help.


But you see, that is the point. The fact that your salaries are paid elsewhere does not change the fact that you are performing work while on Italian soil. Your income, therefore, IS taxable in Italy - if you are "tax resident" which, in my opinion, you are. There may be a question as to the fact that you were not present in Italy for at least 183 days in 2014 (but I think this is overridden by the fact that you have a permesso and established residenza), but it will certainly be the case if you stay well into 2015. 

I don't mean to ignore your question regarding ASL, but this is really a situation that you need to get worked out. It may be a good idea to find a good commercialista (basically, an accountant).

Yes, everyone in Italy does their best to avoid taxes, but it is getting much more difficult to get away with it and the penalties when caught can be substantial.


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## joshuamac

Hi,

Thanks again for the help. I'm not trying to say that we won't pay taxes. We'll be seeking a commercialista, as you suggest, some point later this year to try and figure out our tax liability in Italy and then will probably be using an accountant in the U.S. to help with filings there.

But my question right now, I think, really does deal specifically with ASL. We just want to opt into the system now so we can get health cards and pick a doctor. Since it's based on that calendar year, it makes most sense to opt in at the beginning of the year. Any chance you can help with my original question about the opt in fee? Its 387 euro, plus a tax on income over 20,000 euro a year... just wanting to know if I need to pay two fees or only one for me, which then extends to my dependents.

Thank you.


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## accbgb

Turn to page 636 of this very helpful Ernst & Young document and note the following:



> *A. Income tax*
> *
> Who is liable. * Tax residents of Italy are subject to tax on their worldwide income. Individuals who are not tax resident in Italy are subject to tax on their Italian-source income only.
> 
> An individual is considered resident for income tax purposes if, for the greater part of the tax year, he or she satisfies any of the following conditions:
> 
> • His or her habitual abode is in Italy.
> • The center of his or her vital interests is located in Italy.
> • He or she is registered at the Office of Records of the Resident
> Population in Italy


http://www.ey.com/Publication/vwLUAssets/Worldwide_Personal_Tax_Guide_2014-15/$FILE/Worldwide%20Personal%20Tax%20Guide%202014-15.pdf


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## joshuamac

Hi again,

I understand that, thanks. Yes, as I said, we will be paying taxes. I'm sorry, but you're not being helpful at this point -- I need to know specifically about paying the opt-in fee to ASL in order to be a part of the Italian healthcare system and to receive the tessera sanitaria. Can you help me with that information?


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## accbgb

The ASL fee should have been quoted to you based on your income and family size. If you were told €387 based on your providing full information regarding your family and situation, then €387 it should be.

This site might be helpful: http://www.stranieriinitalia.it/guida_alla_salute_in_otto_lingue-medical_assistance_1796.html


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## accbgb

joshuamac said:


> Hi again,
> 
> I understand that, thanks. Yes, as I said, we will be paying taxes. I'm sorry, but you're not being helpful at this point -- I need to know specifically about paying the opt-in fee to ASL in order to be a part of the Italian healthcare system and to receive the tessera sanitaria. Can you help me with that information?


Now that we have established that you will be paying Italian taxes retroactively for 2014 and also in the future, I might suggest that you don't need to worry about opting-in to ASL or paying the separate opt-in fees.


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## baldilocks

In addition, as American citizens you will be liable also for taxation the to US on your worldwide income although, as I understand it, you may be able to claim against your US tax liability any tax paid in another country on the same income. A number of US citizens have rescinded their US nationality for the above reasons. As for the handling of any access to Italian healthcare, i have no information.


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## NickZ

L'iscrizione volontaria

http://www.salute.gov.it/imgs/C_17_pagineAree_2522_listaFile_itemName_0_file.pdf



> Per iscriversi volontariamente al SSN occorre corrispondere un
> contributo annuale
> calcolato sul reddito complessivo conseguito nell’anno precedente ( da intendersi come anno
> solare ) in Italia o all’estero.
> Tale contributo si calcola applicando:
> 
> l’aliquota del
> 7,50%
> fino alla quota di reddito pari a € 20.658,28
> 
> l’aliquota del
> 4%
> sugli
> importi eccedenti a € 20.658,28 e fino al limite di €.
> 51.645,69.
> I
> n ogni caso l’importo non potrà essere inferiore a € 387,34


BUT



> coloro che sono titolari di permesso di soggiorno per residenza elettiva e non svolgono alcuna attività lavorativa


Problem is it seems every ASL does this their own way. Many screwing it up. Worse if they do screw it up nothing stops them asking for more money ten or more years from now.


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## joshuamac

Thanks all for the help. I really appreciate the time on this.



accbgb said:


> Now that we have established that you will be paying Italian taxes retroactively for 2014 and also in the future, I might suggest that you don't need to worry about opting-in to ASL or paying the separate opt-in fees.


I don't think you quite get the situation, accbgb. We currently don't have health cards and my wife needs to see a doctor. In order to get the health cards, we have to opt-in to the service. The health cards don't just arrive at our doorstep! Maybe in following years as we're paying taxes it will go easier.


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## joshuamac

NickZ said:


> L'iscrizione volontaria
> 
> http://www.salute.gov.it/imgs/C_17_pagineAree_2522_listaFile_itemName_0_file.pdf
> 
> 
> 
> BUT
> 
> 
> 
> Problem is it seems every ASL does this their own way. Many screwing it up. Worse if they do screw it up nothing stops them asking for more money ten or more years from now.


NickZ, thanks for this. I saw that site, too. The form I'm looking at from my ASL (in my municipio of Rome) is a bit different -- it gives a fee of 387.30 euro up to a salary of 20,658 euro. But it also says: "il contributo forfetario anno ... e' estesa anche ai familiari a carico."

My main question is: Does that language mean I list my wife as a dependent and then pay one opt-in fee based on my salary for both of us? I'm not trying to cheat the system, but just adhere to the rules. Thanks for any help.


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## NickZ

Like I said they all do it differently. 

€387 is the absolute min. It's what is supposed to be charged if the 7,5% works out to be equal or less then 387.

My guess is you should be using family income. But what does the form say?

Also since both of you are working they shouldn't let you sign up. But like I said they all do things differently.


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## accbgb

joshuamac said:


> Thanks all for the help. I really appreciate the time on this.
> 
> I don't think you quite get the situation, accbgb. We currently don't have health cards _*and my wife needs to see a doctor*_.


Perhaps I don't quite get the situation because you are giving it to us in little bits and pieces.

To clarify Nickz's post, the contribution for ASL is 7.5% of income up to €20658 and then 4% of the additional income up to €51645. The €387 fee is only for persons with essentially zero earned income (actually income of €5160 or below). 

If you sign up at the €387 annual rate, you are stealing from the Italian government and from everyone you meet on the street as, I presume, you and your wife have combined _worldwide _ earned income in excess of €5160 (~$5965).

More importantly, you would be committing a crime with a high risk of getting caught. 

So, I will return to my original post and say that you need to get your entire tax situation straightened out. Once you have done that, ASL will fall into your lap easy as pie.

In the meantime, take your wife to any medical facility and simply show her US passport. In all likelihood, she will receive the care she needs at zero or minimal cost.


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## joshuamac

accbgb said:


> Perhaps I don't quite get the situation because you are giving it to us in little bits and pieces.
> 
> To clarify Nickz's post, the contribution for ASL is 7.5% of income up to €20658 and then 4% of the additional income up to €51645. The €387 fee is only for persons with essentially zero earned income (actually income of €5160 or below).
> 
> If you sign up at the €387 annual rate, you are stealing from the Italian government and from everyone you meet on the street as, I presume, you and your wife have combined _worldwide _ earned income in excess of €5160 (~$5965).
> 
> More importantly, you would be committing a crime with a high risk of getting caught.
> 
> So, I will return to my original post and say that you need to get your entire tax situation straightened out. Once you have done that, ASL will fall into your lap easy as pie.
> 
> In the meantime, take your wife to any medical facility and simply show her US passport. In all likelihood, she will receive the care she needs at zero or minimal cost.


Can you please stop responding to my inquiry? I'm trying to be charitable, but I just don't think you're being kind or trying to understand our situation.

I am not trying to steal. I'm just trying to understand how to opt into the system. I am new to the country (here six months) and am not 100 percent comfortable and do not understand everything.

For example, if I make $36,000 as a journalist living in Rome I know that I have to pay 387 euro plus the difference above 20,000 euro in my annual salary. Do I then add my wife's salary to that and pay the rate for our two salaries together? Or do I have to pay two opt-in fees, separately?

I'm really just trying to understand how much to pay. I'm not trying to underpay, but I just want to pay the correct amount! Thank you.


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## BBCWatcher

Joshua, I think your question was answered. There's a national standard and fee formula, but each local ASL office has been known to handle the process differently.

Enrollment is very easy. Simply go to the ASL office, bring your documentation (PdS or PdS receipts, passports, etc.), tell them you and your wife want to enroll, and fill out the forms and answer all questions truthfully, including your and your wife's total worldwide incomes (if they ask, and they probably will). They'll calculate your enrollment fee, and that fee will range from 387.50 euro to around 2000 euro last I checked (possibly 2000 euro per person), and depending on your and your wife's incomes and your local ASL office's ability to follow the national rules. If they charge your household 387.50, great, consider yourself lucky _but do not lie_. Now (January) is a very good time to enroll because the fee is based on calendar year enrollment and not pro-rated, so bravo for your timing.

A point of order here. Eligibility for enrollment in the Italian public health system has nothing whatsoever to do with one's amount of (income) taxes owed. The _funding_ for the system comes from tax revenues, of course, but this is not a pay-to-play system for individuals and households. It's very important not to get confused about that. Medicare care is considered a right in Italy, available without enrollment fee to certain categories of individuals (e.g. Italian citizens) and with an income-dependent enrollment fee for other categories. But never, never is it based on somebody's income tax liabilities.

"Dumb" question: You and your wife could not have gotten into Italy -- could not have gotten visas -- without at least Schengen minimum medical insurance. You are not required to enroll in the public medical system. Why is your wife apparently missing medical insurance? You and she are already required to maintain at least that minimum coverage. Something doesn't add up here. But yes, you and your wife can enroll in the public system -- I presume you're considering _switching_ coverages. Just drop by the ASL office, tell them the truth, and let them figure out your enrollment fee.


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## NickZ

You're all confusing issues.

He is working. They SHOULDN'T let him use the voluntary enrollment for non working persons. If they let him the fee he'll be paying will be in addition to the taxes he is paying.

His health care is paid by the regional income tax. Some by the national tax. By things like the car insurance health fee.

In theory if he shows his work contract that is all he needs. Who knows what the ASL will think of a US contract.


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## accbgb

joshuamac said:


> Can you please stop responding to my inquiry? I'm trying to be charitable, but I just don't think you're being kind or trying to understand our situation.


We are both trying to be charitable. But you keep trying to make this into an ASL opt-in question and I have been trying to make you understand that it is nothing of the sort.



> I am not trying to steal. I'm just trying to understand how to opt into the system. I am new to the country (here six months) and am not 100 percent comfortable and do not understand everything.
> 
> For example, if I make $36,000 as a journalist living in Rome I know that I have to pay 387 euro plus the difference above 20,000 euro in my annual salary. Do I then add my wife's salary to that and pay the rate for our two salaries together? Or do I have to pay two opt-in fees, separately?


No, as both Nickz and I have pointed out two, three times, the fee is 7.5% of the first €20658 of your worldwide income plus 4% of your worldwide income between €20658 and €51645. If you want to use your $36000 income as an example, that is about €31140 and your ASL fee would then be .075 x 20658 + .04 x 10482 = €1968.63. If your wife's income is similar to yours, the total fee will be much, much higher. Either way, a far larger number than €387.

Medical care in Italy is far less expensive than in the US, but they don't give it away...




> I'm really just trying to understand how much to pay. I'm not trying to underpay, but I just want to pay the correct amount! Thank you.


Finally, as Nickz alludes to above, if you were properly reporting your worldwide income and paying *all* applicable taxes on same, you would not need to pay a separate ASL opt-in fee. As a taxpayer, you would automatically be entitled to full medical coverage because you would be paying the ASL tax along with your general income tax liabilities.


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## joshuamac

Thank you all for the help. BBCwatcher: We have health insurance, but it's been a big hassle to try and use doctors in Italy since the international plan we have covers so little. We just wanted to make it easier for ourselves and participate in the system here.

When I went to the ASL before they told me that as an American I needed to opt-in and could list my wife as a dependent, therefore saving paperwork and money. I was just unclear if I need to pay two opt-in fees or not. And as I have to make the deposit(s)/transfer(s) before applying at the ASL office, I wanted to be clear on that so my money just didn't disappear.

Maybe what's confusing people is that we're not being paid in Italy. My paycheck is issued in the U.S. (as is my wife's), which means we are not having Italian taxes deducted from our salaries. We'll have to report taxes voluntarily in September, which we plan to do anyway (based on our worldwide income, as several have underlined).

If we want to get our health cards before next year (when we start paying taxes ordinarily) I think we absolutely have to opt-in to the system, which is what we're trying to do. If anyone has any more advice, particularly anyone who has opted into the system before, I'd be grateful. Thank you.


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## BBCWatcher

I would take the ASL office's advice on including your wife, assuming she would like to be enrolled.

_As a separate issue_ Italy requires advance payment of personal income and wealth taxes, much like the U.S. does. I can't remember if you get a free pass the first year or not, but that'd be something to check as soon as you can. As I recall there are two advance payment due dates: June 20 and November 30. Obviously those dates are now past for tax year 2014, but if you don't get a first year pass it might still be a great idea to make those estimated advance payments now so they're less late rather than more late.

Fortunately you'll only owe (at most) the difference between your U.S. income tax rate and your Italian rate since you'll get a tax credit on your Italian tax return for your U.S. income tax, plus a bit of wealth tax perhaps, plus any late fees (if applicable).

Don't forget Form RW.


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## joshuamac

BBCWatcher said:


> I would take the ASL office's advice on including your wife, assuming she would like to be enrolled.
> 
> _As a separate issue_ Italy requires advance payment of personal income and wealth taxes, much like the U.S. does. I can't remember if you get a free pass the first year or not, but that'd be something to check as soon as you can. As I recall there are two advance payment due dates: June 20 and November 30. Obviously those dates are now past for tax year 2014, but if you don't get a first year pass it might still be a great idea to make those estimated advance payments now so they're less late rather than more late.
> 
> Fortunately you'll only owe (at most) the difference between your U.S. income tax rate and your Italian rate since you'll get a tax credit on your Italian tax return for your U.S. income tax, plus a bit of wealth tax perhaps, plus any late fees (if applicable).
> 
> Don't forget Form RW.


Thank you very much for this help. I really appreciate the information and will do as you suggest.


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## rsetzer99

As a follow up question to this thread.

Assuming two retired Americans move to Italy. Stay long term and have acquired all the proper paperwork, including health insurance policies. 

Income would be from US social security, pension, and 401K savings. 

1. Would it be allowable for this couple to opt into the Italian health system?
2. If yes, would there be reasons they would want to?


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## joshuamac

rsetzer99 said:


> As a follow up question to this thread.
> 
> Assuming two retired Americans move to Italy. Stay long term and have acquired all the proper paperwork, including health insurance policies.
> 
> Income would be from US social security, pension, and 401K savings.
> 
> 1. Would it be allowable for this couple to opt into the Italian health system?
> 2. If yes, would there be reasons they would want to?


I can't speak for others, but the main reason my wife and I wanted to opt in was because of the simple ease of the system. We have found having international insurance to be a real hassle. First of all, it doesn't cover nearly as much as we'd like (and we're very young with no health problems) and trying to get the plan to reimburse you for care obtained in Italy is a real hassle.

We liked the idea of having simple and easy access to a doctor and medications as necessary.


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## accbgb

This brochure may be helpful: http://www.salute.gov.it/imgs/C_17_...terioriallegati_ulterioreallegato_4_alleg.pdf


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## BBCWatcher

Yes, Rsetzer99, you would be allowed to enroll in those circumstances, for a fee.

Another reason many people choose to enroll in the public system is that it's a good value. Also, many people find the Italian public system plus EHIC privileges to be sufficient for their travel patterns -- or at least a strong foundation that they can then supplement with travel medical insurance if needed.

Joshuamac might simply have a bad insurance carrier. If you're happy with your private medical insurance and find it to be a good value, then you don't need another option such as Italy's public medical system.


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## rsetzer99

Thanks for the feedback. We have about five years to go, but it sounds like, for a US expat, buying into the system, along with a supplemental policy might be an option to keep in the pool.


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## BBCWatcher

FYI, the Italian Health Ministry has a useful guide to the public medical system that's well worth reading.


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## accbgb

BBCWatcher said:


> FYI, the Italian Health Ministry has a useful guide to the public medical system that's well worth reading.


Already linked in message #25, above.


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## misha38

joshuamac said:


> Thank you very much for this help. I really appreciate the information and will do as you suggest.


joshuamac, did you end up paying 2 separate fees or were able to list your wife as a dependent? At this point I am just trying to budget and having read a lot of information in both Italian and English it's still not clear to me if I can apply using a family income and list my wife as a dependent or we need to apply separately the same way we will be paying the Italian tax (we are planning to apply for ER visa with all our passive income coming from the USA). Thanks


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