# S-1 application process in Italy?



## Napol01

Hello,

Does anyone here know the various ways to apply for Italian S-1 coverage? This is an EU benefit whereby Italy agrees to pay long-term for medical care for Italians resident in France (or other EU countries etc.) as happens in retirement.

I believe it is only for citizens who have earned this benefit by working in Italy for a long time, but I'm not 100% sure on that. And, I don't know if you need to request this from a Consulate, Minister of Health in Rome, or the local ASL where the Tessera Sanitaria was issued. It's a mystery...

Any help is appreciated!


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## Bevdeforges

This page from the europa.eu site explains the details about health care cover transfer from one EU country to the next. Health insurance cover in your host country - Your Europe As it says at the top of the page, "In the EU, the country responsible for your social security and your health cover depends on your economic status and your place of residence – not your nationality."

But read through the rest of the page to check on the details and there are a couple of links that might help you nail down what your entitlements should be - and where and how to claim an S-1 if Italy will pay for your health cover in the French system.


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## Crabtree

You will only get an S1 in Italy if you are in receipt of the Italian state pension and if so you would need to apply to INPS who deal with pensions and such like.If you are of state pensionable age it is generally the last country in which you worked in the EU that is responsible for pulling together your pensions and funding your retirement health care 
I believe you have to have worked for a minimum 20 years in Italy and have reached the age of 67 but of course this can include other EU working but this may have changed


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## Crabtree

INPS stands for Instituto Nazionale di Previdenza Sociale


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## Napol01

Thank you. Well said. The difficulty we have is to apply for an S-1 (which we understand we do not qualify for) and show the rejection letter to the French CPAM.

Although the list of "predicaments" on the site provided by Bevdeforges does not include people who are vocationally inactive but not receiving an EU pension, they did list a national EU healthcare "point of contact" in the country of citizenship, so we have written to them to ask for detailed guidance. others may someday find that useful as well.

Excellent resource!


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## Bevdeforges

If you are retired and in receipt of US Social Security, you won't get an S-1, but you will be eligible for what amounts to free entry into the French healthcare system. I don't understand all the details, but that has been in place now for a number of years. You still need to have private health cover to get your initial visa for France, but after three months of residence, you can apply to CPAM for the national cover, showing your US SS benefit as your source of income. The processing can take some time, so don't cancel the private policy until you get the final word from CPAM about your enrollment.

But don't forget that the French health care system only reimburses a percentage of health care costs based on the standard table of fees. For the rest you will need to take out a mutuelle (top up insurance), which you can tailor a bit to your specific needs based on the type of policy you choose and pay for.


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## Napol01

Interesting.

Unfortunately, being citizens of both the USA and the EU, in retirement, but with no state pension makes a French CPAM application rather complicated.

It is likely easier to be just an American retired and using Social Security, and as you have indicated. And, now that the UK is not part of the EU, the same likely applies there. Our EU citizenship permits us to stay, and we can demonstrate rental income from our home in the USA to satisfy the income/burden requirement, but to enroll as "early" retirees, we must also demonstrate to the French that we do not qualify for health resources elsewhere (like Italy). We don't need an S-1, we need a rejection document. So, just knowing how to apply for an S-1 in the country of citizenship (MoH? Consulate? ASL? INPS?) is the first step.

Thank you again for the EU resource (POC). I think this will eventually put some light in this otherwise dark tunnel.


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## Bevdeforges

It has always been an "issue" for early retirees when it comes to applying for visas. Depending on how "early" you are trying to retire, the rental income from your US home may or may not suffice for the visa application (for a "visitor" long stay visa, which does not carry work privileges) - but you will still need private health cover for the first year in France at a minimum.

If you have only a couple of years to go before you reach retirement age in the US, you'll probably be eligible for SS benefits of some variety and you should be able to obtain an official estimate of your eventual SS retirement benefit, which (depending on the circumstances) may be counted as your "potential" income - mainly to show that you won't be draining your life savings during your stay in France. 


Napol01 said:


> but to enroll as "early" retirees, we must also demonstrate to the French that we do not qualify for health resources elsewhere (like Italy)


Not sure where that is coming from (though I admit I am not familiar with all the ways of qualifying for French health cover). As I understand it, if you receive a visitor visa, you can apply for the French system after 3 months of residence in France but without a state pension, you'll be expected to pay an annual fee for the cover, based on your assessed income (usually based on your French tax declaration from the prior year). Unless you're going for some other type of visa.


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## BackinFrance

If they are moving here as Italian citizens they don't need a visa. Whilst they can apply to join the French health system after 3 months, given they will be here on the basis of their EU (Italian) citizenship, then the I assume that it will be the Italian passport they will enter on and present to CPAM. If so, they would likely need to demonstrate that they don't have cover from Italy. Of course their interim private health insurance might suffice in that regard. But if they are under Italian pension age and can demonstrate that, might work. If they enter on US passports, that would work except that without a visa they can only stay 3 months anyway, and they have to be in France for 3 months before they can apply, which would mean reliance on the Italian passports so the issue remains.


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## BackinFrance

I believe an attestation sur l'honneur is sufficient in such circumstances. Problem solved.


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## Bevdeforges

BackinFrance said:


> If so, they would likely need to demonstrate that they don't have cover from Italy. Of course their interim private health insurance might suffice in that regard.


Sorry, forgot about the Italian citizenships - as long as they both have Italian citizenship. If one of the spouses will be relying on the carte de séjour as the spouse of an EU national, they will both have to produce evidence of their interim health care cover when applying for the residence permit. It may or may not be necessary when applying to CPAM after 3 months of residence for an EU national. (It appears to vary by which departement you're applying from.)


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## BackinFrance

They clearly both need private health insurance. One of the advantages though of being here as an EU citizen or spouse of an EU citizen is the difference in income requirement, plus of course they could both work but finding a legal job is not easy and another issue altogether.


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## BackinFrance

Make sure you get your EU passport stamped at passport control when you enter France, even if it means going to a non-EU line.


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## Crabtree

I bet I know what has happened here Did the OP describe themselves as Retired on the CPAM application? AS they are not in receipt of a state pension per se then they need to describe themselves as "Inactif" but then they will need to show that they meet the minimum income requirements so as not to become a burden on CPAM


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## Napol01

Bonjour,

Well, retirement. Subtle meanings get lost. We feel we're well on our way to S-1 rejection in Italy, our stated goal, and topic of this thread, but, some interesting points have been raised on the bigger issue of how to best obtain public cover in France given our unique situation.

We are of legal "retirement age" in the US (minimum is 62) but one is almost at "full" retirement age, and the other is only at entry level. It's complex. Since we have --not-- yet applied to the CPAM (Gard) perhaps it is better to say we are "inactif" as French residents since we both have chosen to defer receiving our American "pensions" from our US Social Security system for a larger payout in the future? Might be better this way.

In the US, besides personal savings, there are many other retirement vehicles such as an Annuity, a Traditional IRA and the Roth IRA, all designed to supplement or replace social security in the later years of an American life, and all starting at 59-1/2 years of age, making age as a retirement gauge a little useless.

So, how to apply to the CPAM is in itself an interesting perspective; thanks Crabtree for raising the point. We can say we are inactif, and demonstrate adequate financial resources to put a check in that box for them.

But, citizenship is tricky. We are both US and EU (Italy) citizens. We are not one or the other, but both and simultaneously. The CPAM application may not be able to handle dual citizenship in an easy-flowing or natural manner, but I don't really know. Anyway, during our visit, the agent pondered it all and suggested writing a full on letter explaining all the oddities of our case. We will do that.

Regarding private cover, one of us has pre-existing medical conditions that are excluded by private plans, so we believe the private insurance option would be (in the view of the French decision-makers) "incomplete" and therefore inadequate cover leaving us with a state option more as a matter of necessity. I wonder if this would improve our chances?

Nobody stamps passports anymore. I'm not sure what attestation under honor means in post #10. What did you mean?


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## Bevdeforges

Napol01 said:


> The CPAM application may not be able to handle dual citizenship in an easy-flowing or natural manner, but I don't really know.


CPAM deals with dual nationalities all the time. The "tricky" part is that one of your nationalities is EU while the other isn't. If you are receiving a pension by the time you reach your 3 months of residence, then your application to CPAM should be accepted. And, according to the US-France tax treaty, IRAs, 401Ks and other self-saving retirement plans are treated here like part of the national plan from the US. Basically, once you start drawing on your US based retirement plan, you should qualify for free registration in the French national plan. 

What we have suggested to some folks is to start making regular (monthly or quarterly) withdrawals from one or more of your retirement plans considered to be "national" and have that deposited in your bank account for a few months before you make the move to France. That gives you a basis for your "pension income" and thus the claim to the French health care system. You may still have to show some form of private insurance for that first three months, though. (Depends on the local CPAM office.) The fact that you enter France as an EU national on your Italian passport is not taken into consideration. If you're only receiving a US pension, then that's what they base your eligibility on.

And, having regular deposits of your "pension" in your US bank account before you move over can also help when opening a French bank account. They often want to know that you have a regular source of income that will be direct deposited in the new account - even if you make the deposit each month or quarter using a service like Wise to make the transfer from your US bank.


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## BackinFrance

BTW, you are not exempt from having some kind of health cover when you move to France as an EU citizen. Anyone who moves to France must have health cover, even if they are French citizens.

You could, if you chose, Google Attestation sur l'honneur. 

Whilst your EU passports would not usually be stamped when you enter the Schengen area, you can certainly ask to have it done. If is proof of how long you have been here and CPAM needs to know that you have been here at least 3 months. However it appears you have already moved. 

Your situation is not unusual.


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## Napol01

Thanks to all for the advice. Once we hear back from the EU healthcare POC in Italy, and can get started on the S-1 rejection process, what you all have suggested here will help us to write a better letter to accompany our application. Yes, we arrived (unstamped) as EU citizens, we have been living legally in the EU for some time now, and we already have a French bank account.

We will explain that as Italians, we have nothing since we worked all our lives in the US. And, as Americans we are not inactive or early retirees in the stricter senses of these words, as we have both been been eligible to receive retirement income for several years, but have exercised our legal rights to defer it, for larger future payments. We consider ourselves retired and will let them decide how to process it. I am already on medicare but my husband is still a few years away, so that may also help them understand. Our rental income is several times the legal income floor for a married couple without children in France, so I remain hopeful it will adequately demonstrate that we are not a burden risk. I guess we shall see.

Still, current healthcare looks like a problem. Having been in France for more than a year, our short-term cover expired several months back and could not be extended past the first six months. Due to pre-existing conditions is was not complete coverage, and we cannot buy any private insurance that is complete (e.g. covers these conditions). As such, the state option with the CPAM is indeed our only remedy. I believe it will help our application, but I'm not sure...


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## Bevdeforges

Worst case scenario (in line with the idea of making things easy for the clerk handling your application) you could start taking one of your pensions now, which makes you eligible for the French health care system (both of you, actually) and leave the other US pensions to accumulate until whenever it is you choose to take them. With any kind of luck, you may never be asked for your current health insurance information. You'll probably still need to "prove" that you aren't entitled to the Italian S1, but that's a technicality.


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## Napol01

Makes sense; thank you. The amounts would not have to be grand to demonstrate a "retirement."

Form 710 (Questionnaire "recherche de droits" Ressortissants Européens Inactifs) in the second paragraph essentially says: _"If you are not entitled in any way to benefits in kind from a French or European health / maternity insurance scheme and you have not taken out any private health insurance or if it turns out to be "incomplete" (or that circumstances beyond your control prevent you from being entitled to it), you will be able to benefit, under certain conditions, from universal health coverage (CMU) and complementary universal health coverage (CMUC)."_

If anyone has thoughts on how to best convey in the letter our inability to procure "complete" private cover here in France, or elsewhere that covers us here, presenting it well would be helpful. Perhaps a note from our local médecin généraliste (attesting to the pre-existing condition) would be a good idea?


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## Bevdeforges

Don't spend too much time trying to compose a heart-rending letter or compile rock solid proofs or anything. The officials are well aware of the limits of private insurance, expat policies and whatever. Just state that you lived for x number of years in the US prior to moving to France, so you have no entitlement to health cover in Italy. (The French system works the same way, so they should be able to understand that.) Then, simply state that you have xyz pre-existing condition, which makes private health cover prohibitively expensive or not available or whatever the situation is. You may also want to provide a little list of those US retirement pensions you will start at a later date, including any amounts you have been advised you will be eligible for as of zzzz (whatever year you plan on taking them). (Refer to the latest estimation of benefits that you should be able to get from the US Social Security Administration. They are supposed to send you an estimate every couple of years.) Until then, you have $xx per month in rental income coming in. 

Generally, if you lay things out simply like that, they will contact you if they need any paperwork, "proofs" or have any questions about what you've said. But you're far from the first to have a somewhat similar situation so it may very well suffice. (And don't forget about the need for a mutuelle once you get your CPAM approved.)


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## BackinFrance

Bevdeforges said:


> Worst case scenario (in line with the idea of making things easy for the clerk handling your application) you could start taking one of your pensions now, which makes you eligible for the French health care system (both of you, actually) and leave the other US pensions to accumulate until whenever it is you choose to take them. With any kind of luck, you may never be asked for your current health insurance information. You'll probably still need to "prove" that you aren't entitled to the Italian S1, but that's a technicality.


I doubt very much that they will need to prove that they are not entitled to an S1 from Italy. It's not as if citizenship gives you cover, far from it. After all there are massive numbers of non-EU citizens around the world who are covered because they have contributed to those EU health systems, primarily through work. I do not believe it is a routine question posed by CPAM for dual nationals. 

It is worth noting that they have not even attempted to apply to CPAM at this time.


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## Bevdeforges

What can I say, BiF? Great minds think alike. I'm not even sure that France gives retirees an S1 form to confirm their status in the French health care system if they move elsewhere in the EU. (Though as perfect as France is, where else would they move? <gg>)

I've found in practice that if you start out by simply listing out the situation as simply and directly as you can, that may actually be enough. And if it isn't, most administrative agencies here in France will simply ask for a specific document or two for whatever they have doubts about.


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## BackinFrance

I don't know about the S1 from France because the only people I know who moved elsewhere in the EU did so for work.

I think perhaps it's only done by individual agreement between EU countries involving an agreed amount to be paid.


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## BackinFrance

@Napol01 I think Bev and I both agree that you should just go ahead and make your applications to CPAM to join the French health system. If they require any additional information, be it an S1 or something else, they will tell you precisely what they need and it's a far better way forward than you trying to guess in advance.


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## Napol01

Thanks again for the comments. We heard back from the Italians today:

"You will have to request a model S041 (formerly E104) from the ASL where you were registered in Italy." So, it's the local healthcare folks, not a consulate or ministerial procedure. Despite the form jungle, I think it's coming together...


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## BackinFrance

Napol01 said:


> Thanks again for the comments. We heard back from the Italians today:
> 
> "You will have to request a model S041 (formerly E104) from the ASL where you were registered in Italy." So, it's the local healthcare folks, not a consulate or ministerial procedure. Despite the form jungle, I think it's coming together...


Go ahead with that if you wish, but in the meantime make your applications to CPAM, at the very least you will avoid further unnecessary delay!


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## Napol01

With many thanks to all the collective suggestions provided, no follow-ups were requested and our CPAM acceptance letters arrived the other day; we purchased our mutuelle this morning. For others following here with EU passports, we hope this proves helpful to you as well. Bienvenue en france!


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