(Most everyone needs to get around. If you live in a large city, public transportation may be all you need. However, life in small cities or the countryside often requires the use of a car. Here’s some basic information on both. Keep in mind that much of what’s written here pertains mostly to our corner of Le Marche, and that, as with many things, your experience may be quite different in different parts of Italy.
National Health Care System (‘Servizio Sanitario Nazionale’)
Italy has a national health system, similar but not identical to the one used in the UK, France and Spain. Other European countries, including Germany and Switzerland (and the ACA, for that matter) use a government-regulated insurance approach.
In Italy, all citizens are automatically enrolled in the national health system. Legal Italian residents who are citizens of another EU country are also entitled to use the health care system under EU reciprocal agreements. Certain family members of those in the previous two categories are also eligible. Legal residents from other countries are allowed to buy into the system. Premiums are income-based, and range from €400 to €2700 per person per year.
Coverage is comprehensive, and includes things like rehabilitation services which are often treated as supplemental services in the US. There are no deductibles, and for new registrants, there are no exclusions for pre-existing conditions. Public system doctors do not make house calls, but the system does provide transportation for the elderly or others in frail health who are unable to get themselves to a treatment facility.
Co-Pays and Other Costs
Coverage includes an unlimited number of visits to your primary care physician, without co-pays.
There are co-pays for certain items like annual blood tests. Co-pays are subject to a statutory maximum, currently €46 (about $50), but depending on the test can sometimes be less. Co-pays are waived for those on limited incomes, or for those in certain medical categories like cancer survivors.
Co-pays also apply to consultations with specialists. If you get a referral from your primary physician, and are willing to take the next available specialist, you pay €46. If you make the appointment on your own, or you want to see a specific doctor, you pay €100 (about $110).
There are no co-pays for emergency room or hospital services.
Mammograms are free every two years. If you (or your doctor) want them more frequently, you can schedule them, subject to the standard co-pay.
Drugs prescribed for active conditions (e.g., antibiotics for current infections) are free. Maintenance drugs are either free or low cost (see “Medications” below).
When you are enrolled in the system, you select a primary care doctor who is generally your point of entry. If you don’t like your doctor, you can change without cost or penalty (although you will have to wait in line at the administrative office).
The system is administered locally. Within each region, there are smaller administrative areas which ensure that most of your medical care will be provided for by practitioners close to where you live. In our case, our primary care physician is a 10-minute walk from our house. Our primary hospital and emergency room is a 10-minute drive from our house, or 20 minutes by bus (served by three bus lines). Within walking distance from where we live, there is a satellite center for blood tests and immunizations, so you don’t have to go all the way to the hospital. There is also a small private hospital within walking distance where you can get some services at additional cost.
Although your primary care physician is located in your area, you can actually go to a public system doctor anywhere in the country. If you want to see a knee specialist in Perugia or a heart specialist in Rome, you are covered, subject to co-pays and availability. If you have a rare condition and the only available specialist is in another city, the system will cover your train ticket.
The system is set up for efficiency, which is not necessarily the same as convenience for the patient. If you are very sick, or have a medical emergency, you will be seen quickly, for example only a few days between cancer diagnosis and treatment. On the other hand, if you go to your doctor with an important but not urgent medical problem, you will probably sit for 2 hours in your doctor’s waiting room. Most primary care doctors here practice individually, with at most a nurse assisting.
Waiting times for non-urgent specialist consultations, or non-urgent medical procedures, like “extra” mammograms or colonoscopies, can sometimes be months long. If the appointment is truly non-urgent (e.g., you want a second medical opinion to confirm a prior medical conclusion) you may not mind the wait. And you can sometimes get an appointment quicker if you are willing to go to another doctor in the region, which can be an hour or two away. Or you can go to a private doctor.
Private System as Supplement
One of the most interesting features of the Italian medical system is the way you can go to a private doctor or a private hospital on a one-off basis, even though you are covered by the national health care system. This is not the case in the UK (or the US for that matter), where you are either in the public system or the private system, but you generally can’t utilize both systems at the same time.
So, for example, if you want a colonoscopy, and don’t want to wait months for a hospital appointment, you can make an appointment for the same procedure at a private hospital, generally with a much shorter waiting time. Similarly, if you want a specialist consultation in weeks instead of months, you can pay for a private doctor.
Private facilities also provide services for the public system on a contract basis. A friend of ours had minor surgery at the local private hospital, which was fully covered by the public system. Private facilities also provide diagnostic services for the national health system on a space available basis.
There are also some doctors who have both public and private patients, with shorter wait times (and higher fees) for the private patients.
The reason why this back-and-forth between the public and private systems works is that the costs, even at most private facilities, are very reasonable The cost of a mammogram from a private doctor, for example, is 80 euro. A consultation with a private surgeon is €150. And the cost of a colonoscopy at the private hospital was €130. These costs are not only reasonable for us as Americans, used to paying staggeringly high prices, but they are also within the means of middle-class Italians.
We think that most people in our area use the public health system for most of their medical needs. People in certain situations might use private doctors for primary care. People with chronic medical conditions, women expecting a baby, or working parents with small children, for example, often prefer the convenience of being able to make an appointment.
With respect to major medical services, though – surgery, broken bones, treatment for cancer or other serious illnesses – it seems that most people, rich or poor, use the public system.
Registering for the SSN
As stated above, the SSN is administered locally, so each region (or sub-region) will have it’s own processes. In Ascoli, the administration function for SSN enrollees is performed at the Anagrafe Assistiti in an office at the main hospital, but the acronym ASL (Agenzia Sanitaria Locale) is more generally used to name this office. The office handles SSN signups, choice/change of doctor, and exemption on co-pays (tickets) for people of lesser means.
Italian citizens and family members of citizens are eligible for Iscrizione Obbligatoria (gratis enrollment), and most likely will not have to visit this office again except maybe to change primary doctors (medico di base).
Folks who are not family members of EU citizens must sign up for Iscrizione Voluntaria. There is a form that you will need from the ASL. This form does not appear online as far as we can tell, so you will have to go there or find someone else with a copy. Payment is made according to the formula below. Income in most regions is self-certified and is intended to include worldwide sources. (Some regions require official income certification, which causes those folks serious pain.)
7,5% of total income up to €20,658.28 plus 4% of the amount exceeding €20,658.28 up to €51,645.69, and in no case less than €387.34 .
Payment is for a calendar year. It is not possible to pay in advance, and there is no pro rata reduction for a partial year. Payment is made by F24 form, the same form using which income tax is paid. But you need to include the specific coordinates for your regions SSN. Our ASL is known to be picky in that an “original receipt” must be shown for the electronic F24 payment. We suggest that you go to your bank to make the electronic transfer and ask the clerk to produce an official receipt. Actually, ask for two official receipt (see below).
You must provide your Carta d’Identità or other proof of local residence, and your Permesso or Carta di Soggiorno. Your SSN enrollment will be valid only until the expiry of your Permesso/Carta, so you may need to return to this office after any renewal. Renewal receipts are supposed to be sufficient, but this is Italy, so you can’t be sure. The ASL may also ask you for another “original receipt” of payment like the one you submitted at the beginning of the year. So, it’s best to ask for two when you make your payment at the bank.
Once you have your payment receipt, you can go back to the ASL to complete the signup.
Choosing a Doctor
Choosing a medico di base is not easy given that the rolls are fairly full and that there is not much to go on. The best method may well be to get a recommendation from someone you trust. Keep in mind that there is a mandatory retirement age, so if you sign up with an older doctor, you may be choosing again in a few years.
Doctors have a lot of flexibility when it comes to organizing their practices. Some practice in small groups. Some schedule appointments. Some have assistants, some don’t. But it is most common, at least in Ascoli, for doctors to offer office hours, usually for a few hours a day. You go to the office, ask “Chi è l’ultimo?” and wait. You may want to choose a doctor best suited to your tolerance for waiting. Bear in mind that the amount of attention that a doctor may choose to spend helping you may be proportional to your wait time.
Using the SSN
After visiting the ASL, your first experience with the SSN will probably be with your chosen medico di base. After waiting for your turn, your doctor will probably talk to you, maybe take your blood pressure, and then order a battery of tests. For blood tests, you can go to a local centro prelievi. In Ascoli, the ASL operates one at ex-Gil and one at the hospital. You will supply the co-pay first, of course. Private facilities are possible as well, although those might cost more. Your results will be available at the same location, or online.
For specialized tests, for example an ECG, you need to go to the CUP (Centro Ufficio Prenotazione). In Ascoli, that is at the hospital. (They are currently experimenting with allowing appointments to be made online or at pharmacies.) When you return to the hospital for your test, be prepared to pay in advance at the CUP or just afterwards. Policies differ. And of course, you can always go to a private facility instead. Or, the CUP might send you to a private facility for your test at the public rate.
Quality of Medical Care
The quality of the medical care is difficult to judge for those of us who are not doctors. But the SSN doctors seem attentive and well-informed. In cases where we have had the same procedure done both in the US and here, our experience here was better.
Many procedures done by physician assistants or nurses in the US are done by doctors here. In the US, when a test is done by a medical tech, the technician is often prohibited by law from discussing the results of the test with the patient. In Italy, when tests are done by doctors, they write up and discuss their results with you in real time.
In our experience, doctors, or at least medici di base, are a lot less “hands on” than doctors in the US. They rely a lot more on looking at test results rather than examining you physically.
In the Italian medical system, test results, whether in a public or private facility, are typically immediately available and are your property. This puts the responsibility on you for maintaining your personal medical records – you often see people in doctor’s offices carrying around thick folders with their medical history. But it also means that if you change doctors or move to another region, you don’t have to struggle to get copies of your medical records.
Private insurance is available, and is generally not costly, but in my region, at least, it seems that few people use it.
Certain specialties are not well-covered in the national health service, but you can find excellent service in private practice. Here are some details specific to Ascoli Piceno.
- Dental service, at least in Ascoli, is excellent in our experience. At least as good at the US if not better, and an approximately half the cost. We recommend Dr. Gino Chiodi on Via Cola d’Amatrice.
- Again, we have found opthamalogical service here to be on a par with that in the US. Eyeglasses, however, seem to be more expensive. We recommend dott.ssa. Stefania Aliberti on Via Marcello Federici.
- Dermatology specialists are hard to find in the SSN. We have had good luck with dott. Massimo Cioccolini who is in private practice on Via Erasmo Mari.
Doctors can issue two types of prescription. One is directly in the SSN computerized system allowing you to pay the “ticket” price for the medicine, which is close to nothing. Such prescriptions are typically for limited duration: 2 months at most. Or your doctor can hand-write a prescription outside the system for up to 6 months. In this case, you pay full freight which is not usually very much. This can save time waiting in the doctors office. For example, a common statin costs €6 per month.
Vaccines (especially flu vaccines) are sometimes available at doctors offices, but çan often be available directly at pharmacies (at reasonable cost). A pharmacy may or may not be equipped to administer the vaccine. It is not so uncommon for people to give shots at home.
Painkillers are less widely used here, whether by prescription or OTC. Doctors here use painkillers for pain reduction, not pain obliteration — increased pain is a symptom they don’t want to mask. There are drug abuse problems in Italy, but there doesn’t seem to be an epidemic of opiate abuse.
- European equivalents to Common US over the counter drugs
- Importing special drugs
This section covers a number of important services for homeowners and renters alike.
One thing most of these services have in common is that you have to regularly pay for them. Some providers allow payments using credit cards. All of them accept payment using bollettini postali at the Post Office. But in general, if you have a bank account, you might find it easier to pay using direct debit from your conto corrente. Not only is there no charge for this, but you don’t run the risk of falling into arrears. Although utility bills arrive quite late in the cycle by American standards, they often allow relatively little time for payment.
The Codice Fiscale is the Italian tax ID number, and is used for a variety of purposes in Italy, including obtaining health insurance and opening a bank account. Anyone who has legally entered Italy can obtain a codice fiscale – you don’t need to have signed a lease or filed a tax return.
If you are seeking an Elective Residency visa and don’t already have property in Italy, you will need to present a signed copy of your lease or rental agreement at your consular appointment, together with proof that your lease has been registered with the Agenzia delle Entrate. To register the lease, even if your landlord does it for you as is usually the case, you will need to obtain a Codice Fiscale.
To obtain a Codice Fiscale you should go to the local office of the Entrate. You will need your passport (or residence permit or Carta d’Identità if you have them already). You can generally complete the application and be assign ed a number on the same day as your visit. (If you are working with a local realtor, they can help you with this process). The Entrate will eventually send you a plastic card evidencing your number, but you can start using the number right away. (According to the official website, the Codice Fiscale can also be obtained at the Sportello Unico per l’Immigrazione at the Prefettura. We haven’t tried that.)
The Codice Fiscale is actually computed using an algorithm applied to your name and birthdate and place of birth. Merchants can verify the data you enter, for example to a website, to check if the codice you entered is correct. For this reason, if you need to enter a Codice Fiscale anywhere in addition to your name, be sure to enter the same exact name, including middle name, that you used for registering for the Codice Fiscale.
Important Note: In order to apply for the Codice Fiscale, you will need to demonstrate that you have legally entered Italy. The easiest way to do this is by showing a passport stamp issued by an Italian border official. If you entered the EU through another country (e.g., Germany) you will not have an Italian stamp in your passport, because there are no border controls within the EU. The Entrate will not accept a passport stamp from another EU country for this purpose, and you will have to first register your entry into Italy at the local questura (police station). To avoid this frustrating additional step, we strongly advise arranging your trip such that you enter the EU through Italy.
The elective residency visa is designed specifically for persons (especially retired persons) who wish to reside permanently in Italy and have adequate financial resources to do so. The elected residency visa is not designed for extended tourism, but for those who intend to establish a permanent home in Italy. Individuals who receive this visa cannot work in Italy – they must be able to sustain themselves from their existing financial assets. You must obtain the Elective Residency visa in the United States. You may not enter Italy as a tourist and seek to extend your stay by obtaining an elective residency visa from Italy. The Elective Residency visa is valid for exactly 365 days, and may not be renewed. You must convert it to a “permesso di soggiorno” (residence permit) once you arrive in Italy.
Obtaining an Elective Residency visa
In general, obtaining an Elective Residency visa requires an interview with the appropriate consulate, and the presentation of required documents.
You must present your documents at the appropriate consulate, depending on where in the U.S. you reside. Note that the appropriate consulate may not necessarily the one closest to your residence. Here is a list of Italian consulates in the USA and their jurisdictions.
Once you have identified the appropriate consulate, you can find the requirements for the Elective Residency visa on the website for that consulate. Each consulate has its own list of requirements, which
differ slightly. IMPORTANT NOTE: These requirements change frequently and often without notice. You should check your consulate’s website not only when you begin the process, but at regular intervals thereafter, to make sure requirements haven’t been changed or added.
General Requirements: These documents are required by all consulates
- Valid US passport. Most consulates require the expiration date be at least three months after the expiration date of your visa. Since the visa is for one year, that means that your passport must have an expiration date no sooner than 15 months from the the start date on your visa.
- Your passport must at least one blank page (or, for some consulates, two blank pages) for affixing the visa.
- Proof of physical residence in the consular jurisdiction, e.g., driver’s license, state ID, utility bill).
- Passport-sized photograph (check specific dimension and other requirements on your consulate’s website)
- Long stay visa application (form available on the consular website)
- Lease, rental contract of deed for property in Italy, in your name. If you are a married couple, the lease should have both your names on it.
- Proof of sufficient financial resources: bank or brokerage firm statements, copies of pension of social security checks, other sources of income.
- Letter stating why you want to move to Italy, where you will live, and who is moving with you ((e.g., spouse or children)
- Declaration for Mailing Passports (form available on the consular website); this authorizes the consulate to mail your US passport back to you once the visa has been affixed.
- Self-addressed pre-paid US Express Mail envelope which the consulate will use to return your passport; the consulate will not accept regular US mail envelopes or envelopes from couriers such as Federal Express.
- Visa application fee, which must be paid in the exact amount by money order made out to the Consulate General of Italy. The fee (approximately $140 as of spring 2019) adjusts every three calendar months based on the government’s official exchange rate.
Certain other documents are required by some consulates and not others:
- FBI criminal background check
- Proof of overseas health insurance
- Flight reservations
- Certified copy of marriage certificate (if traveling with spouse) or childrens’ birth certificates (if traveling with children); note that these documents will be required in any event to obtain the permesso di soggiorno.
- Although most of these requirements are straightforward, some require additional explanation
Financial Resources: Since this visa does not allow you to work in Italy, you need to demonstrate to the satisfaction of the consular official that you have enough resources to support yourself in Italy. Some consulates state only this general requirement; others require you to bring specific documents such as bank statements for the last six months, tax returns for the last six months, or letters from your bank financial advisor, or accountant. If you are receiving Social Security or pension checks, you should bring evidence of those.
Unfortunately, there is no hard and fast rule for how much income is enough to meet this requirement, although the Los Angeles consulate suggests a minimum income of $3,375/month for a single applicant.
In general, fixed sources of income, like Social Security and pension benefits, are preferred to variable ones, like income from investments.
Registered Lease: The housing requirement has changed significantly during the last few years. Short-term leases, or contracts to enter into a lease, which were accepted by some consulates in the past, will no longer be sufficient. Unless you already own property in Italy, and intend to live there, you will have to present a signed lease with a term of at least one year during your consular interview, together with proof that the lease has been registered with the Entrata (the Italian tax authority). If you are working with a realtor in Italy, they should be able to help you with registering the lease.
Be sure to negotiate a clause in the lease under which you forfeit only the first month’s rent if for some reason the visa does not issue. In order to register the lease in Italy, you will need a Codice Fiscale (Italian Tax ID number).
Overseas Health Insurance: Some consulates require you to present evidence of a health insurance policy that will cover 100% of your medical expenses in Italy; some consulates have a specified minimum policy limit. Travel insurance policies are generally sufficient.
Even if proof of health insurance is not required by your consulate, it is probably a good idea to purchase short-term health insurance anyway, to bridge the gap until you are able to buy into the Italian health insurance system.
FBI Criminal Background Check: You can order this directly from www.fbi.gov. However, since processing of individual requests can take several months, we recommend that you use an expediter, who can usually provide turnaround of about a week.
You will need a set of fingerprints to begin the FBI background check. In the US, fingerprint services are often available at copy shops or the offices; larger cities may have dedicated fingerprint specialists.
You must present your documents in person at the appropriate consulate. Consular interviews are by appointment only, which you can book online. Your appointment date must be within 90 days of your departure date.
For an ER visa, the typical wait time for an appointment is 2-3 months, although that may vary by consulate. When beginning this process, you should check your consulate to see how far ahead appointments are being made so you have an idea how to organize the timing. If your application is approved, the consulate will affix a visa to your passport and mail it back to you. Consular websites indicate this can take up to three months. However, our experience has been that turnaround is much faster — anywhere from 48 hours to a couple of weeks after your visit.
As you can see from the outline above, getting the required documents in the right order can be a bit of a juggling act. If you are renting in Italy, you will need to get the lease signed and registered before your visa is issued. It is a good idea to start collecting documents about 6 months before your anticipated departure date. You want to make sure that you have all the required documents before the date of your consular interview, especially if your consulate is in another state.
Here is an illustrative schedule, assuming an October 1 departure date:
- Check validity of US passport and get passport renewed if necessary
- Get fingerprints and begin FBI check (if required)
- Schedule consular interview for July
- May – June
- Schedule trip to Italy to select apartment, sign lease, obtain Codice Fiscale; if you are working with a realtor, he or she can help you with these documents. (If you already own property in Italy, obviously you can skip this step!)
- Collect required documents – note that some documents (like letters of reference from banks or accountants, if required) may take more time than others
- Periodically check consular website to make sure requirements haven’t changed
- Verify current visa fee amount on website (changes at beginning of calendar quarter) and obtain money order
- Consular interview, with visa dated October 1
- Visa arrives up to 2 weeks later
Tips for the Consular Interview
The Elective Residency visa is a discretionary visa, which means that they don’t have to issue one to you even if you meet all the requirements. You should indicate, by your manner and the way you present yourself, that you take the process seriously. Dress as you would for a job interview. Arrive on time.
Have all your documents organized and readily available.
- Don’t put your documents in individual plastic folders. The consulate is likely going to open a paper file on you and they don’t need any more volume than necessary.
- Order your documents in the order they are listed on the website.
- Bring the original copy of your lease as well as a copy for the consulate file. You will need to retain the original copy of your lease for a number of purposes in Italy, including establishing residency, obtaining health insurance and opening a bank account
- You may be able to find sites on the Internet where people share experiences and tips on the consular interview. The value of the tips on these sites varies widely, but you may find useful information, particularly with respect to your consulate.