The introduction of a new minimum charge of €2,000 to register with Italy’s public health service has been a source of alarm and confusion among Italy’s international residents since it was first announced in the draft budget in October.

As the final 2024 budget law was published at the end of December, the text cleared up some of the uncertainty around what fees would apply to which categories of foreign resident, and who would be exempt – though some questions still remained.

READ ALSO: Q&A: What you need to know about Italy’s €2,000 healthcare fee

An Italian health ministry spokesperson told The Local on Tuesday: “As established by the law, the amount of 2000 euros represents the minimum contribution.“

See all the details we have so far about how the new rules work below.

Who has to pay?

When it comes to healthcare, Italy divides foreign residents into two categories: those who must register with the national health service (Servizio sanitario nazionale, or SSN) on a ‘mandatory’ basis, and those who have the option of registering on a ‘voluntary’ basis.

Anyone who falls into the ‘mandatory’ category has the right to register for free, while those who fall into the ‘voluntary’ category must pay to register.

Until the start of 2024, that charge was calculated on the basis of an individual’s income, and ranged from €387.34 to €2,788.87.

Under changes introduced in Italy’s 2024 budget law, the progressive rate has changed drastically, and fees for almost (see below) all ‘voluntary’ now begin at €2,000.

Who falls into the ‘mandatory’ category?

According to the Italian health ministry, those entitled to free mandatory registration by right are:

• Residents who have a regular ongoing contract with an Italian employer, are self-employed, or are registered on Italy’s unemployment lists (liste di collocamento).
• People waiting for their residency permit to be issued on the basis of employment or family reasons.
• People waiting for their residency permit to be renewed on the basis of employment or self-employment, for family reasons, for asylum, for subsidiary protection, ‘special cases’, or special protection; for medical treatment, for those waiting to adopt or foster children, and for those in the process of acquiring citizenship.
• Dependant family members of people in the above categories.
• All minors, including unaccompanied foreign minors, regardless of their legal basis in Italy.

READ ALSO: Public vs private: What are your healthcare options in Italy?

Who falls into the ‘voluntary’ category?

Almost everyone not named in the ‘mandatory’ list falls into the ‘voluntary’ category. According to the health ministry, that includes, but is not limited, to:

• Students and au pairs, including those in the country for less than three months (the maximum period you can stay in Italy before registering as a resident).
• People in Italy on an elective residence visa.
• Religious personnel.
• Diplomatic and consular staff of foreign governments and organisations, unless employed under an Italian contract (in which case they have the right to mandatory registration).
• Volunteers.
• People over the age of 65 in Italy for family reunification reasons, who arrived after November 5th, 2008.

Foreigners in Italy on a medical treatment permit and those in the country for tourism purposes are not eligible for voluntary registration.

If you’re unsure which category you fall into, you should ask your commercialista (Italian accountant) for clarification.

READ ALSO: ‘Very professional but underequipped’: What readers think of Italy’s hospitals

Are there any exceptions?

Non-EU foreigners in Italy on a study permit and au pairs pay a discounted rate – although under the new rules, they’ll still have to pay significantly more than they did in the past.

Students will pay at least €700 euros, up from the previous rate of €149.77. Au pairs, meanwhile, will be charged €1,200, an increase from €219.49.

Am I legally required to pay the fee?

No – if you fall into the ‘voluntary’ category, you can opt to pay for private insurance instead of paying to register with the SSN.

Either way, you must have healthcare coverage as an Italian resident.

What if I’m an EU citizen/covered by the Brexit withdrawal agreement?

Many of The Local’s British readers living in Italy have asked since the plan’s announcement whether the new charge would apply to them or if they would be exempt under the post-Brexit Withdrawal Agreement.

An Italian health ministry spokesperson told The Local on Tuesday: “British citizens resident in Italy before Brexit, covered by the Withdrawal Agreement, who have acquired a permanent right, retain the right to compulsory registration.”

This appears to mean nothing has changed under the new law for British residents who were previously entitled to free (or ‘mandatory’) registration.

The Local has contacted Italy’s health ministry and finance ministry for clarification on the situation of EU citizens

Please note that The Local is unable to advise on individual cases. For more information on how the revised healthcare fees may apply in your situation, consult your local Asl office or your Italian commercialista (accountant).