Public Healthcare for Expats: Spain €60, Italy €2,000 a Year

Moving to southern Europe often comes with a promise of free public healthcare for residents. For someone who does not work there, the promise usually comes with a price, a waiting period, or both.

Spain sells access for a fixed monthly fee after a year of residence. France opens the door after three months, then reimburses part of each visit. Italy charges non-EU residents at least €2,000 a year. Portugal charges almost nothing once a residence permit is in place. This article compares the four on the same terms: what a non-working resident pays, how long they wait, and what is left out.

Four countries on the same terms

Spain: a fixed fee, after a year

Spain's buy-in is set by Royal Decree 576/2013. A resident who has no other right to public care can sign a "convenio especial" with their regional health service.¹ The monthly fee is €60 for anyone under 65 and €157 for anyone 65 or older.¹ The national order applying it in Ceuta and Melilla repeats the same two figures.¹⁰

The amounts have not changed since 2013. The consolidated text on Spain's official gazette shows no update since July 2013.¹

The waiting period is the first hurdle. Applicants must prove at least one continuous year of actual residence before applying, and must be registered with a town hall.¹ Anyone arriving on a non-working residence visa therefore has no public route for at least the first year.

The second hurdle is what the fee buys. The decree gives access to the national system's "basic common" set of services.¹ Two relocation advisers independently report that this leaves out outpatient prescriptions, so members pay the full pharmacy price.⁶⁷ One of them, Moving to Spain, adds that pre-existing conditions are not excluded.⁶

France: three months, then partial reimbursement

France covers anyone who lives there "in a stable and regular manner" under its universal health protection scheme, known as PUMa.¹¹ For someone who does not work, the government's public-service portal is explicit: "you must wait 3 months" after arriving before rights open.² After that, the cover continues if you live in France for at least six months of the year.²

There is no joining fee. But cover in France is partial by design. A GP visit costs €30, and the national health insurance reimburses 70% of it, minus a €2 flat charge that it never refunds.⁸ Patients without a declared regular doctor receive much less back.⁸ A private top-up policy, known as a mutuelle, can cover that gap.

Some non-workers also pay a levy, the cotisation subsidiaire maladie. In 2026 it applies to residents whose earned income is below €9,612 and whose investment income is above €24,030.⁵ The maximum rate is 6.5%, applied to investment income above that threshold, and it falls as earned income rises.⁵ Retirees on a pension are exempt.⁵

Italy: €2,000 a year at minimum

Italy lets non-EU residents who have no automatic right to public care register voluntarily, for an annual payment. Italy's 2024 budget law raised the minimum to €2,000 a year.¹² Before that, the minimum was €387.34.¹²

The new floor is in force. A March 2026 decision by the Piedmont regional government refers to two payments of €2,000 each, made in 2024 and 2025, as "the minimum annual amount fixed by Law 213/2023."³ That decision refunded both payments to a resident who should not have paid them, which is a reminder to check whether you qualify for free registration first.³

Portugal: legal residence is the key

Portugal's health law makes foreign citizens with permanent or temporary residence beneficiaries of the national health service.⁴ The health regulator says that once registration is complete with a valid residence permit, the service covers the costs.⁴ Without a valid permit, the patient pays, apart from emergencies, maternity, children's care and vaccinations.⁴

Charges at the point of care are now rare. Portugal stopped charging its "taxas moderadoras" in almost all services from 1 June 2022.⁹ They remain only for emergency visits made without prior referral that do not lead to admission.⁹

What the headline numbers leave out

The fee is not the total cost. In Spain, prescriptions are paid in full.⁶ In France, the uncovered 30% of each bill is usually insured privately.⁸ Neither cost appears in the headline price.

Each country also has a gap at the start. Spain's year of residence and France's three months have no public route at all, so that period has to be covered privately.

Rules move. Portugal's parliament voted in December 2024 to require proof of health coverage from non-residents and undocumented migrants, outside emergencies.¹³ That vote did not concern legal residents, but it shows that access rules for foreigners are a live political issue.

Finally, these are national rules applied regionally. Spain's regions run the convenio and may add services and charge more for them.¹ Italy's fee is collected region by region.³ Your experience will depend on the office that handles your file.

How to plan the move

Work out the date your public cover will actually start, not the date you arrive. In Spain that is at least a year away. In France it is three months away for non-workers.

Then price the bridge. Get a private policy quote for that period, and check whether your visa already demands one.

Finally, price what the public route leaves out: prescriptions in Spain, the 30% in France, and the annual fee in Italy. That total, not the word "free", is the number to compare.

Footnotes

1. https://www.boe.es/buscar/act.php?id=BOE-A-2013-8190 — Agencia Estatal Boletín Oficial del Estado, "Real Decreto 576/2013, de 26 de julio", consolidated text (last updated Jul 27, 2013). Accessed Oct 3, 2026. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹

2. https://www.service-public.gouv.fr/particuliers/vosdroits/F34308 — Service-Public.fr, French government, page on joining the national health insurance as a resident. Accessed Oct 3, 2026. ↩ ↩² ↩³ ↩⁴

3. https://www.regione.piemonte.it/governo/bollettino/abbonati/2026/12/attach/dda1410000152_11200.pdf — Regione Piemonte, Determinazione dirigenziale n. 152 of Mar 19, 2026, on a refunded voluntary national health service contribution (published Mar 26, 2026). Accessed Oct 3, 2026. ↩ ↩² ↩³ ↩⁴ ↩⁵

4. https://www.ers.pt/en/users/frequently-asked-questions/faq/access-of-foreign-citizens-to-healthcare-services-in-the-national-health-service-sns/ — Entidade Reguladora da Saúde (Portugal's health regulator), "Access of foreign citizens to healthcare services in the national health service" (updated Aug 20, 2025). Accessed Oct 3, 2026. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

5. https://www.keobiz.fr/le-mag/taxe-puma-2026/ — Keobiz, "Taxe PUMa 2026" (updated Mar 13, 2026). Accessed Oct 3, 2026. ↩ ↩² ↩³ ↩⁴

6. https://movingtospain.com/convenio-especial-spain-guide/ — Moving to Spain, "Convenio Especial in Spain" guide (updated Sep 14, 2026). Accessed Oct 3, 2026. ↩ ↩² ↩³ ↩⁴

7. https://www.healthplanspain.com/blog/health-news/2284-convenio-especial-spain-expats-2026.html — Health Plan Spain, "Convenio Especial in Spain for expats, 2026" (published Feb 9, 2026). Accessed Oct 3, 2026. ↩ ↩²

8. https://www.toutsurmesfinances.com/argent/a/medecins-tarifs-et-montants-des-remboursements-de-la-securite-sociale — Toutsurmesfinances, "Médecins : tarifs et montants des remboursements de la Sécurité sociale" (updated Mar 26, 2025). Accessed Oct 3, 2026. ↩ ↩² ↩³ ↩⁴

9. https://www.sabado.pt/portugal/detalhe/ex-ministra-marta-temido-estremece-com-anuncio-de-isencao-de-taxas-moderadoras-nao-existem-desde-2022 — Sábado, on the end of most user charges in the national health service from Jun 1, 2022 (published Aug 22, 2025). Accessed Oct 3, 2026. ↩ ↩² ↩³

10. https://www.boe.es/boe/dias/2014/08/06/pdfs/BOE-A-2014-8499.pdf — Agencia Estatal Boletín Oficial del Estado, "Orden SSI/1475/2014, de 29 de julio" (published Aug 6, 2014). Accessed Oct 3, 2026. ↩

11. https://www.ameli.fr/assure/droits-demarches/principes/protection-universelle-maladie — Assurance Maladie (ameli.fr), "La protection universelle maladie" (updated Jan 12, 2026). Accessed Oct 3, 2026. ↩

12. https://www.thelocal.it/20231017/what-we-know-about-italys-plan-to-charge-non-eu-residents-e2000-for-healthcare — The Local Italy, "What we know about Italy's plan to charge non-EU residents €2,000 for healthcare" (published Oct 17, 2023). Accessed Oct 3, 2026. ↩ ↩²

13. https://portugaldecoded.substack.com/p/parliament-limits-sns-access-for — Portugal Decoded, "Parliament limits SNS access for non-residents and undocumented migrants" (published Dec 19, 2024). Accessed Oct 3, 2026. ↩

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