JUDGMENT NO. 4

YEAR 2026

ITALIAN REPUBLIC

IN THE NAME OF THE ITALIAN PEOPLE

THE CONSTITUTIONAL COURT

composed of:

President: Giovanni AMOROSO;

Judges: Francesco VIGANÒ, Luca ANTONINI, Stefano PETITTI, Angelo BUSCEMA, Emanuela NAVARRETTA, Maria Rosaria SAN GIORGIO, Filippo PATRONI GRIFFI, Marco D’ALBERTI, Giovanni PITRUZZELLA, Antonella SCIARRONE ALIBRANDI, Massimo LUCIANI, Roberto Nicola CASSINELLI,
has pronounced the following

JUDGMENT

in the constitutional legitimacy review proceedings concerning Articles 98, 117, 132, 160, and 217 of the Law of the Puglia Region of December 31, 2024, No. 42, providing for "Provisions for the formation of the 2025 budget and the multi-year budget 2025-2027 of the Puglia Region (Regional Stability Law 2025),” initiated by the President of the Council of Ministers with an appeal served on February 28, 2025, filed with the Registry on March 1, 2025, registered under No. 12 of the Appeals Registry 2025 and published in the Official Gazette of the Republic No. 12, special first series, of 2025.

Having reviewed the statement of defense of the Puglia Region;

Having heard Judge Rapporteur Angelo Buscema at the public hearing of November 5, 2025;

Having heard State Attorney Davide Di Giorgio for the President of the Council of Ministers, as well as Attorney Paolo Scagliola for the Puglia Region;

Deliberated in the Council Chamber on November 5, 2025.

Facts of the Case

1.– With appeal registered under No. 12 of the Appeals Registry 2025, filed on March 1, 2025, the President of the Council of Ministers, represented and defended by the Advocate General of the State, initiated, among others, constitutional legitimacy questions regarding Articles 98, 117, 132, 160, and 217 of the Law of the Puglia Region of December 31, 2024, No. 42, providing for "Provisions for the formation of the 2025 budget and the multi-year budget 2025-2027 of the Puglia Region (Regional Stability Law 2025).”

1.1.– Article 98 of the challenged regional law (titled "Promotion of virtual reality in medical and healthcare professional training") allegedly allocates funding within the perimeter of the regional health budget to entities external to the National Health Service for interventions and activities variously related to professional training.

This provision is asserted to be in contrast with Article 117, third paragraph, of the Constitution, regarding the matter of "coordination of public finance," in relation to Article 20 of Legislative Decree June 23, 2011, No. 118 (Provisions concerning the harmonization of accounting systems and budget structures of Regions, local authorities, and their bodies, pursuant to Articles 1 and 2 of Law May 5, 2009, No. 42).

Specifically, Article 20, paragraph 1, of Legislative Decree No. 118 of 2011 stipulates that "[w]ithin the regional budget, Regions shall ensure an exact delimitation of revenues and expenditures related to the financing of their regional health service, in order to allow for immediate comparability between health revenues and expenditures recorded in the regional budget and the resources indicated in the acts determining the standard regional health requirement and identifying the related funding sources, as well as an easy verification of further resources made available by the Regions for the financing of the same regional health service for the current fiscal year." Therefore, the inclusion in the regional health budget of costs related to training activities or university study and research would entail a violation of the rules on reporting regional health expenditure.

The violation of state discipline is deemed evident, considering that the challenged provision, charging Mission 13 of the Puglia Region's budget, related to health protection, with expenses aimed at financing activities linked to training for entities external to the NHS, would result in an incorrect representation of regional health financing, in violation of the principle of exact delimitation of revenues and expenditures related to the financing of the Regional Health Service, as established by Article 20 of Legislative Decree No. 118 of 2011.

These arguments are considered supported by the ruling of this Court in Judgment No. 68 of 2024, which recognized, in a similar case concerning the Law of the Sardinia Region of February 21, 2023, No. 1 (Regional Stability Law 2023), that expenses for the activation and accreditation of training courses for various professions, such as socio-health operators and veterinary doctors, "go beyond the scope of resources connected to the financing of the regional health service" and therefore "alter the structure of the health perimeter prescribed by Article 20 of Legislative Decree No. 118 of 2011, thus evading the purposes of accounting harmonization."

1.2.– Similar objections are raised against Article 160 of the Puglia Regional Law No. 42 of 2024 (titled "Extraordinary contribution for research and digital health studies and digital technologies for Puglian healthcare"). This provision assigns financial allocations from Mission 13 of the regional budget to the University of Salento, an entity external to the NHS, to support study and research activities on telemedicine and other medical-IT technologies managed by the Department of Experimental Medicine.

By so doing, the Puglia Region would charge the regional health budget with expenses that have no specific relevance to the field of health protection, leading to an incorrect representation of the health budget and a violation of the principles of "coordination of public finance" and accounting harmonization established by the State (citing this Court's Judgment No. 80 of 2017 on this point).

The appellant fully invokes the arguments previously put forward regarding the alleged constitutional illegitimacy of Article 98 of the challenged regional law, alleging the violation of Article 117, third paragraph, of the Constitution, in relation to Article 20 of Legislative Decree No. 118 of 2011, as resources allocated to finance the health system cannot be directed to university institutes for the activation of degree or post-graduate training courses, nor for the support of study and research programs.

1.3.– Article 117 of the same Puglia Regional Law No. 42 of 2024 (titled "Staffing in therapeutic-rehabilitative residences for the treatment of subjects with Eating Disorders") is also challenged. It stipulates that "[i]n the regulatory or implementing provisions of the Regional Council regarding structural, technological, and organizational requirements for the authorization and accreditation of the Assistance Network for Eating Disorders, the professional figure of the nutritionist biologist shall be provided for, among others."

The provision is allegedly constitutionally illegitimate because, by requiring facilities to have a nutritionist biologist, it refers to a professional category not provided for by national law, in violation of Article 117, third paragraph, of the Constitution, which reserves to State legislation the determination of fundamental principles in the matter of professions, in relation to Article 1, paragraph 3, of Legislative Decree February 2, 2006, No. 30 (Recognition of fundamental principles regarding professions, pursuant to Article 1 of Law June 5, 2003, No. 131), cited as the intermediate norm.

Specifically, the challenged provision is alleged to be in conflict with the aforementioned Article 1, paragraph 3, of Legislative Decree No. 30 of 2006, according to which "[r]egional legislative power shall be exercised over professions identified and defined by state legislation," which sets the fundamental principles of the matter, identifies new professional figures, and regulates the establishment of new professional registers.

The Advocate General asserts that the Italian legal system does not provide for the nutritionist biologist as an autonomous and specific professional figure, but only for that of the biologist, without prejudice to the specific knowledge and skills acquired through training.

Given this, the challenged regional provision, precisely by providing for the presence of a nutritionist biologist as a requirement for authorization and accreditation of the assistance network—a figure not provided for by State law—allegedly violates Article 117, third paragraph, of the Constitution, in relation to Article 1, paragraph 3, of Legislative Decree No. 30 of 2006.

1.4.– Finally, the appellant challenges Articles 132 and 217 of the Puglia Regional Law No. 42 of 2024 for violation of Article 117, third paragraph, of the Constitution, also in relation to Article 1, paragraph 3, of Legislative Decree No. 30 of 2006, cited as the intermediate norm.

Article 132 (titled "Treatment of Autism Spectrum Disorders provided for by Articles 4, 5, and 6 of Regional Regulation 9/2016") regulates the commencement of activities of specialized centers for the treatment of autism spectrum disorders and provides for the interchangeability, for a transitional period of a maximum of 24 months, of rehabilitation healthcare professionals—pending the programming of adequate training for certain currently lacking professional figures—in relation to the assistance needs of subjects undergoing treatment and for shift rotation requirements.

Article 217 of the same regional law provides that, to allow for the commencement and enhancement of activities of psychiatric residential assistance communities (CRAP) dedicated to high-complexity patient offenders, pending the programming of adequate training for certain currently lacking professional figures, interchangeability is arranged for a transitional period of a maximum of 24 months for rehabilitation healthcare professionals (occupational therapist, professional educator, socio-health educator, psychiatric rehabilitation technician, neuropsychiatric rehabilitation technician).

The aforementioned Articles 132 and 217 are allegedly constitutionally illegitimate as they conflict with national legislation that reserves to the State legislative power the identification of the various professional figures, along with their respective profiles and enabling titles.

The concept of interchangeability underlying both challenged provisions is specifically contested, as the appellant observes that within healthcare professions, each figure has reserved and distinct competencies and responsibilities based on its specific profile and training pathway, determining its belonging to distinct professional orders.

Providing for the interchangeability of rehabilitation professional figures would entail a violation of the fundamental principles in the matter of professions, wherein, according to the orientation of this Court, the identification of professional figures with their respective profiles and enabling titles is reserved to the State, and the regulation of aspects specifically linked to the regional reality is attributed to the legislative competence of the Regions (citing Judgments No. 178 of 2014 and No. 108 of 2012).

2.– By a document filed on April 4, 2025, the Puglia Region appeared in the proceedings, arguing the inadmissibility and lack of merit of the constitutional legitimacy questions raised by the President of the Council of Ministers regarding Articles 117, 132, and 217 of the Puglia Regional Law No. 42 of 2024. However, the Puglia Region did not present defenses regarding the questions concerning Articles 98 and 160 of the same regional law.

According to the Puglian defense, the objections raised by the appellant stem from a partial, misleading, and disorganized reading of the challenged provisions.

In the Region's view, the challenged regulation precisely circumscribes its scope of application, limiting it to the perimeter of legislative and administrative competence reserved by the Constitution to regional power, "without providing for any derogation or infringement of the constitutional parameters and/or the intermediate norms, which were improperly invoked."

2.1.– Regarding the challenge to Article 117 of Puglia Regional Law No. 42 of 2024, the Region first objects to the inadmissibility of the question due to lack of reasoning: the Advocate General of the State allegedly merely invoked general norms, as well as an opinion from the Superior Council of Health of 2011, without any reference to the actually relevant intermediate norm, namely the state law establishing the profession of biologist (Law May 24, 1967, No. 396, concerning the "Regulation of the profession of biologist"), which also contains the relevant discipline and the modulation of the scope of competencies.

This defect allegedly affects the exhaustiveness of the reasoning process, as challenging the constitutional illegitimacy of the regional provision for having created a new professional figure, without examining the state legislation regulating the profession of biologist, renders the reasoning merely assertive and deficient (citing this Court's Judgment No. 80 of 2023).

On the merits, the Region first observes that the challenged Article 117 provides for the nutritionist biologist figure within a regulation aimed at "enhancing the profession of the biologist operating in a specialized team for the management and treatment of eating disorders, without however encroaching upon the competencies of the medical surgeon, the biologist, and the dietitian, as regulated by current national legislation."

Based on the reference legislation, the biologist, as such, is authorized to autonomously develop nutritional profiles, whereas the nutritionist biologist operates in a context of close interdisciplinary collaboration with other healthcare professionals, each within their respective competencies.

By way of example, the regional defense contends that the nutritionist biologist cannot make medical diagnoses or prescribe drugs, as their primary role is that of nutritional education, including for the prevention of many pathologies.

From a technical-scientific perspective, the nutritionist biologist possesses in-depth knowledge of food and its effects on individual patients, enabling them to develop personalized dietary plans, respecting the patient's nutritional needs.

Unlike the nutritionist biologist, the dietitian is a specialized physician competent to diagnose various nutrition-related pathologies and prepare the following therapeutic treatments.

In this context, the nutritionist biologist can intervene subsequent to the medical diagnosis to develop a targeted nutritional plan, contributing to the care and prevention pathway.

Pursuant to Article 3 of Law No. 396 of 1967, "[t]he profession of biologist shall cover: a) classification and biology of animals and plants; b) assessment of the nutritional and energy needs of humans, animals, and plants; c) problems of genetics of humans, animals, and plants; d) identification of pathogenic agents (infectious and parasitic) of humans, animals, and plants; identification of organisms harmful to foodstuffs, paper, wood, artistic heritage; control measures; e) control and study of the activity, sterility, harmlessness of insecticides, fungicides, antibiotics, vitamins, hormones, enzymes, sera, vaccines, medicines in general, radioisotopes; f) identification and control of goods of biological origin; g) biological analyses (urine, exudates, excreta, blood; serological, immunological, histological, pregnancy, metabolic); h) biological analysis and control of drinking and mineral water; i) functions of expert and arbitrator concerning all the aforementioned attributions. The listing in this Article does not limit the exercise of any other professional activity permitted to biologists registered in the register, nor does it prejudice what may form the subject of the activity of other categories of professionals, pursuant to laws and regulations."

The competencies of the biologist are also defined by the Decree of the Minister of Grace and Justice of July 22, 1993, No. 362 (Regulation governing fees, indemnities, and criteria for reimbursement of expenses for professional services of biologists), which, in its annexed Table F, establishes the tariffs for the assessment of nutritional and energy needs of humans; a decree which is reportedly reiterated by administrative jurisprudence (Council of State, Fifth Section, November 16, 2005, No. 6394) in identifying the competencies of biologists.

The Puglia Region highlights that the National Order of Biologists has also provided for the existence of an activity code for the nutritionist biologist, confirmed the biologist's competence to develop diets, citing the regulatory provisions and the Council of State ruling of 2005 mentioned, and reiterated that specialization is not necessary to practice as a nutritionist biologist, registration in the National Order of Biologists in Section A of the relevant register being sufficient (citing opinions of the Superior Council of Health of December 15, 2009, and April 12, 2011).

The same Order, the Region reports, has argued that Article 3 of Law No. 396 of 1967 and the aforementioned Decree No. 362 of 1993 allow the biologist to develop optimal diets and that the nutritionist biologist can practice their profession in total autonomy without the presence of a physician. The regional defense also clarifies that while a biologist holding a five-year degree registered in Section A of the National Order of Biologists can autonomously sign diets and nutritional consultations, the dietitian is a healthcare professional with a three-year degree who organizes and coordinates specific activities related to nutrition in general and dietetics in particular; collaborates with bodies responsible for safeguarding the hygienic-sanitary aspect of the food service; develops, formulates, and implements diets prescribed by the physician and monitors their acceptability by the patient; collaborates with other figures in the multidisciplinary treatment of eating disorders (Decree of the Minister of University and Scientific and Technological Research of April 2, 2001, concerning the "Determination of the classes of specialized university degrees for healthcare professions," Annex 3, Class 3).

The Region further notes that the Decree of the President of the Republic of June 5, 2001, No. 328 (Amendments and additions to the discipline of requirements for admission to the State Examination and the related tests for the exercise of certain professions, as well as the discipline of the related regulations), in Article 31, contributes to defining the professional activity of the biologist registered in Section A of the register (the latter reserved for those holding a specialized degree, including that of the "Human Nutrition Sciences" degree class 69/S – subsequently defined as LM/61 by the Decree of the Minister of University and Research of March 16, 2007, concerning the "Determination of University Degree Classes," as last amended by the Decree of the Minister of University and Research of December 19, 2023, No. 1649, concerning "Master's and single-cycle Master's Degree Classes - Reform 1.5 - Degree Classes (Milestone M4C1-10)")—which is also valid for admission to the State Examination aimed at registration in Section A of the aforementioned register.

The regional defense also represents that the National Order of Biologists, by reiterating the opinions expressed by the Superior Council of Health of December 15, 2009, and April 12, 2011, specified the tasks of the nutritionist biologist, concluding that they must acquire specific professionalism and adequate knowledge in matters pertaining to the profession (citing the resolution of the Council of the National Order of Biologists of September 26, 2019, No. 433).

It thus emerges from the referenced sector legislation that the constitutional legitimacy questions are entirely unfounded, as the challenged provision has not introduced a new professional figure.

The regional defense further contends that, for a different reason, there is no risk of the nutritionist biologist's competencies encroaching upon those of the medical surgeon, given that the presence of the latter figure and the dietitian is already provided for by the Regulation of the Puglia Region of March 21, 2017, No. 8, concerning "Structural, technological, and organizational requirements for the authorization and accreditation of the Assistance Network for Eating Disorders. Requirement," which provides, for any type of facility (outpatient clinic, intensive outpatient clinic, and non-hospital therapeutic-rehabilitative residence), for the professional figures of internist/endocrinologist/specialist in food sciences, as well as the dietitian.

Moreover, the very purpose of the challenged provision raises doubts, in the Region's view, as to the correctness of the constitutional parameter invoked by the appellant, since the matter effectively affected is "health protection" under Article 117, third paragraph, of the Constitution, in relation to Articles 8-ter, paragraph 4, and 8-quater of Legislative Decree December 30, 1992, No. 502 (Reorganization of health discipline, pursuant to Article 1 of Law October 23, 1992, No. 421), which attribute to the legislative competence of the Regions and Autonomous Provinces the regulation of health authorizations.

In conclusion, the challenged provision does not regulate the tasks of the nutritionist biologist, nor does it establish a register or a new professional figure; on the contrary, the provision pertains to the matter of "health protection," including the aspect of regional health organization.

It contains a provision that affects health authorizations and health organization, an integral part of the matter of "health protection," attributable to the concurrent legislative competence under the third paragraph of Article 117 of the Constitution, "as the organizational modalities of the health service constitute the functional and operational framework that guarantees the quality and adequacy of the services provided" (citing this Court's Judgment No. 9 of 2022). Consequently, Article 117 of Puglia Regional Law No. 42 of 2024 is perfectly compliant with the constitutional division of legislative powers, as an analogous professional figure is already expressly provided for at the national level.

2.2.– With regard to the questions raised against Articles 132 and 217, the Region first objects to their inadmissibility due to lack of reasoning, as it is not clarified how the regional provisions could cause the alleged harm, nor are the intermediate norms allegedly violated cited.

On the merits, the appeal is nevertheless unfounded.

The institution of interchangeability—the regional defense affirms—does not possess a definitive character, but constitutes a transitional measure, limited to a maximum period of 24 months, a term necessary to allow the commencement of activities of specialized centers for the treatment of autism spectrum disorders (Article 132) and the activities of psychiatric residential assistance communities dedicated to high-complexity patient offenders (Article 217).

In the Region's view, the recourse to the interchangeability of professional figures, as regulated in the challenged provisions, cannot violate the fundamental principles set by the State in the matter of professions, inasmuch as interchangeability should not be understood as "substitutability" between professionals belonging to different disciplines, but rather as a measure aimed at ensuring the presence of the most appropriate professional figures for the specific needs of the patient.

In concrete terms, once the presence of all professional figures provided for by current legislation is guaranteed (in the case of Article 132: speech therapist, neuro-psychomotor therapist, occupational therapist, professional educator, as well as psychologist), the healthcare facility could proceed with interchangeability exclusively with reference to any professional figures in excess of or additional to the guaranteed minimum core, assessing the assistance needs of individual patients undergoing treatment.

Interchangeability, therefore, would operate only in a "residual" capacity, i.e., after ensuring the presence of all professional figures required by the respective regional regulations and limited to surplus professional figures; this is also provided for by the challenged provisions themselves, which expressly state that both the overall number of units and the presence of professional figures provided for by the reference discipline remain unchanged.

Therefore, if one wishes to consider the provisions in question to fall within the matter of professions, the perimeter of state legislative competence is respected, as the regional legislator has adopted measures linked to the territorial reality, without affecting the discipline of individual professions or modifying the scope of their respective competencies.

In the regional defense's opinion, the question is unfounded in any case because it concerns the matter of health protection, as the challenged provisions relate to organizational measures of regional healthcare.

3.– The Puglia Region, close to the public hearing, filed a memorandum reiterating the inadmissibility and, subsidiarily, the lack of merit of the questions concerning Articles 117, 132, and 217.

3.1.– The regional defense reiterates the inadmissibility of the objections addressed to Article 117 of Puglia Regional Law No. 42 of 2024, as formulated with assertive and deficient reasoning, since the appellant has not addressed the legislation regulating the figure of the biologist and their academic training.

The question is nonetheless unfounded, as the regional provision has not introduced a new professional figure but has merely provided that in centers for the treatment of eating disorders, a biologist specialized in nutrition sciences must be present.

3.2.– The questions concerning Articles 132 and 217 are also inadmissible due to lack of reasoning, as the appeal does not demonstrate the harm caused by the challenged regional provisions to the principles established by the State in the matter of professions, nor has it indicated the intermediate norms allegedly violated.

On the merits, the regional defense insists on the lack of foundation of the objections, as this is an intervention aimed at guaranteeing the best care for patients in the indicated centers, attributable to the matter of "health protection."

Considerations in Law

4.– With the appeal indicated in the heading (Appeals Reg. No. 12 of 2025), the President of the Council of Ministers challenged various provisions of Puglia Regional Law No. 42 of 2024.

Having reserved the decision on the further constitutional legitimacy questions raised by the same appeal for separate pronouncements, those relating to Articles 98, 117, 132, 160, and 217 of the aforementioned regional law are now examined. These were raised with reference to Article 117, third paragraph, of the Constitution, regarding the matters of "coordination of public finance" and "professions," in relation—as to Articles 98 and 160—to Article 20 of Legislative Decree No. 118 of 2011, which establishes the principle of the exact delimitation of revenues and expenditures related to the financing of the Regional Health Service; and—as to Articles 117, 132, and 217—to Article 1, paragraph 3, of Legislative Decree No. 30 of 2006, pursuant to which "[r]egional legislative power shall be exercised over professions identified and defined by state legislation," both norms considered fundamental principles of the aforementioned matters.

4.1.– More specifically, the appellant considers that Articles 98 and 160 of Puglia Regional Law No. 42 of 2024, insofar as they provide for the use of resources pertaining to the so-called health perimeter to cover expenses aimed—respectively—at promoting virtual reality in the new degree courses in medicine and surgery and healthcare professions, and for supporting the Department of Experimental Medicine of the University of Salento, violate the accounting principles on the so-called health perimeter established by Article 20 of Legislative Decree No. 118 of 2011, thereby infringing upon the State's legislative competence in the matter of "coordination of public finance" under Article 117, third paragraph, of the Constitution.

4.2.– Regarding the challenged Article 117 of the regional law (titled "Staffing in therapeutic-rehabilitative residences for the treatment of subjects with Eating Disorders"), according to the appellant, this provision, in requiring the presence of nutritionist biologists in therapeutic-rehabilitative residences as a condition for obtaining the authorization and accreditation necessary for the activation of health services, violates Article 117, third paragraph, of the Constitution, which reserves to State legislative power the determination of fundamental principles in the matter of "professions," in relation to Article 1, paragraph 3, of Legislative Decree No. 30 of 2006, cited as the intermediate norm.

Indeed, national law does not provide for an autonomous professional figure of the nutritionist biologist, but only that of the biologist: thus, the challenged provision is in conflict with the cited Article 1, paragraph 3, of Legislative Decree No. 30 of 2006, by virtue of which, in the matter concerned, regional legislative power is exercised over professions identified and defined by state legislation, to which the identification of new professional figures and the establishment of new professional registers remain reserved.

4.3.– The appellant finally challenges Articles 132 and 217 of Puglia Regional Law No. 42 of 2024, which provide for the interchangeability, for a maximum transitional period of 24 months, of rehabilitation healthcare professionals—in relation to the assistance needs of subjects undergoing treatment and for shift rotation requirements, respectively in specialized centers for the treatment of autism spectrum disorders and in psychiatric residential assistance communities dedicated to high-complexity patient offenders—pending "the programming of adequate training for certain currently lacking professional figures."

The aforementioned Articles 132 and 217 also violate Article 117, third paragraph, of the Constitution, in relation to Article 1, paragraph 3, of Legislative Decree No. 30 of 2006.

The concept of interchangeability underlying both challenged provisions is particularly contested, as the appellant observes that within healthcare professions, each figure possesses reserved and distinct competencies and responsibilities based on its specific profile and training pathway, determining its belonging to distinct professional orders. Providing for the interchangeability of rehabilitation professional figures would violate the fundamental principles of the "professions" matter, wherein, according to the orientation of this Court, the identification of professional figures with their respective profiles and enabling titles is reserved to the State, and the regulation of aspects specifically linked to the regional reality is attributed to the legislative competence of the Regions.

5.– Preliminarily, it must be noted that, in appearing in the proceedings, the Puglia Region presented no defense regarding the questions concerning Articles 98 and 160 of Puglia Regional Law No. 42 of 2024, which allocate contributions for supporting telemedicine and digital health, but only concerning those related to Articles 117, 132, and 217 of the same regional law, as to which it initially objected to inadmissibility.

5.1.– Regarding the challenged Article 117, concerning the figure of the nutritionist biologist, the Puglia Region argues that the appeal must be declared inadmissible because it does not contain any reference to the actually relevant intermediate norm, namely the state law establishing the profession of biologist. This defect allegedly affects the exhaustiveness of the reasoning process, as the objection, disregarding any examination of the aforementioned legislation, is considered deficient and merely assertive.

This exception is unfounded.

The reasoning of the President of the Council of Ministers, although concise, is sufficient to identify the *ratio decidendi* of the objection—namely, the circumstance that the Region's intervention did not limit itself to regulating the figure of the biologist within the scope of the fundamental principles identified by state discipline, but created a "new" professional figure with competencies belonging both to the biologist and the medical surgeon—the correctness of the arguments put forward in support pertains, rather, to the merits of the question (in this sense, *ex multis*, Judgments No. 80 of 2025, No. 32 of 2023, and No. 53 of 2020).

5.2.– Regarding the questions raised against Articles 132 and 217, the Region objects to their inadmissibility due to lack of reasoning, as the appeal fails to clarify how the regional provisions could cause the alleged harm, nor does it indicate the intermediate norms assumed to be violated.

This exception is also unfounded.

The concise reasoning of the appeal did not prevent the regional defense from developing a comprehensive defense argument on the merits (in this sense, *ex multis*, Judgments No. 80 of 2025, No. 53 of 2020, No. 80 and No. 14 of 2017, and No. 215 of 2015).

6.– On the merits, concerning the questions relating to Articles 98 and 160 of the challenged regional law, the *thema decidendum* must be limited to paragraph 5 of Article 98 and paragraph 2 of Article 160, insofar as they provide that the interventions established by the preceding paragraphs of the same articles shall be financed with resources from Mission 13 "Health," Program 7 "Further expenditures on health matters," specifically Title 1 "Current Expenditures" and Title 2 "Capital Expenditures."

The President of the Council of Ministers alleges that these provisions violate the accounting principles on the so-called health perimeter established by Article 20 of Legislative Decree No. 118 of 2011, set by the State legislator in the matter of "coordination of public finance," under Article 117, third paragraph, of the Constitution.

6.1.– The questions are founded.

This Court, with consistent case law, has clarified that Article 20, paragraph 1, of Legislative Decree No. 118 of 2011 requires Regions to guarantee, within the budget, "an exact delimitation of revenues and expenditures related to the financing of their regional health service," for the declared "purpose of allowing immediate comparability between health revenues and expenditures recorded in the regional budget and the resources indicated in the acts" of health financial programming (Judgment No. 1 of 2024, and similarly, Judgments No. 169 and No. 68 of 2024).

The general accounting principles established by Legislative Decree No. 118 of 2011 and applied to the health sector constitute, as provided by Article 19, paragraph 1, of the same decree, fundamental principles of coordination of public finance and are aimed at protecting the economic unity of the Republic with a view to ensuring that the entities involved in managing expenditures financed by resources intended for the National Health Service contribute to achieving public finance objectives.

To achieve this objective, paragraph 1 of Article 20 requires the adoption of a budget breakdown that ensures "separate evidence" of the typified elements, the first of which, in Section A "Revenues" (letter a), indicates "ordinary current health financing as derived" from the referenced programming sources, corresponding, in letter a) of Section B "Expenditures," to "current health expenditure for the financing of essential levels of care (LEAs)" (Judgment No. 197 of 2019).

For the health perimeter thus highlighted, specific accounting rules are then set, which, as stated in the subsequent paragraph 2, are intended to "guarantee effectiveness to the financing of essential levels of care."

In summary, the cited Article 20 not only establishes rules aimed at ensuring the delimitation of revenues and expenditures related to the financing of the Regional Health Service, also in the context of coordinating public finance objectives, but also establishes "indefectible conditions in the identification and allocation of resources pertaining to the essential levels of performance."

6.1.1.– Indeed, the challenged Article 98 allocates 150 thousand euros (paragraph 5) to "strengthen collaboration relationships and synergies between the higher education-university system and technical training institutes (ITS) and the local fabric of small and medium-sized enterprises operating in the field of technological innovation," also through "promotion of innovative teaching methods" (paragraph 1). Paragraph 2 then identifies the various financable interventions. Specifically: projects aimed at using innovative technologies based on virtual reality for teaching and training in the medical and healthcare professions area; the implementation of teaching and training activities that allow a wide audience of students and professionals in training access to practical exercises, such as in anatomy, surgery, and patient assistance, otherwise impossible to carry out; the creation of a collaborative environment between universities, ITS, and the network of Apulian small and medium-sized enterprises through the establishment of formal communication and collaboration channels; training initiatives aimed at promoting knowledge and progressive familiarity with virtual reality by students and professionals in training; information and dissemination activities of innovative teaching activities based on virtual reality, also aimed at increasing the attractiveness of regional training offerings to a national and international audience. Paragraph 3 then provides that these interventions may be activated "by Medical Schools, University Departments hosting degree courses in Medicine and Surgery, Dentistry and Dental Prosthetics and degree courses in healthcare professions, by ITS hosting training relevant to the health area, in collaboration with small and medium-sized enterprises in Puglia with proven experience in the field of virtual reality applied to teaching."

A reading of the referenced regional provisions highlights that the resources under the challenged Article 98, paragraph 5, directed towards praiseworthy informational and educational activities, are not intended, even indirectly, to finance healthcare services; consequently, in order to avoid accounting opacity and undue diversion of funds intended for financing health expenditures, it must be recognized that the provision for their financing conflicts with the principle of exact delimitation of such expenditures, established by the cited Article 20 of Legislative Decree No. 118 of 2011.

6.1.2.– The appeal is also founded regarding the challenged Article 160 of Puglia Regional Law No. 42 of 2024, which provides, in paragraph 1, that the Region supports the Department of Experimental Medicine of the University of Salento in the study and research on digital health and the most up-to-date digital technologies, "both as prevention tools for early childhood health, and for the innovation of health services and clinical engineering: telemedicine, neurodevelopment, digital technology, and sensor technology for preventive, participatory, and personalized medicine," allocating 30 thousand euros for the year 2025 for these purposes in paragraph 2.

It should be noted that the development of telemedicine and, more generally, technology in the health sector is a significant objective which, not coincidentally, is also the subject of a specific Mission of the National Recovery and Resilience Plan (PNRR) (Mission 6, C1), dedicated to health. Within this Mission, telemedicine is considered a means to help reduce current geographical and territorial disparities in healthcare through the harmonization of care standards guaranteed by technology, to ensure a better care experience for patients, and to improve the efficiency levels of regional health systems through the promotion of home care and remote monitoring protocols.

The interventions provided for in the challenged regional provision, intended to finance the Department of Experimental Medicine of the University of Salento, could have been covered by savings from health management (Article 30 of Legislative Decree No. 118 of 2011), if the Region were not already engaged in a recovery plan; or they could be financed with PNRR funds, with regard to projects linked to the aforementioned Mission 6, C1.

In the case at hand, however, the funds from the Regional Health Service—which, for Regions in a recovery plan like Puglia, are pre-ordered to finance essential levels of care—cannot be used for expenses that, like the ones in question, are not directly aimed at health services, although it cannot be excluded that in the future application techniques of telemedicine may be developed that allow the related interventions to be included within the same scope.

In the case under review, what conflicts with the invoked constitutional parameters is not, therefore, the Region's commitment to supporting the aforementioned expenses: "the coverage of the charges connected to these initiatives with the specific ordinary resources allocated to current expenditures for the financing and guarantee of LEAs is constitutionally illegitimate" (Judgment No. 132 of 2021).

Article 160, paragraph 2, insofar as it provides for the disbursement of Health Fund contributions for purposes not directly attributable to health services, links a certainly health-related revenue (the Health Fund) to an expenditure extraneous to this scope, thus altering the structure of the health perimeter prescribed by Article 20 of Legislative Decree No. 118 of 2011, the purpose of coordination and accounting harmonization of which is clearly evaded (similarly, Judgment No. 233 of 2022).

6.1.3.– Therefore, Articles 98, paragraph 5, and 160, paragraph 2, must be declared constitutionally illegitimate for conflict with Article 20 of Legislative Decree No. 118 of 2011 and, consequently, with Article 117, third paragraph, of the Constitution.

The declaration of unconstitutionality of paragraph 5 of Article 98 and paragraph 2 of Article 160 requires the Puglia Region, should it intend to implement the interventions provided for in the same articles, to find the resources for their coverage by reducing expenditures other than health expenditures.

7.– The question concerning Article 117 of Puglia Regional Law No. 42 of 2024 is not founded.

This Court has consistently affirmed that the identification of professional figures along with their respective enabling profiles and titles is reserved to the State, while Regions are attributed the power to adopt detailed regulations concerning any organizational aspects of professions that have a connection with the regional reality (Judgments No. 196 and No. 161 of 2025, No. 127 of 2023, No. 98 of 2013, No. 138 of 2009, No. 93 of 2008, No. 40 of 2006, and No. 424 of 2005).

However, the challenged regional provision does not in any way result in the creation of a new professional figure distinct from those operating under state legislation.

Article 117, contrary to the assertion of the Advocate General, does not establish a new professional figure, but merely provides that centers for the treatment of eating disorders must have a biologist specialized in nutrition.

The national legislation governing the matter is contained in Article 3 of Law No. 396 of 1967, which states that "[t]he profession of biologist shall cover: [...] b) assessment of the nutritional and energy needs of humans, animals, and plants [...]. The listing in this Article does not limit the exercise of any other professional activity permitted to biologists registered in the register, nor does it prejudice what may form the subject of the activity of other categories of professionals, pursuant to laws and regulations."

According to the consistent case law of this Court, also recently confirmed (Judgment No. 161 of 2025), while the identification of professional figures is reserved to the State, "the regulation of aspects that have a specific connection with the regional reality remains within the competence of the Regions" (Judgment No. 209 of 2020; similarly, Judgments No. 127 of 2023, No. 6 of 2022, and No. 241 of 2021).

If, therefore, the establishment of new and different registers from those already established by state laws falls outside the concurrent legislative competence of the Regions in the matter of "professions" (among others, Judgment No. 127 of 2023), in the present case, the Region has limited itself to specifying the professional figure that must compose the team of specialists present in regional centers for the treatment of eating disorders, identifying it as the nutritionist biologist, already inferable from state legislation. This is done in the full exercise of its concurrent competence in the matter of health protection, regarding which health organization represents an essential component (ex multis, Judgments No. 84 of 2025, No. 202 of 2024, and No. 112 of 2023).

Nor is the State's legislative competence in the matter of professions violated due to potential overlaps between the figure of the biologist and that of the dietitian.

While a biologist holding a five-year degree registered in Section A of the National Order of Biologists can, like a physician, formulate diets and provide nutritional advice, the dietitian is a healthcare professional with a three-year degree who organizes and coordinates specific activities related to nutrition in general and dietetics in particular, collaborates with bodies responsible for safeguarding the hygienic-sanitary aspect of the food service, develops, formulates, and implements diets prescribed by the physician and monitors their acceptability by the patient; collaborates with other figures in the multidisciplinary treatment of eating disorders (Decree of the MUR April 2, 2001).

The biologist's competence regarding the formulation of diets, therefore, not only does not conflict with the tasks of the dietitian but is also broader. The National Order of Biologists has, in fact, provided for the existence of an activity code for the nutritionist biologist, confirming their competence to develop diets, adding that specialization is not required to practice as a nutritionist biologist, registration in the National Order of Biologists in Section A of the relevant register being sufficient, as also confirmed by the Council of the same Order.

From this, the lack of foundation of the objections is deduced, as the challenged provision has not introduced a new professional figure.

8.– Regarding the questions concerning Articles 132 and 217 of Puglia Regional Law No. 42 of 2024, they are unfounded, in the terms specified below.

Article 132 provides for the interchangeability, for a maximum period of 24 months, of rehabilitation technical health professionals (specifically: speech therapist, neuro-psychomotor therapist, occupational therapist, professional educator, psychologist) to allow, pending the programming of adequate training for certain currently lacking professional figures, the commencement of activities of specialized centers for the treatment of autism spectrum disorders.

Article 217 similarly provides for the interchangeability, for a maximum period of 24 months, of rehabilitation healthcare professionals (specifically: occupational therapist, professional educator, socio-health educator, psychiatric rehabilitation technician, neuropsychiatric rehabilitation technician), pending the programming of adequate training for certain temporarily lacking professional figures, to allow for the commencement and enhancement of activities of psychiatric residential assistance communities dedicated to high-complexity patient offenders.

8.1.– It should be noted that at the national level there is a single register of technical health professions encompassing eighteen distinct profiles identified by as many ministerial decrees. While the State's competence to regulate the professional orders and profiles *de quibus* remains firm, it must be noted that the challenged provisions do not violate the State legislative competence protected by Article 117, third paragraph, of the Constitution; rather, they are attributable to the regional competence in the matter of health organization, as they are functional to guaranteeing the best service to patients accommodated in centers for the treatment of autism spectrum disorders or in the aforementioned residential communities. The interchangeability—necessarily temporary for the limited period identified by the regional provisions—must indeed be understood not in terms of "substitutability" between professionals belonging to different disciplines, but as the possibility of deploying different professionals according to the number and type of patients attending the facilities concerned, in order to ensure the presence of the most appropriate professional figures for the specific needs of the patient.

As observed by the regional defense, the facility, once the minimum number of all professional figures required by current legislation is guaranteed, may proceed, according to the assistance needs of individual patients undergoing treatment and in any case for a maximum period of 24 months, with interchangeability exclusively with reference to professional figures in excess of or additional to this minimum number.

The regional legislator has intervened in a particularly delicate sector by providing for interchangeability in a strictly temporary and residual manner, considering the shortage of certain professional figures in the Apulian territory, in order to guarantee the start-up of specialized centers for the treatment of autism spectrum disorders and psychiatric residential assistance communities, after ensuring the presence of all professional figures required by their respective regional regulations.

8.2.– In light of the foregoing, the challenged provisions, as interpreted, are therefore not detrimental to Article 117, third paragraph, of the Constitution because, far from providing that one professional figure must or may perform the tasks of another, they are oriented toward ensuring better and more effective assistance to the patient, in the exercise of the Regions' concurrent legislative powers in the matters of "professions" and health organization, as an integral part of the matter of "health protection."

for these reasons

THE CONSTITUTIONAL COURT

reserving the decision on the further constitutional legitimacy questions raised by the appeal indicated in the heading for separate pronouncements;

1) declares the constitutional illegitimacy of Article 98, paragraph 5, of the Law of the Puglia Region of December 31, 2024, No. 42, providing for "Provisions for the formation of the 2025 budget and the multi-year budget 2025-2027 of the Puglia Region (Regional Stability Law 2025)";

2) declares the constitutional illegitimacy of Article 160, paragraph 2, of Puglia Regional Law No. 42 of 2024;

3) declares unfounded the constitutional legitimacy question concerning Article 117 of Puglia Regional Law No. 42 of 2024, raised with reference to Article 117, third paragraph, of the Constitution, in relation to Article 1, paragraph 3, of Legislative Decree February 2, 2006, No. 30 (Recognition of fundamental principles regarding professions, pursuant to Article 1 of Law June 5, 2003, No. 131), by the President of the Council of Ministers with the appeal indicated in the heading;

4) declares unfounded, in the terms set out in the reasoning, the constitutional legitimacy question concerning Article 132 of Puglia Regional Law No. 42 of 2024, raised with reference to Article 117, third paragraph, of the Constitution, in relation to Article 1, paragraph 3, of Legislative Decree No. 30 of 2006, by the President of the Council of Ministers with the appeal indicated in the heading;

5) declares unfounded, in the terms set out in the reasoning, the constitutional legitimacy question concerning Article 217 of Puglia Regional Law No. 42 of 2024, raised with reference to Article 117, third paragraph, of the Constitution, in relation to Article 1, paragraph 3, of Legislative Decree No. 30 of 2006, by the President of the Council of Ministers with the appeal indicated in the heading.

Thus decided in Rome, at the seat of the Constitutional Court, Palazzo della Consulta, on November 5, 2025.

Signed:

Giovanni AMOROSO, President

Angelo BUSCEMA, Rapporteur

Roberto MILANA, Director of the Registry

Filed in the Registry on January 22, 2026