Employment, Social Affairs & Inclusion

Germany - Health insurance benefits in kind in the event of illness

The benefits of the state health insurance (GKV) are generally paid as cash benefits or benefits in kind. Persons insured with the state health insurance can be treated by a doctor when presenting their insurance card. They are generally given the necessary medical treatment as well as medication, remedies and aids as benefits in kind.

Under what circumstances am I entitled to benefits?

The services of the state health insurance system are normally provided as cash benefits or as benefits in kind. Persons insured with the state health insurance system are treated by a doctor when they present their insurance card. They normally receive the necessary medical treatment as well as medication, remedies and aids as benefits in kind.

Eligibility requirements

The services of the state health insurance system are normally provided as cash benefits or as benefits in kind. Persons insured with the state health insurance system are treated by a doctor when they present their insurance card. They normally receive the necessary medical treatment as well as medication, remedies and aids as benefits in kind.

What am I entitled to and where can I apply for the benefits?

The services of the state health insurance currently include among other things:

Medical check-ups for early diagnosis of illnesses:

  • Health checks for children and young people (currently 10 check-ups at pre-defined times up to the age of 6, as well as one check-up between the 13th and 14th year).
  • Check-ups for adults: from April 2019, under the Prevention Act 2015 18-34 year olds covered by statutory instance are for the first time entitled to one free check-up, and insured people over 35 are entitled to a check-up every three years. This is aimed at identifying health risks and the early diagnosis of conditions such as cardiovascular diseases and type 2 diabetes mellitus. In certain cases, doctors may recommend certified offers for behavioural prevention, such as for remedying movement deficiencies or stopping smoking.
  • One-off ultrasound screening for the early detection of abdominal aorta aneurysms (pathological enlargement of the abdominal artery) for men over 65. Early detection scheme for cervical cancer for women over 20. Under the Early Cancer Detection and Recording of Act of 2013, eligible women covered by statutory insurance are, from January 2020, written to every five years by their health insurance company to inform them about the early detection of cervical cancer (women aged 20 to 34: annual cytological smear (pap smear) / women over 35: combined check-up every three years with pap smear and HPV test); and for all women over 30: (annual) tactile examination by a doctor for the early detection of breast cancer.
  • Mammogram screening for early diagnosis of breast cancer for women between 50 and 69 years. Women are invited in writing to come to this X-ray check-up every other year by a “central body”.
  • Early detection of prostate cancer in men over 45: annual tactile examination.
  • Scheme for the early detection of bowel cancer for women and men over 50: from July 2019, under the Early Cancer Detection and Recording Act of 2013 eligible people covered by statutory insurance are written to every five years by their health insurance company regarding the early detection of bowel cancer (regular immunological faecal occult blood test; two colonoscopies for early diagnosis every 10 years.
  • Early detection of skin cancer in women and men over 35: every other year, skin examination with the naked eye.

Medical care:

Insured parties are entitled to treatment by GPs, specialists and dentists.

Medicines, treatments and equipment:

The health insurance company in general pays the costs of medicines which have been prescribed as a panel prescription by a doctor who has a contract with the health insurance company (accredited doctor). For most medicines insured parties pay 10% of the sales price themselves (contribution), with a minimum of EUR 5 and a maximum of EUR 10. The supplementary payment may not be higher than the price of the medicine. Supplementary payments are limited: children under age 18 are exempt.

Non-prescription drugs are not reimbursed. This does not apply to children under 12 and young people with development disorders under 18. By way of exception, prescription drugs the “German Joint Federal Committee” has recognised as being standard treatment for severe illnesses are not reimbursed

Medicines to treat colds and flu infections, including head colds, painkillers, cough relief and cough remedies, mouth and throat treatments (except for fungal infections), laxatives and medicines against travel sickness you must pay for in full.

Nor does the health insurance company pay for medicines "used primarily to improve the quality of life". This refers to medicines to cure erectile dysfunction, increase sexual potency, treatments to stop smoking, weight loss regulators or hair growth formulas. If need be, ask your health insurance company about possible exceptions to this rule.

The insured parties are also entitled to treatments prescribed by a doctor such as physiotherapy (remedial gymnastics), speech therapy, occupational therapy or foot treatments (professional pedicure). In this case too, patients must pay 10% of the costs themselves, plus EUR 10 for each prescription.

The health insurance company also pays a part of the costs for medically essential hearing devices (e.g. hearing aids), prostheses and similar aids. Generally, adults only receive a contribution for aids to vision such as glasses or contact lenses. For the health insurance companies to contribute to the costs for such aids, you should apply to the health insurance company BEFORE buying them. The insured parties must pay part of the costs themselves: The supplementary payment for aids is 10% of the price, with a minimum EUR 5 and maximum EUR 10 for consumable aids, or maximum EUR 10 for one month's supply.

Dentistry:

Necessary conservative dentistry and surgical treatments are usually covered by health insurance funds.

For standard orthodontic treatments (protection and correction of tooth and jaw misalignment, e.g. with braces), insured parties pay 20% of the costs themselves. If orthodontic treatment is required for at least two insured children who have yet to turn 18 when the treatment begins and who live in the same household as their parents or legal guardians, the contribution for the second and any further child is 10%. The fund reimburses this contribution at the end of the treatment.

For insured parties under 18, the funds pay in full for essential standard orthodontic treatments from their range of treatments.

For dentures and crowns, depending on the dentist's findings, the insured parties receive a contribution of 50% of the costs at the "standard rate" defined by the "German Joint Federal Board". A person who goes to the dentist at least once a year and proves this by his bonus booklet, receives in addition up to 30% of the costs for dentures from the health insurance fund.

Low-income insured parties receive necessary medical standard care for free. In addition, the accompanying hardship provisions prevent insured parties being affected by "unreasonable charges".

Home nursing care and domestic help:

Insured persons are eligible for home nursing care in addition to medical care, if treatment at hospital is needed, but cannot be implemented or if it can be avoided or shortened by providing nursing care at home. A person is only eligible if no one in the same household is able to care for and look after them to the extent needed.

The health insurance companies stipulate in their rules whether and how they pay for home nursing care in other cases too.

If you are unable to look after yourself due to hospital treatment or illness and nobody living in the same household can run the household, the health insurance company will pay for domestic services. The prerequisite for this payment is that a child lives in the household who has not completed 12 years by the beginning of the domestic help or is disabled and requires help. Domestic help can also be claimed, when it is impossible to keep the household due to severe illness or the acute worsening of an illness, in particular after hospitalisation (for up to at the most four months). The entitlement is extended to 26 weeks, if there is a child in the household, who has not completed 12 years by the beginning of the domestic help or is disabled and requires help. The health insurance company pays for the domestic help for at most four weeks if:

  • you are so unwell that you can no longer shop, clean, wash or perform other household chores for yourself and
  • there is a child under 12 or with disabilities living in your household who cannot be cared for by any other person in the household.

Hospital treatment:

All health insurance companies must also pay for hospital treatment if a doctor deems it necessary. For a maximum of 28 days per calendar year, you must pay a supplementary payment of EUR 10 for each day.

Travel costs:

In some cases, health insurance companies also pay for the necessary travel (travel costs) to medical treatment, for example to a doctor or hospital. 10% of this is to be paid for by the insured parties themselves (personal contribution) with a minimum of EUR 5 and a maximum of EUR 10 per journey. Health insurance companies do not pay travel costs for outpatient treatments.

Benefits in kind in the event of illness:

Before a doctor treats you at the health insurance company's expense, you must present your health insurance card (e-health card). In urgent cases, the doctor will treat you even without this card. You must then present it at the doctor's practice within 10 days.

90% of all established doctors and dentists with their own practice are approved by one or more state insurance schemes. Only with this approval can patients be treated at the expense of the state health insurance scheme. You can get a list of approved doctors in your area from your health insurance company.

If necessary, your GP may refer you to a specialist, an outpatient clinic, a hospital or a similar institution.

In Germany, the health insurance is covered by two different systems: the state health insurance and the private health insurance.

State health insurance is compulsory in particular for the following groups of people

  • Employees whose remuneration for their employment amounts to more than EUR 450, but does not exceed the limit for general compulsory insurance. For employees with minor employment special regulations apply:
  • Recipients of unemployment benefit or alimonies pursuant to SGB III under certain conditions recipients of unemployment benefit II.
  • Trainees and students under certain conditions and interns who carry out a practical activity required as part of their course or examination regulations and do not receive any remunerations.
  • Pensioners as long as certain qualifying periods have been fulfilled,
  • Agriculture and forestry entrepreneurs and their family members who work in their businesses as well as Altenteile, parts of a farm retained by a retired farmers,
  • People with a disability (in workshops or homes),
  • Artists and journalists.

Children, spouses and registered partners of members may under certain circumstances, be covered by family insurance without the need for contributions, if they have their residence or habitual abode in Germany and provide of a total income that does not regularly lie below a certain income threshold (in 2020: EUR 455 per month). For employees with minor employment the permissible threshold of their total income is EUR 450 per month. Family members must not be subject to mandatory insurance elsewhere or be exempt from compulsory insurance to be eligible for family insurance.

Anyone who drops out of the mandatory insurance and is not covered by family insurance can generally still be insured as a voluntary member of the state health insurance scheme.

People who are not entitled to be protected in the event of an illness and have their residence or habitual abode in Germany must mandatorily have been insured in the state or private health insurance pursuant to certain regulations since 1 January 2009.

Insurance premiums:

The state health insurance is financed by contributions and a federal subsidy. The contributions including the supplementary contributions of the individual health insurance funds are calculated based on a percentage of the assessable income.

In case of compulsorily insured parties this includes remuneration from work, pensions of the state pension fund, pensions and related benefits (e.g. occupational pensions) as well as remuneration from self-employed activities obtained in addition to a pension of the state pension insurance or other pensions and annuities. Voluntary members pay furthermore contributions from other income, such as for example capital income or income from tenancy or lease.

For both compulsorily insured and voluntarily insured members a total income up to the assessment ceiling of EUR 4,687.50 per month or EUR 56,250 per year (as at 2020) is taken into account. The legally determined general contribution rate is 14.6% of the income subject to compulsory contributions. The employer and pension insurance institute must cover half of it for employers and pensioners respectively. The reduced contribution rate is 14.0% of the assessable income of the members.

Health insurances that cannot cover their financial neds with the allocations from the health funds can also charge their members a supplementary contribution. Employers and pension insurance companies each pay half of the supplementary contribution, which may vary for every health insurance. An overview of the current supplementary contributions of health insurances is available on the website of the Federal Association of Health Insurances on www.gkv-spitzenverband.de. In as far as a health insurance levies a supplementary contribution for the first time or increases its supplementary contribution rate, the members have the option to change their health insurance within the framework of the legal special cancellation rules. Co-insured children or partners (family insurance) do not pay supplementary contributions. Employers pay the supplementary contribution for their employees directly to the health insurance. Basic insurance is covered by the responsible agencies in case of social security recipients and recipients of basic insurance.

Jargon busters

  • Earnings: Your regular wage or salary
  • Health insurance card (e-health card): An identity document in a credit card format that you receive from your health insurance company. All important data are stored on it
  • Statutes: Rules which organisations (e.g. health insurance companies) set for themselves under statutory provisions

Application forms

The health insurance companies pay the doctors and hospitals directly for treatments at the doctor's surgery or the hospital provided that you have presented your health insurance card in the practice or clinic beforehand. Money for some dental treatments must be applied for in advance to your health insurance company. The dentist who is treating you will inform you in this case.

Your rights

The links to the following sites are not European Commission sites and do not reflect its opinions:

  • The health insurance companies inform their members about their rights and entitlements by telephone and over the Internet. If you do not agree with a decision made by your health insurance company, you can seek advice from independent patient advice centres. These centres can also help you with problems following errors in medical treatments.
    http://www.patientenberatung.de

European Commission publications:

Further information

Compulsorily and voluntarily insured parties can always freely choose their state health insurance. The 105 state health insurances in Germany may differ in their service and supplementary services (optional services). The amount of the supplementary contribution of health insurances may also be an important criteria in choosing a health insurance. It is therefore worthwhile to compare the different products on offer. Farmers have their own health insurance.

You can find a list of the state health insurance policies and plenty of other relevant information at http://www.gkv-spitzenverband.de/ on the site of the federal association of state health insurance funds.

If you still have social security cover in one or more countries besides Germany, ask about the effects on health insurance:

GKV Spitzenverband,
Abteilung Deutsche Verbindungsstelle
Krankenversicherung - Ausland (DVKA)
Pennefeldsweg 12 c
53177 Bonn
Tel.: +49 228 95300
http://www.dvka.de

You can find the Federal Ministry of Health at http://www.bmg.bund.de

The employer calculates the social insurance contributions for compulsorily insured employees (the contributions for health, nursing care, pension and unemployment insurance), and transfers the total contribution as part of the payroll deduction procedure to the health insurance fund, which then forwards the contributions to other social welfare funds. The normal health insurance contribution rate is currently 14.6%. The employer pays half of this (7.3%) for compulsorily insured employees, and the employee pays the other half (7.3%). This is complemented by the supplementary contribution health insurances can levy.

The contribution to the nursing care insurance amounts to 3.05%. Childless insured parties born since 1940 pay an additional 0.25% from age 23.

The compulsory insurance of employees whose remuneration exceeds the applicable annual remuneration limit (compulsory insurance limit) ends at the end of the calendar year, if your remuneration will also exceed the corresponding applicable annual remuneration limit in the following calendar year. The general compulsory insurance limit is an annual income of EUR 62,550.00 (or EUR 5,212.50 per month) for 2020. If this terminates the employee’s obligation to be insured, the parties affected always have the option to remain insured as a voluntary member of the health insurance or to change to a private health insurance.

The authorities and social insurance providers (you can find the addresses at the end of the relevant chapter) can offer you advice and information about your rights and entitlements. The website http://www.deutsche-sozialversicherung.de provides a summary and many additional links.

Trade unions as well, among others, offer their members free advice on issues relating to social legislation. Charitable associations such as unemployment centres help those in need with the forms and will also accompany you, if required, to the public authorities.

The insurance authorities for citizens of other EU member states have set up a number of information offices in Germany (see Annex). These answer questions about social insurance in Germany and other EU states.

You can find the federal laws at http://www.gesetze-im-internet.de. The Federal Ministry of Labour and Social Affairs has set up a search engine at http://www.bmas.de/DE/Service/Gesetze/inhalt.html, which searches laws and regulations by keywords.

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