Health Insurance

German Statutory ("Public")

Are you aware that yet again your statutory health insurance is most
likely to have increased by 0.2% as of Jan. 2021???
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Did you know that "public" insurers
differ in price up to 2% ???
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What all this actually means in money-terms ...
... ask ERICON broker.

In July of 2020, of the approximate 83 million people registered in Germany, a record number of 73.4 million were insured with the statutory ("public") system. The number of actual contributing members hit 57 million and dependents, thus those insured 'free of charge', was over 16 million people.

Of those making contributions, 34.1 million (59.7%) were enforced by legislation to be insured with the statutory system because their income did not meet the 'Annual Income Threshold' of 62,550€, today in 2021 set at 64,350€. 6 million (10.6%) contributng members were voluntarily insured and the rest people of different status (e.g. students or pensioners).

Legislation

In Book V of the German Social Security Statue book (SGB V) the legislator has defined the benefits to be provided by the statutory health system (GKV). Contrary to what one would expect though - a list of treatments & benefits - §12 reads: „Benefits must be sufficient, functional and economical; these are not allowed to exceed a measure of necessity. ... “.

So let us take a closer look at what the German legislator has defined as necessary for over 70 million people, more than 85% of the German population who are insured with one of the 103 statutory providers in 2021.

Treatment & Benefits

Although Book V of the German Social Security Statue Books (SGB) is dedicated to the intricacies of the German "public" health system (GKV), contrary to what one would expect, a detailed listing of treatments & benefits is to be found nowhere. Scrutinising the legislative texts, §2 begins with pointing to the benefits in chapter III but in the same sentence anticipation is subdued by hinting that §12 that gives us an idea of what people should really expect: „Benefits must be sufficient, functional and economical; these are not allowed to exceed a measure of necessity. Treatment not necessary or uneconomical, the insured cannot claim for, service providers cannot ensure, and health providers will not grant“.

So, let us take a closer look at what the German legislator has defined as necessary for over 73 million people, nearly 88% of the German population. Chapter III §11 lists the following benefits:

  1. Pregnancy and maternity
  2. Prevention of illnesses and their worsening, as well as contraception, sterilisation, and abortions
  3. Detection of health risks and early diagnosis of diseases
  4. Treatment of a disease
  5. Personal budget, according to § 29 of the XI Book

 

It then goes on to state:
The insured are also entitled to medical rehabilitation benefits and those to maintain their livelihood along with other supplementary benefits that are necessary to prevent, cure, relieve, counterbalance, prevent the worsening, or mitigate the consequences of a disability or need for long-term care.

General

  • In-Patient, Day-Patient & Out-Patient medical and dental treatment
  • Free choice of registered doctors and dentists
  • Prescribed medicines, dressings, therapies and aids such as hearing/ vision aids, crutches or wheelchairs
  • Measures for the prevention and early detection of certain diseases
    • Children in the first six years of their life and at the beginning of puberty
    • Adults every two years from the age of 35
    • Annual Cancer-Screening for women from the age of 20 and men from the age of 45
    • Preventive inoculations, excluding immunisations for private travels, as provided for in the articles of the relevant health insurance funding plan
  • Expenses for necessary preventive and rehabilitation treatment are fully or partial reimbursed
  • ‘Sickness per diem Allowance'
    • By law the employer has to continue to pay the salary for 6 weeks when the employee is unable to work due to illness. After this period the statutory health insurers will pay up to approx. 70% of the person's regular gross wage but only up to the Contribution Assessment Ceiling (2016: 50,850 € pa or 4,237.50 € pm) and no more than 90% of your most recent salary. The sickness allowance can be claimed for up to 78 weeks within a 3 year period.

Dental

  • Orthodontic treatment
    Usually only for children and adolescents up to the age of 18, however adults may receive funding if a severe jaw abnormality is present that requires oral surgery.

    German statutory medical insurers do however not pay for all kinds of treatments, therefore have categorised symptoms into 5 Orthodontic Indication Groups, German: "Kieferorthopädische Indikations-Gruppen (KIG)":
     
    • Groups 1 & 2 are considered minor anomalies; therefore treatment is not refundable. Should the orthodontist certify that medical treatment is necessary, private Top-Up Dental plans are helpful.
       
    • Groups 3 - 5 are paid in full, yet an initial 20% co-payment is required that is reimbursed once treatment has been successfully completed.
       
    Good to know:
    In any case, all German statutory health providers pay for an initial orthodontic consultation without needing a referral from a dentist!

     
  • Preventive dentistry
    In particular individual and group prophylactic measures to prevent dental disease

In Vitro Fertilisation (IVF) treatment

IVF treatment is a medical technique to help those with fertility problems to have a baby.
Having removed the egg from the ovaries and fertilised it with sperm in a laboratory, the then called embryo is planted into the womb to grow and develop. Who the egg/sperm donors are is not important for the success rate.

Insurance requirements

  • The couple must be married and only the eggs and sperm of the spouses may be taken.
  • Both partners must be at least 25 years old.
    The woman must be younger than 40, the man younger than 50.
  • A doctor not performing the artificial insemination must give detailed consultation to the couple in advance.
  • A HIV test must be available from both partners.
  • The woman must have extensive immunisation protection.
    Important are: rubella, chickenpox, and whooping cough.

Insured costs:

As legally obliged, 50% of the costs for artificial insemination are covered by all German statutory providers.
Many insurers have even increased their contributions, and some cover the costs in full.

Preferred German statutory providers for IVF treatment:

ProviderContribution
BKK24300€ allowance per cycle, max. 4 cycles
BKK Akzo Nobel Bavaria1,000€ allowance per cycle, max. 3 cycles
BKK excklusiv250€ allowance per cycle, max. 3 cycles
BKK firmus500€ allowance per cycle, max. 3 cycles
BKK FreudenbergPer married couple 2,000€ for 1 cycle within 24 months
BKK Pfaff100%
BKK Scheufelenif both parents insured with BKK, 500€ allowance per cycle, max. 9 cycles
IKK Classicif both parents insured with IKK, 500€ allowance per cycle, max. 3 cycles. If one parent not insured with IKK, 250€ per cycle
IKK Nordmax. 3 cycles
IKK Südwest1,000€ allowance per cycle, max. 3 cycles
Salus BKK250€ allowance per cycle, max. 3 cycles
Viactiv500€ allowance per cycle, max. 3 cycles

Financing and contributions

German statutory health insurance is financed by its members contributions and federal subsidies.

Contributions are based on a percentage of each individual's income that is subject to contributions.
So, if you are compulsorily insured then the rate will be calculated based on your wage, state pension (except orphan's pension) and any provident fundings, e.g. Company Pension Schemes. Also any additional, self-employed income a compulsory insured person receives is taken into consideration.

Self-employed or freelances pay their contributions not only based on the before-mentioned, but also revenue generated from capital-investments, rent or lease income is added.

Luckily for all there is a limit, the so-called 'Contribution Assessment Ceiling' (German = Beitragsbemessungsgrenze), which caps the income that is subject to contributions at 4,537.50€ per month, respectively 54,450€ per year. (2019)

Pricing amongs providers

Generally, contributions across the board for all providers are set at 14.6% of an individual’s gross income, of which each party (employer & employee) pay 7.3%.

On top of this the provider - there are approx. 108 at present time - is allowed to load the contribution with their own additional rate, which varies between 0.2% - 2.50%.
The standard additional charge ranges between 0.8% - 1.2%.

Follow this link to see a listing of all providers and their additional contribution fee.

Kinds of people covered by the statutory scheme

The German statutory health scheme primarily insures employed people, whoms earnings restrict them in their choice to obtain cover with a more comprehensive German private insurance health plan or those who even become a voluntary member of the statutory scheme, as family members need to be included. The hurdle to overcome the "shackles" of statutory health insurance is dependent on the 'Annual Earning Limit', which is set at 5,212.50€ per month or 62,550€ per year gross income. (2020)

Students, self-employed, freelancers, pensioners, jobseekers and also people without any occupation sign up with a statutory provider for all kinds of reasons and quite often it makes sense to join the "public" health scheme, especially for people with pre-existing conditions or families. Hence, families in which just one person is earning or students up to the age of 25 with little to no income, will benefit from a system predominately funded by everybody obliged to contribute towards German Social Security Insurance.

'Worth Knowing'

Spouse has private health insurance

If you are self-employed (freelance) and have the oportunity to contribute towards the German statutory health scheme, thus become a voluntary member, it is extremely important to know that should you partner, married or common-law, be privately insured, his/ her income will be taken into consideration to determine the payable amount due on a monthly basis, for both medical and long-term care insurance.

Exemptions:
Only if one of the following conditions applies, will your spouse's income not be taken into consideration.

  • You live permanently separated
  • You earn more than you privately insured spouse
  • Your income is at least 2,268.75€* per month

To asses the situation the provider will ask the member to provide a copy of your last Income-Tax-Return (all pages!).

Allowance for children:
For each dependant child the provider can possibly deduct 623€* per month from the joint income.

Contribution Thresholds:

  • Minimum = 1,038.33€* per month
  • Maximum = 2,268.75€* per month

*year: 2019

Fequently Asked Questions

Insurance - Health - German Statutory ("Public")

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  • Can anyone sign up with statutory (public) health insurance?

    The answer to this question is: "Yes, but with exemptions!"
    For this to make sense, one must understand the difference between the following 2 categories.

    1. Obligatory membership
      This means that because of the employee's gross salary, contributing towards Social Security becomes mandatory, then so does statutory health insurance.
    2. Voluntary membership
      1. Even though the employee's salary exceeds a specific threshold, hence they could sign up with a private health insurer, the employee decides to stay with the statutory provider and pay the max. contribution (ca. 900€ per month)!

        --- OR ---
      2. Switching from employment to self-employment one has the right to remain insured as a voluntary member.

        --- OR ---
      3. Arriving in Germany as an EU citizen with previous EU "public" health insurance, one has the right to sign up as a voluntary insured member.

    Exemptions:

    • Arriving in Germany as a self-employed, non-EU person, signing up with a public provider is not possible!
    • Once privately insured, switching to statutory (public) insurance is also not possible, unless the person becomes employed and has an annual salary below the before-mentioned specific threshold, called 'Annual Earning Limit' (German: Jahresarbeitsentgeltgrenze).

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  • I have German "public" insurance, do I have to pay for treatment at the doctor?

    No. When visiting a doctor, dentist, public hospital or any other non-private medical facility, presenting your membership card you will not be billed.
    Invoices are only ever issued when treatment, consultation or service exceed the scope of "public" health cover, hence the patient needs to be billed privately. Latter requires preliminary clarification and the patient's written consent.

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  • Are there any co-payments I need to make with "public" insurance?

    On top of the total 243.5 billion Euros that providers of "public" health insurance paid out in 2018, members made additional co-payments of approx. 4.2 billion Euros for treatments, services, benefits, medication and the below mentioned. Compared to 2017, this is an increase of 108 million Euros!

    Here are just a few examples of the co-payments that people must expect with German "public" health insurance.

    Scenario:Comment:
    Contraceptives and Abortions 
    Hospital stay and treatment 
    Medicines & Dressings"waived if a minor"
    Prevention and Rehabilitation benefits 
    Remedies and Aids 
    Transportation with an ambulance10€ per trip
    Treatment Care and Home Nursing 

     

    For adults co-payments are limited to 2% of their gross annual income and for those who have to see a doctor more often or need frequent medication, i.e. chronically ill people, the co-payment limit is lowered to 1%.

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  • I am self-employed, how are my contributions calculated?

    The amount self-employed/ freelancers must contribute towards the German statutory health insurance scheme is a fixed percentage, plus the providers own 'Additional Fee', both based on income.

    Income is defined as turn-over minus expenses, includes other possible sources of income, e.g. capital yields, rent, etc. and is to be proven to the provider every year by presenting the most recent Tax-Income Assessment.

    To prevent contributions being infinite the so-called "Contribution Assessment Ceiling" (Geman: Beitragsbemessungsgrenze) is applied, which makes sure contributions are capped at an amount that is reviewed annually.
    In 2020 this is set at 56,250€ per year or 4,687.50€ per month.

    Finally the system then differentiates between 2 types of members and therefore applies slightly different percentages.
     

    • Standard Membership:

      • 14.0% Medical insurance

      • x% Provider's additional fee   (current market: 0.3% to 2.5%, depending on provider)

      • 3.05% Long-Term Care insurance

      • Total = 14.0% + x% + 3.05%
         

    • Member is 23 years or older and has no children:

      • 14% Medical insurance

      • x% Provider's additional fee   (current market: 0.3% to 2.5%, depending on provider)

      • 3.3% Long-Term Care insurance

      • Total = 14.0% + x% + 3.3%


    With the average 'Additional Fee' currently at 1.2%, self-employed members can calcuate with 18.25%, resp. 18.50%.

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  • I have just started self-employment, how are my contributions calculated?

    In the event that self-employment has only just started, thus a tax-declaration is yet to be submitted, the health insurers fall back on reliable economic evaluations (German: Betriebswirtschaftliche Auswertung [BWA]) or try to make their own estimates, in expectation to make amendments once the first Tax-Income Assessment can be presented.

    Regardless however of the amount of income the self-employed might expect and declare towards the provider, monthly contributions are generally calculated in accorance with 2 thresholds.

    1. Minimum contribution:
      This so-called "Assessment Base for Minimal Contribution" (German: Mindestbeitragsbemessungsgrundlage) is set at 1,142€ (2019).
      One exception, if the business is a start-up, thus subsidised by the Employment Agency, the Assessment Base for Minimal Contribution is slightly less.
       
    2. Maximum contribution:
      The "Income Threshold" (German: Beitragsmessungsgrenze) for 2019 is set at 4,537.50€ per month / 54,450€ per year.

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  • Will the German public health system pay for gender reassignment sugery?

    Although nowadays one would not think, gender reassigment is still a very complex subject, and especially in Germany.

    Due to the German Constitutional Court ruling in 2011, that a person needs neither sex reassignment surgery nor sterilization in order to legally change their gender, and because of the immense expenses involved in gender reassignment surgery, ultimately carried by the insured community as a whole, the following requirements are needed for a statutory health provider to give their approval.

    Requirements:

    • Applicant's personal statement
    • Application for Gender Reassignment Operation, issued by the insurer
    • Hormone treatment for a period of at least 6 months (evidence required!) AND
      Confirmation of a day-to-day test over a period of at least 18 months
    • Psychiatric treatment of at least 18 months (evidence required!) AND
      Psychiatrist report (brief) for the diagnostic clarification of possible psychiatric comorbidity (if psychotherapeutic treatment is provided by a psychological psychotherapist)
    • 2 court opinions in accordance with §4 (3) Transsexuellengesetz, OR
      proof of an accom­plished change of civil status according to §45b PStG, as far as a first name change was ac­complished
    • Statement from the contracting hospital(s)
    • Specialist medical reports post requested services/ treatment
      (e.g. hormone treatment, epilation, surgical interventions)

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We Recommend:

Techniker Krankenkasse, also simply known as 'TK', is currently the largest statutory health insurance provider in Germany. Founded in 1884, TK has a long history and currently insures approx. 8 of the 57 million paying members.

 

Additional Fee: 1.2%

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