Statutory health insurance (Krankenversicherung) safeguards you and your family in case of illness. It pays for necessary medical treatment. The only exceptions are benefits you claim after an occupational accident or because of an occupational illness. In these cases you are covered by statutory accident insurance.
Until the end of 1995, which health insurance scheme you were in depended on your profession or who you worked for. As of 1 January 1996, anyone in a local, company, guild or other statutory health insurance fund is free to choose which fund they wish to be insured with (company and guild funds can only be chosen if they have changed their statutes to accept outsiders). The Miners Social Security Fund (Knappschaft) can be chosen from 1 April 2007. Special conditions apply for agricultural health insurance funds.
What statutory health insurance covers
As an insured person you can claim:
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). Women from the age of 20 and men from the age of 35 are entitledto annual screeningfor certain cancers
Preventive dentistry and in particular individual and group prophylactic measures for children and adolescents to prevent dental disease
Preventive inoculations recommended by the German Standing Vaccination Committee (STIKO) at the Robert Koch Institute and prescribed by the Federal Joint Committee on the basis of that recommendation
Orthodontic treatment, as a rule up to age 18
Medical and dental treatment, with free choice among panel doctors and dentists, medicalcare centres(MVZ), non-panel doctors or dentists authorised to treat members of statutory health insurance schemes (ermächtigter Arzt/Zahnarzt), and dental clinics and other health care facilities (Eigeneinrichtung) operated by statutory health insuranceschemes
Medicines, dressings, therapies, and aids such as hearing aids and wheelchairs
Medically necessary provision of dentures and crowns
Some or all the cost of necessary preventive and rehabilitation treatment
Sickness benefit (Krankengeld): Normally, your employer will continue to pay your wage or salary for six weeks when you are unable to work. After that your health insurance will pay 70% of your regular wage or salary before deductions up to the contribution assessment limit, though not more than 90% of your most recent take-home pay. You can claim sickness benefit for a maximum of 78 weeks in a given three-year period. If you are a farmer, you will receive an upkeep allowance instead of sickness benefit.
Sickness benefit for up to ten days a year for each insured child under 12 who you have to care for, subject to presentation of a doctor’s note and provided that no other person living in your household is able to supervise, care for or look after the child. If you are a single parent, your entitlement doubles to a maximum of 20 days. If you have several children, your entitlement is limited to a total of 25 working days, or as a single parent 50 working days per calendar year. The entitlement extends beyond the age of 12 for sickchildren who are disabled and in need of help.
Sickness benefit can additionally be claimed indefinitely if your child has an incurable illness and has a life expectancy of only weeks or a few months
Home help if you have to go into hospital or undergo in-patient or rehabilitation treatmentor treatment in the home, you are unable to look after your home as a result, and have a child living in your household which has not reached the age of 12 when home help begins or which is disabled and in need of help
Home nursing care if this helps avoid or shorten a stay in hospital or aids your medical treatment
Home nursing care or home help for women when needed because of pregnancy or childbirth
Social therapy for insured persons who have a severe mental affliction that prevents them from taking medical treatment
Maternity benefit (Mutterschaftsgeld) and maternity allowance (Mutterschaftshilfe) during pregnancy and after childbirth. As a member of a health insurance fund you usually receive child benefit for six weeks before and six weeks after the birth (the statutory period of maternity leave), extended to twelve weeks after the birth in the case of multiple or premature births. The amount depends on your average wage over the last three months, or the last 13 weeks before the benefit period. Your health insurance pays a maximum of €13 a day. Your employer pays the difference between this and your average take-home pay for the duration of the benefit period.
Who is insured
As an employee you are compulsorily insured if your regular income before deductions does not exceed €450 per month and remains below a set annual limit (Jahresarbeitsentgeltgrenze). The annual income limit up to which employed people are automatically and compulsorily insured officially ceased to be linked to pension insurance on 1 January 2003 and now consists of a general annual income limit or a special reduced annual income limit. The general annual income limit for 2014 is €53,550 and thus remains at 75% of the general pension insurance contribution assessment limit in western Germany. For reasons of fairness, a reduced annual income limit of €48,600in 2014 applies for workers who were exempt from compulsory health insurance because they exceeded the contribution assessment limit on 31 December 2002 and switched to an alternative private health insurance fund. This amount is identical to the annual income limit applied in the state health insurance scheme.
The rule on when you cease to be subject to compulsory insurance on account of exceeding the annual income limit has changed under new legislation on the financing of the statutory health insurance system. With effect from 31 December 2010, the rule has reverted to the annual income limit only having to be exceeded for a single year in order for compulsory membership of the statutory health insurance scheme to cease.
The following are also compulsory members of the state health insurance schemes:
Students at state and state-approved universities
People on work experience or in second-chance education
Old-age pensioners who have been in a statutory health insurance scheme or insured as a family member for most of the latter halfof their working life
Disabled people employed at an approved workshop or on employment promotion schemes
Unemployed people receiving unemployment benefit (Arbeitslosengeldand in some circumstances Arbeitslosengeld II)
Members of farming familieswho are primarily employed on the farm and are at least 15 years old or are in training
Retired farmers who have claimed Altenteil(the right to continue living on the farm after making it over to their children)
Artists and members of the publishing professions as provided in the Artists Social Insurance Act (Künstlersozialversicherungsgesetz)
Voluntary membership of the state health insurance scheme is normally possible on first entering employment in Germany andfollowing previous compulsory insurance or insurance through a family member,and, subject to certain requirements, for people with severe disabilities.
Individuals who are voluntarily insured in the statutory health insurance system, for example employees whose pay exceeds the annual ceiling (Jahresarbeitsentgeltgrenze), civil servants and self-employed persons, may opt for private health cover with a private health insurer. In doing so, they should give careful consideration to which of the two systems is the best given their personal circumstances, and take into account that once they have switched to a private health insurer, a return to the statutory health insurance system is only possible in very exceptional circumstances.
No patients’ contributions are payable for early detection screening, inoculations, other preventive measures or dental prophylaxis. Health insurance funds can also grant members partial or full exemption from paying patients’ contributions, for example for certain types of treatment.
According to German health insurance law, anyone living in Germany receives health insurance cover in either the statutory or private health insurance system but has no entitlement to other types of insurance cover.
From 1 April 2007, anyone lacking other provision for the event of illness and who has previously been in the statutory health insurance system is made a compulsory member (Section 5 (1) 13 of Book V of the Social Code/SGB V). You become a compulsory member of your previous statutory health insurance fund or its legal successor, beginning on the day you cease to have other provision for the event of illness within Germany or on 1 April 2007, whichever is the later. The same applies for anyone who has never had statutory or private health cover and comes under the statutory health insurance system. Please seek advice on this from a statutory health insurance fund.
In accordance with Section 193 (3)sentence 1 of the German Insurance Contract Act (Versicherungsvertragsgesetz, or VVG), as of 1 January 2009 anyone living in Germany who is neither insured or required to be insured under the statutory system nor covered by other means must have private health insurance that at minimum covers out-patient and in-patient medical treatment. The annual deductible is limited to a maximum €5,000.
Full-time self-employed persons are not subject to compulsory statutory health insurance and must thus have private health insurance cover unless theywere insured under the statutory system before entering self-employment.
Since 1 January 2009, anyone exempt from the requirement to have insurance cover, especially civil servants, pensioners and others who may claim state contributions towards the cost of health care (Beihilfe) and who have no supplementary insurance to cover healthcare costs, are not covered by the statutory health insurance system even if they were covered by that system previously. Since 1 January 2009, these individuals are required to have private health insurance to cover healthcare costs not covered by the amount covered by Beihilfereceived. This requirement for private insurance also applies for employees who are exempt from the requirement to have insurance cover, i.e. blue-collar and white-collar workers whose regular annual pay exceeds the compulsory insurance ceiling.
The requirement for insurance cover can be met with basic coverage (‘Basistarif’). Private health insurance carriers have been required to offer this type of coverage alongside existing policy optionssince 1 January 2009.
The following applies with regard to provision for recipients of social assistance in case of illness:
For anyone in receipt of regular assistance provided under Chapter 3, 4, 6 or 7 of Book XII of the Social Code (SGB XII) since 1 April 2007 or before, the social assistance agency that provides that assistance will also provide assistance in the event of illness. Under Section 264 of SGB V, the medical treatment is generally paid for by a statutory health insurance fund and then refunded by the social assistance agency. The continued responsibility of social assistance agencies for such recipients of socialassistance in the event of illness after 1 April 2007 is expressly laid down in Section 5 (8a) of SGB V. It is unaffected by aninterruption in entitlement to the regular social assistance of less than one month, irrespective of whether the social assistance agency deregisters a person from the procedure under Section 264 of SGB V –the sole requirement is that the person was in receipt of regular assistance provided under Chapter 3, 4, 6 or 7 of SGB XII and remained in receipt of that assistance without an interruption in excess of one month.
Anyone in receipt of regular assistance provided under Chapter 3, 4, 6 or 7 of Book XII of the Social Code since 1 April 2007 and subject to insurance on a subordinate basis on that date (Section 5 (1) 13 of SGB V) remains a member of the statutory health insurance scheme.
Anyone solely in receipt of assistance in the event of illness provided under Chapter 5 of SGB XII will become subject to compulsory statutory health insurance if they come within the scope of statutory health insurance and, with effect from 1 April 2007 orlater, satisfy the requirements for being subject to compulsory insurance on a subordinate basis in the absence of any other entitlement to provision in the event of illness (Section 5 (1) 13 of SGB V). Being subject to compulsory insurance on a subordinate basis, such individuals also remain members of the statutory health insurance scheme if they later receive regular assistance towards living expenses (assistance under Chapter 3, 4, 6 or 7 of SGB VII).
Recipients of regular assistance under Chapter 3, 4, 6 or 7 of SGB VII are required to have private health insurance if they began receiving assistance on or after 1 January 2009 and are not insured or required to be insured under the statutory health insurance scheme (Section 193 (3) sentence 2 no. 4 of the Insurance Contract Act (Versicherungsvertragsgesetz/VVG). In such instances, social assistance providers pay the insurance premiums provided that they are reasonable in amount (Section 32 (5) of SGB XII). Premiumsare assumed to be reasonable up to amount of the basic coverage (Basistarif) premium as reduced by half for recipients of social assistance.
State health insurance also covers your family at no extra charge. A spouse or civil partner and, up to a certain age, children of members are covered by the insurance, provided among other things that their collective income does not exceed €395a month and they do not have their own insurance (figures for 2014). If you are in marginal employment, the allowable collective income is €450.
All members of state health insurance schemes should promptly report changes in their working, financial and personal circumstances to their health insurance fund. Those receiving unemployment benefit (Arbeitslosengeldand Arbeitslosengeld II) must also promptly report the changes to the local employment agency to prevent any inadvertent loss of insurance cover.
Health insurance has to be paid for in one way or another. This is why we cannot expect it to help with every minor complaint; otherwise, it would soon become unaffordable.
Patients’ contributions in statutory health insurance
Benefits / Patients’ contributions from 1 January 2004
Drugs / 10% of the pharmacy counter priceminimum €5 and maximum €10*
Dressings / As above*
Travel expenses / 10% of the travel expenses minimum €5 and maximum €10 per journey*
Therapies / 10% of the counter priceplus €10 per prescription*
Aids / 10% of costminimum €5 and maximum €10*
Consumable aids / 10% of costmaximum €10 per month
Hospital treatment / €10 per day for a maximum of 28 dayswithin a calendar year
Outpatient rehabilitation treatment / €10 per day
Inpatient preventive treatment and rehabilitation treatment / €10 per day
Post-hospital rehabilitation treatment / €10 per day for a maximum of 28 dayswithin a calendar year, minus contributions paid towards hospital treatment
Preventive and rehabilitation treatment for mothers and fathers / €10 per day
* Not exceeding the actual cost
The insured share the responsibility for their own health. For this reason they are required to contribute towards the cost of certain items. This is laid down in the health insurancelaw, which encourages people to be cost-conscious and responsible in its use.
These contributions are necessary –but they must not be allowed to overstretch your budget. The law takes account of this, so that in certain circumstances youpay less or nothing at all.
Exemption from patients’ contributions
Children and young people under the age of 18 are exempt from patients’ contributions except in the case of dentures and travel expenses.
The limit for patients’ contributions is 2% of assessed gross disposable income (1% for people with chronic illnesses). The assessed income figure is arrived at by deducting an exempt amount for each family member from family gross income and so depends on how many people are in thesame household and live off the income total. Larger amounts are deducted for children than for adults. The deduction of exempt amounts from family gross income means that the contribution limit varies according to the size of the household. The exempt amount for the first dependant living in the same household is 15% of an annual reference figure and comes to €4,977 in 2014. The exempt amount for each additional dependant is 10% of the same reference figure, or €3,318 in 2014. The amount for each child is €7,008. An older 10% rule for each additional dependant now applies in health insurance for farmers only.
Family gross income means family disposable income before deductions: the sum of all income that accrues to the insured and any live-in dependants and is available for meeting living expenses. This includes rental income and capital gains –types of income on which compulsory members of a health insurance scheme do not pay any contributions.
Health insurance law isfounded on the gross income principle. That is, a person’s ability to pay into the system is generally measured by looking at their income before deductions. A person’s health insurance contributions likewise depend on their income before deductions. Accordingly, the same measure, rather than net income, is used to set the limit for patients’ contributions.
The insured and the insured’s spouse or civil partner and any children for whom the insured can claim must keep a record of all patients’ contributions paid over each year. If the contribution limit is reached in a given year, the health insurance fund must issue the insured with an exemption note for the remainder of the year.
The contribution limit applies for all patients’ contributions, including those paid for hospital treatment, in-patient preventive care and rehabilitation.
Concessions for chronically ill patients
Special rules apply for chronically ill patients in acknowledgement of their special situation.
Patients in ongoing treatment for the same illness have a lower contribution limit of 1% of annual income before deductions. The Federal Joint Committee of medical practitioners and health insurance funds is required by law to issue directives defining what constitutes a chronic illness.According to prevailing regulations on chronic illness, an illness is deemed a serious chronic illness if it is medically treated at least once a quarter for at least a year and at least one of three criteria is met:
The patient requires Level II or III care.
The patient has at least a 60% disability under severe disability law/pensions law or at least a 60% incapacity to work under accident insurance law.
Continuous medical care is required (medical or psychotherapeutic treatment, drug treatment, technical nursing, and provision with therapies and aids) without which, on a professional medical appraisal, a life-threatening worsening of the illness, a reduction in life expectancy or a lasting impairment of quality of life is to be expected as a result of the illness.
The task of deciding if a patient has a serious chronic illness as defined in the directive falls to the health insurance fund. The exemption from patient contributions applies for all family members living in the same household.
Concessions for social assistance recipients and other groups
Recipients of welfare benefits under Book IIor XIIof the Social Code (Basic Security Benefits for Job-Seekers orSocial Assistance) or war victims welfare benefits are more favourably placed than other insured persons. For these individuals, their household assessable gross disposable income for the purpose of establishing their contribution limit is equated with only the basic needs assistance (Regelbedarf) for singles or single parents (Book V of the Social Code (SGB V), Section 62(2)).
Such benefit recipients must pay the patients’ contributionsthemselves out of the basic needs assistance. The basic needs assistance is not topped up. The basic needs assistancerate is €4,692 a year. Thecorresponding patients’ contributions to be paid for the household by social assistance and unemployment benefit II recipients each year are as follows:
1% contribution limit (chronic illness): €46.92
2% contribution limit (without chronic illness):€93.84
This concession also applies for people whose costs of accommodation in a home or similar establishment are met by a social assistance agency or war victims support fund, and for the groups named in SGB V, Section 264 (social assistance recipients for whom healthcare is provided by the statutory health insurance scheme and recipients of regular benefit payments under Section 2 of the Asylum Seekers Benefits Act (Asylbewerberleistungsgesetz)). That is, gross disposable income for the entire household is equated with only the standard benefit rate for the head ofa household as specified in the Regelsatzverordnung.
For social assistance recipients living in homes, a standard statutory procedure to help in cases of (temporary) hardship has been put in place (in an amendment to the law integrating social assistancelaw into the Social Code). Under the new provisions, the social assistance agency grants affected individuals a loan in the amount of the applicable contribution limit and pays it out directly to the responsible health insurance fund.The latter issues the affected pocket-money recipients a note exempting them from patients’ contributions.
The pocket-money recipients repay the loan to the social assistance agency in fixed amounts over the entire calendar year.
Special hardship clause for dentures
For dentures, there is a sliding scale in case of hardship based on patients’ monthly gross income before deductions. Please contact your health insurance fund to ask whether you are entitled to partial or complete exemption from the requirement to contribute tothe cost of your dentures.
For further information, please contactyour health insurance fund. They will also give you a receipt book for payments you make towards the cost of treatment.
A uniform general and a uniform reduced contribution rate apply in the statutory health insurance scheme since January 2009.
These contribution rates were laid down by the German government in secondary legislation on the basis of an appraisal panel at the Bundesversicherungsamt(Federal Insurance Office). Since 1 January 2011 they are laid down by law.
The general contribution rate, which applies for contributions from earnings, pensions, etc., is 15.5%. It is made up of a contribution rate of 14.6%that is financed half each by employer and employee or pension insurance fund and pensioner, and a supplementary contribution of 0.9 percentage points that is paid entirely by health insurance scheme members.
The reduced contribution rate, which normally applies for members without entitlement to sickness benefit, is 14.9%. This rate likewise includes a 0.9 percentage point contribution that is paid entirely by members.
Contributory income is calculated and flows together with tax revenue into the new statutory healthcare fund.
To cover their expenditure, the statutory health insurance funds receive lump-sum allocations from the statutory healthcare fund. These allocations are paid per patient together with additional age, risk and gender-adjusted supplements. This approach takes account of differing patient profiles and incidences of illness in the insured population.
If a healthinsurance fund receives allocations that exceedits own funding requirements, it may pay out bonuses to its patients as long as it keeps adequate funding reserves. If a health insurance fund is unable to meet its expenses from the allocations it receives,it must tap into efficiency reserves; if these are not sufficient, the fund requires members to pay additional contributions that are not income-linked. At the same time, a social equalisation mechanism across all health insurance funds ensures socially equitable funding. The social equalisation mechanism ensures that statutory health insurance members do not face an unreasonable burden. If the average additional contribution charged by health insurance funds exceeds 2%of earnings subject to contributions, the social equalisation mechanism is applied by employers and pension funds. The average additional contribution charged by health insurance funds in 2011 was zero. The social equalisation mechanism was consequently not triggered in 2011. The same applies for 2013and 2014.
Statutory health insurance members also have the option, within the framework of the statutory rules on termination, of switching to another health fund to avoid additional contributions. If they do not do this, they must pay the additional contributionsthemselves.
In the case of compulsorily insured employees, the employer also pays half of the portion of the contribution that is equally divided between employer and employee.
Employees who are voluntary members of a statutory health insurance fund pay their health insurance contributions themselves. In certain circumstances, however, they may receive a subsidy from their employer. For example, voluntarily insured employees who are only exempt from being statutorily insured because their annual income exceeds the income limit receive a subsidy equal to the amount that the employer would have to pay for a compulsorily insured employee.
Old-age pensioners who are voluntarily insured in the statutory health insurance scheme receive a contribution supplement to assist with health insurance costs from their respective pension insurance fund.
When calculating contributions, the contribution assessment limit (Beitragsbemessungsgrenze) must be taken into account (€4,050in 2014). This isthe maximum amount used to determine an insured person’s contribution, even if their actual income is higher.
Special rules apply under social security law for employees who fall within the ‘sliding scale’ income band(‘Gleitzone’, from €450.01 to €850). Under new rules,part of their income is exempt from social insurance contributions. Employers are still required to pay their normal contributionson the amount earned.
Auszug aus der Publikation "Soziale Sicherung im Überblick 2014"
des Bundesministerium für Arbeit und Soziales, www.bmas.de