citizens - tourists - expats
Is health insurance mandatory in Germany?
The very short answer is simple: Yes!
When entering Germany for whatever purpose or duration you need an adequate medical insurance. Every resident of Germany is obligated to set-up and keep going a full-service health insurance
, either a staturory (public
) one or a private health insurance
This is the law in Germany since 2007 (Section 5 Subsection 1 No. 13 of the SGB V) and 2009 (for private health insurances according to Section 193 Subsection 3 of the VVG) and has been extended thru several amendments to the relevant laws in 2011, 2013 and so on.
There are also countless court decisions underlining and strengthening this. Thus, it is safe to say that the legal requirement to obtain and hold a compliant health insurance while residing in Germany has well established legally in Germany for more than a decade.Good to know
: If you come from another EU member state, your European Health Insurance Card (EHIC) usually covers you only for the first three months. Once you register your residence in Germany for good, you need a German approved health insurance.
Working in Germany: how to get health insurance?
Now, if health insurance is mandatory in Germany, it should be simple to find one and set it up, right? After all, if the government puts you under an obligation, it must also make sure that you can fulfill it, one would think. But, sadly enough, this is not always the case.
Some people working in Germany, especially employees, will be able to register fairly easily into a legally compliant health insurance when moving to Germany. Others, mainly the self-employed and freelancers will find it quite a challenge.
One of the reasons that makes the German health insurance system so hard to navigate is that the system is basically unique in the world. Only some countries in South America, such as Chile, have a similar system. The German system is not compatible with the rest of the world. Germany has a great social security system, but it is constructed as if Germany was an island.
Why the German health care system is so different?
The German system is so unique because there are two different types of health insurance side by side:
1. Public or statutory health insurance
2. Private health insurance
Only in Germany is the private health insurance a full substitute of the statutory health insurance. In fact, you leave the public health insurance system when you take fully comprehensive private health insurance. In most other countries you just add better private health insurance on top of a more or less adequate public or national health insurance coverage. Not so in Germany.
Good to know: Once you have opted out of the public health insurance in order to have private health insurance, the way back can be hard or even impossible. That is not a myth as some may claim but the sad truth experienced by so many Expats who received inadequate advice when starting off in Germany.
Therefore, careful planning is important when coming to Germany and selecting your public or private health insurer. It is quite a challenge and you should have an independent and specialized advisor help you pick it.
This is not an area for amateurs or “DIY”. At Chambervelt & Rooselain we have years of experience in advising Expats coming to Germany.
German healthcare system: the most important basics
The statutory health insurance is the basis of health care in Germany. In principle, every employee is insured under this model. The benefits of the statutory health insurance are regulated by law and are the same for all public health insurance companies. This corresponds to approximately 95 percent of the health insurance benefits.
In addition to the legally defined benefits, public health insurance companies offer voluntary supplementary benefits. These differ between the various health insurance companies. The insurance premium is based on one's gross income, of which a fixed percentage is paid to the health insurance company.
In the case of private health insurance, the scope of benefits depends on the respective insurance tariff. The policyholder is free to decide whether he or she wants basic coverage or comprehensive premium coverage. The insurance premium depends on the tariff and the selected benefits. Private health insurances, therefore, differ very significantly from one another in terms of price and coverage.
Who can be in which system?
Not everyone has a free choice between statutory and private health insurance. There are fixed rules as to who is allowed to choose at all. Two aspects play a relevant role: gross income and employment relationship.
- Employees with an annual salary of up to € 66,600 are compulsorily insured in the statutory health insurance
- Employees with an annual salary of more than €66,600 can be exempted from statutory health insurance and switch to private health insurance
- The self-employed and freelancers can choose private health insurance regardless of their income
Comparison of private and statutory health insurance
German Private Health Insurance
German Public Health Insurance
Employees with an income above €66,600 per year, freelancers and civil servants can take out private insurance
Regardless of income, everyone is insured through the German public health insurance system
Cost varies depending on age, coverage and any pre-existing conditions
Cost depends on your income
Family members are not automatically covered. However, they can be additionally insured for a fee
Children and non-working spouses are covered free of charge
Private hospital rooms can be additionally insured
Private hospital rooms are not covered by the statutory health insurance
People with pre-existing conditions often have to expect higher monthly contributions
Even with pre-existing conditions you are insured without surcharge
Living and working in Germany as an employee
When coming to Germany as an employee, under German laws and regulations taking out health insurance is fairly simple. If your gross salary is below a certain amount, you will be signed up with a public health insurance.
The relevant amount for your gross salary changes almost every year. For 2023 you are obliged to have a public health insurance if your gross salary is below 66,600 EUR (Versicherungspflichtgrenze GKV / compulsory insurance threshold for health insurance).
See our video on health insurance for employees in Germany:
Even if you are obliged to choose public health insurance, you have lots of options. There is a large number of public health insurances in Germany. Their coverage is decided by law within the Social Code V health insurance (Sozialgesetzbuch V Krankenversicherung). Hence, around 95 percent of coverage is basically the same with all statutory insurances. They may differ only in:
1. Additional premium (Zusatzbeitrag)
In order to take into account different financial circumstances and benefits of public health insurances, the law allows them to set additional premiums on top of the standard premium that is the same for everyone. The standard premium in 2023 is set at 14.6 % of your monthly gross salary but with a cap at € 59,850 gross salary per year. It means that the average costs you’ll have to pay for public health insurance in Germany in 2023 is set at € 807.98 per month at the standard premium, including 1.6% average additional premium.
However, since public insurances are allowed to decide how much they add to this 14.6 % standard premium, you’ll find a wide range of additional premiums, currently set at +0.8 % to max. +1.99 %. On average the additional premium is +1.6 %. Advice on getting a good public health insurance with low additional premium can save you up to € 700 in premium costs per year.
2. Additional coverage (Zusatzleistung)
In order to differentiate by quality rather than by price alone, some public health insurances offer additional coverage above and beyond what is required by law. This can include alternative healing/natural healing, improved dental coverage or increased coverage for dental care and dental replacements as well as better coverage for health check-ups or infertility treatments.
Good advice from a health insurance expert knowing the complex diversity on the market can help you find the best public health insurance solution for you.
3. Bonus programs and pay-backs
Last but not least, some public insurances offer some bonus-programs where you’ll receive some pay-backs annually if you live healthily (and show proof of that). For instance thru adhering to a regular check-up schedule etc. Others offer pay-backs if you have not used/needed your health insurance for an entire year at all.
Whether this is of interest for you obviously depends on your personal priorities as well as your life style. Hence a good advice process can be crucial here.
Additionally you can improve the coverage of the public health insurance with private add-ons like a private dental insurance or other private add-ons such as improved hospital care or access to doctors only offering services to privately insured patients. An in-depth analysis of your own wishes and priorities combined with a thorough check across the market for fitting add-on insurance plans is therefore strongly recommended.
Private health insurance as an employee with gross salary above € 66,600 p.a.
If your gross salary exceeds that particular amount (€ 66,600 in 2023), you have the right to opt out from public health insurance and join a private health insurer of your choice. Please note that you just have the right, not the obligation. You may also decide in favour of a statutory insurance.
Private health insurance can be quite attractive financially in the short term. And often, though not always, the private system provides superior health insurance coverage.
But the decision to use a private health insurance in lieu of public health insurance is basically a one-way-road: You can’t turn around and change your decision later. If you switch to private - you stay there. That's the rule.
There are ways, at least till age 55, to return to public health insurance but it is never simple. Anyone who tells you anything different is just trying to sell you a private health insurance for THEIR own best interest (commission) and not yours.
To sum up: employees have it simple and only those with higher yearly income may face a not so easy decision between public and private health insurance.
Living and working in Germany as self-employed or freelancer
If you come to Germany as a self-employed or freelance worker it is somewhat different and more complex. First of all, while for employees the employer pays half of the health insurance contributions (up to a point), being self-employed means you have to pay the full costs for your health insurance premiums (of course, mostly tax deductible), regardless of whether you have opted for a private or statutory insurance.
Can the self-employed and freelancers join a public health insurance?
Yes, it is possible to join a public health insurance as a self-employed or freelancer.
But, only if you have been either in a German public health insurance or an EU-member state’s national health insurance/state health insurance for the preceding 12 months or at least 24 months total out of the last 5 years. In this case you may join the public health insurance.
This is true for both EU citizens or Expats with a passport from outside the EU. Even EU citizens who have lived more than 5 years outside the EU, and hence did not have health insurance coverage from an EU member state, cannot apply for German public health insurance. Your application with any German public health insurance will be rejected due to ineligibility to join.
This situation can be bad if you have a large family coming with you or if you or family members have certain medical conditions. Especially in those situations, you should check all the options when attempting to get into a statutory health insurance. If you have any questions about that or if you need assistance, do not hesitate to give us a call or send us an email.
In this video we explain more about health insurance and self-employment in Germany:
Private health insurance for the self-employed and freelancers
Most self-employed or freelancers must opt for private health insurance. There is a large number of different insurance companies available, each offering a range of different insurance plans from basic to all-inclusive.
In contrast to the public health insurance, there is a wider range of differences between them both regarding monthly premiums (which are NOT calculated based on your income but based on your age and health status) and the quality of coverage.
Therefore, the search for and selection of a good health insurance for you and your family should be based on your own wishes and priorities. The following aspects should be included in your thoughts:
Current premiums and financial stability of the insurance plan or insurance company per se.
The complete range of coverage in comparison to the market and competition.
Health insurance plan details for coverage; track record for claim approval and settlement, etc.
Admission guidelines and requirements. A number of German private health insurances will accept newly arrived foreigners only after a stay of at least 2 years in Germany, for instance.
Additional roadblock when looking for private health insurance coverage in Germany
However, there is yet another challange with private insurances: Since 2009 the German private health insurances are not allowed to cancel a health insurance contract even if you stop paying your monthly contributions. To make matters worse for the insurance companies, they even have to keep up an emergency coverage for you.
This situation is good for you, as soon as you are a member of any of the insurance companies. For the companies it is quite bad. At times, more than 150,000 people in Germany have been unable to meet their financial obligations, thus causing the German insurance companies to lose nearly 750 million EUR due to unpaid contributions.
As a consequence, anyone who is considered to be a financial risk is routinely rejected when applying for a private German health insurance. And if you come freshly to Germany, you are often considered a financial risk because there is no German credit or income history for you. And your credit history from home does not count.
Therefore, the number of German private health insurances that will accept a self-employed or freelancing person who has just arrived in Germany is rather limited. It requires a lot of solid preparation for presenting your financial background, too.
Use professional advice: The German healthcare system is quite complex. In particular, applying for private health insurance for expats requires a lot of experience. You should not take this step without an experienced advisor.
International health insurance instead of German healthcare system?
Expats often select an international health insurance which they have already used elsewhere in the world or know about. Applications with them are usually fairly simple. And among those international health insurances there are some pretty good ones, granted.
But, they do not meet the legally set requirement to become a substitute for German public health insurance. If somebody tells you differently, have them sign a guarantee to cover your cost and back charges in the future if you need to switch to German health insurances! Because that’s what is going to happen: As soon as the systems finds out about your inadequate insurance, they will back-charge.
How do they find out? For example, when you need to join a German health insurance because you’re taking on employment. At this moment, the German insurance has to check how you were insured in Germany before. Failure to show proof of legally accepted and adequate health insurance coverage will lead to back-charges of the contributions for up to five years. Depending on how long you have already lived in Germany.
There are ways to solve this problem. But they require in-depth knowledge and know-how from someone who is specialized in this kind of Expat advice.
In which case is the international health insurance compliant under German laws?
International insurances are only good for folks sent to Germany by their employers in the form of secondment. Or for folks with a clearly and transparently defined short time-span for staying in Germany. Expat insurance may also be sufficient for students and academics who come to Germany on a short-term project.
If you don’t belong to either group, you’ll need to have either a public German or private German health insurance. Should you have selected something else in the past and require a solution, we offer a special German private health insurance tariff with ASEIG that can help you avoid the back-charges. Just ask for our advice for this.
To sum up, international health insurance or expat insurance works for:
- Students or academics
- Employees on secondment
- Short-term stays in Germany
FAQ about the German healthcare system
Is private or statutory health insurance better?
It would be too easy if this question could be answered with a clear answer. It always depends on the individual case. That is why choosing the right health insurance is one of the most difficult decisions in the insurance sector.
Of course, only if the choice is possible at all. Employees whose income is below the threshold for mandatory public health insurance must be insured in the statutory health insurance scheme.
Is international health insurance or expat insurance enough?
It depends. For students, tourists or employees who only work in Germany for a short time, such insurance is sufficient. Expat insurance is also suitable for the first three months after arrival. For employees and self-employed persons living permanently in Germany, private
or statutory health insurance
How much does health insurance in Germany cost?
As an employee in the statutory health insurance scheme, the insurance contribution depends on the gross salary and is 14.6% plus an additional contribution of between 0.8 and 1.99%. In private health insurance, the insurance contribution depends on the benefits chosen, the age at entry and the state of health.