public health insurance
Statutory health insurance Germany - the most common model
In Germany, around 73 million insured persons are covered by a statutory health insurance fund. That corresponds to around 90 percent of the population. While this is good to know: For expats, the most common question is whether they qualify to become a member of a statutory health insurance fund or not.
For expats of any nationality arriving from another EU member country where they were previously insured in the state system of that country this is generally non-problematic. However, there is just a 3-months-long window of opportunity when you take up your residence in Germany to apply for voluntary membership in the German public health insurance system.
This is unfortunately a typical mistake made by many that this chance to join the public insurances in Germany is lost for lack of a timely application. Therefore, ask for professional advice and assistance the moment when you take up your residence in Germany.
As an employee, if you are employed in Germany for the first time, entering the statutory health insurance in Germany is fairly easy. If your gross salary is below € 5,362.50 per month/ € 64,350 EUR per year, you become a compulsory member of the public health insurance no matter what.
If you are earning in excess of this threshold, you can decide to become a voluntary member or join instead a private health insurance. Unless you are over 55 years old…. in which case you might not get into public insurance either if you did not have national or state health insurance from another EU member state beforehand for some time.
For freelancers or self-employed arriving in Germany without having been previously insured in the state health insurance scheme of an EU member country for the previous 12 months (or 24 months in the previous five years), joining the statutory scheme is usually not possible at all. They can only apply for private health insurance in Germany instead as a full substitute.
Where it still would make sense to join a statutory fund in such cases (e.g. because of pre-existing medical conditions or large families that are best jointly insured), there can be options to sign up with public health insurance, but this is not simple and may require extensive consultation.
How public health insurance works in Germany
Statutory or public health insurance in Germany works on the principle of solidarity: all members of a public health insurance fund are entitled to medically necessary treatment – regardless of the level of their health insurance contributions or their income. It also covers all existing medical conditions.
Family members without an income of their own are jointly insured under the statutory health insurance at no extra cost. This is one of the great advantages of public health insurance that all dependent close family members are covered with just one monthly premium if there is only one major earner of income in the family.
The main advantages of public health insurance funds are:
- everybody gets the same treatment regardless of income or contribution
- family members without income are insured free of charge
Germany has one of the most expensive healthcare systems in the world: healthcare spending in 2018 amounted to more than 387 billion euros, which is more than one billion per day. The number of public health insurance providers, so-called “Krankenkassen” has steadily decreased over the years.
While in 1970 there were 1,815 health insurance funds, by 1990 the number had already fallen to 1,147. In 2000, there were still 420. Today, there are only 97 health insurance funds (as of January 1, 2022). However it is even more a challenge to compare them today than it was in the past.
How much is the premium?
In the past years, health insurance contribution rates have been set by the Federal Government. A high add-on in premiums may be a sign that the financial stability of that particular public insurance is not too good – and a switch to another one might be a good idea.
The standard premium in 2020 was set at 14.6 % of your monthly gross salary but with a cap at € 58,050 gross salary per year. This means the max costs you’ll have to pay for public health insurance in Germany is in 2022 set at € 769.16 per month at the standard premium.
However, since start of 2015, health insurance funds can levy surcharges on the contribution rate if they see financial needs in order to continue working sustainable. So it can make sense to look for lower premium costs for nearly equal coverage.
This is easy to understand when you look at the wide range of additional premiums set at +0.3 % at the currently lowest end of the line to the max. +2.4 % for the most expensive public health insurances on the market. On average across the board the additional premium is +1.3 %.
Important to know: In Germany, the employer pays a share of the costs for the employees' statutory health insurance. This share also amounts to 14.6% of gross salary. It is not deducted from the employee's gross salary, but is a separate employer contribution.
How to save money on public health insurance premiums?
Save money by comparing the additional contributions of health insurance companies. BMW BKK, for example, has an additional contribution of only 0.3%. BKK 24, on the other hand, has a rate of 2.4%. The Techniker is in the middle with 1.3%. With a gross monthly income of €5,000, that means:
- Additional contribution BKK 24: € 120 per month
- Additional contribution Techniker: € 65 per month
- Additional contribution BMW BKK: € 15 per month
As you can see, you save € 1,260 per year by choosing the cheaper health insurance in our example. Unfortunately, not all health insurance companies are open to all employees. Advice on getting a good public health insurance for Expats with low additional premium can save you a lot of money.
If you already are set up with a public health insurance without prior knowledge of these differences: You can switch after 18 months membership to any other public health insurance with just two months’ notice (you can switch to private health insurances at any time, btw. And you don’t have to wait so long to give notice). We can assist you in such a switch if you like, just contact us.
General coverage of the statutory health insurances in Germany
There is no real list of exact coverage that you can look up somewhere. The benefits catalog is specified in the Fifth Social Code (SGB V) only as a framework law: The law states that the insured person has a right to adequate medical treatment of the sick in line with needs and in accordance with the generally recognized state of medical science.
State health insurance include in particular:
- Medical, dental and psychotherapeutic treatment
- The provision of medicines, dressings, remedies and aids
- Home nursing care
- Hospital treatment
- Medical rehabilitation services and other services
It is also stipulated that the services must comply with the efficiency principle. This means that they must be sufficient, appropriate and economical and must not exceed what is necessary. GKV (Public insurance)-accredited physicians are obligated to provide these services as part of their mandate to ensure the provision of health care.
Differences in benefits among statutory health insurers
In the statutory health insurance, 95 percent of the benefits are determined by the legislator and the benefits do not differ between the insurance funds. However, public health insurance funds can offer their customers additional services. These additional services can be within the scope of additional benefits in medical care, bonus and selective tariffs as well as comprehensive customer service.
The differences may be of interest to certain groups (e.g., diabetics, asthmatics, or young parents). Comparing benefits can therefore also be useful within the statutory health insurance system.
Moreover, the health insurance funds offer numerous tariffs: healthy people who rarely go to the doctor can save money with selective tariffs. People who are sporty and health-conscious can benefit from bonus programs and receive money back.
Additional statutory services can now be offered, for example, in the following areas:
Preventive and rehabilitation measures
Services provided by midwives during pregnancy and maternity
Dental treatment (excluding dentures)
Non-prescription pharmacy drugs
Home help and non-approved service providers
Cost coverage for new medical inventions and treatment methods
For new diagnostic and therapeutic procedures, the Federal Joint Committee decides whether they meet the above requirements and can therefore be provided by the statutory health insurance system. The approval of a new treatment method is not only about the medical aspect, but also about economic efficiency and appropriateness.
For example, if a treatment makes medical sense but costs a disproportionate amount of money, it will not be paid for by the health insurance fund. A good example of such a benefit is the provision of an implant as a dental prosthesis. The statutory health insurance does not pay for this, but only for the provision of a significantly cheaper dental bridge.
According to a decision of the Federal Constitutional Court (decision of the First Senate of December 6, 2005 - 1 BvR 347/98), insured persons with a life-threatening or regularly fatal illness or with an illness that is at least comparable in terms of value for which a generally recognized service that meets the medical standard is not available can also claim an examination or treatment method that has not been approved by the G-BA.
The prerequisite is a not entirely remote prospect of cure or of a noticeable positive effect on the course of the disease. However, it is obviously a complicated and time-consuming process to insist on such a treatment.
Risk of reduction of benefits by the legislator
Political and financial reasons can lead to legally guaranteed benefits being changed by the legislature. In the long term, statutory health insurance will face problems anyway. The so-called pay-as-you-go system creates long-term financing problems for health insurance.
This is because fewer and fewer young working people not only have to finance their own health care, but also have to pay the health care costs of more and more aging population. In the long term, this will mean higher health insurance premiums for those with statutory health insurance. On the other hand, far fewer services will probably be paid for by health insurance in the future.
In theory, the resulting insurance gaps can be closed with the help of private supplementary health insurance. The problem with this is: as with private health insurance, the availability and cost of supplementary insurance depends not only on the scope of benefits selected but also on the age at which the policy is taken out, and of course also the actual state of health.
Usefull private supplementary health insurances
Based on the modular principle, insured persons can choose additional insurance coverage in the following areas, for example:
Health insurance for abroad
The health insurance for abroad is important whenever you travel outside Germany/the EU. German statutory health insurance only covers you within the EU. Outside the EU you will have to cover all treatments yourself, hence the absolute need for everyone in public insurance to add coverage for all travels abroad.
Supplementary dental insurance
The coverage for dental treatments has suffered the most in public insurance over the last decades. Especially the more expensive treatments like dental bridges, crowns, implants etc cost a lot and the public insurance cover only so-called “Festbeträge”, i.e. fixed amounts which often account not even for 50% of the actual costs your dentist bills you.
If you have small children you will want to add coverage for them early on in case you’ll later need orthodontic treatment (braces etc) because these are only covered now in case of very serious deformations. And orthodontic treatment can easily cost several thousands of Euros over the years.
Supplementary dental insurance is the most taken supplementary health insurance in Germany. More than 20 million people have one already.
Supplementary hospital insurance
Private treatment in hospital some see more as a nice-to-have private add-on. Clearly, if you need to be treated in a hospital, you will always be admitted and treated well. With the private add-on you will enjoy the privilege to be treated by the head of department (Chefarzt) who is the most and longest qualified expert in the hospital.
Plus: you’ll have the right to enjoy a single-bed-room instead of been stationed with other peoples in the same room. Not only is it probably the really worst point in time to make “new friends” who may have very different sleeping patterns or views on daily routine and respect of others privacy. Especially when you are self-employed you might need to do some work with phone or laptop while in the hospital which you can only do well in a single-bed-room.
Daily sickness benefits
Public insurances offer some limited income protection during sickness. Limited with regards to the max. income amounts covered and the duration. If you have a good income, you might want to check or have it checked if the income protection offered by the public health insurance is sufficient for you or leaves a serious gap in your monthly income.
And it is always advisable to set up coverage for income protection in case you are not just ill but actually occupationally disabled because your health insurance does never cover that.
Supplementary nursing care
The state coverage for long-term nursing care is effectively only covering around 50% of the actual costs, especially when you require 24-7 nursing care. It is a matter of protecting your family from having to pay for this why you should set up extra coverage here. Because your children are liable to pay for this if your own income, assets are exhausted for what the nursing care insurance does not cover.
Disadvantage: long waiting times at doctors and rejected treatments
In principle, citizens and doctors are still satisfied with healthcare in Germany: 77 percent of citizens and 89 percent of doctors rate it as "good" or "very good". But there are also numerous points of criticism about the declining services in important areas, the sometimes still very long waiting times for treatments compared to the faster care of private patients, and the sometimes very non-transparent decisions to reject treatments requested and recommended by doctors.
Yet, many ask: Why are statutory health insurers allowed to pay their customers for medically questionable services such as homeopathy or infant osteopathy, but not give them more help when they buy glasses or dentures? Why are they allowed to spend ever-increasing millions on advertising?
Is it acceptable in a system based on solidarity for insurers to orient their voluntary benefits primarily to the needs of young, high-earning customers and almost not at all to the needs of the elderly and socially disadvantaged? And shouldn't the insured be better informed about the differences in quality between the insurers?
In the case of people over 18, there is a "fundamental exclusion of benefits" for visual aids that cannot be circumvented by voluntary statutory benefits, only with private add-on insurances. Only patients with a maximum visual performance of 30 percent in both eyes receive a subsidy. And, as mentioned above, with dental prosthesis treatments the public health insurance providers may not show themselves more generously than legally prescribed.
Therefore it can make sense when you look at quality of coverage foremost to compare what you can achieve from a combination of public health insurance plus private add-ons on one side and from fully comprehensive private health insurance on the other side in comparison.
As said above, a large majority of clients are quite content with their public health insurance. And particularly Expats with experience from some home countries with slow and ineffective national or state health insurance system may find the actual quality in Germany extraordinary at first glance. However, a second look reveals that more and more clients in Germany have reason to complain about important issues. (Survey conducted by the Allensbach Institute for Public Opinion Research).
Long waiting times when seek treatment from specialists
Take long waiting times, for example: More than six out of ten Germans (62 percent) now say they have to wait too long for a doctor's appointment. That's more and more. In 2012, just over one in two complained about this (52 percent); in the 2016 survey, it was already 55 percent. This is a trend that gives pause for thought. As expected, those with statutory health insurance are disproportionately affected, with 65 percent agreeing.
This is not a myth but reported constantly and often. If this is not what you want, private coverage would be a sound alternative.
Treatments rejected by the public insurances for cost reasons
One third of respondents (34 percent) of the above mentioned survey also feel that they are being denied services for cost reasons. This figure is down on the last survey in 2016: At that time, 40 percent still agreed. In 2012, the figure was 31 percent.
The survey of physicians shows that citizens are not wrong to suspect they are not receiving certain services due to cost. Almost every second doctor (45 percent) confirms that he has already had to deny his patients medical services for cost reasons. Here, too, the trend is steeply upward. In 2012, not even one in three physicians (31 percent) confirmed this; in 2016, 44 percent already agreed.
It is even more common for treatments to be postponed for cost reasons. 64 percent of physicians have already been forced to do this - and the trend is also rising. Three years ago, this happened much less frequently (2016: 57 percent).
Find the best health insurance option for you
Despite some of the points of critics above, joining public health insurance can still make a lot of sense for some, not so much for others and there are even some (mainly self-employed without prior coverage in Germany or another EU-member state’s state health insurance) who can’t join public insurance because they are not eligible for it. Same is true for Expat coming to Germany older than 55 years of age without prior statutory coverage.
Since 2006 we have set up thousands of clients with health insurances in Germany: public or statutory health insurances where advisable and available, private health insurance for those where such a selection was more beneficial or fit better to their wishes and explanations regarding quality of coverage.
We are happy to analyze and then discuss your options with you so that at the end you feel able and comfortable to make an educated decision.