Health insurance

One of your first priorities when considering coming to Germany should be health insurance. Medication and hospital treatment is extremely expensive, so you must make sure that you are covered for sickness and emergencies.

How do I cover my medical expenses in Germany?

In most cases you will need health insurance in order to get a residency permit. Health insurance is also mandatory for all employees and students in Germany, so you will not be able to start working or studying without it.

Since 1st January 2009, anyone resident in Germany is required to possess health insurance cover from a provider licensed in Germany.

If you intend to take up long-term residence in Germany you must exchange the card for a local health insurance scheme. Holders of the European Health Insurance Card (EHIC) are entitled to medical treatment under the same terms as German citizens. However if they plan to stay in the country longer than a year (or become employed in Germany), they should sign up for insurance with a local health insurance provider.

Contributions to health insurance are split roughly equally between employers and employees. Germans are also required to carry long-term nursing care insurance, which is charged at 2.2% of their gross income. Students are offered special student insurance schemes with favourable rates. Note that health insurance in Germany is part of the social security system.

Statutory and private health insurance explained

In Germany, there are two parallel health insurance systems:

• The German government runs state health insurance. Most foreigners (and Germans as well) are obliged to take out state health insurance.
• Private health insurance can be chosen in some specific cases. It generally offers more extensive cover, but is not necessarily an advantage for all cases.

Almost everyone can join the state insurance scheme, but only a few exceptions are allowed to leave this system for private insurance. Around 85% of the population actually detains a statutory health insurance. See below to work out which insurance scheme fits is best for you:

1. Find out whether you can choose between private and public insurance. If you're obliged to join the state system, it is irrelevant to compare it with private insurance. To find out whether the state system is mandatory for you, have look at the information below.

2. If you are allowed to take a private health insurance, you should compare the advantages and disadvantages of both systems before making a final decision.

Although this is complicated, take the time to analyse your situation in order to make the right decision. The health insurance guide will lead you step by step through this decision process.

When is state health insurance mandatory?

State Health Insurance (Gesetzliche Krankenversicherung) is compulsory for the following groups:

• Employees whose regular income before deductions does exceed 400€ per month and remains below a set annual limit. All employees in Germany are subject to mandatory health insurance. Up to a gross salary of 54,900€ or 4,575€ per month (upper income limit for 2015) you must be insured by a private health insurance company.
• Students at state and state-approved universities. The current (2015) premium for health and nursing care starts at 80.41€ per month for a local student over 23 years with no children. International students can get insurance from 26 €/month.
• People on work experience (internships) or in secondary education
• Old-age pensioners who have been in a statutory health insurance scheme or insured as a family member for most of the latter half of their working life.
• Unemployed people receiving benefits from Federal Employment Services

You can within a period of three months join a state health insurance scheme voluntarily if you:

• Have been a compulsory member, your membership is terminated and you have certain qualifying insurance periods
• Are an employee and your income in your first job exceeds the limit, as long as you apply for membership within three months of starting work
• Are severely disabled (subject to additional requirements)
• Have been insured through a family member for a specific minimum period and this insurance has expired

Students from countries with which Germany has concluded a social security agreement, which includes an insurance clause, can continue to be covered by their home insurance company while they are in Germany.

Further information can be gained at your institution's International Office. In such cases, you will be required to present proof of insurance cover to the health insurance company in Germany:

• EU citizens who have an EHIC can remain in their country’s health care system. However they should still bring their EHIC to a state insurance office and ask for exemption.
• Short term non-EU residents who do not wish to change their health insurance company during their stay in Germany should bring a confirmation from their home insurance company in both English and German that their insurance covers all possible medical costs. This document should be submitted in a German statutory health insurance for approval. If the document is approved, an exemption from statutory German health insurance will be issued.
• Long-term non-EU residents should get a contract with a local health insurance provider depending on their situation (freelancers and self-employed people should apply for private health care insurance).

Who can opt for private health insurance?

Around 11% of Germans opt for private health insurance (Private Krankenversicherung, PKV). By choosing a private health insurance, you can expect to receive a wider range of medical treatments.

In theory, everybody not in the categories above can choose a private insurance scheme including German civil servants and people working part-time earning less than 450€/month. Be aware, once you've opted out of the state insurance scheme, it can be very difficult to go back. Switching back to state insurance is possible under the following circumstances: when someone has lost their job; your salary is below the 54,900EUR a year or you used to be self-employed but now have a full-time position with a similar salary. Careful Consideration should be taken before you make this decision.

If you opt out of statutory health insurance and cannot go back, the private insurance companies will be forced to offer you a basic tariff with the same fees as the statutory insurance from 2009.

What are the advantages/disadvantages of the two systems?

This depends heavily on your individual personal circumstances. To assist, the list below shows some of the pros and cons to each system:

Contributions: To understand the main differences between the two systems, you should bear in mind that state and private insurance work on completely different contribution models:

• State health insurance contributions are based on your gross income (around 15.5% with an income cap, 7.3% of which covered by the insurer). If you have a high income, it might therefore be cheaper to opt for a private insurance policy. Students can use a special insurance scheme that offers favourable rates.
• Private health insurance contributions are based on your risk profile i.e. health status and age, not on your income. For example, women and older people generally pay higher contributions than young men. This is due to a calculation of the average cost for medical treatment for different groups. The older you are, the less attractive it thus becomes to opt for a private insurance.

Note that contributions are always equally split between employer and employee regardless of whether you are in a private or public scheme.

Payment of medicines and treatments

You only pay a nominal fee for treatments and medicines if you are insured through the state as your insurance company directly pays these for. If privately insured, you pay doctor's fees and medicine costs and send all medical receipts to your insurance company for reimbursement. Although this makes no difference in the long run, it might be important if you have cash flow problems.

Private health insurance

Private health insurance schemes provide more extensive cover, including the option of private/semi-private hospitals, alternative therapies such as acupuncture and herbal treatments, glasses and contact lenses and other treatment that may not be available under the state scheme. In the past few years, some statutory insurance companies have also extended their coverage of alternative treatments, but it’s still not as readily available as the coverage of private insurances.

At the doctors, you will often be treated preferentially compared to state insured patients, as you are generally more profitable. Some doctors even restrict their practices only to private patients. Another advantage is that private insurances don't expect you to pay any additional co-payments (Zusatzzahlungen) for medicines and treatment as in the state scheme (see below for more information).

You will find that some private insurance policies offer you the option of a (Selbstbehalt), which means that for each case of illness part of the cost is paid by you up to a certain amount per year. Generally the insurance company will lower your contributions if you go for this option.

Statutory insurance

Despite the known complaints of Germans, the state health insurance scheme also offers some advantage compared to private schemes. The main advantage is that it also insures your family at no extra charge! Your spouse or civil partner and, up to a certain age, your children are covered by your insurance, provided among other things that their collective income does not exceed 365€ per month. In case they are working, their income shouldn’t be over 400€ per month.

You need to bear in mind that the state insurance system has come under serious pressure during the last decade. As in most countries the government is cutting the cost of health care, co-payment (i.e. the portion of costs the patient has to pay themselves) has been increasing for all kinds of medical treatment and medicines and is likely to increase further. In areas such as dental/orthodontic treatment and glasses, state health insurance only covers a very small proportion of the cost.

The state health insurance system

Statutory health insurance is provided by a network of non-profit making companies working with the state to administer the national health program (Gesetzliche Krankenkassen). Some of the most popular ones include the TK, AOK and BEK. Since 1996, anyone is free to choose the fund they wish to be insured with. Even though benefits are similar across all companies, it is often worth comparing contributions since these can vary significantly.

Your insurance company will issue you a health insurance card, which you have to take with you whenever you visit a doctor, dentist or specialist.

Note that benefits of statutory health insurance often change so it is in your interest to stay updated. Some of the treatments covered are (as of 2015):

• Medical and dental treatment, with free choice of doctors and dentists
• Hospital treatment
• Drugs, dressings, complementary treatment, hearing aids and wheelchairs
• Sickness benefit (Krankengeld): Normally, your employer will continue to pay your salary for six weeks if you are unable to work. After that your health insurance would pay 70% of your regular wage or salary before deductions for a maximum of 78 weeks
• Measures for the prevention and early detection of certain diseases
• Preventive dentistry and in particular individual and group prophylactic measures
• Preventive inoculations, excluding inoculations for non-work-related foreign travel
• Orthodontic treatment, normally only up to the age of 18.
• Medically necessary dentures and crowns.
• Glasses
• Immunizations
• X-rays

If you have children, you can claim a range of additional benefits. The Federal Ministry for Health and Social Security offers detailed and the latest information on benefits at http://www.bmgs.bund.de.

Patients covered by the state insurance system still need to pay 10€ per quarter year in case they need medical help in a period of 3 months. That is, 10€ are paid for the first doctor’s visit during a quarter of a year. If a person doesn’t make any visits in a quarter year, no payment is required. Dentists costs another 10€ for the first visit per quarter.

In the following cases, you will have to an additional contribution to treatments and medicines (as of 2015):

• The cost of dentures 20 - 70% of these costs may be paid by the state. (case by case basis)
• A share in the cost of in-patient preventive treatment and rehabilitation, out-patient rehabilitation, and in-patient hospital care (€10/day for a maximum of 28 days)
• 10% of the cost of prescription drugs and dressings, minimum 5€ and maximum 10€.

If your income is below a certain level, you can be exempted from these additional payments.

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