Hi! Welcome to the last article in the 3-part series on reimbursement. This time, I’m sharing some facts about private health insurance in Germany.
I hope you found the previous pricing and reimbursement series helpful. In the next weeks, my posts will focus on the details about the German HTAs.
About 90% of the German population are insured with an SHI fund. The remaining 10% have private health insurance. In addition, there is the option for people to have private health insurance on top of the SHI.
Key characteristics of private health insurance in Germany
Private health insurance is an option for everyone who is not compulsorily insured in SHI according to § 5 SGB V. This means:
- Government officials, judges and other persons entitled to assistance (German: “beihilfeberechtigt”)
- Self-employed and freelancers
- Workers and employees with a gross income above the annual income limit. The government reviews this annual income limit annually. For 2022, the limit is a gross income of €64.350 per year or €5,362.50 per month.
- People without their own income or with an income below the marginal income threshold, including students who are exempt from compulsory insurance, as well as e.g. children
While health care insurance is included in the SHI, people with private health insurance have to also take out private care insurance.
The private health insurance companies do NOT have to insure everyone who applies for insurance. While they have to accept everyone who is meeting the requirements for the base tariff, they are free to reject applicants based on their prior medical history, age, etc. for other types of tariffs.
People insured with a private health insurance also can switch (back) to a SHI, if
- they are under 55 years old and
- they become subject to compulsory insurance (e.g. as an employee by falling below the compulsory insurance limit or through unemployment), or
- a family insurance is possible.
Types of tariffs
Private health insurers can offer different types or levels of tariffs, which include different coverage of services. They all have to offer a base tariff.
Base tariff
The services included in this tariff are comparable to those covered by SHI.
In this base tariff, private insurers are not allowed to charge excess or co-payments, or to exclude any services based on a higher health risk of the insured person. The treating physicians are part of the KBV or KZBV.
The insurance premium must not exceed the respective maximum premium of SHI, and is recalculated on January 1 of each year.
Requirements for the base tariff:
Everyone meeting these conditions can switch from SHI to the base tariff of any chosen private insurance fund:
- People who have taken out private health insurance or are taking out insurance after 1 January 2009, or
- People without insurance coverage, who were formerly insured with or can be assigned to private health insurance, or
- voluntary members of the SHI, within six months after the start of the option to switch to the private insurance, or
- Entitled to assistance (German: “Beihilfe”) as a supplement.
Premiums
The premiums for private health insurance are specific to the insured person and differ between people. In detail, the private insurance companies base their premiums on
- the risk of the insured person at the time of the start of the insurance. This risk assessment considers the age and individual risk of disability and illness.
- which services are included and covered by the insurances,
- amount of excess.
The premiums are higher while an insured person is younger because a surcharge is applied. This cost difference should ensure that the premiums counterbalance the expected higher healthcare costs as much as the person becomes older.
Reference: https://www.bundesgesundheitsministerium.de/private-krankenversicherung.html
Receiving treatments and care
Patients with private health insurance are free to choose their clinicians and the hospitals where they receive their treatments. In addition, privately insured patients often get appointments much easier and faster. This is based on the different payment systems for clinicians and hospitals, which makes it financially preferable to treat privately insured patients.
Unlike with SHI, patients with a private health insurance receive an invoice directly from their hospital or clinician. The patients should check the invoice, e.g using this software, and have to pay the bill. They then submit the invoice, and prescriptions, etc. to their insurance company, who will reimburse the payment. If the expected costs exceed €2,000, the patient can request a binding statement from their insurer which costs they’ll cover, before the treatment commences.
Summary of key similarities and differences
| Statutory health insurance in Germany | Private health insurance in Germany | |
| Services | Outpatient services covered in EBM All inpatient services, unless excluded by G-BA Funds can offer additional services | Outpatient services covered in GOÄ All inpatient services, unless excluded by G-BA Funds can offer additional services |
| Receiving services | Free choice amongst clinicians in KBV or KZBV, but only after referral from family doctor / GP | Free choice of treating clinicians and hospitals Faster appointments |
| Insurance premiums | Based on income | Based on individual risk, covered services, and amount of excess; surcharge applied based on age |
| Availability | Compulsory for most Option for some people with private health insurance to switch (back) to SHI | Base tariff open to everyone eligible for private insurance Funds can reject applications for other tariffs |
Further reading related to reimbursement in Germany
- Are you interested in drug reimbursement in Germany? – Get up to speed here
- Three new methods were added to the catalogue of SHI funds
- Wound treatment: bandage material or other products – an important difference for reimbursement
- NUB method assessments to become faster
- 8 NUB assessments of high-risk medical devices (§ 137h)
- G-BA assesses method of allogeneic SCT in ALL, AML and NHL
- Another reimbursement restriction in Germany
- How much does a certain treatment cost in Germany? – What you need to know
Newsletter
If you liked this post and don’t want to miss the next one, sign up for my free weekly newsletter!