TechnologieRegion Karlsruhe TechnologieRegion Karlsruhe

If you become ill, the costs of consulting physicians, staying in hospital, therapies, medication and other services can be very high. The health insurance system exists to ensure that everyone can afford appropriate healthcare. Health insurance providers bear the full or partial treatment costs for their insurees. All employees have health insurance – either under a statutory health insurance scheme or provided by a private health insurance company. 

Statutory health insurance (GKV)

Statutory health insurance is broken down into compulsory and voluntary insurance. The statutory health insurance schemes also cover family members free of charge (family insurance).

Who is subject to compulsory insurance?

  • All employees (white-collar and blue-collar) and trainees who receive payments for their vocational training
  • Recipients of unemployment benefits (ALG/ALG II)
  • Farmers and their family members who also work on the farm
  • Artists and publicists
  • Young people in special youth welfare institutions
  • Persons with special needs, who work in recognized workshops, for example
  • Students at state or state-approved colleges (for max. 14 semesters, or until they are 30 at the latest)
  • Pensioners and pension claimants if a certain pre-insurance time has elapsed
  • Persons without other health insurance cover if they are eligible for statutory health insurance

Compulsory insurance requires membership in a statutory health insurance scheme, for which contributions must be paid. The contributions are calculated based on specific income which is subject to contributions (e.g. wages, pension), up to a contribution assessment ceiling of € 3,937.50 per month in 2013.

In the event of an illness, the employer shall continue paying wages in the first six weeks. If the illness lasts more than six weeks, the health insurance company pays the employee after the first six weeks. The basic insurance cover under statutory health insurance covers the following services:

  • Out-patient medical treatment, for example in medical practices
  • Dental care
  • Medication, remedies and aids
  • In-patient stays and treatments, for example in hospitals
  • Medically-necessary rehabilitation measures
  • Services for pregnant women before, during and after birth

Family members are co-insured by statutory health insurance schemes. Spouses, registered partners and children (including foster children, step-children and grandchildren) of the insuree can be co-insured under statutory health insurance provided they

  • reside or have a habitual abode in Germany
  • are not subject to compulsory insurance or are voluntarily insured themselves (exception: recipients of unemployment benefits (ALG II) or students up to a certain age limit)
  • are not exempt from insurance or exempted from compulsory insurance and
  • are not self-employed on a full-time basis

Note! 

If only one parent has statutory health insurance, and the income of the other parent exceeds the compulsory insurance threshold and is exceeds that of the parent with statutory health insurance on a regular basis, the children cannot be co-insured free of charge.

They are free to choose their health insurance provider. The health insurance scheme you join does not depend on your profession or industry. Health insurance contributions are deducted directly from your wages. If your monthly wage exceeds the assessment ceiling (in 2012 this was € 4,237.50 gross), you do not have to remain in the statutory health insurance scheme and can join a private health insurance scheme.

The conditions and the extent of the services which the statutory health insurance schemes provide are legally specified and therefore identical for all health insurance companies. For some services (for example health promotion, home help), the individual health insurance companies offer different scopes of services based on their by-laws.

Private Health Insurance (PKV)

In general, anyone can take out private health insurance with the relevant insurance companies. If the insuree is not covered by statutory health insurance, full insurance is possible. There are also private supplementary insurance policies to add to the cover provided by statutory health insurance schemes (e.g. spectacles, treatment by senior consultant, dental prostheses).

The contributions to private health insurance schemes are calculated based on risk factors (e.g. age, pre-existing conditions), not income. By contrast to the statutory health insurance companies, private health insurance providers can refuse to insure specific individuals, or impose risk surcharges.

However, persons without health insurance cover who are eligible for private health insurance (in particular the self-employed), are entitled to receive access to private health insurance at a “standard rate”. They are accepted without risk evaluation and risk surcharges. The standard rate guarantees their entitlement to medical healthcare and covers services comparable with statutory health insurance.

The electronic health care card

Everybody who is insured with a statutory health insurance company receives an electronic healthcare card bearing their name, date of birth, a photograph, the insurance number and insurance status. It serves as evidence of insurance cover for physicians and other service providers, and must therefore be presented every time you visit a doctor, so that the physician in question can bill the insurance company for your treatment. As a result, the patient does pay for treatment themselves in the medical practice or hospital. The healthcare card is valid in all 27 EU countries as well as Iceland, Lichtenstein, Norway and Switzerland. That means that if you become ill in these countries while vacationing or on a business trip, you can present the healthcare card to receive access to local medical services. We recommend that you contact your health insurance company in good time before travelling abroad for information on what to do in an emergency.