Of the approximate 84.7 million people registered in Germany at the end of 2023, more than 74.3 million were insured with one of the 96 statutory ("public") health providers.
The number of actual contributing (paying) members increased from 57.22 million in 2021 to 58.14 million (+1.61%), and their dependents, in other words those insured 'free of charge', numbered at 16.16 million, a slight increase of 0.37% since 2021. The remaing difference are members with a different status, e.g. students or pensioners.
Taking a closer look at those 58.14 million members enforced by legislation to be insured with the statutory system, these reason why they make up 78.20% of the statistics is because they were employed receiving salaries that did not exceed the so-called 'general Annual Income Threshold' (German: allgemeine Jahresarbeitsentgeldgrenze) of gross 66,600€, a legal requirement to opt-out of statutory health insurance and a "financial hurdle" that increases on a yearly basis, set at 69,300€ in 2024.
Source: Statista GmbH (link)
Legislation
In Book V of the German Social Security Statue book (SGB V) the legislator has defined the benefits to be provided by the statutory health system (GKV). Contrary to what one would expect though - a list of treatments & benefits - §12 reads: „Benefits must be sufficient, functional and economical; these are not allowed to exceed a measure of necessity. ... “.
Treatment & Benefits
Although Book V of the German Social Security Statue Books (SGB) is dedicated to the intricacies of the German "public" health system (GKV), contrary to what one would expect, a detailed listing of treatments & benefits is to be found nowhere. Scrutinising the legislative texts, §2 begins with pointing to the benefits in chapter III but in the same sentence anticipation is subdued by hinting that §12 that gives us an idea of what people should really expect: „Benefits must be sufficient, functional and economical; these are not allowed to exceed a measure of necessity. Treatment not necessary or uneconomical, the insured cannot claim for, service providers cannot ensure, and health providers will not grant“.
So, let us take a closer look at what the German legislator has defined as necessary for over 73 million people, nearly 88% of the German population. Chapter III §11 lists the following benefits:
- Pregnancy and maternity
- Prevention of illnesses and their worsening, as well as contraception, sterilisation, and abortions
- Detection of health risks and early diagnosis of diseases
- Treatment of a disease
- Personal budget, according to § 29 of the XI Book
It then goes on to state:
The insured are also entitled to medical rehabilitation benefits and those to maintain their livelihood along with other supplementary benefits that are necessary to prevent, cure, relieve, counterbalance, prevent the worsening, or mitigate the consequences of a disability or need for long-term care.
General
- In-Patient, Day-Patient & Out-Patient medical and dental treatment
- Free choice of registered doctors and dentists
- Prescribed medicines, dressings, therapies and aids such as hearing/ vision aids, crutches or wheelchairs
- Measures for the prevention and early detection of certain diseases
- Children in the first six years of their life and at the beginning of puberty
- Adults every two years from the age of 35
- Annual Cancer-Screening for women from the age of 20 and men from the age of 45
- Preventive inoculations, excluding immunisations for private travels, as provided for in the articles of the relevant health insurance funding plan
- Expenses for necessary preventive and rehabilitation treatment are fully or partial reimbursed
- ‘Sickness per diem Allowance'
- By law the employer has to continue to pay the salary for 6 weeks when the employee is unable to work due to illness. After this period the statutory health insurers will pay up to approx. 70% of the person's regular gross wage but only up to the Contribution Assessment Ceiling (2016: 50,850 € pa or 4,237.50 € pm) and no more than 90% of your most recent salary. The sickness allowance can be claimed for up to 78 weeks within a 3 year period.
Dental
- Orthodontic treatment
Usually only for children and adolescents up to the age of 18, however adults may receive funding if a severe jaw abnormality is present that requires oral surgery.
German statutory medical insurers do however not pay for all kinds of treatments, therefore have categorised symptoms into 5 Orthodontic Indication Groups, German: "Kieferorthopädische Indikations-Gruppen (KIG)":
- Groups 1 & 2 are considered minor anomalies; therefore treatment is not refundable. Should the orthodontist certify that medical treatment is necessary, private Top-Up Dental plans are helpful.
- Groups 3 - 5 are paid in full, yet an initial 20% co-payment is required that is reimbursed once treatment has been successfully completed.
In any case, all German statutory health providers pay for an initial orthodontic consultation without needing a referral from a dentist!
- Groups 1 & 2 are considered minor anomalies; therefore treatment is not refundable. Should the orthodontist certify that medical treatment is necessary, private Top-Up Dental plans are helpful.
- Preventive dentistry
In particular individual and group prophylactic measures to prevent dental disease
In Vitro Fertilisation (IVF) treatment
IVF treatment is a medical technique to help those with fertility problems to have a baby.
Having removed the egg from the ovaries and fertilised it with sperm in a laboratory, the then called embryo is planted into the womb to grow and develop. Who the egg/sperm donors are is not important for the success rate.
Insurance requirements
- The couple must be married and only the eggs and sperm of the spouses may be taken.
- Both partners must be at least 25 years old.
The woman must be younger than 40, the man younger than 50. - A doctor not performing the artificial insemination must give detailed consultation to the couple in advance.
- A HIV test must be available from both partners.
- The woman must have extensive immunisation protection.
Important are: rubella, chickenpox, and whooping cough.
Insured costs:
As legally obliged, 50% of the costs for artificial insemination are covered by all German statutory providers.
Many insurers have even increased their contributions, and some cover the costs in full.
Preferred German statutory providers for IVF treatment:
| Provider | Contribution |
|---|---|
| BKK24 | 300€ allowance per cycle, max. 4 cycles |
| BKK Akzo Nobel Bavaria | 1,000€ allowance per cycle, max. 3 cycles |
| BKK excklusiv | 250€ allowance per cycle, max. 3 cycles |
| BKK firmus | 500€ allowance per cycle, max. 3 cycles |
| BKK Freudenberg | Per married couple 2,000€ for 1 cycle within 24 months |
| BKK Pfaff | 100% |
| BKK Scheufelen | if both parents insured with BKK, 500€ allowance per cycle, max. 9 cycles |
| IKK Classic | if both parents insured with IKK, 500€ allowance per cycle, max. 3 cycles. If one parent not insured with IKK, 250€ per cycle |
| IKK Nord | max. 3 cycles |
| IKK Südwest | 1,000€ allowance per cycle, max. 3 cycles |
| Salus BKK | 250€ allowance per cycle, max. 3 cycles |
| Viactiv | 500€ allowance per cycle, max. 3 cycles |
Financing
German statutory ("public") health insurance is financed by its members' contributions and federal subsidies.
What the individual contributes on a monthly basis is a percentage of their income, consisting of those sources of capital that are subject to contributions, These can be the person's salary, state pension (except orphan's pension) and even provident fundings, such as a Company Pension Scheme. Also, additional self-employed income too is taken into consideration once it reaches a certain amount!
For self-employed or freelancers their contributions are not only based on the before-mentioned, but also included revenue generated from capital-investments, rent or lease income.
Contributions / Payments
Contributions for medical and long-term care insurances are set across the board for all providers, of which there are currently 96 in 2023. On top the provider load the contribution with their own 'Additional Fee', varying between 0.80% - 1.90% depending on the insurer and currently averaging at 1.30%.
Link to all providers and their Additional Fee
Fortunately for all members there is an absolute payment limit, the so-called 'Contribution Assessment Ceiling' (German = Beitragsbemessungsgrenze), a cap that limits the amount of income subject to contributions at 4,987.50€ per month, respectively 59,850€ per year (2023).
| Insurance Type | Employed | Self-employed |
|---|---|---|
| Medical: | 14.60% | 14.00% |
| Long-term Care: | 3.05% | 3.05% |
| Maximum contribution: | 880.29€ | 850.37€ |
| 23 years of age or older and without children | ||
| Medical Insurance: | 14.60% | 14.00% |
| Long-term Care Insurance: | 3.30% | 3.40% |
| Maximum contribution: | 892.76€ | 867.83€ |
Employment:
Premiums are split 50/50 between employer and employee, apart from for those 23 years of age and without children who must pay an additional 0.25% for Long-term Care insurance.
Kinds of people covered by the statutory scheme
The German statutory health scheme primarily insures employed people, whoms earnings restrict them in their choice to obtain cover with a more comprehensive German private insurance health plan or those who even become a voluntary member of the statutory scheme, as family members need to be included. The hurdle to overcome the "shackles" of statutory health insurance is dependent on whether of not income exceeds the 'general Annual Income Threshold', set at 69,300€ gross yearly income in 2023.
Students, self-employed, freelancers, pensioners, jobseekers and also people without any occupation sign up with a statutory provider for all kinds of reasons and quite often it makes sense to join the "public" health scheme, especially for people with pre-existing conditions or families. Hence, families in which just one person is earning or students up to the age of 25 with little to no income, will benefit from a system predominately funded by everybody obliged to contribute towards German Social Security Insurance.
'Worth Knowing'
Spouse has private health insurance
If you are self-employed (freelance) and have the oportunity to contribute towards the German statutory health scheme, thus become a voluntary member, it is extremely important to know that should you partner, married or common-law, be privately insured, his/ her income will be taken into consideration to determine the payable amount due on a monthly basis, for both medical and long-term care insurance.
Exemptions:
Only if one of the following conditions applies, will your spouse's income not be taken into consideration.
- You live permanently separated
- You earn more than you privately insured spouse
- Your income is at least 2,268.75€* per month
To asses the situation the provider will ask the member to provide a copy of your last Income-Tax-Return (all pages!).
Allowance for children:
For each dependant child the provider can possibly deduct 623€* per month from the joint income.
Contribution Thresholds:
- Minimum = 1,038.33€* per month
- Maximum = 2,268.75€* per month
*year: 2019
Fequently Asked Questions
Insurance - Health - German Statutory ("Public")
Can anyone sign up with statutory (public) health insurance?
The answer to this question is: "Yes, but with exemptions!"
For this to make sense, one must understand the difference between the following 2 categories.- Obligatory membership
This means that because of the employee's gross salary, contributing towards Social Security becomes mandatory, then so does statutory health insurance. - Voluntary membership
- Even though the employee's salary exceeds a specific threshold, hence they could sign up with a private health insurer, the employee decides to stay with the statutory provider and pay the max. contribution (ca. 900€ per month)!
--- OR --- - Switching from employment to self-employment one has the right to remain insured as a voluntary member.
--- OR --- - Arriving in Germany as an EU citizen with previous EU "public" health insurance, one has the right to sign up as a voluntary insured member.
- Even though the employee's salary exceeds a specific threshold, hence they could sign up with a private health insurer, the employee decides to stay with the statutory provider and pay the max. contribution (ca. 900€ per month)!
Exemptions:
- Arriving in Germany as a self-employed, non-EU person, signing up with a public provider is not possible!
- Once privately insured, switching to statutory (public) insurance is also not possible, unless the person becomes employed and has an annual salary below the before-mentioned specific threshold, called 'Annual Earning Limit' (German: Jahresarbeitsentgeltgrenze).
- Obligatory membership
Can statutory health providers cancel children retrospectively?
Unfortunately, this is the case and depending on the provider thus, when they send out their questionnaire to assess family circumstances, a cancellation can go as far back as more than 2 years, resulting in substantial amounts of back payments.
To understand to whom in general, how and why this can happen, one must have studied the German Social Security Statute Book V, a cumbersome undertake and a type of legislation lawyers specialise on.
SGB V §10 (3) is the piece of legislation that enables the “removal” of contribution-free children when e.g. the member has a spouse.
"Children are not insured if the member's spouse or common-law partner related to the children is not a member of a statutory health provider and their total income regularly exceeds one twelfth of the ‘Annual Income Threshold’ per month and is regularly higher than the member's total income; in the case of pensions, the amount paid is considered."Link to official source (German)
I would like to switch from my EU to German statutory insurance. What are the steps?
Thanks to cross-border digital data exchange switching from one EU statutory (“public”) health company to another requires in most cases nothing more than submitting an application to the German provider of your choice.
The procedure:
- On receiving the application, the German insurer inputs the member into their system and sends notification to the foreign insurer that membership has been requested.
- The foreign insurer acknowledges holding or having held membership for the applicant and for its part confirms end of membership.
The same procedure applies to those few countries not connected to the data exchange system too, yet in written form.
I have German "public" insurance, do I have to pay for treatment at the doctor?
No. When visiting a doctor, dentist, public hospital or any other non-private medical facility, presenting your membership card you will not be billed.
Invoices are only ever issued when treatment, consultation or service exceed the scope of "public" health cover, hence the patient needs to be billed privately. Latter requires preliminary clarification and the patient's written consent.Will the German public health system pay for gender reassignment sugery?
Although nowadays one would not think, gender reassigment is still a very complex subject, and especially in Germany.
Due to the German Constitutional Court ruling in 2011, that a person needs neither sex reassignment surgery nor sterilization in order to legally change their gender, and because of the immense expenses involved in gender reassignment surgery, ultimately carried by the insured community as a whole, the following requirements are needed for a statutory health provider to give their approval.
Requirements:
- Applicant's personal statement
- Application for Gender Reassignment Operation, issued by the insurer
- Hormone treatment for a period of at least 6 months (evidence required!) AND
Confirmation of a day-to-day test over a period of at least 18 months - Psychiatric treatment of at least 18 months (evidence required!) AND
Psychiatrist report (brief) for the diagnostic clarification of possible psychiatric comorbidity (if psychotherapeutic treatment is provided by a psychological psychotherapist) - 2 court opinions in accordance with §4 (3) Transsexuellengesetz, OR
proof of an accomplished change of civil status according to §45b PStG, as far as a first name change was accomplished - Statement from the contracting hospital(s)
- Specialist medical reports post requested services/ treatment
(e.g. hormone treatment, epilation, surgical interventions)
Are there any co-payments I need to make with "public" insurance?
On top of the total 243.5 billion Euros that providers of "public" health insurance paid out in 2018, members made additional co-payments of approx. 4.2 billion Euros for treatments, services, benefits, medication and the below mentioned. Compared to 2017, this is an increase of 108 million Euros!
Here are just a few examples of the co-payments that people must expect with German "public" health insurance.Scenario: Comment: Contraceptives and Abortions Hospital stay and treatment Medicines & Dressings "waived if a minor" Prevention and Rehabilitation benefits Remedies and Aids Transportation with an ambulance 10€ per trip Treatment Care and Home Nursing For adults co-payments are limited to 2% of their gross annual income and for those who have to see a doctor more often or need frequent medication, i.e. chronically ill people, the co-payment limit is lowered to 1%.
I am self-employed, how are my contributions calculated?
The amount self-employed/ freelancers must contribute towards the German statutory health insurance scheme is a fixed percentage, plus the providers own 'Additional Fee', both based on income.
Income is defined as turn-over minus expenses, includes other possible sources of income, e.g. capital yields, rent, etc. and is to be proven to the provider every year by presenting the most recent Tax-Income Assessment.
To prevent contributions being infinite the so-called "Contribution Assessment Ceiling" (German: Beitragsbemessungsgrenze) is applied, which makes sure contributions are capped at an amount that is reviewed on an annual basis. In 2024 it is set at 62,100€ per year, resp. 5,175€ per month.Finally, the system then differentiates between two types of members, consequently slightly different percentages are applied.
Standard Membership:
14.60% Medical insurance
x% 'Provider's Additional Fee' (current market: 0.50% to 2.70%, depending on provider)
3.40% Long-Term Care insurance
Total = 14.6% + x% + 3.40%
Member is 23 years or older and has no children:
14.60% Medical insurance
x% 'Provider's Additional Fee' (current market: 0.50% to 2.70%, depending on provider)
4.60% Long-Term Care insurance
Total = 14.6% + x% + 4.60%
With the average 'Additional Fee' currently at 1.70%, self-employed members can calculate with 19.10%, resp. 18.70%.I have just started self-employment, how are my contributions calculated?
In the event that self-employment has only just started, thus a tax-declaration is yet to be submitted, the health insurers fall back on reliable economic evaluations (German: Betriebswirtschaftliche Auswertung [BWA]) or try to make their own estimates, in expectation to make amendments once the first Tax-Income Assessment can be presented.
Regardless however of the amount of income the self-employed might expect and declare towards the provider, monthly contributions are generally calculated in accorance with 2 thresholds.
- Minimum contribution:
This so-called "Assessment Base for Minimal Contribution" (German: Mindestbeitragsbemessungsgrundlage) is set at 1,142€ (2019).
One exception, if the business is a start-up, thus subsidised by the Employment Agency, the Assessment Base for Minimal Contribution is slightly less.
- Maximum contribution:
The "Income Threshold" (German: Beitragsmessungsgrenze) for 2019 is set at 4,537.50€ per month / 54,450€ per year.
- Minimum contribution:
What are the cancellation terms of statutory ("Public") health insurance?
In principle, statutory health insurance comes with a twelve-month commitment period, yet depending on any optional tariffs that may be included, the binding period can be extended up to three years.
The notice period required to terminate the contract at the end of the month is two full calendar months.
What is a "Midijob" and what are my benefits finanicially?
Employees in a German "Midijob" are those whose monthly salary is periodically within the transition bracket of 538.01€ - 2,000€, as of January 2024.
The advantage of a "Midijob" is that less contributions need to made towards the social insurances, consequently the employee has more of their salary at their disposal.
