What is the recovery of health insurance benefits

Health insurance

1. The most important things in a nutshell

The statutory Health insurance finances services that maintain or restore health or improve health. The legal basis is the Social Code No. 5 (SGB V). Employees (except civil servants) up to certain income limits, the unemployed, pensioners and many self-employed are compulsorily insured in health insurance. The contribution rate has been 14.6% since 2015. In addition, the health insurance companies charge an additional contribution based on your income.

2. Preliminary remark

One has existed in Germany since 2009 general Compulsory health insurance, i.e .: every resident of Germany got to have health insurance. This article covers Not this general obligation, but the following is about the insurance in the statutory health insurance ("Krankenkasse"), in which many employees are compulsorily insured.

3. Insured

You can belong to the statutory health insurance as a compulsorily insured person, as a voluntarily insured person or as a family insured person.

Anyone who is not assigned to the statutory health insurance system has had to register since 2009 Private assure. this applies Not for people who have a other entitlement to coverage in the event of illness have the right, for example, to free medical care (soldiers, police officers), to assistance, to health care according to the Prison Act, to sickness and medical treatment according to the Federal Supply Act or to benefits according to the Asylum Seekers Benefits Act (Section 193 (3) VVG).

Social welfare recipients who despite compulsory insurance none Have health insurance cover, and asylum seekers are usually reimbursed for the costs of medical treatment by the social welfare office, for more information see Health Assistance.

3.1. Compulsorily insured

(§ 5 SGB V)

Insurance is compulsory e.g. for the following groups of people:

  1. Workers, employees and employees for their vocational training who regularly earn no more than € 64,350 per year or € 5,362.50 per month.
    This also includes recipients of early retirement benefits if they were immediately subject to compulsory insurance and the early retirement benefit amounts to at least 65% of the previous salary.
  2. Unemployed during the time in which you receive unemployment benefit, unemployment benefit II (Hartz IV) or unemployment benefit for professional training
  3. Farmers and their working family members with a certain minimum size of the company and retirees
  4. Freelancers Artist and publicists under the Artists' Social Insurance Act. The social welfare office for artists is responsible and provides detailed information. Gökerstr. 14, 26384 Wilhelmshaven, phone 04421 9734051500, Mon-Fri, 9 a.m. to 4 p.m., www.kuenstlersozialkasse.de.
  5. Persons in institutions of the Youth welfarewho are to be qualified for gainful employment
  6. Participants in services for participation (vocational rehabilitation> services)
  7. People with disabilities, who work in recognized workshops for disabled people, in workshops for the blind or for these facilities in home work or with another service provider according to § 60 SGB IX, more details under workshops for disabled people WfbM and other service providers
  8. People with disabilitieswho, to a certain degree, provide services in institutions, homes or similar institutions that correspond to one fifth of the service of a fully employable person
  9. studentswho are enrolled at state or state-recognized universities up to the age of 30 at the latest, but also if the type of training, personal and family reasons justify a higher age limit. For more information, see Health Insurance for Students
  10. Internswho carry out a work-related activity stipulated in study or examination regulations without pay, as well as trainees in the second educational path
  11. pensioner and pension applicants (under certain conditions), details under pensioners health insurance
  12. people without health insurance coveragewho last had statutory health insurance or were previously neither legally nor privately insured and cannot be assigned to private health insurance based on their professional status, e.g. as full-time self-employed persons (so-called fallback insurance).

3.2. Family insured

(§ 10 SGB V)

Children and spouses who are not employed full-time are usually entitled to the full benefits of the health insurance as so-called family insured persons. More details under family insured.

3.3. Voluntarily insured

(§ 9 SGB V)

The following people have the option of voluntarily taking out statutory health insurance:

  • Persons coming from the Compulsory insurance withdrawn are, e.g. due to exemption from insurance (see below) or for other reasons, e.g. due to control, details under sick pay> no payment. This membership must have lasted uninterruptedly for 12 months before leaving or it must have been at least 24 months in the previous 5 years.
  • Persons whose Family insurance expires or it just does not exist because the higher-income parent is not a member of a statutory health insurance scheme. The person or the legally insured parent must fulfill the above-mentioned previous insurance period. For more information, see Health Insurance for Students.
  • People who take up employment in Germany for the first time if they earn above the compulsory insurance limit.
  • Severely disabled peopleif you, one of your parents, your spouse or partner were insured for at least 3 years in the last 5 years prior to joining, unless they were unable to meet this requirement due to their disability. The statutes of the health insurance company can set an age limit for joining.
  • Employees whose membership is through Employment abroad ended if they return to work within 2 months of their return.
  • Spätaussiedler and their spouses and children within 6 months after the resettlement or within 3 months after receipt of ALG II (Hartz IV), if they were insured with a local statutory health insurance before the resettlement.
  • Regular soldiers who retired from service as of December 31, 2018.

Membership must be declared within 3 months (with the exception of ethnic repatriates) after the respective requirements have been met.

3.3.1. Practical tips

  • Whoever leaves compulsory or family insurance, but Not If you want to be insured voluntarily, you must expressly declare your withdrawal from the statutory health insurance within 2 weeks after the health insurance company has been informed about the possibility of withdrawal and provide evidence of any other entitlement to seamless coverage in the event of illness, e.g. private health insurance. If there is no proof, the insured person will automatically continue to be insured as a voluntary member on the day after the end of the previous insurance (compulsory follow-up insurance, Section 188 (4) SGB V).
  • Anyone who voluntarily takes out statutory health insurance must automatically also take out statutory long-term care insurance. who Not If you want to become a member of the statutory long-term care insurance, you must provide evidence of equivalent private insurance coverage.

4. Exemption from insurance

Certain people are exempt from compulsory health insurance or can apply for it.

4.1. Exemption from insurance by law

(§ 6, 7 SGB V)

For example, who is free of insurance

  • receives regular wages that are above the compulsory insurance limit
  • works as a marginal part-time worker (mini-jobs, marginal part-time employment)
  • as a privately insured person becomes subject to compulsory insurance after the 55th birthday
    and
    was not legally insured in the previous 5 years
    and
    During this period at least 2 1/2 years without insurance, exempted from compulsory insurance, or was self-employed or was married to such a person.
  • had private health insurance immediately before receiving unemployment benefit II (Hartz IV) (Section 5 (5a) SGB V).
  • belongs to a group of people such as civil servants, judges and soldiers.
  • is employed as a working student.

4.2. Exemption from insurance on request

(§ 8 SGB V)

The following people can, for example, be exempted from a newly arising insurance obligation upon application:

  • Employees,
    • who become subject to compulsory insurance again due to an increase in the annual income limit
    • who are partially gainfully employed during parental leave
    • who reduce their regular weekly working hours during care leave or family care leave
    • who have not been legally insured in the last 5 years and who reduce their working hours to half or less than half the regular weekly working hours of full-time employees and whose income is therefore below the compulsory insurance limit, e.g. in the case of part-time employment or partial retirement
    • who take up work in a facility for disabled people
    • who are employed as a doctor in the internship
  • Privately insured unemployed people who receive unemployment benefit or unemployment benefit in the course of further professional training (previously: maintenance allowance) and who have not been legally insured in the last 5 years
  • Pensioners and pension applicants (under certain conditions), more information under pensioners health insurance
  • Rehabilitation patients who take part in an occupational rehabilitation service (participation in working life)
  • Students, interns

The application for exemption from compulsory insurance must be submitted to the health insurance company within 3 months of the start of compulsory insurance. The applicant must prove that he is covered by other means in the event of illness.

The exemption cannot be revoked, i.e. the exemption from insurance exists as long as the conditions leading to the exemption are met, e.g. for the entire duration of the course.

Special regulations apply to agricultural entrepreneurs and artists.

5. Health insurance contributions

(§§ 241 ff. SGB V)

5.1. Contribution rate

Since 2015 the uniform contribution rate has been 14.6%, the reduced contribution rate for voluntarily insured persons without sickness benefit is 14%.

5.1.1. Contributions for voluntarily insured persons

(§ 240 SGB V)

Voluntarily insured persons normally pay their contribution based on the contribution assessment ceiling (€ 4,837.50 per month in 2021), i.e. € 740.14. If they earn less and can prove this to the health insurance company, they pay correspondingly less, but there is a minimum contribution. Self-employed people with a low income of up to € 1,096.67 who are voluntarily insured in the statutory health insurance will generally only have to pay a monthly contribution of around € 165.60 in 2021. The exact amount depends on the individual additional contribution.

5.1.2. Practical tip

Since lower earnings are associated with lower contributions, you should definitely report income below € 4,837.50 to the health insurance company. Your contributions can be corrected retrospectively for up to 12 months (Section 240 (1) SGB V). This can be of particular interest to those setting up a business, as at the beginning, if you do not yet have a proven income, the stated income will be accepted.

5.2. Additional contribution

Since 2015, the health insurance companies have been able to charge an income-related additional contribution if the money from the health fund is insufficient for the services. If a health insurance company charges this additional amount, the insured person can make use of the special right of termination. Details on termination under health insurance.

The additional contribution is paid in equal parts by the employee and the employer. According to a forecast by the federal government, it will average 1.3% in 2021.

Recipients of social assistance and basic security in old age and in the case of reduced earning capacity do not have to pay the additional contribution themselves; this is done by the social welfare office or the basic security office. Recipients of unemployment benefit II (Hartz IV) usually do not have to pay an additional contribution, unless the statutes of the respective health insurance company provide for this.

5.2.1. Practical tip

In fact, all health insurance companies charge an additional fee. An official overview of the amount of the contributions and additional contributions can be found at the GKV-Spitzenverband: www.gkv-spitzenverband.de> Service> Krankenkassenliste.

5.3. Delinquent contributors

Insured persons who do not pay their contributions (arrears at least as high as 2 monthly contributions, § 16 SGB V), although they would be able to do so, only receive benefits for treatments that cannot be postponed, e.g. acute illnesses and pain as well as treatment during pregnancy and maternity. Entitlement to all other health insurance benefits is suspended until the outstanding contributions including late payment surcharges (1% of the contribution debt, Section 24 SGB IV) have been settled. Family insured persons are exempt from this rule. You will continue to receive all services.

Private Insured persons who do not pay their contributions will be upgraded to the emergency tariff, for more information see Private health insurance> Emergency tariff.

5.4. Payment of contributions for social welfare recipients

As a rule, the social welfare office pays health insurance contributions for social welfare recipients. More information under health and long-term care insurance social assistance.

5.5. Additional payment for the uninsured

(§ 256 a SGB V)

Who the legal If you are subject to compulsory insurance, but have not yet registered with any health insurance company, you must retrospectively pay the contributions for each month that you have been uninsured since the introduction of compulsory insurance on April 1st, 2007.

Since January 1, 2014, the subsequent payment of the missed fees has been reduced if the (new) member declares in writing that he has not made use of any services for the period of the reduction and that he will also waive reimbursement of costs for bills afterwards. The reduced fee is calculated as follows: The fictitious income subject to contributions in the amount of 10% of the annually redefined reference value is assumed as the basis for calculation. Of this, the reduced contribution rate of 14% + the additional contribution of the respective health insurance company is calculated. With an average additional contribution of 1.3%, contributions of € 50.34 per month would be due in 2021 for the months to be paid in arrears.

5.6. Expectancy insurance

If the insurance cover is temporarily not required, e.g. if you are staying abroad for a longer period, it can be suspended for a certain period of time by means of an entitlement insurance. The insured then remains a member of his health insurance company, pays greatly reduced contributions, but is not entitled to benefits. The insurance relationship will then be continued under the same conditions. This can be particularly useful in private health insurance.

5.7. Practical tips

  • Uninsured that Not (more) be assigned to statutory health insurance, have to since 2009 Private assure. Those affected should therefore take out medical expenses insurance immediately, as a one-off premium surcharge has to be paid in the event of late taking out. This surcharge is a monthly premium for each month of non-insurance, from the 6th month of non-insurance onwards, 1/6 of the monthly premium for each additional month (Section 193 (3) VVG).
  • Under certain conditions, uninsured persons who have the private Health insurance, entitlement to the basic rate of private health insurance (PKV). The benefits of the basic tariff are comparable to those of the statutory health insurance (GKV) in terms of type, scope and amount, for details see Private Health Insurance> Basic Tariff.
  • Patient info too Contribution debts at www.gkv-spitzenverband.de> health insurance> basic principles> financing> contribution assessment.

6. Who can help?

The public hotline of the Ministry of Health answers questions about statutory health insurance and insurance coverage: Mon-Thu, 8 am-6pm and Fri 8 am-12pm, phone 030 3406066-01.

7. Statutory health insurance benefits

The joint federal committee defines the scope of services and the treatment methods recognized by the health insurance companies in guidelines.

You can find more information on certain statutory health insurance benefits under the following keywords:

Acupuncture for Chronic Pain

Outpatient specialist medical care

Follow-up treatment

Work therapy and stress testing

Medicines and bandages

Foreign treatment

Foreign protection

Companion

Vocational Rehabilitation> Services

clipping

Bonus programs

Aptitude assessment and work trials

Weaning treatment

Supplementary rehabilitation services

Travel expenses for patient transport

Miscarriage and stillbirth

Early detection of diseases

Early intervention for children with disabilities

Genetic counseling

Family doctor model

Home help

Home care

Remedies

Aids

Child care sickness benefit

Compact cure

Medical treatment

Sick pay

Hospital treatment

Artificial fertilization

Medical rehabilitation

Medical rehabilitation for mothers and fathers

Maternity allowance

psychotherapy

Basic psychosomatic care

Pregnancy childbirth

Termination of pregnancy

Contraception

Social medical follow-up care

Social pediatric non-medical services

Sociotherapy

Specialized outpatient palliative care SAPV

Inpatient hospices

Gradual reintegration

Appointment service points

Pension benefits and preventive cures

Dental treatment

dentures

8. Related links

Insurance limits

Contribution assessment limits Contribution rates

Pensioners' health insurance

Health insurances

care insurance

Patient rights


Source of law: SGB V