The German Healthcare System and Health Insurance Options
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Last updated: 17 April 2020 / by Jack Harper
A note about COVID-19: This guide is based on the general rules, but there may be some temporary restrictions in place due to the presence of the COVID-19 virus. We are keeping the situation under close review and will update our guidance as necessary.
The Healthcare System in Germany: an Overview
The German healthcare system is regarded as excellent, and it is one of the oldest in the world. It dates to the 1880s and today comprises general practitioners, hospitals and specialists, plus a range of facilities.
There is free healthcare for all German residents, funded by statutory contributions. This public healthcare runs alongside private healthcare, which can either replace or top up the state provision.
Health Policy is developed by the Federal Ministry of Health and regulated by the Joint Federal Committee.
Contributions made to the public healthcare system are based on your income, with a sliding scale of costs. Individuals on a high salary can still access public healthcare but will have to pay a much higher sum for the privilege.
The way the healthcare system in Germany is structured means that no-one has to worry about costs if they need medical assistance. As all essential services are covered by contributions to either public or private healthcare schemes, there’s no need to make a payment when you need to be treated.
Long term care is separated from health insurance in Germany, and a small amount is taken in social security contributions to cover this.
Who Needs Health Insurance in Germany
Germany expects everyone to contribute to their healthcare, including both German nationals and anyone arriving to live in the country. This includes those who are unemployed and pensioners too; the primary individuals who are exempted from paying are children who are covered by their parents.
Visitors to Germany must have some type of healthcare cover; what they need depends on how long they are planning on staying and where they are from.
Temporary visitors from the EU, Switzerland or EEA can get healthcare via their EHIC card. A European Health Insurance Card provides the holder with access to state healthcare, regardless of which EU country they are in. You should obtain your EHIC card before arriving, as you may be asked for proof.
Some countries outside the EU have a reciprocal agreement with Germany. This means that their nationals can claim state healthcare while in Germany, but only for a temporary period.
If your home country does not have a reciprocal agreement with Germany and you are not from the EU/EEA/Switzerland, you will need travel insurance to visit Germany.
Anyone planning to live in Germany should arrange either private healthcare or join the German state healthcare program. An EHIC card or reciprocal agreement is only suitable for short-term visits, not residency.
Public Health Insurance
The most common type of coverage in Germany is public health insurance, a system which is known as Gesetzliche Krankenversicherung (often abbreviated to GKV). Payment into this scheme is typically managed by the employer. They choose the public insurance company to pay into, and deduct your contribution directly from your earnings.
German employers must also pay a contribution for all their employers, increasing the total that is paid on your behalf into the scheme to 15%. If you are self-employed, you need to pay the full 15%.
Therefore many self-employed individuals prefer to pay into a private healthcare program. The only exception is for self-employed individuals in an artistic field. The government pays half of the 15% contribution under what’s known as Künstlersozialkasse .
The amount you must contribute to public healthcare is directly related to your income. If your income drops, the amount you pay will also reduce as it’s set as a percentage of your earnings.
There are approximately 100 Krankenkassen in Germany; these are non-profit-making companies that administer public healthcare. Once your employer has signed you up to a scheme, you must remain with that particular Krankenkasse for at least 18 months.
If you earn less than €5213 per month (with an annual income of less than €62,550) you will be automatically registered in the public health insurance system. You can still take out extra private healthcare insurance if you want.
Once your earnings reach €62,550 per annum, you can still access public healthcare, but your contributions will increase to the maximum level. At this level, you are known as a “voluntary user”. Alternatively, once you reach €62,550 earnings pa, you can switch to private healthcare entirely instead.
Private Health Insurance
As described above, private health insurance is not compulsory for everyone in Germany. Most people are covered by public healthcare and don’t opt for any top-up insurance from private healthcare.
In addition to the earnings cap, private healthcare is also available at any level to civil servants and the self-employed. Unlike everyone else, if you fall into one of these two categories, you can choose private healthcare regardless of your income.
Unlike public healthcare, the process of arranging private cover is a bit more time-consuming. State healthcare has to accept everyone who registers, with no exceptions on medical grounds. If you want private cover, you may need to attend a medical examination, provide proof of your earnings and answer questions about your medical history.
A private healthcare provider will charge premiums based on the risk you present. This means if you have a poor medical history, or you’re older, you will have to pay more. This is in direct contrast to the premium contributions in the public healthcare system.
If you have had serious medical problems in the past, you may not find it easy to access the private healthcare system routinely. If you are refused, you can use a system known as Basistarif.
Basistarif forces private healthcare companies to offer coverage of the same kind as public healthcare. The only problem is the cost; it is very expensive and you will need to pay for every family member, including children.
It is possible to reduce the cost of private healthcare by choosing a higher excess, or by opting to include a deduction fee, known as a Selbstbehalt. This is where you pay a certain amount of medical costs yourself every year.
Should you need to access the cover, it’s customary for you to pay the medical fees yourself and then claim them back. This isn’t the case with public healthcare; the bill is automatically paid by the state.
Private healthcare can be arranged yourself, it doesn’t need to be organized via an employer. This gives you free rein to pick the company you prefer for your cover.
Public vs Private Health Insurance: Pros and Cons
When you consider the above information, you might be wondering why anyone would prefer private healthcare over the state cover. This is especially the case when you consider that state healthcare in Germany is excellent, with more of the budget allocated than in many other countries.
However, there are pros and cons to each option; here’s a brief overview:
- Automatic enrolment with no medical exam
- Affordable for those on a low income
- Your family is covered for no extra cost
- You cannot be refused if you meet the eligibility criteria
- No need to pay any costs upfront when you have treatment
- May have a lengthy wait for an appointment
Treatment options may be more limited
Your GP will need to refer you for specialist treatment
- Quicker appointment times
- No need to be referred by your GP
- Choose your own doctors
- More time available for the appointment; it’s not rushed
- Can be cheaper if you are on a very high income
- If you don’t claim for several years, you may be given a partial reimbursement
- The best available treatment is provided
It can be easier to access English-speaking doctors
- You’ll need to pay the costs upfront to the doctors and claim the money back
- The premiums can be expensive, especially if you have had medical problems in the past
- Inconvenient sign-up process
- Not everyone is allowed to join as their primary scheme
Can be difficult to switch back to state insurance at a later date
- There is a charge for all family members, including children
In Germany, hospitals are known as Krankenhäuser and can be divided into three different types:
- Public hospitals – Öffentliche Krankenhäuser. These are run by regional and local authorities.
- Not-for-profit hospitals – Frei gemeinnützige Krankenhäuser. These are run by Red Cross organizations or the church.
- Private hospitals – Privatkrankenhäuser
Hospitals typically have spaces allocated to private and public healthcare patients. Having a private room doesn’t mean you will be in there by yourself; it means it is being paid for by private healthcare. There usually are two patients in a private room, with a curtain as a divider. Public healthcare rooms typically have at least four beds to an area with curtain dividers.
Regardless of which type of hospital care you receive, you will generally have to bring your own gowns and toiletries. Visiting hours are normally between 2-8 pm. The standard of treatment in German hospitals is overall very high.
The majority of costs in the hospital will be covered by insurance. The fees for treatment provided under a public healthcare scheme will be sent directly to the insurer. Under private healthcare, you will need to pay the fees and claim them back.
The sole exception is inpatient treatment. Under public healthcare, you will need to pay €10 for every night you are an inpatient in a hospital, up to a maximum of 28 days. You can also pay extra for upgrades, such as to a single room. Children don’t incur any fees for their hospital stays.
Not all hospitals have A&E departments, so if you need emergency care, remember to check before traveling. You can get emergency cover even if you don’t have proof of your insurance or your EHIC card. If you can’t pay all the costs upfront, they will send you a bill; you won’t be refused emergency treatment.
The numbers you might need for an emergency are:
- 19242 – emergency doctor
- 112 – ambulance | general emergency
- 110 – police
Maternity Care and Women’s Healthcare
Gynecologists provide healthcare for pregnant women in Germany. Appointments are available through the public healthcare scheme as well as via private healthcare. Gynecologists also provide a range of other female services outside pregnancy, including treatment for urinary tract infections, screenings for cancer and sexual health.
Gynecology and maternity appointments are free under public healthcare. Although they may be accessible via private healthcare, the costs may not be covered. This will depend on the terms and conditions of the scheme you opted to join so you will need to check the fine print.
Contraception costs are not usually covered by public healthcare, but will require an appointment with a gynecologist to obtain. A gynecologist must prescribe everything – from birth control pills to IUDs, and this comes at a cost.
Screening and preventing is actively encouraged in Germany, and any woman aged over 20 will qualify for free checks for cervical, ovarian and breast cancer.
Termination of pregnancy is available routinely in Germany up to 12 weeks, but it’s mandatory to have counseling first. Terminations can be carried out up to 22 weeks, but only if the mother’s life is in danger, or there are significant risks to her wellbeing.
All children are covered for free under state healthcare until the age of 18 years old. A pediatrician provides their care until they turn 12, at which point they will transfer to a regular GP. You can choose the pediatrician who looks after them in the same way that you would choose a GP.
Vaccinations are also free of charge in Germany. The national program includes vaccinations for:
- Measles, mumps and rubella (MMR)
- Hepatitis B
Pharmacies in Germany are called apotheke and don’t provide services 24/7. They will generally be open from 9 am to 6 pm, Monday to Friday and from 9 am to midday on a Saturday. Services can be available outside these hours in an emergency, but the pharmacy will provide a special address for this.
A prescription from a GP can be taken to any pharmacy. If it’s written out on a pink slip, you’ll need to make a copayment, which is usually €5-10. Not all medications are covered by the healthcare system; basic treatments such as cough medicine must be paid for in full by the patient.
A prescription on a blue slip comes from a private healthcare setting. You will need to pay the cost of the medicine in full and reclaim the money from your provider.
Unlike elsewhere, your medication will not always have written instructions when it’s dispensed. This means when your doctor tells you how much to take, you should write it down so you easily remember. Pharmacists often don’t speak English, so if you aren’t fluent in German, it isn’t straightforward to check the dosage.
Dental treatment is covered by both public and private healthcare, although with the latter, you will be able to choose from a wider range of treatments. In Germany, a dentist is known as a zahnäzte.
The KZBV website has information about dentists operating under the state scheme, and you can search for a local dentist. If you are visiting a dental surgery and want to know if they cover costs under public healthcare, look for a sign that says either or Alle Kassen or Kassenarzt.
Children aged under 18 years old will not have to pay for any dental treatment in Germany.
Dental costs tend to be quite high compared to elsewhere and even with private healthcare, you may have to pay for some of the treatment yourself. More complex work such as crowns or dentures are not always entirely covered by the scheme.
Annual check-ups, basic fillings and hygiene work are normally included for everyone.
If you find yourself needing medical care in Germany, the following words and phrases may be handy:
- Hospital – krankenhaus
- Doctor – Arzt
- Sick – krank
- Ambulance – Krankenwagen
- Patient – patient
- I need a doctor – Ich brauche einen Arzt
- I need a hospital – Ich brauche ein Krankenhaus
- I need an ambulance – Ich brauche enein Krankenwagen
- I am allergic to – Ich bin alergisch gegen…
- There’s been an accident – Es gab einen Unfall
- I’m sick – Ich bin krank
- I have a stomachache – Ich habe Bauchschmerzen
- I have a toothache – Ich habe zahnschmerzen
- I have a headache – Ich habe kopfschmerzen
- I have a sore throat – Ich habe halsschmerzen
- I’m in pain – Ich habe schmerzen
- I feel sick – Mir ist schlecht
Generally, you won’t be applauded for soldiering on when you feel poorly in Germany. If you go into work when you aren’t well, your bosses and colleagues may get very annoyed!
Culturally it’s expected that you will remain home if you are ill, even if it’s only a cold.
If you are going to be off sick for more than three days in a row, you’ll need to provide a sick note to your employer. This is called an Arbeitsunfähigkeitsbescheinigung. You aren’t obliged to inform your employer from Day 1 what the nature of your illness is.
You will need to remain off work for the full duration of your medical certificate or else ask your GP to amend it. This is because if you have been certified as unfit to work, you won’t be insured to be on the premises.
If you have been with your employer for more than six weeks, you will be entitled to receive six weeks of sick pay. This is paid at 100% of your salary. Different periods of sick leave will be added together and will count towards the six weeks.
After you have been off work sick for six weeks, you will switch to a scheme known as Krankengeld. This is part of public healthcare and pays 70% of your gross income, with a maximum of 90% of your net salary. This is payable for up to 78 weeks in any three year period for the same illness.
If you have private healthcare, the extent of sick pay cover will depend on what’s included in your plan. This can vary significantly, so you will need to check your terms and conditions.
If you have to look after sick relatives, under German law, you are entitled to take unpaid family leave, which is known as Pflegezeitgesetz. Up to 10 days of unpaid leave can usually be taken for this.
If you work for a company that has more than 15 employees, you are entitled to take up to six months of unpaid leave. You will have to give 10 days notice, but you can’t be fired for taking the leave.
Leave to look after sick children is treated separately than general family leaves. You can take up to 10 days leave for every poorly child aged under 12, up to a maximum of 25 days per year. In addition, if you are a single parent, you can take a further 20 days as sick leave to cover childcare issues. A maximum of 50 days can be taken.
Comprehensive Cover for All
Whether you choose public or private healthcare, the standard of treatment in Germany is very good.
Widely regarded as one of the best in the world, moving to Germany will provide you with access to good healthcare under a system that is clear, fair and well-structured.