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Healthcare in Germany

Hi,

how does the healthcare system work in Germany ? Is it efficient ?

What are the main differences between public and private sectors?

Is it recommended to purchase private health insurance in Germany?

Thanks in advance for sharing your experience !

Julien

There's compulsory health insurance for everybody living in Germany. The insurance (which isn't cheap) covers all medically necessary treatments at all doctors and hospitals.
There are public and private health insurers, and many of each. Some people have to be in the public system, others in the private one, yet others have a choice. Rates are different in both, and can be costlier or cheaper in each depending on your actual situation. The rules are so complicated that even dedicated professional insurance advisers (and in fact the insurers themselves) often don't understand it. Consult as many as you can if you have to get insured here - never trust the first opinion you hear!
Medical standards are good, but if you're not satisfied just change to another doctor.

Thanks for your contribution beppi!;)

Harmonie.

I´d like to add a point here: non-EU freelancers/self-employed coming to Germany and who haven´t been a member of an EU public health system for the past 12 months or for two of the past five years CANNOT get into German public health insurance ( geseztliche Krankenversicherung ). It is increasingly difficult, too, if you haven´t got around to signing up for public insurance within three months of arrival, to get accepted. Likewise, it is increasingly difficult to get into German private insurance as a newcomer, especially - but not only - for non-EU citizens. This is due to the business risk the insurers see. Why? Because once in, you cannot be thrown out - even for non-payment - due to the obligation to be health insured!!!!

Thanks for the tips john g!;)

Some additional information to what john g. wrote above:

Health insurance is COMPULSORY for everyone (legally) staying in Germany, and the rules, although damn complicated, ensure that everyone is accepted into one of the two systems (public or private).
To my knowledge foreigners (regardless if freelancers or not) who were never in a EU health insurance can get into the public insurance (which costs €280-600/month for self-employed, depending on income, employees pay roughly half of this).
If they cannot, private insurers have to take them at a so-called "basic tariff" (which costs approx. €600/month for freelancers, €300/month for employees). They are not allowed to reject an application or add risk premiums for pre-existing conditions etc.
Of course many insurers still do reject for opaque reasons (probably because they don't want to lose money on risky cases) and it is difficult, but not impossible, to get your rights - especially if you don't know them.

Another addition: Insurers cannot throw you out for non-payment, but they can stop paying for all but life-threatening medical conditions if you don't pay.

Edit: The above reflects current rules. They change all the time, so please consult an expert!

FAQ
German Health Insurance

Newcomers to Germany usually find it difficult to understand how and where to get health insured.
It is a very complex issue and everyone needs an individual solution.

Who can or must join a public“Kasse“ or a private insurance provider?
Here is a summary of the main points:

    Employed and earning between € 401 and € 4,237 per month – mandatory public
    Employed and earning less than € 400 per month –  private or public
    Employed and earning more than € 4,238 per month – choice of public or private

    Self-employed/freelancer: EU Citizens and non EU Citizens arriving in Germany from another EU State where they have been publicly insured can choose between public (voluntary member/freiwillig) or private.
    Self-employed/freelancer: non EU Citizens and EU Citizens arriving in Germany from outside the EU and who have not been in an EU public system must have private health insurance.

    Spouse earning over € 375 per month needs their own health insurance and cannot be co-insured in public health insurance.

    Unemployed: if eligible for unemployment benefit, public health insurance is provided.
    Unemployed: if not eligible for unemployment benefit (e.g. newly arrived in Germany with a non EU passport), private health insurance is mandatory.

    Children: this depends...
Spouse A is privately insured and spouse B is in the public system.

Scenario 1: spouse A earns more than spouse B so the children have to go with private insurance OR pay extra for voluntary membership of a public Kasse.

    Scenario 2: spouse B earns more than spouse A so the children can EITHER be co-insured     for free with the public insurance OR choose to pay for private insurance.

    Scenario 3: spouse A and spouse B earn the same: then the rule in scenario 2 applies.

Here are the rules! I´m afraid beppis is wrong here: self-employed non-EU arriving in Germany from a non-EU country cannot get into public insurance.
I´m afraid the problem also affects private insurance: most private German providers do not want ANY foreigners now if they haven´t already been in Germany for 2 years, already insured and with a good Schufa.

Sorry, I might have been wrong.
Fact is the rules (of which above is only an excerpt and there are exceptions to each!) are too complicated for a layman - and in fact most "experts" - to fully understand.
The last paragraph, about private insurers' dislike to take foreigners, is probably true, but according to the rules they can't reject. This doesn't mean they won't try or that it is easy to enforce your rights (it isn't!).

Well, beppi, I agree entirely with you that there are exceptions - it is madness here with conflicting rules and interpretations!!!
Re foreigners: when you say they can´t reject you, you are referring to the Basis tariff for the sick and virtually uninsurable ( heart attack last week etc!!). But they will fight tooth and nail not to let you in ( and remember: impossible anyway without a long term visa ). The other problem: because you can´t be thrown out ( even for non-payment ), they are even more critical re who they´ll take: so they want a Schufa ( but that is not available until you´ve been here six months ), non-EU: 99% impossible without a long term visa in place, EU citizens: check up, Schufa and....most don´t want you anyway- too risky because they know c.150,000 private health insurance contracts are running with people behind with their payments...PLUS: if you´ve been here a few months already without health insurance, you are considered an even greater financial risk...why didn´t you sign up earlier? No money??? etc etc.....it´s tough, though a solution is possible in many cases. This is a difficult topic NOT to be taken lightly by people considering coming here or already here and not already health insured!!!

I agree completely!

This is really great information. I have one question that I think you folks might be able to answer. I will be retiring in a couple of years and plan on moving to Germany if the finances work out. What would you say I should plan on for medical costs for myself and my wife. She will be 71 and I will be 69 probably when we move. It's really hard trying to find the answers to this. Any other advice on health care in Germany would be most appreciated.

Thanks,
--Gary

Hello Gary! Are you both American citizens with no German passports?
You have, otherwise,  zero chance of either public or private health insurance in the German system.
The only possibility is a legal international health insurance ( no American ones are accepted ). Budget with around 500 euros per person per month with, say, an annual deductible of 1200 euros. Expect to have to sign up for German nursing care, too - at extra cost.
Plus: the authorities would want to see other assets - proof you can support yourselves..pensions, life insurance etc.

Please don´t shoot the messenger! Why Germany?

Best wishes
John

Thanks John,

That's a big help. I had seen many different versions, but none so directly stated. Yep, we're both U.S. citizens with no German passport. Why Germany? We lived in Heidelberg in 1969-70 and fell in love with the country. I've been back a few times. We both went back last summer and it was like going home. It's probably the first choice as we think about moving where there's a different lifestyle and world outlook. There are also lots of universities and other facilities where I could probably go teach a course or two if I got bored. I teach computer science at a university in MA now.

The healthcare issue is, a big one since from what you say would take about $10-15K/year for the two of us. That's not chump change. :)

We have other choices that we're looking at as well, including Italy (still in Europe and that means ease of travel to interesting places), and Ecuador (great bargain and interesting places, but more hassle for quick jaunts to other interesting places).

--Gary

Well, Gary..it wasn´t a wonderful piece of news from me..just the reality.
I cannot speak for Italy but you may find they have health insurance regulations, too, for Americans. European countries as a whole are getting stricter on visa requirements and health insurance.
Perhaps you could google some things eg health insurance requirements for Europe, or Germany or Italy or whatever.
Ecuador: sounds great and apparently cheap..again you might try googling there, too...
Hey, I´m no spring chicken, either..I´m 60 ( and a half! ).
I wish you every success in enjoying the next 20-30 years in good health wherever you end up.
Cheers
John

Hi,

In order to help expats and soon-to-be expats, we would like to invite you to share your experience on this topic, with updated info on the healthcare system.

Thank you in advance,

Julie
Expat.com Team

Hello Julie!
I haven´t been here for a while but  am able and happy to provide any information you and visitors to the site would like to know.  I´ll give it some thought and reply later today.

Best wishes

John

Right then, Julie! I´ve gathered together some information which I hope will be of use to readers on your forum: key health insurance data for Germany in 2015.

I´ll start with employees: an employee earning under 54,900 euros a year MUST have German public insurance and can include his/her spouse and children at no extra cost IF the second spouse is either not working or earns under 405 euros a month as a freelancer OR with income from any other worldwide source (dividends, rented out properties etc ). If the second spouse has a so-called Mini-job ie earning exactly 450 euros a month, he/she can stay co-insured with spouse A.

If the second spouse is an employee earning over 450.01 euros a month, he/she must take out their own public insurance with employer contributions, of course.

Freelancers  of any nationality new to Germany and who have been publicly insured in another EU State for at least the previous ONE MONTH  ( used to be 2 years ) before coming directly to Germany CAN apply as a so-called voluntary member/freiwiilliges Mitglied  for German public insurance as long as they are granted a minmum of a one year residence permit. The same applies to non-working people who have just come from a fellow EU public insurance system eg homemakers, people living off earnings.

Prices for self-employed people in the public system are dependent on income ie 14.9% of gross earnings with a minimum contribution of c 150 euros a month and capped for higher earners at c. 720 euros a month!!


Private health insurance:

Available to employees if wished but only if earning over 54,901 euros a year. If you´re from a non-EU State, you will generally be required to submit a copy of your work contract ( which should be unrestricted or at least 3-5 years ) and equally show a residence permit with at least 3 years to run...at least...case by case, though. A medical check up is required as German insurers do not accept foreign health reports.

Available to freelancers with any income ( though it would have to be, say, at least 2,000 euros a month on average..otherwise you are considered a risky client who may default  on payments ). Needless to say, non-EU citizens will find it difficult to get private insurance in the German system as they may either not have an existing and approved very long residence permit ( usually at least 5 years required ) or don´t have the chance to prove their creditworthiness (the Schufa check ).
The price: it depends on age, state of health and the tariff wanted eg general hospital or private hospital treatment etc. It does NOT depend on income.

Non-EU citizens coming to Germany from outside Europe as freelancers and wanting a work permit / visa etc can NOT apply for German public insurance NOR will 99% of private German insurers accept an application.

Catch 22!!

Now, it is an urban myth that freelancers/self-employed in Germany must have German insurance. Even German insurance companies think that!! It is NOT true. The insurance company can be from elsewhere in Europe and it is legal to take out one of their policies as long as certain minimum conditions are met in the policy and, very importantly, as long as the insurance company is registered with the German Financial Supervisory Board known as BaFin.

This is often the ONLY solution for a non-EU freelancer eg musician, artist, American English teacher wanting to do EFL/ESL work in Germany etc. Important: the non-German provider MUST be able to help you with a signed and stamped document in German called a Bescheinigung to show the Ausländeramt the validity of your insurance. Many well known providers eg BUPA, do NOT offer this so it´s useless to take out their insurance.

One final thing: an artist, musician etc from outside the EU cannot get public insurance at first BUT can take out a legally acceptable international insurance first, get the residence permit and THEN apply for the German Artists Insurance known as the Künstlersozialkasse (KSK)..it can take many many months and the application may be unsuccessful but,  IF accepted , you then become their employee by a quirk of law and get nearly half of the monthly payments subsidized by the KSK! This is very useful if you have a serious pre-existing condition excluded by a private insurer.

Best  regards to all
John

Thank you so much for the info John! Very helpful.

I get quite a lot of emails/phone calls from non-European but also European artists artists asking about visas and health insurance so I thought I´d post here on what this means for them.

Basically, the German State introduced the Artists Social Security Law in 1983 for self-employed/freelance artists and publicists (including writers, journalists, editors ) to make sure they were included in the statutory social insurance system.

Artists and some other professions MAY apply to join the KSK (the short form for Künstlersozialkasse ), which would enable access to German public health insurance ( gesetzliche Krankenversicherung ). You have to submit your application yourself directly to them as insurance agents and even independent insurance brokers in Germany have no say in the matter.

Which criteria need to be met?

All applicants must be working professionally in accordance with their typical occupational profiles. For instance, a music teacher ( but not if an employee at a school ) ...only self-employed/freelance .. may well  be regarded as an artist  but a cabinet maker is considered a craftsman and not an artist!

Sometimes, there are grey areas; so, for example, other factors come to the fore: membership of an artistic association, proof of having held art exhibitions. Income from such activitites must be above the minimum income limit of 3,900 euros per year ( after expenses/costs ).

What are the benefits?

You are considered an employee of the KSK and therefore get into German public health insurance with the employer, so to speak, the KSK, picking up its share of the monthly contributions - just as with normal employees - though you actually remain self-employed/freelance.

Downsides:

it is income related as with employees and income from gigs, royalties and all the rest of it are considered in the assessment of the price of your health insurance.

PLUS: you have to pay just under 10% of your gross income into the German statutory public pension plan ( gesetzliche Rentenversicherung )..this may not be in your interest if you don´t intend to stay in Germany for , say, three or four years only - the money is gone!! Nothing for you!

It is, however, a great advantage for you to have public insurance IF you really have a chronic illness/pre-existing health condition which would either make it impossible to choose private insurance if wished or which would lead to a possible/probable exclusion of your illness from treatment paid for by the insurance company.

It´s not a perfect world.

Best regards

John

I came over from the states last spring, and have been trying for a year to find affordable health care insurance. I am working part time for the U.S. Army and currently have health insurance through work, but am having some health issues and need to stop working. Because of my age (I am 75), health insurance that I can afford is simply not available. Expat policies do not cover people over age 74, private insurance would cost me 500-800 Euro per month and I am not eligible for  German public Krankenversicherung.

I was naive. Now I must pay to ship my household goods back to the states and sell my house here.

The health care system in Germany is generally good. There is some difference between the private & public sectors. It used to be that if you earned above a certain sum you automatically went to the private health insurance but not any more. You also get appointments with specialists a little faster & the meds do not have to be generic as you pay & it does not affect the doctors budget..

trufflelily Today 10:27:21
I came over from the states last spring, and have been trying for a year to find affordable health care insurance. I am working part time for the U.S. Army and currently have health insurance through work, but am having some health issues and need to stop working. Because of my age (I am 75), health insurance that I can afford is simply not available. Expat policies do not cover people over age 74, private insurance would cost me 500-800 Euro per month and I am not eligible for  German public Krankenversicherung.

I was naive. Now I must pay to ship my household goods back to the states and sell my house here.

I see CIGNA has inserted an ad. I purchased CIGNA for a few months until I started work with the Army. The premium was $525 per month with, if my memory is corredt, $1500 or 1700 deductable, and they excluded my only medical problem, arthritis as pre-existing.  That is a lot of money, and basically useless except for catastrophic.

This isn't true! I'm an Australian freelancer and I am insured by BARMER GEK, gesetzliche krankenkasse. The reason public insurance (initially) will refuse to take you as a freelancer is because you ARE already insured if you're working legally. You can't work without insurance. And the state insurance won't double insure someone.

BUT with enough questions and answers you can manage it. Call around, go in person, state your case. If you do go private, and there's ups and downs to both, you can NEVER go back to state if you change your mind.

By the way, when I first arrived in Germany I was totally covered for all emergencies by Travel Insurance Direct, but they did NOT cover me for basic and routine medical. If you're living in the country, its better to have an actual German insurance membership.

missbeesy :

This isn't true! I'm an Australian freelancer and I am insured by BARMER GEK, gesetzliche krankenkasse. The reason public insurance (initially) will refuse to take you as a freelancer is because you ARE already insured if you're working legally. You can't work without insurance. And the state insurance won't double insure someone.

BUT with enough questions and answers you can manage it. Call around, go in person, state your case. If you do go private, and there's ups and downs to both, you can NEVER go back to state if you change your mind.

Good for you, missbeesy! You were lucky. Most public insurers will not have insured you unless you have just come from  a public system in a European country. This is only theoretically possible with a public insurance company which is looking for clients and willing to bend the rules under the Paragraph 13 rule. But not if you claim you are self-employed but living off savings only. They will want proof of the work visa after that.
It is, however, still highly unusual and i hope it doesn´t come back to bite you.

Just one more point: I agree totally with your view about pros and cons of public v. private insurance but you are wrong that you can never change to public insurance if you start with private insurance. If you become an employee earning over 450.01 euros a month, you MUST change to public insurance  if your income is under 54,900 euros a month.
IF your income is over that, you can either choose fully comprehensive private insurance OR change to voluntary membership of public insurance if it´s your first employee job in Germany

By the way, are you married to an EU citizen with public insurance? This may have been the factor getting you into public insurance : first co-insured and then striking out into self-employment and voluntary membership of public insurance? I´m trying to understand how it was possible!

john g. :
missbeesy :

This isn't true! I'm an Australian freelancer and I am insured by BARMER GEK, gesetzliche krankenkasse. The reason public insurance (initially) will refuse to take you as a freelancer is because you ARE already insured if you're working legally. You can't work without insurance. And the state insurance won't double insure someone.

BUT with enough questions and answers you can manage it. Call around, go in person, state your case. If you do go private, and there's ups and downs to both, you can NEVER go back to state if you change your mind.

Good for you, missbeesy! You were lucky. Most public insurers will not have insured you unless you have just come from  a public system in a European country. This is only theoretically possible with a public insurance company which is looking for clients and willing to bend the rules under the Paragraph 13 rule. But not if you claim you are self-employed but living off savings only. They will want proof of the work visa after that.
It is, however, still highly unusual and i hope it doesn´t come back to bite you.

Just one more point: I agree totally with your view about pros and cons of public v. private insurance but you are wrong that you can never change to public insurance if you start with private insurance. If you become an employee earning over 450.01 euros a month, you MUST change to public insurance  if your income is under 54,900 euros a month.
IF your income is over that, you can either choose fully comprehensive private insurance OR change to voluntary membership of public insurance if it´s your first employee job in Germany

By the way, are you married to an EU citizen with public insurance? This may have been the factor getting you into public insurance : first co-insured and then striking out into self-employment and voluntary membership of public insurance? I´m trying to understand how it was possible!

It's no picnic getting the Gesetzliche to take you. That much I'll admit. I was covered by travel insurance direct (backed by Allianz) and that was enough for me to work. My initial freelancer visa was for a year. So by the time I had worked it out with BARMER I was faced with 2 options: either a) back pay a full year (as one year is the minimum they will insure) or b) wait for a new visa to be approved.

While I did marry a German with public insurance, this had very little to do with my application. The main stumbling block seemed to be that I was already insured to stay and work in the country and they didn't want to double insure. It wasn't until a couple of back and forth emails that I managed to clarify what I wanted and why. Some were more willing to take self employed than freelancers, many flat out said at first they weren't interested in freelancers. I kept calling anyway.

Marriage to a German does in some ways benefit you, as it demonstrates a longer commitment to the country and provides you with a translator when the vocab gets really tricky. Neither one of these factors could not have been negated with a helpful friend.

And as far as the idea that you can't go back to public after being insured with private, that's something I heard from the agent who worked out my insurance, my international colleagues, a head administrative nurse, and many other people. So if there is a new (or even old) rule about it, its not well known.

And everyone I know with private health insurance insists that they are often over treated, over diagnosed, held in hospital longer as there is the feeling that they are being milked for their insurance. And there's quite a few of these people at my workplace. The most I've ever paid for a treatment that wasn't covered by state was 107 euros for a scan. So I don't find that to be too hard to bear.

Thanks John and everyone, this has been very enlightening for me. An a Non-EEU resident  in Germany, iv gone through alot of confusion over this matter...I eventually got into the public system!

We were looking at PVT for my husband and Public for me and the children, however we changed our minds when we asked a question.

If hubby was on PVT and I lost my job, we would have to convert all of us to PVT as once you are on PVT you can only change back to Public, if the PVT person lost their job.

My main comment is it is horrendously expensive, even compared to the NHS

I was with public while employed but now I work for myself I have to be private and the cost is so astronomical that I am looking at options to move elsewhere - really, the healthcare cost is ludicrous.

If using it then the doctors, dentists etc. all have wonderful equipment - which may explain the cost - and use it at every chance they have.. .charging it back to the insurance and putting up the premium.

The doctors etc. are no  better than the NHS and just as prone to mistakes (I have examples from my families experiences).

All in all I would point out that the proliferation of 'companies' providing the 'insurance' means many many more 'snouts in the trough' than is needed with profits all around. This is clearly less efficient than it could be (and yes, before someone states the obvious the NHS has hundreds of thousands of pen pushers it would do better without).

The last real issue for me is the turn up at a doctor or hospital with your arms and legs hanging off and they want to process your health insurance card before they do anything else... horrendous.

There are plenty of great things in Germany, the health service though is not one of them.

You didn´t have to switch to private because you became self-employed, dhitchman , You could have stayed as a voluntary member of public insurance but I assume private worked out cheaper than public without the employer contribution OR you  were given false information.

Sounds like I was given a bum steer then... I will have to double check though I suspect it is too late for me.

Like the UK the tax, benefits and health care system here is stupidly complex... designed by committee more interested in creating paper shuffling jobs than doing something useful.... just like the UK in that respect :(

What options does a 77 years old retired Canadian have to get a health insurance that is accepted by the German authorities to issue an 'Aufenthaltserlaubnis'?  I am insured in Canada (state health insurance). I came on a tourist visa 3 months ago and have contacted the 'Auslaenderbehörde' to get an appointment, in order to apply for an 'Aufenthaltserlaubnis'. My children are both German and live in Germany.
My tourist visa got automatically extend because of my appointment.
I was asked to bring some documents, among them the 'Auslaenderbehörde' asked me to get a German health insurance or an equivalent to it for my application for an 'Aufenthaltserlaubnis'.

The compulsory health insurance companies and the private ones ( gesetzliche und private Krankenkassen) all told me that I would need a residence title for specific purposes (Aufenthaltstitel) in order to get a health insurance from them. With a tourist visa I cannot get an insurance with them.
So here is my question: Where and how can I get a German health insurance or an equivalent insurance in order to be able to apply for an 'Aufenthaltserlaubnis'? And how much would it cost?

Thank you and regards

If I understand you correctly, you are applying for a residence permit and a German health insurance is required for that.
Since you cannot join one BEFORE you have the residence, you need to get a letter from one of the insurers (public or private scheme) that they will admit you once you have it.

Dear Beppi! Thank you! Yes, you did understand me correctly.
In fact I got a letter from a public one and I hope that this will do the work.
I also was told at the Auslaenderbeauftragte, that I should get a letter from the visa authorities that they will admit me a resident permit if I get an insurance. :))
Catch 22

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