Moving To Germany Series – How To Arrange Health Insurance in Germany
In this post I look at how to arrange health insurance when you m,ove to Germany to liarrive Berlin.
Interested in moving to Berlin?
You’re not the only one.
Some 50,000 people a year are now making the move to Berlin, from othve and work. er regions of Germany – as well as from all parts of the world.
It’s not hard to see why.
Berlin is quite simply Germany’s most energetic, lively – and most happening city.
Check out my new series all about moving to Berlin – and how to get the best out of living and working in Europe’s coolest and most exciting capital.
How to Arrange Health Insurance in Berlin
The one thing that has to be said about the German health system is that it’s complicated.
Or to put it more precisely, the health insurance system that pays for it is complicated.
How Health Insurance Works in Germany
Unlike Britain, Germany does not have a free national health service.
In Germany everyone is required by law to have health insurance – and this is expensive. In fact for many people it’s the biggest single living cost item after paying the rent.
And it has to be German health insurance, not insurance from overseas. This is a condition of residence for everyone in Germany, even for EU citizens.
This is because by law German health insurance has to include long-term care provision insurance in their tariffs and coverage. Overseas insurers do not normally meet this legal requirement.
Only Staying In Germany For Less Than 90 Days?
If you’re only staying in Germany for less than 90 days and not intending to take up residence or work there, then you are not required to take out German health insurance.
But for everyone else coming to Germany to live, work or study, you are required by law to have valid health insurance.
Although German health insurance is not cheap, health care provision in Germany is at least of a high standard.
In fact, some consider the level of provision to be overly generous and this is certainly one reason why German health insurance costs so much.
Germany Has Two Health Insurance Systems
There are basically two health insurance systems in Germany.
A public system, called the Gesetzliche Krankenversicherung or GKV which is operated by a number of autonomous non-profit-making insurance funds known as Krankenkassen or sickness funds.
And a private insurance sector or Private Krankenversicherung or PKV, provided by competing commercial for-profit companies who sell health insurance policies to higher income earners, self-employed, and freelance people.
Hospitals, doctors, and clinics mostly (though not always) serve both publicly and private insured patients – there is no such thing as a “public hospital” or “private hospital” as in the UK or US.
However, the type of insurance you have does to some extent determine the standard and extent of services you will be able to use.
In Germany you can only take out private insurance if you earn over a certain amount, or are freelance or self-employed.
Otherwise you will normally be enrolled in one of the public Krankenkassen or sickness funds.
Public Health Insurance in Germany (Krankenkassen)
Most people in Germany are insured with one of a number of non-profit making sickness funds known as Krankenkassen.
The Krankenkassen are all tightly regulated by the government in terms of provision, conditions of insurance, and what they can charge.
The premiums for Krankenkasse insurance currently tend to be around 15 percent of your gross salary, half of which is paid by your employer. Insurance premiums are paid every month and are deducted from your salary by your employer who is responsible for forwarding them to your Krankenkasse.
If you become unemployed the government employment office or Arbeitsagentur pay your Krankenkasse premium in full.
To fully understand Germany’s health insurance system, there are two long German words you will need to get to know: the Versicherungspflichtgrenze or Compulsory Insurance Limit, and the Beitragsbemessungsgrenze or Contribution Assessment Limit.
The Compulsory Insurance Limit or Versicherungspflichtgrenze
If you are an employee with an income under a certain amount, known as the Versicherungspflichtgrenze or Compulsory Insurance Limit (sometimes more simply called the Einkommensgrenze or Income Limit), and currently set at 54,900 Euros per year, then you are required by law to be compulsorily insured with a public Krankenkasse.
In 2016 this income limit will be raised to 56,250 Euros.
This is also known as being “insured by law” or compulsory insured – gesetzlich or pflichtversichert.
If you earn over the Versicherungspflichtgrenze or if you are self-employed or freelance, then you can leave the public Krankenkasse system and take out a health insurance policy with a private insurance company of your choice instead.
Alternatively, you can opt to remain with the Krankenkasse system instead of switching to private insurance. In this case this is known as being voluntarily insured (freiwillig versichert) under the public system.
If you are self-employed or freelance, then you have to pay the entire Krankenkasse or private insurance company premium yourself.
The Beitragsbemessungsgrenze or Contribution Assessment Limit
There’s a top contribution limit for Krankenkasse premiums, known as the Beitragsbemessungsgrenze. or Contribution Assessment Limit.
If you earn more than this amount, you will not pay more than the current insurance percentage rate for that year’s top contribution limit.
This contribution limit is set by the government every year. The limit for 2015 is 49,500 Euros. For 2016 the Beitragsbemessungsgrenze will be 50,850 Euros.
Note that there are two different income limits here – the Beitragsbemessungsgrenze or Contribution Assessment Limit, and the Versicherungspflichtgrenze or Compulsory Insurance Limit – and for two different purposes.
The former defines an upper cap on the level of Krankenkasse contributions higher income earners have to pay. This is so as to not over-burden higher income earners with too-high health insurance premiums (though the premium levels are in any case already high enough).
The latter is used to define the income level beyond which people are permitted to freely quit public health insurance and opt instead for private insurance.
For many years there was just one income limit which was used for both purposes, but this has since been replaced by two separate income limits at different rates for these different purposes.
The Biggest Public Krankenkassen in Germany
The largest Krankenkassen in Germany are the AOK, the Barmer and the Techniker Krankenkasse.
There are also many other Krankenkassen too numerous to list here, such as the LKK or Landwirtschaftliche Krankenkasse, the BKK or Betriebskrankenkasse, and the IKK or Innungskrankenkasse.
The AOK or Allgemeine Ortskrankenkasse has traditionally been the “default” Krankenkasse for employees. Traditionally all these different Krankenkasse grew up to meet the health insurance needs of specific occupations, industries, or specific parts of the country.
However, most of them have abandoned these restrictions and they now offer membership to pretty well anyone regardless of occupation.
The main Krankenkasse of choice for many people still tends to be the AOK, followed by the Barmer and the Techniker or Tk Krankenkasse.
In particular the Techniker has enjoyed good reviews in recent years and many people consider them the best Krankenkasse.
The Techniker are at www.tk.de
The Barmer are at en.barmer-gek.de I used to be insured with them at one time before I switched to private insurance.
The AOK are at www.aok.de
You can start the registration process on their websites, but you will in most cases also have to go along to one of their branches in person to complete the formalities.
All these three Krankenkassen have websites in English.
There is some element of competition between the different Krankenkassen, but this is limited as the system is tightly regulated by the government.
There can be small differences in premiums of around 1-2% or so between different Krankenkassen and from one year to another.
There is also some minor variation in the level of provision. Mostly this is limited to provision of non-essential supplementary services such as courses and information seminars, workshops, phone hotlines etc.
Private Health Insurance in Germany or Private Krankenversicherung (PKV)
The private health insurance system in Germany is also fairly tightly regulated by the government, though it has more freedom than the public Krankenkassen.
If you earn over the Einkommensgrenze (Income Limit) or are freelance or self-employed then you can opt for private health insurance instead of being insured by a Krankenkasse.
However, children are not normally covered by adult private health insurance policies as they are with the Krankenkassen. You have to take out an additional policy for this.
So if you have children or are intending to have children at some point, or if you’re unsure about your future level of income, then it may be better to remain in the public Krankenkasse system.
Health Insurance for Students in Germany
Public Krankenkassen in Germany offer much lower health insurance rates to students.
If you’re going to be a full-time student in Germany then you will usually be able to obtain insurance at a lower rate with the Krankenkassen.
As well as being a full-time student at a recognized institute of education, you must also be under 30 years of age to be entitled to student health insurance.
The current monthly Krankenkasse premium for students is currently between around 65 and 70 Euros per month.
Health Insurance for Artists in Germany
Strange as it may seem, but artists in Germany are treated as a protected species at least in one respect.
If you’re officially classified as a professional full-time freelance artist, then you can join a special insurance fund open only to artists, known as the Künstlersozialkasse or KSK. Insurance premiums are much lower with the KSK than they are with other Krankenkassen.
The problem with the KSK is the process of actually getting recognized as a bona-fide artist in order to be accepted for KSK insurance.
This can be a bureaucratic process as the government want to make sure the KSK is not misused by “pseudo-artists” attempting to use this loophole to escape the costly mainstream Krankenkasse and private health insurance in Germany.
You will need to satisfy the KSK with your artist qualifications, work and portfolio and also proof that your artistic work is your main source of income, and possibly also proof of recognized training in your respective artistic profession.
My advice: If you’re a bona-fide artist who can meet their requirements, then it can be worth applying for health insurance with the KSK. But you will need plenty of proof acceptable to the KSK.
For more information on conditions and tariffs (in English) see www.kuenstlersozialkasse.de/wDeutsch/download
The KSK are at www.kuenstlersozialkasse.de
Coming to Germany from the UK? Get An EHIC Card Before You Leave
The EHIC or European Health Insurance Card is a scheme which allows UK residents to obtain free health insurance coverage in Germany and other EU countries for a continual period of up to 90 days from their date of arrival in Germany.
Officially the EHIC is only meant to be used by tourists or short stay visitors, and not by people who are intending to stay in the country. But that aside, you might find that it comes in useful in the event of needing any medical provision during the first few months of your arrival.
Visit www.nhs.uk/NHSEngland/Healthcareabroad/EHIC/Pages/about-the-ehic.aspx for more info. This is the official government NHS link.
Be aware there are a number of privately run sites who offer to arrange the EHIC for you for a fee. There is no need to use any of these sites. The EHIC is issued free of charge to UK citizens. There is no fee involved if you apply for your EHIC from the official government site.
My advice: If you’re coming from the UK, make sure you order your EHIC in the UK before you leave. This entitles you to free health care in Berlin for up to 90 days on arrival.
Private Health Insurance in Germany Can Be Cheaper Than Public
Strange as it may sound, but private health insurance in Germany can be cheaper for many people than public health insurance.
If you earn over the current Versicherungspflichtgrenze– or if you are freelance or run your own business, then you are permitted to switch over to private health insurance or Private Krankenversicherung (PKV) as an alternative to the public Krankenkasse system.
Private Health Insurance Premiums in Germany are Based On Age and Health
Whether private health insurance in Germany does actually work out cheaper depends upon your individual circumstances.
Private health insurance in Germany is not charged according to your income, but rather on such factors as your age, any pre-existing medical conditions, and whether or not you wish to insure any dependents (unlike for the Krankenkasse insurance, with PKV you pay additionally for each dependent), as well as the level of coverage that you want.
For private health insurance in Germany, as elsewhere, it goes without saying: the younger and healthier you are, the lower your premiums will be.
German Private Health Insurance Premiums Are More Stable than in the US and UK
Private health insurance in the UK or USA tends to be cheap for younger people, but prohibitively expensive for older people.
However in Germany, private health insurers are required to keep premiums relatively stable throughout the lifetime of the policy.
To do this they set the initial starting premium relatively high. But at the same time, the premium will increase in the future largely only in line with inflation.
In Germany, private health insurance schemes are required to build up reserves for their clients to cover the costs of medical care as they get older.
This means that whilst premiums for German private health insurance do indeed rise over the years, they will at least not rise at the rate of anything like private health insurance premiums in North America for example.
Also if you terminate a private insurance policy you are now entitled to have your accumulated reserve credited to your replacement insurance policy with your new insurer.
German insurers are also not permitted to exclude pre-existing medical conditions unlike in the US – although they are allowed to charge higher premiums for this.
If You Leave Public Insurance, You Can’t Easily Return
Another important point to bear in mind is that if you move from the public Krankenkasse insurance to take up private health insurance, then under German law you’re not normally permitted to return to the Krankenkasse system.
It IS possible in some limited circumstances to return to the public Krankenkasse system after being privately insured.
For example, if your annual income should fall below the level of around 53,000 Euros per annum (this level is adjusted yearly).
And provided also that you are under the age of 55. Once you reach the age of 55 you aren’t allowed to return to the public health insurance system at all, regardless of income level.
This is to stop people taking advantage of cheaper private insurance when they are younger or in good health and returning to public insurance when they are older or in bad health.
If you’re privately insured, then you pay for all your medical services at the point of use. You forward the bill on to your insurance company and they reimburse you according to your individual PKV tariff.
Private Health Insurance in Germany Buys You Better Service
Private health insurance gives you more freedom to choose your doctor, particularly when it comes to specialist consultants and hospital treatment. And you’ll get to enjoy a more responsive and overall better level of service.
I’ve even come across some doctors who maintain separate entrances or waiting rooms for their private patients so they don’t have to rub shoulders with the Krankenkassen patients, although this seems like taking things a little too far.
Beware of International Expat Health Insurance When in Germany
As an attempted workaround to the high costs of private health insurance in Germany, some expats have been tempted to take out private health insurance schemes for expats run by companies outside Germany, such as the UK’s BUPA, AXA PPP or IntraGlobal. These providers tend to charge lower premiums than the German PKV schemes.
However, the German authorities do not generally recognize these policies as fulfilling the requirements for health insurance in Germany.
So if you are looking to take out private health insurance in Germany it’s essential to first make sure that you select a policy that is recognized by the authorities.
For a PKV policy to be recognized in Germany it has to be issued by an insurance company licensed by Germany’s BAFIN federal regulatory agency.
The insurance must also offer full coverage for outpatient and inpatient treatment with a maximum excess option of 5.000 Euros per year. And for women, it must also include coverage for pregnancy and maternity.
Also, recognized PKV policies must contribute to a long-term capital fund designed to keep policy premiums stable throughout the lifetime of the policy. They must also contribute to Germany’s long-term nursing care public insurance scheme known as “Pflegeversicherung”.
Note that most international expat health policies DO NOT fulfill these requirements and so are not recognized in Germany.
If the authorities determine at a later date that your policy is not valid, then you can be required to make additional back payments and this can turn out to be very expensive.
It doesn’t take a mastermind to suspect that the BAFIN and German private insurers are opposed to these cheaper international insurers competing in Germany in order to prevent them encroaching upon their very lucrative national market, which at the moment they have to themselves.
My advice: For the time being it’s probably best to avoid the international expat health insurances whilst you are in Germany and insure yourself with a health insurance policy that is officially recognized in Germany.
Supplementary Private Health Insurance
Anyone who is publicly insured with a Krankenkasse is free to purchase supplementary “add-on” health insurance from a private health insurance company if they wish.
Private Health Insurers in Germany
The biggest German private health insurance provider in terms of number of customers is the Debeka, followed by the DKV or the Deutsche Krankenversicherung.
In third place is the AXA in Germany which might be worth looking at, though reports vary about their customer service. Some people – and that includes myself – have had bad experiences with AXA.
I’m currently looking for an affordable and viable alternative to AXA. But affordable health insurance providers with good service are thin on the ground in Germany.
One good private health insurer I can recommend from my own experience is LKH or Landeskrankenhilfe.
I used to be insured with the LKH and always found their service to be efficient. And one thing I especially approved of with the LKH is that although they are a private health insurer, they recycle their profits back into their insurance system to help keep premiums down. So the LKH are a little different to the average private health insurance company.
However in recent reviews LKH premiums were found not to be among the cheapest.
My advice: The most convenient way to find a suitable private health insurer to suit your needs and your pocket is to use the Check24.de comparison site.
Note that comparing private health insurance policies is not a simple process. As well as the considerable variations in premiums, the final cost also depends on the level and extent of coverage, as well as your age and standard of health.
This makes direct comparisons between insurance tariffs of competing companies difficult – which is to the advantage of the insurance companies.
To compare different private insurance policies visit Check24 at www.check24.de/private-krankenversicherung
How German Health Care Works
German health insurance, both public and private, also covers dental treatment.
However there are some additional direct charges for dental treatment for Krankenkasse patients that are not met by the Krankenkassen. Insurance does not usually cover glasses, contact lenses or corrective eye laser surgery.
You receive a Versicherungskarte or Insurance Card from your Krankenkasse. This is a chipcard containing your membership data (not health records – these are held separately by every doctor or other medical service you consult).
You show your Versicherungskarte to the doctor when you make an appointment.
Your doctor or clinic bills your Krankenkasse directly. Until a few years ago there was a 10 Euro per quarter charge for visiting a doctor but this has since been abolished. There is now usually nothing to pay at the source of treatment. However for dental services some charges are made which have to be borne directly by the patient.
Unlike some other countries such as Belgium, in Germany there is no centralized database to maintain your health care information. This means if you consult more than one doctor eg different specialists, or if you change your address and with that your doctor, then your medical data ends up scattered around among all the different providers you have consulted to date.
The onus is on you to inform each doctor as you wish about your medical history and previous consultations. There is no single sole medical history file kept for each patient.
This is rather inefficient, but it’s due to German obsession with data protection and data secrecy.
Whether you are private or publicly insured you are free to choose your doctor. Some doctors only take privately insured patients, but the majority serve both public and private patients.
If you are privately insured, then your insurance company will normally provide you with a Versichertekarte similar to the ones issued by the Krankenkassen which holds your basic details such as address and insurance policy number.
However, the payment procedure is completely different. The doctor bills you directly, though usually at the end of the month or according to their billing cycle rather than on the spot at the time of the consultation.
You are then responsible for paying the doctor’s bill directly and then forwarding the bill on to your insurer (or sometimes an agent go-between if that is how you arranged the insurance), who will in turn then reimburse you.
There is normally an excess amount you will have to cover yourself each year before your insurance kicks in. This excess amount depends on your specific insurance tariff.
If you are insured with a Krankenkasse, then your immediate dependents ie children are insured along with you. This is not the case with private insurance. You have to make additional separate provision for child dependents.
The Downside of Germany’s Healthcare System
The German healthcare system is not as perfect as some people think.
The German health insurance system maybe avoids the worst features of the US system with its inadequate coverage and rocketing premiums in old age. It also avoids the negative aspects of the UK’s free NHS with its often minimal provision and waiting lists.
But the German health insurance system is basically a mess and urgently needs reform. The division of public and private insurance and the inequities caused by this together with the high and ever rising costs are a major problem.
It’s been suggested many times that Germany move to a more equitable and affordable system of basic public insurance with private top-ups along the lines of, for example the Netherlands. But to date no progress has been made on this issue.
One problem is that reforms tend to get blocked by those with their fingers in the pie and their noses in the trough. The current vested interests benefit from keeping things the way they are.
One thing that strikes visitors to Germany is how many Krankenkassen offices there are to be seen on Germany’s city streets.
The Krankenkassen have successfully manoevered themselves into comfortable positions over the years through establishing a bureaucratic layer of middleman administration to operate this complicated insurance system. They largely govern themselves and are able to safely cream off from the insured public to maintain their established positions.
It just shows that bureaucracy can be a profitable business – at least in Germany.
The pharmacies in Germany also have a quasi-monopoly with tight restrictions on competition and basically operate a near cartel. Far fewer over-the-counter medications are permitted in Germany than in the UK or US. The prices charged by German pharmacies for even simple things such as sore throat lozenges or aspirin are exorbitant.
Some Germans living in the border areas with neighbouring countries travel over to buy their over-the-counter pharmacy supplies from the countries next door to save money. And online pharmacy e-commerce stores, often operating from the Netherlands, are also popular as their prices are usually lower than those of German pharmacies.
Doctors, specialists and clinics in Germany all get paid for each and every process they carry out for a patient, regardless of whether it is really necessary or not. They are even allowed to add officially sanctioned “multiples” to the listed price of each item to bump up the final charge.
As a Krankenkasse member this practice is not transparent to you as it all happens out of sight since doctors bill the Krankenkassen directly without the patient noticing.
But if you are a private patient you will be only too well aware of these practices when you receive the bill from your doctor. You’ll find it lists all manner of processes and actions, some of which you were not even aware of.
Doctors bills in Germany remind me of the invoices of those rip-off emergency locksmith services who manage to turn a simple door-opening task into half a dozen or more individually listed items each with an itemized fee which all adds up to an exorbitant charge at the end.
The German health insurance and health care system is inequitable, byzantine – and very expensive. I think it’s also wasteful and inefficient since it encourages costly and sometimes lavish over-provision of services with too little regard for the final cost.
Britain’s NHS might be minimal, and its standard of service basic and utilitarian (and in some cases unacceptably so with long waiting lists for urgently needed services) – but I’d wager it’s more cost-effective than the over-lavish German system which keeps its benefactors in the latest models of Mercedes.
So that concludes this look at Germany’s health insurance system.
One more thing…
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