Pathways to Healthcare for German Citizens

Since 2009, there has been a general health insurance obligation in Germany, meaning there is mandatory insurance, and all individuals must be insured!

The following groups of people have statutory health insurance entitlement by law, which lasts for a maximum of one month after the end of membership:

1. Workers, employees, and those engaged in vocational training who are employed for remuneration (§5 Abs. 1 Nr. 1 SGB V). They must be above the threshold for marginal employment. The entitlement starts from the beginning of the employment relationship, i.e., from the actual commencement, earning of remuneration despite non-commencement, or in case of incapacity to work with a duration of the employment relationship of at least 4 weeks or if the person has worked for at least 1 day.
2. Individuals receiving social benefits, such as SGB III, unemployment benefits I, SGB II, or unemployment benefits II (§5 Abs. 1 Nr. 2, 2a SGB V).
3. Students/KVdS who are not family-insured (§5 Abs. 1 Nr. 9 SGB V), up to and including the 14th semester and/or the age of 30. An extension is possible in some cases, but in such instances, contributions for the entire semester must be paid in advance. Students on leave have entitlements under SGB II.
4. Individuals who are long-term sick must report to the JobCenter, appear before the public health officer, and subsequently have entitlement to health insurance through the social welfare office.
5. Retirees/applicants for retirement have entitlement to health insurance according to §5 Abs. 1 Nr. 11, 11a, 12 SGB V. This includes disability pension, old-age pension, and surviving dependents’ pension. The prerequisite is the fulfillment of the pre-insurance period with a 9/10 rule (since 02/2017, 3 years/child are credited flat. The entitlement begins on the day of the retirement application, and simultaneous notification to the relevant health insurance fund is required! Accident pension and private disability pension are EXCLUDED from entitlement to health insurance coverage.

Mini-jobs and employment contracts below the threshold for marginal employment are generally exempt from insurance!
If you are insured through your employer in Germany but reside in another EU country and wish to receive medical treatment there, you can use the so-called “portable Document” to prove your insurance coverage. The costs will then be covered by the insurance in Germany. Here you can find more information about this.

Private health insurance in Germany is obligated to insure the following groups of people:

1. Recipients of assistance
2. Self-employed individuals
3. Formerly privately insured individuals
4. Individuals with an annual income of over €54,900

After the age of 55, a switch from private to statutory health insurance is no longer possible! Exceptions include switching to family health insurance (if there is no main self-employment) or taking up employment.
Premiums for private health insurance may be higher than those for statutory health insurance. However, there is a basic tariff for private health insurance whose scope of benefits matches that of statutory health insurance in terms of type, extent, and amount. The premium amount depends on the average maximum contribution rate in statutory health insurance, and there must be officially certified neediness. Refusal by private health insurance is only possible in the case of threat, fraudulent deception, or withdrawal due to intentional violation of pre-contractual disclosure obligations, for example, if the health questionnaire is not submitted. The entitlement exists without a risk assessment. Another disadvantage of private health insurance is that privately insured individuals must advance payments, meaning they must initially pay bills themselves and then reclaim the money from the health insurance fund.

Insurance of spouses and children through family health insurance (FamKV)

If you are an active member of statutory health insurance, it is possible to insure your spouse and children. The requirement is that their residence or habitual residence is in Germany or the EU, and identity documents of those to be insured are necessary (e.g., birth certificate, birth announcement, hospital document with paternity recognition, determination of child benefit entitlement, etc.), as well as a completed and signed family questionnaire and the signed declaration of family insurance. Foreign marriages are also recognized if they correspond to local form. In polygamous marriages, only the first wife is eligible for family health insurance. Here you can find more information about family health insurance.

Information for individuals without health insurance

Individuals who left health insurance between April 1, 2007, and July 31, 2013, are legally regulated to be in a backup insurance since 2009. This means that the last health insurance that insured the person must take them back! Those to be insured have no choice and an obligation to provide information and cooperate! Health insurances require an application from the person to be insured! The backup insurance applies to individuals who have no entitlement to other coverage in case of illness and were last insured under statutory health insurance or have never been insured anywhere but can be assigned to statutory health insurance.

For all individuals who left health insurance after August 1, 2013, there is mandatory continuation insurance. This starts after the insured person leaves compulsory or family health insurance. It takes precedence over backup insurance, meaning no pre-insurance and no declaration of intent is required, as it simply continues with the conditions of voluntary health insurance from the last health insurance. These regulations affect the following groups of people:

1. Former voluntary insured individuals who were excluded due to payment default,
2. Former compulsory health insurance or family health insurance individuals who do not meet pre-insurance periods for voluntary membership or have missed continuation,
3. Returnees from abroad who were in statutory health insurance before the stay, and
4. Immigrants from outside the EU if the residence or stay permit is valid for more than 12 months.

Exiting backup insurance or mandatory continuation insurance is only possible by providing evidence of re-entry into another health insurance!
Additional information for uninsured individuals who were previously privately insured:

Private health insurances are subject to a compulsory acceptance into the basic tariff (§125 VVG). This means that those to be insured must be accepted without waiting times, unless it is a case of fraudulent deception. To do this, the medical questionnaire (preferably completed with a doctor) must be fully filled out. This questionnaire has no legal relevance regarding whether one is admitted to health insurance. Acceptance of a complete application must occur within 1-2 weeks; otherwise, a complaint should be filed with the private health insurance association. The benefits of the basic tariff of private health insurance correspond to the benefits of statutory health insurance. Co-payments are possible up to the limit of burden. Payment exemption works as with statutory health insurance.

To be admitted to the basic tariff, there must also be an officially proven neediness according to SGB2/12, and current decisions must be regularly submitted. Despite a protected amount of €10,000, one is still considered in need. The treatment of property is regulated locally. Debts (including to the health insurance) and debt repayment are not included in neediness. However, if paying the contribution to private health insurance alone would result in neediness, this must be certified by the JobCenter or social welfare office, and subsequently, the neediness must be reported. The report can initially be informal via fax. Neediness is considered a special hardship, leading to the interest-bearing deferral of accrued premium surcharges.
Admission to the basic tariff is possible with and without a deductible. Under certain circumstances, people can switch to the regular tariff later.

Insurance debts/contribution debts

If you have contribution debts with a health insurance fund, you should immediately seek debt counseling and have the debts broken down.

If you are insured with private health insurance, the debts should always be repaid as the entire amount. However, if there is a special hardship (e.g., declared neediness), you can request a deferral in writing from the private health insurance. If the insured person was already in need at the beginning of the insurance or would have become in need by paying the maximum contribution, the private health insurance can also calculate only half the contributions for the past. If contribution debts have arisen because the JobCenter has not fulfilled its duty to provide advice and information and has not provided sufficient information about private health insurance, you should file an objection and inform the JobCenter that the debts must be paid.

In the case of non-payment of ongoing contributions, the emergency tariff according to §206 VVG comes into effect after two months, resulting in a suspension of insurance. Excluded from this are individuals with officially proven neediness. In statutory health insurance, this emergency tariff is called “suspension of benefits.” These tariffs have existed since 2013. Those who fell out of health insurance before 2013 were/are not insured in the meantime.

Here you can find a strategic roadmap for (re-)acquiring health insurance coverage. It provides an overview of the documents you need and which institutions are responsible. If you want to come to us for advice on this matter, it’s best to bring this document and the documents listed there already filled out.