Of the myriad of things you will need to deal with during your first weeks after arrival, health insurance in Germany will probably be THE most confusing task as a newcomer.
So, this is a topic which has lots of facets and nuances.
We’ve therefore published separate articles which cover:
- What to consider when choosing between public or private health insurance
- How to approach this is you’re a Freelancer or Self-Employed person (there are different rules)
This article will tackle everything in the box below!
Note that we don’t cover incoming health insurance here for those entering the country on a job seeker visa, or those seeking to apply for a residence permit for self-employment (the “freelancer visa”) from within Germany.
The German Healthcare System Explained
This article will give you a thorough grasp of:
– The major differences in the German healthcare system vs. healthcare in the UK and the US
– The eligibility criteria for private health insurance
– What does health insurance in Germany typically cover?
– How contributions work (Employer vs. the Individual)
– The process of visiting a doctor in Germany
– Making appointments to see specialists
– Common watch-outs and pitfalls
– A brief summary of positives and negatives of the German system
What Options Are Available To Me?
Freelancers & Self-Employed
You automatically have the option of whether to take public health insurance or whether to opt out and take a private health insurance policy.
You don’t automatically have this choice. It depends on how much you earn before tax i.e. your gross salary. In 2020, the threshold is €62,550 before you can opt out of public insurance and select to go private. Anyone earning below this threshold is automatically obliged to take out a public insurance policy.
Private Insurance is subject to acceptance by the insurer
While you may theoretically be eligible for private insurance, it does not necessarily guarantee that a private medical insurance company will offer you insurance. This very much depends on the level of risk they perceive you to be as an individual…
Our Recommended Private Health Insurance for Freelancers, plus Employees Earning Above €62,550 Gross Per Annum
Our Public Health Insurance Partner for Employees (eligible regardless of salary!)
Gesetzliche Krankenversicherung (GKV)
Public Health Insurance
You pay a percentage of your gross salary each month. This is capped for any earnings above €6,900 gross per month (states belonging to former West Germany) or €6,450 (former East Germany)
Private Krankenversicherung (PKV)
Private Health Insurance
You pay a monthly premium which is calculated by the insurance company, based on their perceived risk of insuring you as a patient. Usually the key factors are your age, history of pre-existing conditions and your occupational health risk.
How is the German healthcare system different?
Let’s start with the nuts and bolts of the system:
How does it work in practice and how does it differ from what you are used to in your home country?
The British healthcare system (National Health Service)
This is a fully government / taxpayer-funded single-provider model.
Healthcare professionals such as doctors and nurses in the UK are public sector employees. In fact, the NHS is the biggest single employer in Europe.
Hospitals, clinics and doctors’ surgeries are all administered by the government. Whilst these services are decentralised and are administered locally, the budget itself comes from central government and is funded entirely by the state.
The British system is free at the point of entry. It means that pretty much anyone can turn up in Accident & Emergency at a British hospital, or go to the doctor, and they will be treated unconditionally without having to confirm any valid health insurance.
The US healthcare model (private, insurance-based)
If your insurance policy doesn’t cover you for a certain health complaint, or if you have taken out inadequate insurance, then you as an individual are in most cases liable for your treatment costs.
The Medicare and Medicaid systems provide a basic safety net to cover those most in need i.e. older people, welfare recipients and certain low earners who otherwise would not be able to pay for healthcare, but both of these still rely on an insurer-based model.
Hospitals, doctors’ surgeries, clinics, rehabilitation centres and so forth are private, for-profit businesses. They perform services and then invoice the individual (or the insurance company directly) just like any other regular business would operate.
What does health insurance in Germany have to do with the UK and the US?
The German healthcare system is, for all sense and purposes, a mixture of the best parts of the UK and US systems.
Germany tries, with some degree of success, to take the best bits from both the British and the American methods of healthcare provision.
Germany operates an insurance-based system, but regulates premiums
In the German healthcare system, hospitals are businesses, often owning chains of hospitals and related outpatient and aftercare services.
Doctors and dentists are self-employed individuals, often working together in a practice, paid for through invoices they raise on their patients’ health insurance companies.
Nonetheless, Germany does have a regulated public health insurance system. Just like in the UK, everybody who is registered as being a resident in Germany has the legal right to healthcare provision, and contributions are capped at an upper limit.
Since 2009, all residents in Germany are legally mandated to have adequate health insurance as a condition of residency.
The unemployed, refugees and other welfare recipients are automatically covered by the state.
Unlike in the UK, however, there is a confusing array of choice around what type and level of cover you may take.
You don’t just automatically have your national insurance contributions deducted from your salary. Healthcare is separate from state pension and other social security contributions in Germany, which are automatically deducted from your payslip if you are a regular employee.
Health insurance in Germany must be actively contracted by the individual. There is no single-payer, universal German health insurance provider.
There are over 100 public health insurance providers and even more private insurance providers.
This is why it can be so confusing!
What Will Public Insurance Cover Me For?
Each Krankenkasse has its own nuances and opt-ins and specific advantages or disadvantages, depending on what an individual is specifically looking for.
With that said, the broad level of cover is very similar and does not fluctuate as much as the array of private insurance policies out there.
German law stipulates that they all must cover statutory healthcare requirements such as inpatient and outpatient care, treatment for chronic diseases and pre-existing conditions.
Public insurerance will usually (but not always) exclude common but non-essential medical requirements such as:
- Dental care
- Non-critical sports injuries
- Alternative medicine, such as healing professionals practising techniques such as acupuncture and yoga
- Preventative treatment such as nutritional advice or chiropractic treatments
- Cosmetic surgery
You will need to shop around to understand which of these may, or may not, be covered by various insurers.
If you don’t speak German, this can be tricky. Therefore, we’ve partnered with Barmer, one of Germany’s largest public healthcare providers.
They will give you an individual consultation in English, help with your signup form (also in English), and explain all of this to you before signing up.
You’ll receive confirmation of insurance within 24 hours, which is great if you need to have insurance fast (so as your employer’s payroll department can pay your salary!)
Employer and Individual Contributions
Now comes the tricky and unfortunate part of the German healthcare system. You will have to advise your employer during the first month of your job which type of health insurance you wish to take.
Otherwise guess what? They can’t pay your salary!
Why? Because of employer contributions.
Your employer has to know how much they should contribute towards your insurance.
You will need to produce a letter from your health insurance provider and hand this to your employer’s payroll department during your first month on the job.
This is because regardless of which option you take, your employer is obliged to pay a 50% contribution towards your statutory healthcare costs.
If you choose public insurance, the total payment is calculated as 14.6% of your gross monthly salary.
Your employer will contribute half of this sum and you will pay the other half, which is deducted directly from your salary and paid to your insurer.
Additionally you have the option to purchase extras, some of which were mentioned in the section above, which are not covered under the standard policy.
These additions to your premium can come in at anything up to an additional 1.1% of gross income. This is a voluntary contribution and as such, your employer does not contribute towards this.
Therefore, if somebody wishes to take out the whole suite of extras, the total comes in at 15.7% of gross salary. But, only the 7.3% is funded by the employer and the remaining 8.4% is paid for by the employee.
Opting for private insurance means that your employer will provide a contribution towards your policy.
A policy for private health insurance in Germany is individually calculated based on perceived risk, and has nothing to do with your gross salary.
That’s the main reason why higher earners are often better off going private, especially if they don’t have a non-working spouse or kids.
Employer contributions also work slightly differently. You will receive the employer’s contribution (typically 50% of the monthly policy) directly on your payslip as part of your monthly salary paid into your bank. You are then responsible for paying your entire premium to the insurance company, usually via a direct debit from your bank account.
With private insurance, your employer is only obliged to contribute towards statutory cover. Popular optional extras on your private insurance policy, such as extended sickness payments in case of long-term illnesses, treatment by the head surgeon or upgrading to a private room during hospital stays, are for you to pay in full.
If you’re privately insured, on your payslip the employer’s contribution will be described as “Arbeitgeberzuschuss private Krankenversicherung” or something similar.
Can I Switch From Private Back To Public?
Generally speaking, no.
You can only switch back if you lose your job and register to claim unemployment benefits, or your salary falls below the threshold to be eligible for private health insurance.
There are some exceptions and loopholes but it is extremely complex and beyond the scope of this article.
Going to the Doctor
It’s not a necessity to register with a German doctor, but it is highly advisable, especially if you want the reassuring feeling that the medical professional you are visiting at least knows a bit about your medical history and has sense of familiarity whenever you pay them a visit.
If you go to see a specialist or are admitted to hospital, the first question you will usually be asked is who your Hausarzt (General Practitioner, or GP), is.
Some GP surgeries require an appointment to be made in advance, whereas others have a “walk-in” policy. In busier surgeries and locations, you may need to wait for quite a long time.
Most GP surgeries are open Monday to Friday, sometimes only during the morning. Most surgeries which open during the afternoon also close for one afternoon a week (usually Wednesdays).
Making an appointment is usually done by telephone or in person with the doctor’s assistant (Arzthelfer).
Unless you seek out an English speaking doctor, it may be wise to ask a German speaker to make the appointment as there is no guarantee the doctor’s assistant will speak English.
In major metropolitan areas, a simple Google search or asking in an expat Facebook group will usually yield a few reliable English-speaking GPs. Finding an English-speaking specialist may, however, be a little trickier depending on what you’re looking for.
Once at your German doctor’s surgery, you will need to present your health insurance card to the receptionist. This is credit-card sized and contains a chip with your details on it. If you are seeing the doctor for the first time, you may have to fill out a questionnaire detailing your medical history.
Publicly insured patients will not receive a bill directly. This is invoiced to your insurance company. You will also have to pay a fee of €10 for your first doctor’s visit every quarter, which is usually payable in cash.
Privately insured patients on the other hand are expected to settle their bills directly (invoices are usually sent by post, on anything between 14 and 30 days’ payment terms). You then submit the invoice to your insurance company to be reimbursed.
Making Appointments with Specialists
Germany works somewhat differently to many other countries when it comes to seeking out specialist doctors. While it is normal for you to first to go to your GP and to seek a referral, in most cases it’s not actually a prerequisite.
Specialists in Germany also tend to be located in their own medical practices rather than in an outpatient facility at a hospital or clinic. You can make the appointment directly with the specialist if you wish.
Before doing so, it is recommended to check that the practice accepts all patients. This can usually be determined through their website or a sign at their reception.
“Alle Kassen” indicates that they accept patients in both the public and private systems.
For those who are privately insured, also beware that some insurers have in their terms and conditions that they only reimburse invoices for specialist consultations which have been referred through GPs.
Depending on the specialist treatment required, you may have to wait several days or even weeks for an appointment under the public system. Private patients are usually treated faster.
Advantages and Disadvantages of the German healthcare system
- Germany has one of the highest – i.e. best – density of GP doctors to patients in terms of number of GPs per head of population.
- Doctors’ surgeries are private businesses. Therefore waiting times are generally lower than in a state controlled system where available budgets are allocated based on where the need is deemed to be highest.
- Referral to specialists is very fast and in some cases, you are even able to book appointments directly with specialists without having to go through your GP (especially if you have private insurance)
- It is much easier to get non-essential treatment without enduring long waiting times.
- Hospitals and doctors’ surgeries are luxurious, well-staffed and equipped with the latest technology.
- There is a well-organised emergency doctor network which avoids the need to show up at A & E (or the ER for you Americans!) out of desperation of having nowhere else to go during the night and at weekends
- There is no feeling at all that the system is overstretched or at breaking point.
Just one, really.
Healthcare in Germany is extremely expensive (unless you’re American and comparing with the US system, then it’s cheap!)
And it’s even worse if you’re self-employed because your employer is not covering half the cost.
If you’re a student, receiving benefits or are in a low-paid job, there are pretty much no disadvantages. German healthcare is great.