COVERAGE & PROCESSES UNDER GERMAN STATUTORY HEALTHCARE

All public healthcare insurances, as well as private insurances, offer the financing of the below three pillars

• Prevention of illness
• Treatment of illness or medical indication
• Rehabilitation

Statutory healthcare - basically no payments by the patients

Generally, the statutory system works without cash payments. When going to a doctor or hospital you present your health card. And as long as you don’t have that yet, you can show the membership confirmation which you will get by post from the insurer once signed-up. The data on your healthcard is read by the doctor’s software and any treatment he applies has a defined number of points for which the doctor receives payment from your insurer directly.

When he hands out a prescription there is usually a share that you have to pay to the pharmacy or therapist, but other than that any necessary and proven treatment is free of charge for you. There are treatments which the doctor might recommend but which are not covered by statutory health insurance. Examples are some dental treatments, or additional ultrasonic screenings. The doctor will let you know and you can then decide if you want the treatment and pay directly.

Private healthcare - always out of your pocket first

There are some doctors who are not a member of the health insurance cooperation. Here, your healthcard does not give you any benefits and you need to pay the treatments out of your own pockets. You will see this more for beauty doctors, wellness therapists and the like, but there are also some practices solely devoted to private healthcare patients. In case it is the first time you choose a doctor, you will recognize as the practices will always ask you whether you are privately or statutory insured.

Private healthcare patients will predominantly pay the doctor and any medical treatment out of their own pocket. When treated in hospital, there are sometimes agreements between the hospital and an insurer and the invoices are directly sent to the insurer for payment. But otherwise you have to collect the invoices and send them to your insurer for reimbursement.

Preventive screenings covered by statutory healthcare

Regular screenings and exams

• Women from the age of 20: once a year a genital examination for the early detection of cancer
• Women from up to 25 years: Annual test for infection with chlamydia.
• Women from the age of 30: An annual breast and skin examination is added to women's cancer screening. Patients should be sure to be included in the self-examination of the breast for regular early detection.
• From the age of 35: Every two years, a general health check-up for men and women for the early detection of, for example, kidney, cardiovascular diseases and diabetes.
• From the age of 35: Skin cancer screening every two years (early detection). The skin of the entire body is examined.
• From age 45: For men, annual cancer screening of the genitals and prostate.
• From 50 to 55 years: annual check-up for men and women for colorectal cancer screening (test for hidden blood in the stool).
• From the age of 55: colorectal cancer detection for men and women - every two years stool examination (test for hidden blood) or every two years a maximum of two early detection colonoscopies (colonoscopies).
• From 50 to 69 years: For women every two years Invitation to the mammography exam.
• over 65 years: Since 2018, men have once been entitled to an ultrasound examination for the early detection of aneurysms of the abdominal aorta.

Vaccinations

• Long-term protection against infections is also part of the preventive services. For example,
• Adults are entitled to a vaccine against tetanus and diphtheria every ten years.
• From the age of 60, a one-off pneumococcal vaccine and an annual flu vaccine will be added.

A good orientation on inoculations that make sense, are provided in the annual recommendations of the permanent vaccination committee at the Robert Koch Institute. All vaccinations recommended by the Commission are compulsory health insurance benefits. Each health fund may, however, include in its statutes other vaccination offers as voluntary benefits. This should be clarified by patients in individual cases with their health insurance.

Prenatal care

The preventive care during pregnancy and after childbirth is also part of the performance canon of the statutory health insurance. This includes control of mother's blood pressure and weight, urine tests for protein and sugar, palpation to assess the condition of the uterus and child condition, and control of pediatric cardiac activity. In addition, blood tests to determine blood type and Rhesus factor, as well as tests for infections with chlamydia, rubella, syphilis and hepatitis B. A test for gestational diabetes and HIV, a vaccine against seasonal influenza and 3 basic ultrasound are other benefits of prenatal care fully paid by the public health insurance. All benefits are listed in the so-called Maternity Guideline.

Children

From birth to adulthood, a series of examinations are provided for the early detection and preventive care at the expense of the health insurance companies:

In the first six years of life, a total of ten examinations are scheduled, in which sensory, respiratory and digestive organs, skeletal and musculature and congenital metabolic disorders can be investigated and possible developmental and behavioral disorders can be identified. These are the so-called U-studies U1 to U9, including U7a. Several regular vaccinations - including diphtheria, tetanus, whooping cough, paralysis, measles, mumps, and roughnecks-complete the precautionary care for the youngest. Parents receive an examination booklet after the birth, in which all important investigations are listed.

For teenagers between the ages of 12 and 15, there is another check-up on the physical condition and mental health check (Youth Health Check / J1).

In addition, the cost of cervical cancer (HPV vaccine) vaccination will be paid to girls between the ages of nine and fourteen after a consultation with a doctor.

Bonus programs

If, for example, a dental prosthesis is due, all health insurance companies reward regular visits to the dentist with financial subsidies. Therefore, it is important that the regular check-ups are recorded as proof. Normally the health insurance companies only pay half of the costs for the standard dental care. Those who have their teeth checked at least once a year for five years in a row receive a subsidy of 60 percent; If you can prove that you have ten years of regular check-ups, you will even be reimbursed 65% of the costs. The dental check-up is fully covered by the insurance.

The coverage usually also extents to basic treatment. If you are diagnosed caries fillings from amalgam will be fully paid.

There are a couple of limitations to the public insurance coverage.

There are contributions for prescriptions and over-the-counter medication which is not subsidized.

Should you need to go to hospital the only cost you will bear on your own is a daily contribution of 10 EUR for up to 28 days.  You will receive a bill from the hospital.

If you receive treatments from a therapist you also have a personal share of the cost depending on the therapy. A massage will likely cost a bit over 20 EUR per 6 sessions.

Likewise, if you are prescribed aids, like orthopaedic shoes, the usual contribution is 10 EUR.

Some treatments are not covered at all. Generally speaking, these are treatments which do not primarily improve your health such as beauty treatments or additional screenings, or pre-employment tests.

Services abroad

If you travel abroad for a short period, but restricted to EU countries and countries with a health insurance agreement with Germany, you don’t need additional travel insurance. While your healthcard is sufficient prove of healthcare in EU countries you will need an additional letter of confirmation from your insurer when going elsewhere. The way coverage provided is mostly different though and you need to expect paying the fees yourself and then get a reimbursement once you handed in all the bills. If you want to avoid this, a travel insurance is the right product.

Notification of illness for your employer

When you are ill you have to decide on your own if you need to see a doctor. Latest, you must go to a doctor if you cannot show up for work for more than three subsequent days. This is because you are obliged to hand in a “Krankmeldung” (notification of illness) to your employer after such time. Doctors usually issue the notification in retrospective, but they will want to see you latest on the third day – and if they feel your health situation does not prevent you from working, they may reject issuing the notification. Beware that some employers request you to go see a doctor within a shorter period of time! With shorter periods of no-shows you are also obliged to tell your employer immediately but it can be done orally.

The official illness notification must be signed by a doctor. Such illness is always considered an “emergency” (whether or not you feel like dying).

Emergency visits to doctors

All doctors offer emergency consulting hours, mostly in the mornings. If you are an emergency case (i.e. heavy stomach ache) you can go to the doctor’s practice anytime during opening hours. If the practice is closed you will either go to the next hospital or to the practice the doctor named as replacement (even doctors go on holiday sometimes). If you don’t need to go immediately the best time to go is the early morning. You will face waiting time.

No emergency - make an appointment

Where you feel generally unwell but can still work, so in cases where there is no emergency, you will make an appointment. The Techniker Krankenkasse as well as the SBK offer to support you arranging such appointments and this service can be very helpful at the beginning. Especially, because some doctors have long wait lists or don’t accept new patients anymore. Typical examples are regular check-ups at your gynecologist or dentist, or if you need new glasses, or, if you want to get an annual general check-up.

Doctors to choose at the beginning

Everybody should have a general practitioner who should be aware of your general state of health. He is the one you need to go to when feeling unwell. General practitioners are very well trained and able to name most symptoms correctly or at least develop certain doubts which will result in sending you to a specialist. The other doctor everybody should have is a dentist. Further, every woman should have a gyneacologist and froma certain age onwards, men should have an urologist.

When arriving in Germany, these are the doctors you should select - whether or not feeling ill.

Your healthcard as entry code

As mentioned above, at a doctor’s practice you will rarely pay cash as most treatments are covered by your insurance. The receptionist will ask for your healthcard which will then be scanned and disclose basic information. Linked to the doctor’s program it will put your case on his screen with all your history at this doctor. You will be asked for your healthcard every new quarter of a year.

Prescriptions & Pharmacies

If the doctor hands out prescriptions for medical treatments these are usually printed by the receptionist. Take these prescriptions to the next pharmacy and get the medication. If they don’t have it in store many would send it to your home in the course of the day or latest on the next day at no extra charge. There is a small fee that you have to contribute to mostly every prescription (10% of the medication’s worth but minimum 5 EUR and maximum 15 EUR) – this will require cash payment (or debit card or the like). Over-the-counter medication will only be prescribed in exceptional cases – so expect to pay your painkillers for headache or nose drops yourself. Medication can generally only be obtained in pharmacies – you don’t get them in drugstores or supermarkets. There are also online pharmacies.

Notification of illness - what to do with it

You will need to tell your doctor if you need a notification of illness to present to your employer. He cannot know this! If he agrees that you are unfit for work he will have his receptionist print out a standard form. The form actually consists of two thin papers. One is for your employer – it only states that you are unfit for work and for how long. The second is for your health insurance. It contains the diagnosis. The first has to be sent to your employer by post. Some employers accept electronic post – but they need the piece of paper eventually, so never throw it away.

The second has to be sent to your health insurance by post. They need it so they can prepare paying part of your salary.

Transfer notices to a specialist doctor

The last piece of paper you can eventually receive is a transfer notice to another specialist. If your doctor believes your symptoms should be reviewed by a specialist he will issue that piece of paper. Examples are lung doctors if he hears strange noises in your chest, eye doctors if you can’t see properly, etc. You can ask for recommendations for such specialist and sometimes your doctor can also make an appointment on your behalf which bypasses at least some of the waitlist. Should you believe you know that only a specialist can examine your symptoms, you can go the specialist without transfer notice. Many will ask you though if you have been to your general practitioner before.