Information for German State Insured Patients
Only important for Patients forming part of the German Health Insurance System

Dear Patients,

As you are no doubt aware, the German State Insurance (hereinafter referred to as the Insured Patient) only covers the costs for a suitable, appropriate, sufficient and cost-effective intervention (SGB V).

If this "sufficient" intervention does not meet your expectations, you still have the choice, as state insured patient, to be seen as a private patient. Regarding this question please read the information provided by my colleague Mr. Hans-Peter Meuser:

Reimbursing of Costs (or direct payment)

Die durchs GMG The GMG (law to modernise the health system) has created the possibility for all Insured to remain with their State insurance company and yet be seen as a private patient.

How it works:
Since 1st January 2004 each Insured (of state insurance companies such as AOK, BKK, Ersatzkasse, etc.) can choose 'reimbursement'. Until then, that was available only to those insured voluntarily. 'Reimbursement' means that the patient is classified as a private patient when they see their doctor. They receive invoices according to the GOÄ, the legally binding cost-structure for private patients, which they hand in to their state insurance company. The choice of 'reimbursement' is binding for the duration of one year. The main Insured and their Dependents (co-insured, without insurance contribution) can each choose 'reimbursement' independently of each other.

State Insurance Reimbursement
The state insurance company assesses the invoices and prescriptions, and reimburses the amount that the patient would have paid if they had seen the doctor using the State Insurance ChipCard. NB, Practice fees ('Praxisgebühren'), additional costs for medicines, *pharmacy allowance ('Apothekenrabatt') of € 2,- per item, the insurance company's administration cost and a fee for lacking an efficiency audit are deducted from the amount. When the Patient/Insured compares the invoice and the amount paid, he or she will notice the minimal amount paid to the doctor by the state insurance company for services rendered.

Excess
There is a certain sum which the state insurance companies do not pay. We calculate this amount to be 30-70% of the invoice. It would be an incalculable risk for the Insured not to take out a private 'excess insurance' to cover this excess amount. These types of insurance reimburse the patient for the amount their state insurance does not cover.

'Excess insurance' can be obtained for as little as € 30,- per month for men, and € 45,- for women (starting age 30 years). Requirement: there are no existing serious or chronic illnesses. In the case of less significant ongoing illnesses it is possible to negotiate a top-up payment. Once the insurance is in place, the insurer must pay, even when additional illnesses occur at a later stage. The insurer can under no circumstance invalidate the insurance for emerging illnesses. The insurance can become void if incorrect information is supplied by the to-be-insured at the outset, or payments are delayed. Each individual must be insured separately.

Choosing the right moment
It is crucially important to commence an 'excess insurance' sufficiently early. Once a chronic illness has appeared, it is either no longer possible to take up such an insurance, or only with additional payments.

Your choice
It is entirely the patients' choice whether they choose an 'excess insurance'. It depends on whether they believe their state insurance company will in future be able to provide the service they expect. When making this decision one should consider three things:

1) The legally binding parameter of the SGB V, § 12, requirement to be cost-effective: "(1) Services must be sufficient, appropriate, and cost-effective; they must not go beyond the indispensable minimum. Services that are not necessary or economical cannot be demanded by the insured, will not be given by the service provider, and will not be covered by the insurer." (Original text of the law: 1. Gesetzliche Vorgabe im SGB V: § 12 Wirtschaftlichkeitsgebot: "(1) Die Leistungen müssen ausreichend, zweckmäßig und wirtschaftlich sein; sie dürfen das Maß des Notwendigen nicht überschreiten. Leistungen, die nicht notwendig oder unwirtschaftlich sind, können Versicherte nicht beanspruchen, dürfen die Leistungserbringer nicht bewirken und die Krankenkassen nicht bewilligen." (Originaltext des Gesetzes)

2) Problems. From their own experience patients are aware of today's problems of insufficient budgets and increasing waiting lists for appointments with specialists (see Doctors' Remunerations and Cheated Doctors)

3) The law modernising the State Insurance ('GMG') and State Insurance. The law itself has opened up this possibility for the Insured; the state insurance companies now offer such 'excess insurance' (e.g., the BEK Insurance's 'Five-Star-Programme' offers 'excess insurance' for HUK Health Insurance). BEK would not be making such a service available if there were no demand, if service with the ChipCard covered all eventualities.

Finances
There is naturally always the question of affordability. Many Insured already have an additional insurance for hospital stays and times abroad. Anyone used to spending more money for a better service or greater comfort in other areas (home, car, holiday, clothing, food), will be considering such questions already. Changing to a less expensive state insurance could make the saving that allows taking out a private 'excess insurance'.

Comparing Offers
There are not yet many insurance companies which have entered this sector on the market. The ones we are aware of are: ARAG, HUK, Hallesche, Süddeutsche. It is extremely important to make an independent comparison of services offered, the potential excess and contributions. A doctor is not an insurance broker. A doctor cannot be expected to know (as an insurance broker would) all possible insurance offers in order to name the best option for a particular patient's situation and wishes. The market is too large for this to be possible. A doctor does not aim to be an insurance specialist; it is not his field of expertise. The Association of Medics advises its members simply to point patients in the direction of any independent advisory centre, where they can request further information.

ChipCard Medicine
Many patients are not in a position where they are reimbursed and receive the greater range of treatment a private patient expects, be this for financial reasons, because they are too old to enter this type of insurance, or have existing illnesses that bar them. But medics signed up to taking on state insured patients will certainly give all patients the legally binding 'suitable, appropriate, sufficient and cost-effective' service on presentation of their ChipCard.

Author: Hans-Peter Meuser, general medical practitioner ('Facharzt für Allgemeinmedizin') Last updated on 24th March 2005 / Medics' Association (Ärzteverein) Südkreis Mettman e.V.

Documentation: Generally, paper-based documentation is sufficient. In special cases (being seen at the university hospital, planned operations, etc.) you may receive a film copy. Should you wish a film copy for other reasons or have misplaced the original, we are happy to print out a copy for € 2,50 per page. You also have the choice of having the entire assessment copied onto a CD (readable by any PC) for € 10,- per CD.

Evaluation time: We generally guarantee that your assessment's results are with your referring doctor within a week. Where it is medically imperative, we will certainly prepare the documentation earlier, if necessary on the same day.