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It seems that health insurance is mandatory in Germany and employees with a salary above a certain threshold can choose between private insurance and the regular statutory system (gesetzliche Krankenversicherung). Some discussions I have read also suggest that being privately insured is regarded as a privilege and ensures a better service.

I have a few questions on the consequences of this system for someone moving to Germany for the first time:

  • Do you have to choose between private and public insurance immediately? Can you switch easily later on?
  • How big are the differences really (both in terms of price/premiums and service/access to healthcare)? Are there any general rules about which system is preferable or does it depend strongly on your needs and financial means?

(I am considering someone getting a new work contract with a local employer, neither self-employed, working remotely nor sent to Germany by an employer based abroad.)

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I had very good experience with the public BKK insurance as well as my colleagues. Still the family doctor you choose is very important. My doctor took all prevention measures, did all possible test to be sure I'm OK because I was suspected of a chronic disease, but some doctors are reticent and due to the tests cost will not agree to make them unless it's very critical to do them. Ask around for a good doctor to, maybe go talk to them before deciding. P.S. AFAIK you can switch doctors every 3 months but I didn't so I'm not 100% sure how this works. –  Radu Maris Mar 25 at 7:44

6 Answers 6

up vote 11 down vote accepted

Choosing health insurance in Germany is discussed a lot and recently there was a lot of media coverage suggesting that many privately insured have trouble paying their bills.

The main difference is as follows:

  • The cost of a private insurance is measured on your personal risk which is assessed by the state of your health and the health of your direct relatives at the time you sign up for the insurance and of course by your age. Note however, if you might have concealed information, your contract will be voided and you might even get sued for fraud. At the same time, with private insurance, you will have to pay many treatments yourself and can only send in the bills after you were treated. This requires some extra work and if your insurance determines that some treatment is not covered, you will not be refunded. This is problematic since some doctors try to convince privately insured "customers" to choose extra treatments / check-ups that are not medically meaningful just to earn money. Also, private insurances are not require to insure your kids for free. Furthermore, the fees of private insurance will raise with your age, especially during your retirement. Note that if your kids are born with some sort of health condition, private insurances are allowed to ask for up to twice the amount it would normally cost to insure a child.

  • The public insurance is measured on your personal income. This means that during your retirement, where you do not earn money, you will usually pay less than with private insurance. Your state of health is not considered with this insurance. The fee is however capped at some given amount, such that you will not linearly pay more with increased income. Some doctors in Germany do not treat people with public insurance but those are few since most people choose public insurance. You will not have to pay your doctors a single Euro with public insurance since bills are covered automatically by your insurance. You will get a card for this purpose that you can show your doctor. However, some treatments that are popular in Germany, like for example osteopathy are not fully covered by the public insurance but only subsidized. With public insurance, your kids are insured for free until they leave high school / college. If your spouse does not work, s/he will also be insured with you. This concept is called Familienversicherung.

Doctors are by law forbidden to prefer privately insured over publicly insured, once they decide to get a license for treating publicly insured patients, even though some doctors do of course discriminate. Be aware that once you sign up for a private insurance, you will not be able to sign up for a public insurance scheme unless your income decreases under a certain barrier for a given amount of time. This can ruin you financially if your fees increased with age (some 60+ pay easily 1000+ euro per month for private insurance) and your income falls, which can happen to self employed. (Note that self-employed are not required to come over the income barrier to be privately insured.)

For all these reasons, if private insurance is beneficial for you. I would decide on the following criteria:

  • Do you hate to deal with insurances: Choose a public insurance.
  • Do you have health issues: Choose a public insurance.
  • Do you have / plan to have kids in Germany, a non-working spouse: Choose a public insurance.
  • Are you young, healthy and planning to stay in Germany on a short-time basis: Choose a private insurance.
  • Do you have an income around the German average: Choose a public insurance.

The German Wikipedia provides a decent overview of all the summarized information.

Be further aware that some treatments might or might not be covered by a specific public health insurance. There is however a catalog of treatments any insurance (public or private) must cover. If you cannot pay your insurance bill with a private insurance, you will be reduced to a (still costly) scheme that covers this exact catalog. Furthermore, it is possible to get private dental insurance in addition to your public health insurance. This becomes more and more common since the public insurance has cut costs in this sector in the recent years. Consider this as an option. There are additional "extra health insurances" such as Pflegetagegeldversicherung (daily money if you need to live in a care home for long time), Krankenhaustagegeldversicherung, (pays you money for each day you spend at the hospital, interesting for self-employed) Krankenhauszusatzversicherung (grants you a single room / different food etc in a hospital), Chefarztbehandlung ("go away interns when I am in a hospital"-insurance).

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All the answers were useful but this one is the most thorough and covers all aspects nicely so I accepted it. –  Gala Mar 21 at 18:23
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I would dispute some of your conclusions about the costs of health insurance in old age (info given in my answer). Also, you need to ask the questions: "Might you be healthy now, but get seriously ill in your old age, requiring treatment that may not be covered by public insurance -> choose private" and last but not least "Do you look like a low status foreigner? -> choose private" (only you can decide how important this factor is for you). –  user571 Mar 22 at 16:48
    
@user571 What might those treatments be? I am not particularly keen on osteopathy and the like; Are there any important evidence-based treatment that are not covered by public insurance? –  Gala Mar 22 at 16:53
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There are some drugs that are not available on the public insurance, but are covered by private insurances for example. This is much too detailed to post on this site, also it changes from year to year, so I would recommend asking this question to agents from private health insurances "What treatments do you offer for common conditions that are not available on the public health insurance?" –  user571 Mar 22 at 16:57
    
That is simply not true for prescription medicine. Private insurance sometimes pays "original" medicine while public tends to only pay for generica. Public insurances do however not always cover alternative medicine which you could however purchase yourself. –  Rafael Winterhalter Mar 22 at 17:54

If you earn more than 50850 EUR / year, you can choose between private and statutory health insurance. If you earn less than 50850 you cannot get a private insurance.

The only way to switch back to statutory health insurance is to earn less than 50850 EUR / year and be younger than 55 years. After that age you cannot switch any more.

The private insurance will often pay for more service - like nonprescription medicine or head physician. But some of the private insurance are just co-insurance and you will have to pay for services that are free for statutory health insured patients.

Another difference is that privately insured patients (sometimes) have to pay themselves for the services, and then send the invoice to the insurance to get their money back.

And if you're young and earning good money, you will pay less in comparison to the statutory health insurance, because the private insurane is independent from your salary. However later you will have to pay more and more, even if you're out of a job. Here is an article in German about an annual increment of 71%!

By the way wikipedia has a good comparison between the private and statutory health insurance in Germany.

So if you want to stay in Germany for a long time, the statutory health insurance should be the better option, but it's up to you.

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+1 Thanks for all this info! But I am not sure I understand your third paragraph. Does that mean that private health insurance is not regulated and coverage for basic care is not necessarily included? Or that private insurance contracts have deductibles (i.e. you pay up to x€ and the insurance kicks in after that) whereas statutory insurance does not? Also, what's a head physician? And by “statutory health insured employers” do you mean employees with statutory health insurance? Finally, what's good money? Around the threshold or way more than that? –  Gala Mar 21 at 10:51
    
The Wikipedia link is especially valuable, thanks! –  Gala Mar 21 at 10:53
    
Yes, the private insurance is not regulated, so the price and service may vary. It's possible that you pay only a small monthly contribution, but have to pay 5-10% of the price of the medical treatments. I meant employees, not employers. And...IMO 50k is good money. –  Dirty-flow Mar 21 at 11:03
    
IMO too I am just making sure I understand ;-) –  Gala Mar 21 at 11:07
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@GaëlLaurans: I think it is also important that your partner is NOT insured with you using a private insurance. With the regular insurance you can insure your partner with you if (s)he is not working. Many people in Germany insure themself regular and add an additional private insurance to that for a small amount of money. –  juergen d Mar 21 at 12:30

There is a social side to this question too. Private insurance is cheaper if you are probably not going to use it - if you are young and healthy and childless. (If you are planning on getting old or having children it's not worth it.)

So a lot of young healthy people use it because it seems cheap at the time. They are paying into a system which is cheap because (on average) only young healthy people use it. This means they are paying less into the state system, which has to struggle to make ends meet for the old, for seriously and chronically sick people (diabetes, MS, cancer), or for children (do you know what childbirth costs?). And the privately insured are using the entire vast infrastructure paid for by everyone.

So getting private insurance may be regarded as anti-social by some people. You have to consult your conscience on this one.

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+1 Good point. My instincts would pull me toward the statutory system anyway but I was mostly interested in understanding the differences from a practical point of view. –  Gala Mar 21 at 12:06
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That's exactly the reason you can't easily get back into public health insurance. If you didn't contribute at all while you were young and healthy, why would they accept you when you get old or need more expensive treatments? –  Marko Mar 21 at 14:04
    
This answer is not the whole picture about health insurance as you get older. Please see my answer about this. –  user571 Mar 22 at 16:36

I've had a coworker that had a private insurace, and there were some discussions, so I have some general overview:

  • You get some priviledges when you have private insurance. Your are first in row to be handled, it's faster to arrange a visit in hospital (although I had no issues in small "Praxis" for "Krankenmeldung" being mandatory secured)
  • The dentist services are not fully returned in Germany, with private insurace you get more coverage, still having to pay some part (it may be an additional variant of private insurance as well, you must ask, my coworker has opt-in and had to pay even more for insurace, when he had paradontose treatment his cost were 90% covered, but he had to argue with insurance company, initially they wasn't going to pay)
  • I think you can switch to private insurance any time, but going back is a hard way. From what I know, the only way to switch back to mandatory insurance is to end your job contract. It's probably the way to prevent people to switch to private insurance before getting hospitalized, and switching back afterwards.
  • The costs differ, but as far as I remember, my coworker has paid about 600 Euro a month, in comparison to 400 Euro that would be taken from his salary for mandatory insurance. It can vary, but it is substantially more expensive.
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+1 Thanks for your feedback! –  Gala Mar 21 at 11:03

Disclaimer: this is the English translation of the wikipedia site that compares private and state health insurances, and might contain translation errors. If you find some, please fix them.

Differences between Private and State Health Insurance

  • Family members without their own income are co-insured free in case the member who is working is part of the regular health insurance. For a private health insurance separate insurance is required for each person.
  • For regular insurance contributions are based on the percentage of your income up to the contribution ceiling. In private insurance the cost is calculated based on your age, profession and current health.
  • For regular insurance costs rise or decrease with your wages (up to the contribution limit). For personal insurance costs can also rise due to the rising costs of medical treatments, or because the heath state of the insured changes.
  • In private insurance persons without pre-existing health conditions pay a smaller contribution, but as they get older the costs can rise well above the contributions of the regular insurance, as shown by Stiftung Warentest in 2003 and 2004
  • For employees the employer pays directly to both the private and state health insurance. The share of the employer is half of the total contributions (currently at 0.9%). For private insurance the employer also pays the half of the contribution but only up to the amount he would pay if you'd be insured by the state.
  • If you are self-employed you have to pay the full price of either the statutory or the private health insurance, which therefore will be twice as high as what is specified for employees. This is misleading though, as the user is still insured for the same price, but the part of the contribution is payed by the employer.
  • The services of private health insurance are specified in the insurance contract and therefore can differ between different insurance companies and also comapred to the statutiry health insurance. Typically, there are better benefits in private health insurance for non-prescription drugs, vision aids and dentures, but this depends on the insurance company and the contract, as they can also be worse, for example for psychotherapy services.
  • In the statutory insurance the patient has to explicitly demand for a receipt to know the billing details. In private insurance an invoice is automatically created for any transaction that can be reimbursed by the insurance company either in whole or in part.
  • Benefits of the statutory health insurance "must be sufficient, effective and economical, and must not exceed what is necessary. Services that are unnecessary or uneconomical can not be claimed by the insured." For private health insurance however there are no such specific rules.
  • Lawsuits against the statury health insurance can be made before the social courts as complaints from a public or social insurance. Actions against a private health insurance are done in the civil courts.
  • Personal insured people can change their amount of personal contributions to the scheme, while statutory insured people can not.
  • Statutory health insured persons, who are not students or voluntary insured can use their parents' allowance for free. Personal insured can not do this.
  • Privately insured people receive no sick pay and no subsidies during their sickness, unless they have a separate insurance for them. SRegular insurance still pays sick pay. Private insurance also doesn't pay sick pay if you are left at a partial disability.
  • It is said that statutory patients are treated worse than private ones. For example based on a study only one third of the German patients had a healthy blood pressure, and they were mainly privately insured.
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+1 I found this info very valuable, the translation might be useful. –  Gala Mar 22 at 17:14

There are already a lot of answers to this question, but I haven't seen the following information:

The money that you pay for private health insurance includes a contribution towards making your health insurance cheaper in old age. This is mandatory for German private health insurances. So German private health insurances are not really comparable to the international, truly free market insurances. The latter are very cheap when you are young and healthy, and rise a lot as you get older and sicker. German private insurances are a lot more stable in price (mine actually fell by a few cents last year for example, not counting no-claims bonuses).

On top of this mandatory government scheme for trying to keep your health insurance costs down, a small number of German private health insurance providers also offer their own schemes for keeping costs down as you get older.

The amount you pay into these schemes varies according to how old you are, but a rough estimate that I was given, involved paying 200 euros per month on top of my health insurance now, and getting 400 euros per month back when I'm over 60. I was told that this, together with the mandatory government scheme, would mean that my health insurance costs would drop to almost zero when I'm 60.

I mention this quote only to give you an idea of what's available. Of course, you need to speak to agents from several private health insurances, who can explain your options in detail.

Don't be shy about asking for an agent who speaks good English. However good your German is, insurance is full of small details that may be easier to absorb in your native language. German financial products are not always the same as what is offered in other countries, so you really need to take time to understand them well. Unfortunately, many immigrants are forced to make the private/public health insurance choice before they are really well-informed.

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(+1, thanks for the additional info). How are these contribution and schemes called in German? What about the reports posted elsewhere about steep increases in old age? Does it depend on the specific plan/insurer you chose? –  Gala Mar 22 at 16:50
    
Yes, I think it does depend partly on the provider that you choose. The insurer's own scheme that I mentioned, is only available from a small number of insurers. That's why it's important to get quotes from many. Some are better capitalised than others. Some advertise more than others, but are not necessarily the best. –  user571 Mar 22 at 17:01
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"Alterungsrückstellungen" covers the general concept of paying in advance to keep your costs down. –  user571 Mar 27 at 13:50

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