Principles of Statutory Health insurance Benefits

Persons with statutory health insurance are entitled to comprehensive medical care regardless of income or age. Legislators have set down the basic entitlement to benefits:

• Benefits for the treatment of illnesses and diseases:  Every person insured with a statutory health insurance fund is entitled to medical treatment in accordance with the current standard of medical science.
• Benefits for the early detection of illnesses and diseases.
• Benefits that prevent and alleviate illnesses, and benefits for contraception and abortion.

The benefits to which every insured person has an unconditional right include, in particular, medical, dental, and psychotherapeutic treatment, the provision of medicines, dressings, remedies, and aids, at-home nursing care, hospital treatment, and medical rehabilitation.

Benefits catalog of the statutory health insurance funds
The term "benefit catalog" refers to the total scope of all benefits provided by statutory health insurance funds. The benefits must be sufficient, appropriate, and economical, and must not exceed what is necessary. There is a restriction on the scope of benefits for the treatment of secondary illnesses or diseases resulting from unnecessary medical interventions – for example, complications relating to cosmetic surgery or piercings.

Statutory health insurance funds can also stipulate additional service obligations in their statutes – from travel vaccinations to vacation health courses. Competition is becoming increasingly fierce in the area of these additional benefits.

Principle of benefits in kind
Statutory health insurance funds act according to the "principle of benefits in kind" (Sachleistungsprinzip). The health insurance companies settle directly with the doctor or hospital. The patient does not have to pay anything in advance but also does not learn anything about the actual costs incurred. Every member of a statutory health insurance fund can consult a doctor of their choice – as long as the doctor is approved by the health insurance company.

Co-payments
A co-payment is charged for medication. Medicines for treatment of minor health problems are not covered by statutory health insurance – be it laxatives, cough syrup, or nasal spray.

The insured person usually pays around 15 percent of the cost for massages and physiotherapy. For aids such as bandages or orthotics, it can be as high as 20 percent. The insured person also pays the lion's share of the cost of eyeglasses. These risks can be covered with supplementary insurances.

While the cost of dental treatment and maintenance is covered in full by statutory health insurance funds, the patient pays a large proportion of the cost of crowns, bridges, and partial or full dentures. Only if the patient can provide proof of prophylactic checkups for the previous five or ten years is the personal contribution reduced. To cover the potential cost of dental treatment, a large market of private supplementary health insurance policies has developed to supplement the statutory benefits.

Hospital choice
The scope of benefits for inpatient treatment in a hospital includes all services required for medical care in the hospital: medical treatment, nursing care, provision of medicines, remedies and aids, accommodation, and meals. The health insurance company covers the cost of inpatient treatment in the hospital in full without any time limit. The co-payment for inpatient treatment for insured persons is ten euros per day.

However, the freedom of choice of the hospital itself is limited. Physicians must refer patients to the nearest hospital that can provide the required therapy. In the hospital, the insured person receives all medically necessary services and treatment from the doctor on duty. Only private patients are entitled to a single or double room and treatment by the head physician. You can close the gap between statutory and private hospital treatment by taking out supplementary insurance.

Sick pay
All compulsorily insured employees receive sick pay. Sick pay is paid as an "income replacement benefit" to employed, paying members after a six-week period of the continued payment of wages by the employer. Students, family members, and retirees are not entitled to such benefits. Sick pay amounts to 70 percent of gross salary and a maximum of 90 percent of net income. If this is not enough for the household budget, it is advisable to take out supplementary insurance.

At-home nursing care
At-home nursing care is also included in the benefits financed by health insurance funds if it is necessary for medical reasons and hospitalization can be avoided. Pregnant women and young mothers are entitled to at-home nursing care or assistance if this is required for medical reasons, and no one living in the household can take over the care.