Getting health insurance in Germany: A complete guide

Germany has a claim to being the home of health insurance. Its system dates back to the 1880s and the time of Bismarck. It’s a universal system: all German residents have to have health insurance. But you’re responsible for choosing your own policy, and there may be a number of options open to you. Read on to find out how the impressive but complex German health insurance system works.

What kind of healthcare system does Germany have?

Germany is well known for its excellent healthcare system. Being a universal system, everyone in the country has to have Krankenversicherung (health insurance). There are both state and private insurance options, although restrictions exist about who can be covered by each. About 90% of people have state health insurance and have the option to top this up with private insurance. The remainder are fully private.

The price of insurance is considerable, but this means that if you do have need, the medical bills you end up facing in Germany will be low. By law, all health insurance policies have to cover most costs towards a good range of essential services.

Who needs to be covered by health insurance, by how much, and what’s actually covered?

Everyone who lives in the country has to have health insurance. It’s a legal requirement to have a policy with a Krankenkasse (insurance provider, or literally ‘sickness fund’) that offers at least a basic level of coverage.

State coverage is quite thorough, and private insurance from German providers is often even more so. The minimum threshold all health insurance policies have to meet includes hospital fees, outpatient treatment, pregnancy, prescription drugs, and basic dental care. Policies - whether public or private - often don’t cover 100% of these costs, although they generally do cover most of it.

How long can I be uncovered by health insurance?

Technically you need to be insured all the time. If you’re coming from the EU, you should try and get it sorted as soon as you arrive and are registered. There’s a brief grace period from your registration date, and if you’re moving straight into a job your employers should know what to do. Coming from outside the EU, if you’re after a residency visa, you’ll need proof of valid German health insurance in advance. So plan this well before you make your move.

If you have a European Health Insurance Card (EHIC), you may initially be entitled to some treatment on that, but this isn’t a substitute for German health insurance. The EHIC is for temporary visitors only.

Are there any penalties for not being covered by medical insurance?

You’ll be fined with back payments if you’re discovered not to have had health insurance for a period of time living in Germany. Unfortunately, these will go all the way back to cover the whole time you’ve been in the country.

What’s the average cost of health insurance?

Because a big majority of people are on public health insurance policies, the most common cost is a percentage rather than a number - 7.5% of your monthly salary. Self-employed people often have to pay more, though, and private insurance might work out as either cheaper or more expensive, depending on a range of factors.

Cheaper rates are also available for students, people on benefits and low earners. If you earn less than around €450 a month you can often join your partner's health insurance scheme for free, if they’re earning more.

The system is packed full of details, so read on for more information on the costs and benefits of German health insurance.

Because you need to get your health insurance in order quickly, it’s vital to have enough money in hand at the beginning of your move or even before. Wise can help with that. It offers the real exchange rate you can find by searching on Google and only charges a simple, upfront fee. Which means you can move money into Germany without losing out to the banks and traditional money transfer services, who nearly always mark up the exchange rate they offer you and then pocket the difference. If you’re one to prepare or will still be living between countries for a while, Wise’s Borderless account will let you hold your money in euros and up to 27 other currencies until you need to transfer it locally. In the interim, until you’ve gotten your German bank account set up, you can even generate an IBAN so that you can receive money into the same account locally.

Private or public health insurance: which should I choose?

Both public and private systems exist, but there are legal restrictions concerning which you can use. A large majority, around 90%, are on public policies but it’s worth knowing who is eligible for what.

Statutory health insurance in Germany (GKV)

The public system in Germany is known as gesetzliche Krankenversicherung (GKV), which translates as ‘statutory health insurance’. If you say ‘public health insurance’, Germans might look at you blankly. This is the default type of insurance. You have to have GKV, unless you fall into one of the categories listed in the next section.

GKV is state-backed, but you won’t deal directly with the state itself. A number of independent non-profit organisations offer different healthcare policies you can choose between. They all offer similar services for similar prices, but with slightly different weightings and benefits.

If you’re employed by a German employer, the costs of GKV are split between the both of you. You pay around 7.5% of your income and your employer pays a similar amount on top. If you’re a bit concerned about high premiums, it’s helpful to know that there’s a cap - nobody pays more than €683 monthly.

If you’re self-employed, you’ll have to pay the full amount yourself - around 15% of your income - unless you’re eligible for support from the Künstlersozialkasse, a system for self-employed people with artistic jobs where the state pays half the cost of health insurance, like an employer would. More on that later.

Private health insurance in Germany (PKV)

A handful of German residents can opt for private Krankenversicherung (PKV, or private health insurance). You’re allowed to do this if:

• You earn more than a fixed amount (€57,600 per year in 2017)
• You’re self-employed
• You’re a (German) civil servant
• You’re a student, in which case you can choose PKV for the duration of your studies

If you’d rather stick to GKV, there’s nothing forcing you to go private in these cases. You just have the option to. Making private insurance mandatory isn’t common, although if you’re a high earner who’s been privately insured abroad, there’s a chance you might have to take a private policy in Germany too.

Unlike public insurance, what you pay private insurance companies isn’t dependent on how much you earn, but rather on your likely state of health. Essentially, private companies need to calculate how big a risk you pose to them. Of course, the amount depends on how much coverage you want, as well.

If you have a job, your employer will still continue making contributions if you switch to private insurance. If you’re self-employed, though, you’re still responsible for the whole bill yourself. However, private insurance might well work out cheaper than the 15% of your earnings that you’d have to pay with public insurance. It sounds odd, but a lot of self-employed German residents choose private insurance to save money.

German private health insurance works on the same style of system that you’ll find in any insurance policy. Each month you pay a monthly premium and can choose a level of excess (or deductible) on top of that. A €600 excess, for instance, means you have to pay the first €600 of healthcare coverage yourself before your insurer starts paying. You can ask the insurance company directly about this. And, while you’re at it, ask about any other discounts available. For example, paying a full year’s bill upfront is sometimes cheaper if you have the savings.

Supplementary private insurance

If you have to have GKV but want further insurance options, you can take out private insurance in addition to your state plan, but not instead of it. This is obviously quite costly, but may be useful if you want to be covered for treatment in a private hospital or to be covered for eyewear costs or additional dental care - anything else not generally on GKV plans.

International insurers

Since health insurance became mandatory in 2007, there has been some controversy surrounding international health insurance providers and the question of whether or not the schemes they offer are legally sufficient in Germany. Some international policies meet the German government’s minimum criteria, meaning they might be legally acceptable. You can read more about the international health insurance issue in many online forums and see which ones are compliant.

International insurance companies are a bit of a controversial topic because some of these schemes are considerably cheaper than those offered by German providers. Which means that choosing one could make a serious difference for self-employed people earning low to average amounts. There are a number of caveats that aren’t yet clearly defined, however. For instance, international insurance policies won’t include the nursing care costs known as Pflegepflichtversicherung that are** another legal requirement. Which may end up causing trouble for you further down the line if you need care. You should also be very clear with the insurers about how long the policy is valid for.

It’s worth seeking out professional advice before going for this option to check through the specifics. Generally, if you’re fishing around for the very cheapest insurance policy you can find, it really is worth considering what is and isn’t covered by the plan. The bare legal minimum of private insurance might be cheapest month by month, but in the event you actually need your health insurance, it could cost you dearly.

The Künstlersozialkasse (KSK)

The traditional wisdom in Germany is that self-employed people are better off going private. But since 2010, a sizeable group of freelancers have had another option. If you’re a freelancer working in a creative area such as writing, art or PR, you’re eligible for support with your health insurance via the Künstlersozialkasse (KSK). This government-run organisation is not itself an insurance provider - you’ll still need to get a policy. Instead, it acts like an employer and pays half of your monthly insurance bill, meaning statutory health insurance will cost about 7.5% of your income - just like if you were employed - rather than twice that.

The KSK will sometimes help people with private insurance, but only in quite particular circumstances. It’s best to check with them directly before you get a policy. For the most part, being eligible for KSK support means the cheapest and most secure option is to get state insurance.

There’s just one catch, however, which is that it takes months to get set up with the KSK. The reason for this is that you’re required to prove your line of work with documentation such as invoices, bank statements and the like - and this all has to be processed centrally. But the savings in the long run should justify the delay, and you should check with whichever public insurer you choose to see if they can put you on a placeholder rate until you are properly signed up with the KSK.

Pflegepflichtversicherung (compulsory care insurance)

The catchily titled Pflegepflichtversicherung (compulsory care insurance) is another obligatory payment that must form part of your health insurance coverage to plan for the future. Just over 2% of your salary will need to be paid towards nursing care that you may need now or in old age. As this is a legal requirement, it should be included in whatever package you opt for as long as you’re with a German insurer rather than an international one.

Do I need to choose a family doctor / GP?

Yes, you’ll need to get yourself registered with a Hausarzt. They will refer you to specialists if necessary - or you can sign up directly with some specialists if you want. There’s an official German website to find doctors near you, and Med-Kolleg is another helpful site for this - with an English version.

Are pre-existing conditions covered?

Pre-existing conditions aren’t an issue with statutory (GKV) policies. With private coverage, if you have known conditions when you sign up, your premiums may be higher. However, they are legally obliged to accept anyone, so you can’t be denied health insurance because of a pre-existing condition.

Are there any deductions I can make for medical expenses in my German taxes?

Yes, if you have private insurance (PKV), then those premiums are tax deductible.

How do I sign up for medical insurance?

If you have a job, the first step is simply talking to your employer about getting registered, although remember that you do have the right to choose your insurer yourself. If you’re not working for a company, it’s all down to you. See below to find out how to choose between the options.

Which insurance company should I choose?

Statutory insurance

The complete official list of GKVs (in German) is a little overwhelming - there are over 100. What’s more, because the system is so closely regulated, they are all very similar in terms of what they offer.

They can offer slightly different rates and also different perks such as cash back if you do regular exercise or give up smoking, so you should think about what you might like to have and look through a few different options. Your employer might have tips too. This German-language website has a comparison tool and further information on the different GKV policies available.

It’s a difficult decision, but only because of how many options there are. It’s not something to lose sleep over.

Some of the largest, all of which have English websites, are:

• AOK
• Barmer
• Techniker Krankenkasse (TK or TKK)
• DAK

If you think you might be eligible, don’t forget to contact the Künstlersozialkasse too, though you might need help from a German-speaking friend.

Private insurance

There are a number of PKV comparison websites, including PKV-Gesundheit, Krankenkassen Deutschland and Check24. Through comparison websites, you may be put in touch with an insurance broker who can help you get some quotes for free. While this may sound a bit dodgy, they won’t ask you for money as they get paid by the insurance company if they set you up.

If you’re looking for a complete list, you can find a list of all German private insurers online- not including the international companies mentioned earlier. Familiar names to non-Germans might include Allianz and AXA, but one size of private insurance definitely doesn’t fit all, so you should use a comparison site. Or, better still, speak to someone before making the choice.

The forum Toytown Germany has a very active community, including some professional authorities on health insurance, so it’s also worth taking a look there and maybe asking a question.

The health card

Once you’re registered, you’ll be sent a Krankenversichertenkarte (health card) from your insurer, which you should keep with you as it will be used to directly invoice the health insurer.

How do I submit a claim to my insurance company?

Your doctor or hospital will bill a statutory insurance company directly, but if you have private insurance you might have to pay the bill yourself and then claim it back from your insurers. You’ll need to check the process with your provider.

The system looks daunting at first, but once you’re set up you’ll have access to one of the world’s best healthcare systems. A bit of complexity is a price worth paying.