Basic rate in private health insurance (PKV)

Benefits for privately insured persons as an emergency solution

Max Mergenbaum is a trainee editor at Finanztip. He studied politics, economics and society as well as German language and literature at the Ruhr University Bochum. After a semester abroad in Canterbury, he completed his studies in political science at the Free University of Berlin with a Master’s degree. He gained his first professional experience in the media industry and in associations.

Annika Krempel was an editor in the Insurance and Pensions team until January 2018 and now works as a freelancer for Finanztip, among others. Previously, she had gained experience as a consumer journalist at ZDF-Wiso, RBB and Stiftung Warentest.

• The basic rate of private health insurance (PKV) is an emergency solution. It is suitable for privately insured persons who are not helped by an internal tariff change and who cannot return to a statutory health insurance fund.
• No provider of private health insurance may deny an insured person the basic tariff if he is older than 55 years. A health check is not necessary for the change.
• The benefits in the basic tariff are comparable to those of the statutory health insurance (GKV).
• Tariffs with excess or the conclusion of supplementary insurances are possible in the basic tariff.
• Compared to the standard PKV tariff, the basic tariff is usually considerably more expensive and only offers slightly better services.

• The first thing to check is whether a different tariff is more suitable for you or whether there is a way back to the statutory health insurance.
• Only if there is no other way, switch to the basic tariff at your provider.
• If you are in need of help, the contribution is reduced and you can receive a subsidy from the social welfare office.
• Check whether you can afford supplementary insurance for some benefits

In this guide

The basic rate in private health insurance (PKV) is intended to help privately insured persons who can no longer pay their premiums – or who have not had health insurance for a long time and now have to take out private insurance. The insurers may not refuse the basic tariff to anyone who fulfils the conditions for it. They are not allowed to charge risk surcharges to the insured person or to exclude benefits when switching.

Who can claim the basic rate?

Anyone who joined the private health insurance scheme after 1 January 2009 may take advantage of the basic tariff at any time and without preconditions. A privately insured person who took out a policy before 2009 may switch to the basic tariff if he or she

• is at least 55 years old
• or receives a statutory pension or a civil servant pension
• or can prove that he can no longer afford the insurance premium.

For most of these insured persons, however, the standard tariff is the more favourable solution.

Basic tariff offers health insurance benefits

The type, scope and amount of the basic tariff must be comparable with the benefits provided by the statutory health insurance funds (§ 193 (5) VVG). This means that the insured person must forego the more extensive insurance cover provided by private health insurance. Sometimes the benefits in the basic tariff differ considerably from those in a good private full health insurance.

It is therefore advisable to check whether switching to a different insurer’s tariff is cheaper and more sensible than the basic tariff.

Can there be problems with reimbursement?

The Kassenärztliche Vereinigung (Association of Statutory Health Insurance Physicians) must guarantee the care of patients in the basic tariff. In return, the insured persons must point out during a visit to the doctor that they are covered by the basic tariff, as the statutory health insurance physicians then charge different rates than those usually charged to private patients.

Sometimes patients in the basic tariff also remain sitting on a part of their doctor’s bills. This is usually the case if they do not seek treatment from a physician or deliberately make use of services that go beyond those covered by statutory health insurance. This difference is not reimbursed by their private health insurance.

Therefore, it is often advisable to switch to another insurer’s tariff instead of the basic tariff. If there is a dispute about the reimbursement of a benefit, patients can apply to the relevant statutory health insurance association or dental health insurance association for a basic tariff.

Are provisions for old age maintained?

Privately insured persons who switch to the basic tariff within an insurance company take their pension provisions with them in full. The provision for old age is the amount that the insurance company saves from the premiums of the insured in order to keep the contributions constant in old age. In theory, policyholders can also switch to the basic plan of another private health insurer, but then they lose a substantial portion of their retirement provisions.

More information about social tariffs in private health insurance can be found in the PKV Association brochure of the same name and in our guide to standard tariffs in private health insurance.

What is the contribution in the basic tariff?

The maximum contribution in the basic tariff is limited to the maximum contribution in the statutory health insurance plus the average additional contribution rate of the health insurance funds; in 2019 this maximum contribution will be around 703 euros per month. If the applicable income threshold increases, the maximum contribution also rises.

If insured persons are in need of help or become in need of help due to excessively high health insurance contributions, the insurance premium is reduced by half. In emergencies, privately insured persons only have to pay a premium of around 354 euros in the basic tariff (as of 2019). If this is still too expensive, the basic insurance provider participates in the reduced contribution. The term “need for assistance” is based on the Social Code (§ 9 SGB II).

Is there a deductible in the basic rate?

Insurance companies must offer insured persons a deductible in the basic tariff of 300, 600, 900 or 1,200 euros per year. However, it only makes sense to opt for such a deductible if the insurer also reduces the monthly premium for health insurance in return. This is not always the case with lower deductibles.

In principle, insured persons must maintain the deductible in the basic tariff for at least three years. If, however, it turns out that the agreed deductible does not adequately reduce the insurance premium, the insured can at any time demand that his private health insurance be converted to the basic tariff without a deductible.

In addition, insured persons in the basic tariff can take out supplementary insurance with the same or a different provider in order to expand their health care beyond the level of the statutory health insurance.

Is the standard tariff or the basic tariff more reasonable?

Many privately insured persons who are 55 years of age or older can choose between the basic tariff and the standard tariff. In most cases, the standard tariff is the much cheaper option, as the contribution of the basic tariff usually corresponds to the maximum contribution to the statutory health insurance – in addition, there is the average additional contribution.

However, the premium should not decide alone, as the basic tariff offers slightly better benefits in some areas. The following table will help you choose the right tariff:

Comparison of benefits of PKV social tariffs

Source: Financial tip research (as of 3 January 2019)