The extra items for the various benefits approved by the health insurance can quickly add up to a considerable amount, especially for those who are temporarily seriously or permanently ill.
In statutory health insurance, insured persons are entitled to benefits that prevent illnesses or serve to treat illnesses. The Patients’ Rights Act stipulates that health insurance funds must decide on applications for benefits (e.g. for therapeutic appliances and aids, domestic help, domestic nursing care) within three weeks of receipt of the application. If an expert opinion is required, in particular from the Medical Service of the health insurance funds, the health insurance funds must decide within five weeks of receipt of the application whether the service is to be approved. If it is unable to meet the deadline, it must inform the insured person in good time and in writing, stating its reasons. If no written justification is given after the expiry of the deadline, the application for a benefit shall be deemed to have been approved. Insured persons can then procure the required benefit themselves and invoice the Fund.
So that patients are not overcharged for maintaining their health, maximum limits have been set for co-payments in statutory health insurance. Statutory health insurants should check in good time before the end of the year whether they have reached the limit for the following calendar year and whether they can be exempted from excess co-payments. The most important co-payments in statutory health insurance concern
The aids include a large number of products such as incontinence aids, compression stockings, shoe inlays, prostheses, wheelchairs or hearing aids. For aids that are intended for consumption (e.g. insulin syringes), you pay 10 percent of the cost per pack plus a maximum of ten euros for the total monthly requirement of such aids. For all other aids, the co-payment rule of 10 percent applies – with a minimum of five euros and a maximum of 10 euros. You must pay this amount to the aid provider.
In a further article you will find additional information on the entitlement to and application for medical aids from the health insurance fund.
Blood pressure or blood sugar monitors are reimbursed only if necessary for the independent monitoring of the disease and confirmed by the doctor.
Only children and adolescents under the age of 18 are entitled to visual aids and glasses. Adults must pay all costs themselves. Only in special exceptions can the costs for visual aids and glasses be reimbursed. On the one hand, if you need a therapeutic vision aid due to an eye injury and on the other hand, if there is a severe visual impairment in both eyes. A prescription for vision aids and glasses in these exceptional cases is the responsibility of ophthalmologists. If you are entitled to benefits, your health insurance company will cover the costs for the necessary visual aids in the amount of the contractually agreed prices up to a maximum of the applicable fixed amounts.
Among the remedies are physiotherapy, massage, speech therapy or ergotherapy. For remedies, the co-payment is 10 percent of the costs plus 10 euros per prescription.
medicaments and dressings
For medicines, the co-payment is 10 percent of the cost, a minimum of 5 euros and a maximum of 10 euros, but not more than the cost of the drug. If the health insurance company has concluded discount contracts with pharmaceutical companies, it can cut the co-payment in half or waive it altogether. Some drugs are very inexpensive and therefore exempt from co-payment.
For a stay in hospital you pay 10 Euro per calendar day. The additional payment is limited to 28 days or 280 Euro per calendar year. If an inpatient rehabilitation is necessary afterwards, the co-payments are limited to the 28 days including hospital treatment. For mother/father/child cures, you have to pay an additional 10 euros per day without any time limit.
Home nursing care
You pay ten euros per prescription and 10 percent of the costs for home nursing care. The co-payment is limited to a maximum of 28 calendar days per year.
If the health insurance company approves a domestic help, you must pay 10 percent of the daily costs, but at least 5 euros, maximum 10 euros.
Costs for the journey to outpatient treatment are only covered by the health insurance funds in a few exceptional cases and only after prior approval. These exceptional cases have been defined by the Joint Federal Committee in the Health Transport Directive. The prerequisite for prescribing a trip to outpatient treatment is:
- that the patient has to be treated over a longer period of time because of a basic illness, and
- that this treatment or the course of the disease leading to this treatment is life-threatening for the patient.
These prerequisites are given, for example, with the
- dialysis treatment
- Oncological radiotherapy
- Oncological chemotherapy.
In addition, trips to outpatient care can be prescribed if:
- the insured person presents a severely disabled person’s identity card with the mark “aG” (extraordinary disability), “Bl” (blind) or “H” (helpless) or
- the insured person can submit a classification decision in accordance with SGB XI into nursing grades 3 (only in the case of permanent restriction of mobility), 4 or 5.
In these cases you will need a prescription from your attending physician. He will check whether there is a need and, if necessary, select the means of transport required. Only journeys that are medically necessary in connection with a health insurance service are recognised. Only journeys on the direct route between the place of stay and the nearest suitable treatment option are recognised.
Insured persons must pay ten percent of the travel costs, but at least five euros and no more than 10 euros per trip. If the travel costs are less than five euros, you will of course only pay the actual price.
So that you as a patient are not overburdened financially, there are maximum limits for the co-payments to be made. The charge limit is calculated from the total of all copayments in the statutory health insurance area. You should therefore keep all copayment documents in a safe place.
Doctors, medical supply stores and all other service providers, as well as health insurance companies, have to pay the co-payments free of charge.