Co-payments and exemption from co-payment

Anyone with statutory health insurance is required to contribute a payment, known as a co-payment, to certain medical costs. These payments apply, for example, to medication, physiotherapy or a stay in hospital. Co-payments of varying amounts also apply to other health-related products and services. Children and adolescents under the age of 18 are exempt.

Medicinal products and bandages/dressings

For prescription medicinal products and bandages/dressings, the co-payment is equivalent to 10 percent of the price, subject to a minimum of 5 euros and a maximum of 10 euros.  No co-payment applies in the case of some low-cost medication. For more information, see the article “Medication costs – insurance cover and co-payments”.

Medical aids

For medical aids like compression stockings, wheeled walkers, walking aids or wheelchairs, the co-payment is equivalent to 10 percent of the cost, subject to a minimum of 5 euros and a maximum of 10 euros. The co-payment for consumable medical aids such as incontinence aids is 10 percent per unit of consumption, subject to a maximum of 10 euros per month.

Therapeutic services

For therapeutic services such as physiotherapy or speech and language therapy, the co-payment is 10 percent of the cost plus 10 euros per prescription.

Travel costs

If your health insurance fund covers travel costs, you are normally required to cover 10 percent of the costs yourself, subject to a minimum of 5 euros and a maximum of 10 euros per journey. As a rule, you should never be required to pay more than the actual costs incurred. This also applies to children and adolescents. Return journeys are regarded as two separate journeys.

Inpatient treatment

A co-payment of 10 euros per day applies for:

• full-time inpatient hospital treatment and follow-up care (for a maximum of 28 days per calendar year)
• inpatient preventive care (health resort visit)
• inpatient medical rehabilitation (rehab)
• visits to health resorts and inpatient rehabilitation (rehab) for mothers and fathers

Home help

For home help approved by your health insurance provider, you are required to contribute 10 percent of the costs per calendar day, subject to a minimum of 5 euros and a maximum of 10 euros.

Home nursing

If you avail of home nursing, you are required to pay 10 percent of the costs plus 10 euros per prescription. Co-payments are to be paid for a maximum of 28 calendar days.

Where do co-payments have to be paid?

Most co-payments have to be paid directly where they are incurred – for example, in pharmacies, hospitals or specialist orthopedic shops. For special services, such as emergency transfer to hospital, the health insurance fund issues a bill at a later date.

If you would like to know whether you can get a co-payment exemption, you must first calculate all of the co-payments that you have already made over the course of the year – this includes co-payments for all family members who are insured with the same statutory health insurance fund.

If co-payments exceed a certain proportion of your income within one calendar year, you can be exempted from further co-payments for the remainder of the calendar year. This proportion of your income, which represents the maximum amount you are required to contribute in co-payments, is known as your contribution limit (“Belastungsgrenze”).

An exemption from co-payments therefore does not mean that people with statutory health insurance are not required to pay any contribution towards their medical costs. However, the individual contribution limit is intended to prevent anyone from having to pay for medical care above and beyond their financial means.

When is the contribution limit reached?

The contribution limit is reached when the co-payments of all family members living in a household add up to 2 percent of the gross family income. Tax-exempt amounts are deducted in the calculation. The contribution limit is 1 percent of the gross income for people who have a severe chronic illness. For people who rely on state financial support, the limit is calculated on the basis of the standard support requirement (“Regelbedarf”).

Calculating the contribution limit

To calculate the contribution limit, you must first determine your gross income for subsistence. If you live with family members in a household, the gross incomes of all family members in the household are added together. This includes spouses or civil partnership partners, children under the age of 18 and children over the age of 18 who are insured as family members on their parent’s health insurance. Even if spouses or civil partnership partners in need of care live in a full-time residential care facility, they are still considered part of the same household – to the extent that the long-term care insurance fund covers the cost of their care. Unmarried couples are considered separately.

All incomes available to cover living costs are included in the calculation of gross income. These include: wages/salary, self-employed income, earnings replacement benefits, unemployment benefits or pensions, but also rental and leasing income, capital assets, financial settlements and company pensions. Not included, for example, are incomes from child benefit, financial supports for education and training (BAföG), care allowance and parental allowance up to a limit of 300 euros.

Tax-free allowances for each family member can be deducted when calculating the gross income for the household. These allowances are adjusted by law on an annual basis.

Details of the current tax-exempt amounts are available on the website of the Federal Ministry of Health (Bundesministerium für Gesundheit).

Which co-payments are considered?

When calculating the contribution limit, co-payments are only included in the calculation if they are demanded by statutory health insurance funds as contributions towards essential medical products and services. Receipts must be provided as proof of these co-payments.

Costs that are not normally covered by health insurance funds cannot be included in the calculation. These include, for example, individual health services (IGeL) or extra charges that apply due to individual requirements – for example, a medical aid with special features. Personal contributions towards dentures or artificial insemination, for example, are also excluded. People on a low income can apply for a subsidy towards dentures from their health insurance fund in accordance with hardship provisions.

A contribution limit of 1 percent applies to people with a chronic health condition. This means that, at most, they are required to pay 1 percent of their gross income as co-payments for health benefits.

In order to be exempted from further co-payments, they require a doctor’s certificate as proof that they have had a chronic illness for at least one year and are receiving ongoing treatment. They must also be able to verify that they have undergone the early cancer screenings recommended by the statutory health insurance funds.

In addition, at least one of the following prerequisites must be met:

• There must be no gaps in the medical care the person is receiving so that their health condition does not deteriorate.
• They are in need of care and have been assigned a care grade of 3 or higher.
• Their earning capacity is reduced by at least 60 percent or their degree of disability or injury is 60 percent or more.

Their doctor has provided them with a specific form (“Muster 55”), certifying that they have a severe chronic illness. It specifies their diagnosis and indicates when the individual began ongoing treatment for their illness and whether their therapy needs to continue.

A contribution limit of 1 percent also applies to chronically ill patients taking part in a structured program of treatment (disease management program).

A special rule applies to people in receipt of state support. In such cases, the health insurance fund calculates the contribution limit for families, spouses and civil partnership partners based on the standard rate. For co-payment exemption, this set rate for a single person is applied to the family as a whole.

No tax-free amounts apply in such cases. If the contribution limit has been reached, all members of the household who have statutory health insurance can be exempted from further co-payments for the remainder of the current year.

This applies to people in receipt of the following forms of state support:

• financial aid to cover living expenses (social welfare)
• unemployment benefit II
• basic security benefits for old age or reduced earning capacity
• social welfare office payments for accommodation in a nursing home or similar facility

You are not automatically exempt from further co-payments once you reach the contribution limit. The statutory health insurance funds don’t automatically take action in this case. You must take responsibility for keeping track of your co-payments and collecting your receipts.

The receipts must include the first and last names of the patient, the type of service provided, the co-payment amount, as well as the relevant date and location.

The application must be accompanied by the original receipts. The application form is available from your health insurance fund. Proof of income must also be attached to the application.

If the health insurance fund approves your application, it will send you a certificate known as the “exemption card”. For the remainder of the calendar year, you must then present your exemption card whenever you are required to make a co-payment.

If you have already made more co-payments above your limit, the excess amount will be reimbursed to you. It is also possible to submit a retroactive application for an exemption – this is limited to the past four calendar years only.

It is possible to get an exemption from co-payments in advance, i.e., for the remainder of the year or for the full calendar year ahead. To obtain an advance exemption, you need to apply to your health insurance fund for advance payment.

If the health insurance fund approves your application, you will, however, be required to pay the fund an amount to cover your expected co-payments for the entire calendar year in advance. This is the total co-payments you expect to pay up to your contribution limit. The advantage to this approach is that you won’t need to keep any receipts.

However, an advance exemption is only recommended if you are very confident, at the start of the year, that you will reach your personal contribution limit – in other words, that you will make co-payments equal to more than 2 percent of your gross income over the course of the calendar year ahead. This is because the advance payment you make to your health insurance fund won’t be repaid to you.

The calculation of your contribution limit is subject to change. If you subsequently earn considerably more than expected or if your personal circumstances change, you may need to make additional payments.

In the event of any uncertainties, individual questions or problems in relation to your application for a co-payment exemption, refer, for example, to the Independent Patient Advice Service for Germany (UPD).