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Applying for exemption from co-payments in statutory health insurance


If you have statutory health insurance, you have to pay part of the costs yourself for certain services - for example a hospital stay, medicines or remedies such as physiotherapy - the so-called statutory co-payments. However, you only have to pay these co-payments up to the so-called burden limit, after which you can be exempted from them. To do this, submit an application to your health insurance company.

The burden limit is 2 percent of your annual gross income for living expenses. If you are seriously chronically ill, the stress limit is 1 percent. You can prove your serious chronic illness by means of a medical certificate (model 55). Further evidence may be required. Your health insurance company will inform you about this.

If you are married, live in a registered civil partnership or have minor children or children with family insurance and live with them in the same household, the co-payments and income of all relatives are added together. Allowances for members of your household are deducted from the family income, so that your family income to be taken into account is reduced.

You have to pay co-payments for certain medical services that are covered by your statutory health insurance. These include:

  • Drug
  • Home Nursing
  • Remedies such as massages or physiotherapy
  • Assistive devices such as wheelchairs
  • Inpatient hospital treatment
  • Inpatient rehabilitation or preventive measures
  • Travel costs

Not all costs for medical or medical services are considered co-payments. No co-payments are, for example, your own contribution or additional costs for dentures, medical services without a doctor's prescription or individual health services.
 

Process flow

To be exempted from co-payments in the statutory health insurance, proceed as follows:

  • Collect the receipts of your statutory co-payments.  
  • If you have reached the annual burden limit, submit an application for exemption from co-payments to your statutory health insurance company.
  • You can apply for exemption from co-payments by post or – in the case of many statutory health insurance companies – hand it in in person at the office or submit it online.
  • Your health insurance company will issue you with a certificate stating that you no longer have to pay co-payments. If you have already paid too much, you will be refunded.
  • Alternatively, many health insurance companies allow you to pay the amount of your annual co-payment limit in advance. Then you don't have to collect any receipts and your health insurance company will directly issue you with a certificate of co-payment exemption.
  • If you and your relatives living in the same household are insured with different health insurance companies, you can submit the application together to one of the health insurance companies. The health insurance company will determine the burden limit for your family, issue you with a certificate of exemption and reimburse you on a pro rata basis for the excess co-payments made. With the decision of the health insurance company, you can then inform the health insurance companies of your relatives, who will also issue the exemption notices for your relatives and reimburse them just as proportionately for the overpaid co-payments.
     

Requirements

  • You've already paid at least 2 percent of your gross living expenses for statutory co-payments.
  • If you are seriously chronically ill, a limit of 1 percent applies.
  • You are considered seriously chronically ill if you have been treated by a doctor for the disease at least once a quarter for at least one year and if at least one of the following characteristics applies to you:
    • You are in need of care and have a care level of at least 3;
    • You have a degree of disability of at least 60 percent due to the illness or your earning capacity is reduced by at least 60 percent;
    • You need certain medical treatment on a permanent basis, because otherwise your state of health would deteriorate in a life-threatening way or there would be a reduction in life expectancy or a permanent impairment of quality of life due to your illness.

There are exceptions to the co-payment in the following cases, among others:

  • Children under the age of 18 do not have to pay any additional fees (exception: travel expenses).
  • If you are pregnant, you do not have to pay a co-payment for medicines, bandages, remedies and aids if you need them due to your pregnancy; Your hospitalization during childbirth or due to common pregnancy complications is also free of co-payment.
     

Which documents are required?

  • Proof of income
  • Proof of additional payments already made, such as invoices, receipts or a copy of a bank statement
  • Chronically ill: Proof of a serious chronic illness from your doctor

In individual cases, further documents may be required. Please contact your health insurance company for more information.
 

What are the fees?

You do not have to pay anything for the application for co-payment exemption.

What deadlines do I have to pay attention to?

You can apply for exemption from co-payments up to 4 years retroactively.

Processing duration

It usually takes about 4 to 8 business days to process.

In order to process and make a decision quickly, your health insurance company must have the necessary information and, if necessary, documents complete and meaningful.
The health insurance company decides on applications promptly, whereby the statutory processing deadline is observed in order to protect patients' rights.
Please note that the stated processing time is an average value for all health insurance companies. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and can be extended accordingly. The same applies if documents or records are sent to you or your health insurance company by post.
 

Applications / forms

  • Forms: yes
  • Online procedure possible: Many statutory health insurance companies offer an online procedure.
  • Written form required: no
  • Personal appearance required: no
     

Appeal

  • Contradiction
  • Appeal to the Social Court

Technically approved by

Federal Ministry of Health
 

Professionally released on

30.11.2021

Author

The text was automatically translated based on the German content.

Source: Serviceportal Niedersachsen (Portalverbund des Bundes und der Länder)