In Germany, the public health insurance system, known as Gesetzliche Krankenversicherung (GKV), provides comprehensive healthcare coverage. Funded by mandatory income-based contributions and the state, the system is run by different Krankenkassen (health insurance funds).
Here's an overview of what is typically covered:
1. Doctor visits and specialist care
General practitioner (GP):
Unlimited visits to general practitioners (Hausärzte) are fully covered.
GPs serve as the first point of contact and can refer patients to specialists.
Most insurers follow a “Hausarztmodell” (GP-centered care): patients commit to consulting the GP before seeing specialists (optional but incentivized).
Specialist care:
Access to specialists (Fachärzte)—e.g., dermatologists, cardiologists, neurologists—is fully covered.
You can see a specialist without a referral, though for some (e.g., psychiatrists, psychotherapists), a GP referral may ease access.
Long wait times are common for non-urgent cases.
Variation among insurers:
Insurers like TK or AOK may offer bonus programs for enrolling in the Hausarztmodell, which can come with reduced waiting times or digital services.
Some insurers offer telemedicine GP services via apps or partner clinics.
Some offer faster access via specialist appointment hotlines (e.g., TK’s "Facharztterminservice").
Private supplementary insurance can shorten wait times by covering private practices (Privatärzte).
2. Checkups and preventive care
General checkups:
Once every 3 years from age 35 (called “Check-up 35”).
Includes cholesterol, blood sugar, and blood pressure.
Cancer screenings:
Cervical: Annually (age 20+).
Breast: Mammography every 2 years (50–69).
Skin: Every 2 years (35+).
Colon: Stool tests (50+), colonoscopy (55+).
Dental: Twice per year (for preventive cleanings).
Variation among insurers: Some offer more frequent check-ups or additional screenings, e.g., TK covers professional teeth cleaning partially.
3. Emergency medical services
In Germany:
Emergency transport (ambulance/helicopter within Germany).
Emergency room treatment.
Emergency hospitalization.
Co-payments: €10 per ambulance ride.
Abroad:
Covered within EU/EEA/Switzerland via EHIC card.
Outside EU: not covered; private travel insurance recommended.
No significant variation among insurers.
4. Hospital treatment
Inpatient Care: This covers hospital stays, including surgery, nursing care, medications, and therapies needed during the stay.
Basic Room and Board: The coverage usually includes a shared hospital room, although private or semi-private rooms may require additional private insurance or out-of-pocket payments.
No significant variation among providers
5. Medications and prescriptions
Prescription drugs: Most medications prescribed by doctors are covered; some require a co-payment from the insured (usually around 5 to 10 EUR per prescription).
Over-the-counter medications: Generally not covered unless they are deemed necessary for specific chronic conditions (like insulin for diabetes).
Variation among insurers: Some reimburse OTC products under bonus plans or integrative medicine schemes.
6. Vaccination
Standard vaccines covered (per STIKO recommendations): MMR, polio, tetanus, influenza, COVID-19, HPV, hepatitis, etc.
Flu vaccines are covered annually for those 60+, chronically ill, or pregnant.
Not covered: travel vaccines (e.g., yellow fever, typhoid, rabies)
Variation among insurers: TK and some others partially reimburse travel vaccinations or offer occupational-related immunizations.
7. Pregnancy and childbirth
Prenatal care:
Fully covered: blood tests, urine, 3 ultrasounds (12, 20, and 30 weeks), screenings for infections, and gestational diabetes.
Optional extras (e.g., 3D ultrasound, toxoplasmosis, NIPT) are self-paid unless high risk.
Birth:
Fully covered in hospitals and birth centers.
Home births with licensed midwives are also reimbursed.
Postnatal:
Midwife visits (up to 12 weeks), postnatal pelvic floor training, and baby check-ups.
Variation among insurers: Some cover additional services through bonus programs (e.g., prenatal classes, lactation consultants, digital midwife consultations, midwife-on-call).
8. Pediatric care
U1–U9 preventive checkups fully covered (first years of life).
Developmental screenings, immunizations, and referrals to specialists.
No significant variation among insurers: pediatric care is a core GKV offering.
9. Dental care
Basic dental care: Covers routine check-ups, simple tooth cleaning, and minor dental procedures like fillings.
Prosthetics and crowns: Partial coverage is provided, with co-payments depending on the specific procedure and the patient’s dental bonus book status.
Variation among insurers: Some cover simple and professional cleanings fully or partially. Partial coverage for treatments can vary from a fixed amount to different percentages.
10. Orthodontics
For children and adolescents under 18, GKV covers 60% of treatment costs (up to 80% if multiple siblings are treated), reimbursed after successful treatment.
Treatment must be classified as KIG level 3–5 (medically necessary). Levels 1–2 (cosmetic issues) are excluded.
Adults only receive coverage for severe jaw misalignments requiring surgical intervention or after accidents.
Variation among insurers: Some providers (e.g., TK) may offer partial subsidies or bonus programs for milder corrections, but generally adult coverage is very limited.
11. Therapies and rehabilitation
Physical therapy, occupational therapy, and speech therapy:
Covered if prescribed (e.g., post-surgery, chronic pain, injury).
Requires a 10% co-pay of treatment cost + €10 per prescription.
Number of sessions is limited (e.g., 6–10 sessions per condition).
Necessary medical rehabilitation programs after surgery or for chronic conditions are covered.
Variation among insurers: Some offer more rehab options or partnerships with wellness programs.
12. Mental health services
Psychotherapy:
GKV covers evidence-based approaches:
Cognitive Behavioral Therapy (CBT), psychodynamic therapy, and analytical therapy.
Requires:
Initial sessions (“probatorische Sitzungen”).
Formal application for long-term therapy (often approved).
Often long waiting times (especially in rural areas).
Psychiatric treatment: Covered under specialist referral. Includes psychiatric evaluation, diagnostics, inpatient stays, and crisis intervention.
Variation among insurers: Some offer short-term teletherapy or digital support while waiting for full therapy access.
No variation among insurers in core psychiatric coverage
13. Medical aids and devices
Hearing aids, wheelchairs, orthopedic shoes, and others: Partially or fully covered if prescribed by a doctor.
Glasses and contact lenses: GKV covers basic lenses and frames for:
Children and adolescents under 18.
Adults with severe visual impairments (≥6 diopters of myopia/hyperopia or ≥4 diopters of astigmatism).
Premium features (anti-reflective coating, lightweight materials, fashion frames) are not covered.
Variation among insurers: Some providers offer bonus programs or optical subsidies; e.g., TK or Barmer might offer annual reimbursements for frames/lenses.
14. Sick leave and compensation
Sick leave pay: For employees unable to work due to illness, public health insurance provides Krankengeld (sick pay), which is 70% of the regular gross salary (capped at 90% of net salary) from the 7th week of sick leave, as the employer covers the first 6 weeks. Freelancers can opt in for this coverage.
15. Sexual and reproductive health
STD screenings:
Covered if symptoms are present or a partner is positive.
HIV test covered once after age 35 or during pregnancy.
Contraceptives:
Free up to age 22 (pill, IUD, injection, etc.).
After 22: Self-funded unless medically indicated (e.g., hormone therapy).
Abortion counseling and medically indicated abortions (e.g., health risk to mother) are covered.
Variation among insurers: Some may reimburse contraception costs over 22 in hardship cases or through bonus programs.
16. IVF and related treatments
Eligibility criteria:
The couple must be married.
The partners must be of opposite sex (same-sex couples and single individuals are typically not eligible under GKV).
Both partners must have undergone a medical and psychological consultation prior to treatment.
The woman must be between 25 and 40 years old, and the man between 25 and 50 years.
Covered treatments:
3 cycles of IVF or ICSI (Intracytoplasmic Sperm Injection)
8 cycles of insemination without hormone stimulation
3 cycles of insemination with hormone stimulation
Only 50% of the treatment costs are typically covered. The couple must pay the other half themselves.
Diagnostic procedures:
Necessary diagnostics to determine infertility are fully covered.
This includes hormone testing, semen analysis, ultrasound, and similar procedures.
What GKV does not cover:
More than 3 IVF/ICSI cycles or more than the allowed number of insemination attempts.
Treatments for unmarried couples, same-sex couples, or single women.
Cryopreservation (freezing of eggs or embryos) and storage costs.
Use of donor sperm or donor eggs (only homologous procedures—using the couple’s own gametes—are supported).
Preimplantation Genetic Diagnosis (PGD) is only covered in very specific, medically indicated situations and often requires case-by-case approval.
Variation among insurers: Some providers cover up to 100% for the first 3 cicles depending on the situation, some offer additional payments (TK for example provides additional €500 per cicle)
What is not covered?
While public health insurance offers broad coverage, there are some limitations:
Cosmetic surgery: Not covered unless it is medically necessary (e.g., reconstruction after an accident).
Alternative medicine: Some treatments, like acupuncture or homeopathy, are covered only under specific conditions or supplementary private insurance
Luxury hospital services: Private rooms, specialized doctors (Chefarzt), or additional comfort services in hospitals typically require supplementary private insurance.
Co-payments and out-of-pocket costs
There are small co-payments for certain services:
Doctor visits: generally, no co-payment.
Medications: 5-10 EUR per prescription.
Hospital stay: 10 EUR per day for a maximum of 28 days per year.
Rehabilitation services: May require a daily co-payment for a limited number of days.
All things considered, Germany has a comprehensive public health insurance system that strives to offer its members basic medical care.
To enhance their coverage, many public health insurance members choose supplementary private insurance, such as dental health insurance, travel health insurance or others, to address specific needs.