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) and Specialist Visits: Coverage includes visits to general practitioners, family doctors, and specialists like dermatologists, gynecologists, or cardiologists.
Preventive Check-Ups: Regular check-ups, such as cancer screenings, cardiovascular risk assessments, and vaccination consultations, are included.
2. Hospital Treatment
Inpatient Care: This covers hospital stays, including surgery, nursing care, medications, and therapies needed during the stay.
Emergency Services: Emergency room visits and ambulance services are also covered.
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.
3. 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).
4. Preventive and Health Promotion Services
Vaccinations: Most vaccinations recommended by health authorities (e.g., flu shots, tetanus, MMR) are covered.
Prenatal and Postnatal Care: Regular check-ups for pregnant women, childbirth, and postnatal care for both mother and baby are covered.
5. Maternity and Childcare
Maternity Care: Includes prenatal exams, childbirth (in hospital or birth center), midwifery services, and postnatal care.
Child Health Exams: Preventive medical check-ups for children (U1 to U9 screenings), including hearing tests and developmental assessments, are covered.
Orthodontic Treatment: Covered for children and adolescents if medically necessary.
6. 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.
Orthodontics: Treatment for severe misalignments is covered for children and adolescents.
7. Therapies and Rehabilitation
Physical Therapy, Occupational Therapy, and Speech Therapy: Covered when prescribed by a doctor.
Rehabilitation Programs: Includes coverage for necessary medical rehabilitation programs after surgery or for chronic conditions.
8. Mental Health Services
Psychotherapy: Covered if deemed necessary by a doctor or psychiatrist, but usually requires approval and may have waiting times.
Psychiatric Treatment: Coverage includes consultations and treatments with psychiatrists.
9. Medical Aids and Devices
Hearing Aids, Wheelchairs, and Orthopedic Shoes: Partially or fully covered if prescribed by a doctor.
Glasses and Contact Lenses: Covered only for children or in cases of severe visual impairment in adults.
10. Sick Leave and Compensation
Sick Leave Pay: For those 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.
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.
Luxury Hospital Services: Private rooms, specialized doctors (Chefarzt), or additional comfort services in hospitals typically require 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.