Health insurance in Germany

Germany’s healthcare system (Deutsches Gesundheitssystem) is among the best in the world, ranking fourth behind only Switzerland, Ireland, and the Netherlands. It provides a comprehensive benefits package and universal access to relatively high-quality and effective care for all residents.

So how does it work for special cases, such as students, pregnant people, or freelancers? Can you use your European Health Insurance Card (EHIC) or do you have to take out private insurance?

Let’s dive in:

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Health insurance in Germany

Everyone living and working in Germany is required by law to take out health insurance. The healthcare system is a mix of public and private sectors, and you cannot use them interchangeably. Only a handful of people are allowed to go for private insurance, and once they do, it’s difficult to go back to public health insurance – unless their financial situation requires it.

Most people (around 89% of the population) will sign up for statutory public health insurance (Gesetzliche Krankenversicherung – GKV). Insurance fees are paid through social security contributions that are deducted directly from their salaries. Those who are unemployed can also sign up for public healthcare, more on that below.

Self-employed people and higher earners can choose to take out private health insurance (Private Krankenversicherung – PKV). In 2021, only 11% of German residents signed up for private health insurance.

(International) students

Students under 30 attending a Bachelor’s or Master’s program at a German university can get statutory health insurance at a reduced rate (Gesetzliche Krankenversicherung für Studenten). Because enrollment is not automatic, you must sign up manually with a public insurance company. Depending on which provider you choose, you can expect to pay a fee of about €117 per month.

Due to international health insurance agreements, some international students don’t need to take out separate insurance as their national health insurance is valid in Germany as well. Those that don’t need mandatory insurance include students from:

• The EU
• Bosnia and Herzegovina
• Iceland
• Israel
• Liechtenstein
• Macedonia
• Montenegro
• Morocco
• Norway
• Serbia
• Switzerland
• Tunisia
• Türkiye

Trainees and interns who earn €520–5,550 per month (as of 2023) can also benefit from the student rate. Unfortunately, students over 30 or doing a PhD program do not qualify for public insurance. If that’s you, you can sign up with a private provider instead. For example:

• Allianz Care
• Cigna Global
• Feather Insurance

Freelancers and self-employed people

There are specific rules regarding the health insurance of self-employed people or freelancers working in Germany. For example, self-employed Germans are not legally obliged to take out health insurance, but foreigners moving to the country from abroad are.

The cost of health insurance each month is based on a percentage of your monthly income, between 14.9% and 15.4%. In other words, the less you earn, the less you pay. Moreover, insurers will only look at salaries between €1131.67 and €4987.50 per month (as of 2023). Anything under or above will pay the same minimum or maximum rate.

Keep in mind that because of this reduced rate, you will not be covered for sick leave. Instead, you can take out additional insurance (Wahltarif Krankengeld für Selbstständige).

Welfare-recipients and pensioners

If you lose your job or fall ill, you will stay insured like you were before. So if you already had statutory health insurance, the social welfare office (Sozialamt) or basic security office (Grundsicherungsamt) will take on the responsibility to make contributions for you.

The same rule applies to pensioners as well. Your pension provider will make social security contributions to ensure you keep your statutory insurance. If you had private health insurance, you will stay insured that way. However, you will likely see your premiums go up, as they are based on age and risk factors.

If you worked and retired abroad and move to Germany as a pensioner, you’ll get insured through the statutory insurance scheme. That is because, under German law, all foreign pensions must make health and long-term care insurance contributions as well.

Unemployed family members

Spouses, civil partners, and children (up to age 23, or 25 if they are a student) can sign up for a collective family policy if they have an adult family member with statutory health insurance. Dependents usually don’t need to pay contributions, provided their income does not exceed €520 monthly.

Expats and other temporary residents

Temporary residents from the EU, the European Free Trade Association (EFTA – Iceland, Liechtenstein, Norway, and Switzerland), and the United Kingdom (UK) can access healthcare with their European Health Insurance Card (EHIC). Read this GKV pamphlet on using your EHIC in Germany for more information.

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Visitors from outside that region or those without an EHIC must take out private travel or health insurance. In fact, it is a prerequisite for getting a visa or a resident permit. Companies that offer private travel health insurance include:

• Allianz Travel
• Allyz
• Europ

What happens if I don’t have insurance?

Although you are legally required to take out health insurance, you’re not committing a crime if you don’t. You might get tired looks and face heftier bills down the line, but you won’t be prosecuted.

That said, the health insurance scheme is a mandatory part of the German social security system. Even without insurance, you must still make social security contributions. If you don’t and sign up at a later date, you must pay the outstanding contributions over the period of time you didn’t have health insurance. In other words, you will face a lot of debt if you choose to remain in Germany.

Moreover, while you can still see a doctor if you’re not insured, you will only be treated in case of a life-threatening emergency. In other medical cases, you will likely be sent packing.

Statutory health insurance (GKV)

As said before, most people will sign up for statutory health insurance. There are currently just over 100 public insurance companies and coverage does not vary much between the different providers. In fact, 95% of benefits are the same across the board.

That said, contribution rates and additional services differ, as well as the availability of English-speaking staff. Krankenkassen.de offers a comparison tool to see which insurance company covers which benefits.

What is covered by statutory insurance?

Public health insurance covers all basic urgent care, including:

How to apply for statutory insurance as an expat

Because it is linked to your social security, you can only apply for statutory health insurance when you have your social security number.

Next is finding a job. Your new employer will sign you up with a regional insurance company once you’ve signed the contract. Although you are free to choose your provider, you should do so within two weeks of your start date. Otherwise, you might be registered with a different insurance company.

If you’re self-employed, you’ll need to register yourself. It’s usually a fairly straightforward process that includes an online form and signing electronically.

Once you’ve become a member, your health insurer will issue you a health card (Gesundheitskarte) or EHIC (Europäische Krankenversicherungskarte). You’ll have to this show each time you visit a new doctor or specialist.

Private health insurance in Germany (PKV)

Only a select few people are allowed to switch from statutory to private health insurance. Generally, if you earn more than €66,600 per year (as of 2023), you can go private. Others that can or must get private insurance:

• Freelancers and self-employed people
• Civil servants
• Students over 30 years old or pursuing a PhD
• Those who can’t register for public health insurance

While private healthcare does come with a lot of perks (including shorter waiting times), switching from public isn’t always advisable. For example, your monthly premium is based on personal factors and prices increase with age, health risks, and additional family members.

Those with certain medical conditions might also have difficulties getting accepted into a private scheme in Germany. However, if you want private insurance regardless, you can go for a basic tariff (Basistarif). This obligates insurance companies to accept all cases under the same conditions as the statutory system.

Pros and cons of private health insurance

Private health insurance often offers more choices, including more specialist treatments, better accommodation, and English-speaking doctors. The waiting times are shorter, and you won’t need to make any additional co-payments for prescription medication.

Then again, it’s usually more expensive than the statutory insurance scheme. Not all treatments are covered, and, as said before, pre-existing conditions are often not covered by private health insurance companies.

Plus, insurance memberships typically run for 18 months. You can only switch with a two months notice before the expiration date or a price hike. So if you’re planning to stay in Germany for less than that, or you have trouble committing long-term, private insurance might not be the best option.

Private German health insurance companies

Around 1 in 10 residents has private insurance, with about 40 companies making up this side of the market. Private insurers offer a wide array of packages to suit every budget and lifestyle.

The best insurance companies in Germany with expat-friendly policies include:

• Allianz Care
• Cigna Global
• Embea – covers critical healthcare such as heart attacks and cancer
• Feather Insurance

If you need help choosing a health insurance plan, it’s worth reaching out to a broker who can guide you through the process. Insurance brokers operating in Germany who specialize in helping internationals organize their (health) insurance include:

• KLforExpats
• Versicherungsbüro Weiss

How much is German health insurance?

In 2019, Germany spent around 11.7% of its GDP on healthcare (or €4,505 per person). That is more than any other country in the EU, where the average is 9.9% of the GDP (or €3,523 per person). Moreover, out-of-pocket spending amounts to only 12.7 %, well below most other EU countries.

Although you won’t get a hefty medical bill, German healthcare isn’t free either. Health insurance fees are part of your social security contribution and are deducted from your salary before it even gets to your bank account. The contribution is 7.3% of your net income, with your employer paying an extra 7.3%. Your total contribution is then 14.6% of your net income per year.

Some public insurers also charge an additional contribution, which can fluctuate year-to-year depending on healthcare expenditure. In 2021, the average additional contribution rate across all public insurance companies was 1%.

Reimbursements and co-payments

With statutory health insurance, your medical bill will be sent directly to the insurer. In other words, you won’t have to pay for the treatment yourself. However, if you have private insurance, you will usually pay your bills first after which you can ask for reimbursement from your insurance company.

In recent years, the German government has come under pressure to cut healthcare costs. So in some areas, such as dentistry, orthodontics, and vision care, statutory health insurance only covers a portion of the cost. Co-payments currently stand at around 10% for treatments and medicines, but they may increase again in the future.

There are also some exceptions for people who are chronically ill and require a lot of medical treatment and prescription drugs. The healthcare system places a co-payment limit of 1% of their gross annual income on anyone with reduced earning capacity due to medical impairment.

Health insurance deductibles in Germany

Some insurance companies allow you to pay less premium in exchange for an insurance deductible. That means you’ll get more money in your bank account every month, but will have to pay (part of) the costs of any medical treatment you might need.

If you have statutory health insurance, the deductible is called an optional tariff (Wahltarife). Available optional tariffs include:

• Deductible (Selbstbehalt) – save up to 20% on your annual fee and risk paying up to €600 for treatment
• Premium refund (Beitragsrückerstattung) – if you don’t use any healthcare services during the year, you can get your premium back
• Waiver of benefits (Leistungsverzicht) – get a bonus if you waive your right to benefits, such as the childcare benefit or sick pay
• Deductible, premium refund, and benefits waiver (Kombination) – this is a combination of extra risk, premium refund, and benefits waiver
• Reimbursement (Kostenerstattung) – you agree to pay the healthcare costs yourself first, after which you ask for reimbursement from the insurer

If you have private health insurance, the deductible is called Selbstbehalt or Selbstbeteiligung. Available options include:

• Fixed (Fest) – same as the deductible above, you risk paying a fixed amount for medical treatment in exchange for a discount
• Percentage (Anteil) – you’ll only pay a percentage of the costs of medical treatment and save on your monthly fees
• Modular (Modulare) – you’ll pay for selected procedures (e.g., dental treatment) and get a discount on your premium

Be sure to check with your health insurance company to see which deductible they offer in Germany.

Insurance for long-term care

Long-term care insurance is also compulsory in Germany. So in addition to the 14.6% premiums paid for state healthcare, you must join a separate public nursing care scheme (Pflegepflichtversicherung). This will cover the costs of long-term care would you need it (e.g., bathing or feeding if living with a disability).

Those with private health insurance must add long-term care to their policies, either with the same provider or a different one.

Useful resources

• Deutsche Sozial Versicherung – information on health insurance for expat students
• GKV Spitzenverband – German agency in charge of statutory health insurance
• Ministry of Health – call 030 340 60 66 01 for information on health insurance
• PKV Association – head organization for private health insurance