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Health insurance in Germany – Part 3: Differences in Coverage

As we continue our exploration of Germany’s dual health insurance system, we arrive at a crucial aspect that often sways individuals in their choice between Public Health Insurance (GKV) and Private Health Insurance (PKV): Differences in Coverage.

Understanding these differences is essential, as they directly affect the quality of healthcare you receive and the financial implications that come with it.

Coverage in Public Health Insurance (GKV)

GKV, known for its wide accessibility and solidarity principle, offers a comprehensive coverage that is largely uniform across all insured individuals: one size fits all.

This includes:

Basic Medical Care: Full coverage of most general medical treatments, including visits to doctors, hospital stays, basic dental care, and essential medications.
Preventive Services: Regular check-ups and preventive measures are available but can be very limiting. GKV will only cover according to the legally prescribed guidelines.
Family Coverage: Spouses and children can be covered under the family insurance scheme at no additional cost (given that they do not have their own source of income).

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However, GKV has limitations:

Limited Choice of Providers: Patients may have fewer options in choosing specialists or hospitals. You can be treated only by doctors with public health insurance approval.
Additional Payments: Certain medications, dental prosthetics, and special treatments might require co-payments.
No Private Room or Chief Physician Treatment in Hospitals: Standard care doesn’t include private hospital rooms or treatment by chief physicians

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Always keep this in mind with GKV: if it is medically necessary, it is most probably covered. Everything that goes beyond that is usually not covered!

Coverage in Private Health Insurance (PKV)

PKV, on the other hand, is known for its customizable plans and often more extensive coverage.

You are able to find a plan that fits your specific needs and it typically includes:

Customized Plans: Coverage can be tailored to individual needs, allowing for more comprehensive health services. You can choose what is important in your personal case and which deductible you prefer in your plan, which can reduce your costs significantly.
monthly costs significantly

Broader Treatment Options: Access to a wider range of treatments, including alternative medicine, newer medical technologies, and more extensive dental care as well as shorter waiting times.

Choice of Providers: Freedom to choose doctors and specialists, often including access to chief physicians and private rooms in hospitals.

Refunds: If you are a healthy individual with little to none yearly doctor visits, you can choose plans with premium refunds to save even more costs in case you don’t use the insurance plan during the year.

Depending on the plan you select, the PKV covers many more options than the GKV.

The best part is that you get to choose how you want to be covered. The private insurance companies offer many different plans that cater to different individuals. You essentially have full control of the covered costs.
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In the table below we have covered the main differences that you might find interesting for yourself:

	Public health insurance	Private health insurance
Outpatient treatment (Ambulante Behandlung)
Choice of doctor	Only doctors only with “Kassenzulassung”, i.e. a public health insurance license. Specialist and medical specialist only with referral.	Free choice of doctor. Specialist and medical specialist also without referral.
Alternative practitioners (Heilpraktiker)	Usually no coverage.	Covered. Scope depending on your plan.
Psychotherapy	Only with co-payments.	Covered, with the scope of co-payment (if any) depending on your plan.
Glasses/ contact lenses	No coverage, only for children and young people up to the age of 18.	Covered, with the scope depending on your plan.
Medicines & drugs	Due to law, drugs & medicines are always considered under the aspects of economic efficiency, which means if available, generics will be used. Exclusion of non-prescription drugs (flu remedies, cough medicine etc.). Co-payments of 10 %, minimum 5 €, maximum 10 € per prescribed drug.	Any approved medication prescribed by the doctor. Homeopathic medicines (depending on your plan). Co-payments (if any) depending on your plan.
Remedies	Covered, with co-payments of 10 % plus 10 € per prescription.	Covered, with the scope depending on your plan.
Aids	Co-payments of 10 %, minimum 5 €, maximum 10 € per prescribed aid.	Covered, with the scope depending on your plan.
In-patient treatment (Stationäre Behandlung)
Choice of hospital	Local hospital (the hospital nearest to your place of residence, so-called referral clause).	Free choice.
Choice of treating doctor	Treatment by the doctor on duty.	Treatment by the doctor on duty with basic plans. Treatment by doctor of choice for more premium plans.
Accomodation	Shared room.	Shared room for basic plans. Single or double room for more premium plans.
Co-payment	10 €/ day, max. 28 days per calendar year.	General co-payment (if any).
Dental treatment (Zahnbehandlung)
Choice of dentist	Only doctors only with “Kassenzulassung”, i.e. a public health insurance license.	Free choice of doctor.
Coverage and co-payment	Flat-rate payments for dental prostheses in the form of so-called “findings-related fixed allowances”. These are based on the average costs of the standard care. You receive the fixed allowance of 50 % of the regular care (in the case of 5-year / 10-year proven preventative measures, it increases to 60 % / 65 %). In the case of a high-quality restoration (e.g. implants), the carrier does not participate at all or only with the fixed subsidy of a simple restoration. In simple terms, the higher the quality of the selected restoration, the higher the additional co-payments.	Covered, with the scope and co-payment depending on your plan. However, coverage rarely is under 80 % of the costs and no restriction to cheaper materials.
Other benefits
Doctor’s fees	Regular fees.	Reimbursement of the doctor’s fee up to 3.5 times the rate of the fee schedule, depending on your plan.
Continued payment of salary in cases of illness	After week 7, 70 % of the gross wage is paid. Contributions to pension, unemployment and compulsory nursing care insurance are deducted from this. The payments end after 72 weeks at the latest.	Possibility to include a “sick day payments” module.
Maternity leave	Exemption from contributions during maternity and parental leave.	Continuation of premium payments.
Coverage abroad	In EU countries and countries with which a social security agreement exists. However, not all doctors/hospitals accept foreign health insurance certificates. Return transports are generally not paid for.	Unlimited health protection throughout Europe (depending on tariff), usually for temporary stays abroad also worldwide. Including return transport, medicines, bandages, remedies and aids.
Coverage of dependents	Free co-insurance of spouses and children without income.	Need their own plan.
Continuation of coverage	Determined by law and politics.	Determined by your contract.
Addition of coverage	Determined by law and politics, a lengthy process.	New methods are covered quicker and automatically.

Conclusion

The choice between GKV and PKV should primarily not only be a financial decision but also a matter of personal health needs and preferences. While GKV offers uniform coverage and usually cheaper family plans, the PKV provides more personalised options and broader coverage, with varying costs.

It’s crucial to weigh these differences against your individual situation, health needs, and financial capability. Remember, the right choice today can have a lasting impact on your future health and financial well-being.
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Stay tuned for our next part where we will delve into the differences in premiums between GKV and PKV – a topic that directly hits the pocket!