Regionaldirektion Nord
Millerntorplatz 1
20359 Hamburg
Andreas Matthies
Phone: +49 40 30 388-51 21
Mobile: 0151 19 61 52 48
Mail: andreas.matthies@knappschaft.de
Health insurance • Long-term care insurance
- Statutory health and long-term care
- Choice of health insurance
- Compulsory membership or exemption from membership
- Membership and insurance contributions
- Insurance cover for relatives is included
- Benefits of health insurance
- Scope of the statutory nursing care insurance
- Five degrees of care
- Benefits of the nursing care insurance
- Nursing care abroad
Statutory health and long-term care insurance
In Germany there are two kinds of health insurance, the private and the statutory health insurance. All following information relates to the statutory health insurance.
The statutory health insurance is a compulsory insurance for – among others - all employees whose income (regular annual remuneration) falls below the annual remuneration limit. Employees whose regular annual income exceeds the annual remuneration limit may opt either for private health insurance or voluntary insurance in the statutory health insurance.
Seafarers can choose from different health insurance funds
Like any employee, seafarers can now choose their health insurance fund freely. Formerly, seafarers were compulsory members in the statutory maritime health- and nursing care insurance fund. In 2008 this maritime health insurance fund (combined with the maritime nursing care insurance fund) from Hamburg merged with the "Knappschaft" from Bochum to become a new nationwide health and nursing care insurance fund, headquartered in Bochum. Today this new Knappschaft is still the first choice for most seafarers.
Compulsory membership or exemption from membership
Depending on their income (average wages), seafarers are either compulsory members of the statutory health and nursing care insurance or exempt from membership therein. The exemption comes with a (high) income exceeding the annual remuneration limit. This limit is not fixed and generally is increased annually.
A seafarer who
- has an income below the annual remuneration limit, and
- is employed on a seagoing ship flying the German flag, and
- is domiciled in Germany or in a member state of either the European Union (EU) or of the European Economic Area (EEA),
is - by law - member of the statuary health and nursing care insurance. The seafarer will automatically be insured through his employer in a statutory health and nursing care insurance fund freely chosen by the seafarer from the variety of different insurance funds.
Membership and insurance contributions are unaffected by pre-existing illness
Membership and insurance contributions do not reflect the individual and personal health risk of the insured person (e.g., state of health, age, sex). In contrast to private health insurance the statuary health and nursing care insurance accepts also persons with pre-existing illness as members.
Membership starts on the day when the employment commences and ends, on principle, with the final day of the employment. The employer informs the health insurance fund about these dates.
Insurance cover for relatives is included
Spouses or registered partners and children can be insured in the statutory health and nursing care insurance free of charge, unless:
- their normal domicile is neither in Germany nor in a state with social security agreement (Europe);
- they themselves are subject to compulsory insurance or voluntarily insured;
- they themselves are either exempt from membership or have been exempted from compulsory insurance;
- they are full-time self-employed; or
- their total income does exceed one-seventh of the reference value of average income defined in Section 18 of Volume IV of the German Social Insurance Code (§ 18 SGB IV ). The income threshold of low paid work is 450 € per month.
Children under 18 can generally be affiliated. If they are not in employment, this deadline is extended to their 23rd birthday. If children are at university, in primary or secondary education or in vocational training they can be covered by family insurance up to their 25th birthday. However, in that case the provisions listed above – e.g., income thresholds - must be complied with.
Especially for European seafarers the family insurance is a real advantage, since family members are co-insured in the German statutory health insurance. Thus, the family members do not have to reside in Germany to receive the benefits.
If the relative is domiciled in a state with social security agreement (e.g. Spain), the doctor could be paid directly by the health insurance fund. The common practice is however that the insured person pays the doctor and then claims a reimbursement from the insurance fund.
If the relative is domiciled in Europe, the statutory insurance fund will bear the incurred costs.
Germany has entered into several social security agreements with states outside of Europe. Some cover only individual social security branches (e.g. pension insurance), other agreements cover all of the insurance branches. We have compiled a list of states that have entered into a social security agreement with Germany.
The statutory health insurance offers comprehensive benefits
The German statutory health insurance provides comprehensive benefits. Insured persons are entitled to these benefits from the very beginning of their membership, normally when the employment commences. The scope of benefits is defined in volume five of the German Social Insurance Code (SGB V):
- prevention and self help
- group prophylaxis to prevent dental impairment (up to the age of 12)
- individual prophylaxis to prevent dental impairment (for age 6 to 18)
- medical prophylaxis
- medical examinations
- special paediatric examinations
- medical treatment, including psychotherapy
- dental and orthodontic treatment as well as provisions of dentures
- provisions of medicines, dressings, therapeutic remedies and medical aids
- treatment and care at home
- hospital treatment
- benefits for medical rehabilitation
- medical rehabilitation for mothers and fathers and supplementary assistance for rehabilitation
- in vitro fertilization
- social therapy
- home help
- in-patient and out-patient hospice support
- tolerance-level testing and work therapy
- non-medical socio-paediatric support
- sickness benefits, also in case of illness of a child
- travel expenses
- The health insurance fund will pay, if disability or need for nursing care can be prevented, overcome or reduced
- contraception
- sterilisation
- abortion
Scope of the statutory nursing care insurance
The statutory nursing care insurance has to ensure that its members receive the required nursing care. It assists where the independence of the person in need of care is restricted. Depending on the care degree and type of care, the nursing care insurance bodies cover different amounts.
The legal basis for the provision of statutory nursing care is volume eleven of the German Social Insurance Code (SGB XI). Responsibility rests with the nursing care funds which have been established by all statutory health insurance funds.
Five degrees of care
Statutory nursing care insurance focuses on persons in need of nursing care. Being in need of nursing care means having to rely, permanently or long-term, on support for everyday routines due to a physical, mental or psychological illness or handicap. The medical service of the health insurance (Medizinischer Dienst der Krankenversicherung, MDK) acts also on behalf of the nursing care funds and upon application assesses the degree of need for care. The assessment is performed by the medical service in the home of the applicant. Its evaluators focus on the following six areas ("modules") in their assessment:
- Module 1 "Mobility" (i.e. physical mobility and coordination)
- Module 2 "Mental and communicative abilities" (e.g. capacity for remembering, to make decisions, to execute complex actions, to recognize risks and hazards, etc.)
- Module 3 "Behaviour and psychological issues" (reaches from general restlessness over anxieties to aggressive behaviour and depression)
- Module 4 "Self-sufficiency" (e.g. physical hygiene, changing clothes, eating and drinking)
- Module 5 "Independency in dealing with health and therapeutical requirements and strains – as well as coping with them" (this includes medical self-sufficiency and managing medical appointments independently)
- Module 6 "Arrangement of everyday life and social contacts"
The visit of the evaluator will take about one hour, during which the extent of the need of care will be assessed taking into account the six areas of independent living capability. The rating of the individual modules regarding the need for care differs.
The evaluator will ask you to describe your limitations and problems in your every-day life. It is in your best interest not to leave out anything or gloss over your issues. Our advice: Ask a person of trust to join you for this appointment.
The medical service (MDK) prepares an assessment and sends it to the nursing care fund. It is the foundation for the degree of care assigned based on a point system derived from the modules mentioned above:
- Care degree 1: slight impairment of independence or capabilities
- Care degree 2: considerable impairment of independence or capabilities
- Care degree 3: severe impairment of independence or capabilities
- Care degree 4: most severe impairment of independence or capabilities
- Care degree 5: most severe impairment of independence or capabilities, with special requirements regarding nursing care
The higher the care degree the more support is provided to the person in need of care by the nursing care insurance. The notice regarding the assessed need of care and the care degree is sent to you by the nursing care fund via mail.
Benefits of nursing care insurance
Primarily, the benefits of care degree 1 of the nursing care insurance support persons in need of care with measures to further their independence; for example with advisory or counselling services, aids for care or benefits during short-term care and short-term inability to work. The benefits of the nursing care insurance for care degrees 2-5 can be subdivided into different areas:
- In kind benefits: Assumption of the cost of suitable professional caregivers at home
- Nursing care benefits: Assumption of the cost of a privately engaged caregiver, who may also be a relative.
In kind benefits and nursing care benefits can be combined. The nursing care benefit will be reduced accordingly.
If a home caregiver is prevented from care due to leave, illness or other reasons, the insurance fund may pay for a substitute. This is possible for up to 4 weeks per year and within financial limits.
- Aids for care: the insurance fund pays for aids which facilitate ease of care, alleviation of afflictions or a more self-reliant life, as long as these are not to be financed by other funds (e.g. health insurance). The nursing care fund will assess if there is a need for such aids.
- Caregiving relatives and voluntary caregivers can participate in free-of-charge courses about care. These courses are offered or organized by the nursing care funds.
Persons in need of nursing care are entitled to part time institutional care if home care cannot be provided sufficiently. It is provided in designated institutions, either as daytime or night-time care and includes also transportation between home and centre. The amount of benefits depends on the care degree.
Short-time care can be granted for a transitional period after an in-patient treatment or in other situations in which home care or part-time institutional care is not possible or sufficient. It is provided at an institution designated to full-time care for a maximum of four weeks per calendar year.
Persons in need of nursing care are entitled to full-time institutional care if home care or part-time institutional care is not possible. Only costs of care are covered, accommodation and subsistence will only be covered up to the amount granted in benefits after the care has been subtracted. Additional costs for accommodation, subsistence and other agreed services (if any) are to be paid for by the person in need of care.
Different living arrangements, such as service living, multi-generation houses or "accommodation for assistance", and other assisted shared-living arrangements become more and more popular. Because of its large benefit in regard of independence and social interaction, communally organized nursing care at assisted shared-living arrangements is subsidized with a bonus. This also includes persons with care degree 1. New establishments receive substantial financial support.
Nursing care abroad
If a member or a relative covered by the nursing care insurance is permanently domiciled in a foreign European country or Switzerland, Liechtenstein, Norway or Iceland, the German statutory nursing care insurance may only cover either financial benefits or in kind benefits, while a combination of both is not possible. In addition, a membership in a German health insurance as well as registration with a local health insurance is required.
If a member of the German nursing care insurance is entitled to benefits from the social security system of his foreign state of residence, benefits from the German insurance are put on hold.
When assessing the degree of need for care, the same standard applies in Germany and abroad. Abroad, the medical service in Germany (MDK) cooperates with a partner organization in the state of residence for such assessment. The assessment report is forwarded to the German medical service which evaluates it, accepts or rejects the need for care and finally informs the responsible nursing care insurance fund.