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Apply for exemption from co-payments in statutory health insurance

Source: Zuständigkeitsfinder Schleswig-Holstein (Linie6Plus)

Service Description

If you have paid more than 2 percent of your gross family income as statutory co-payments in the current calendar year, you can be exempted from this for the rest of the year. For the chronically ill, the so-called burden limit is 1 percent.

If you have statutory health insurance, you have to pay part of the costs of certain services - for example hospitalization, medicines or remedies such as physiotherapy - yourself, the so-called statutory co-payments. However, you only have to make these co-payments up to the so-called "maximum limit", after which you can be exempted. To do this, you must submit an application to your health insurance company.

The limit is 2 percent of your annual gross income for living expenses. If you have a serious chronic illness, the contribution limit is 1 percent. You must provide evidence of your serious chronic illness in the form of a medical certificate (sample 55). Further evidence may be required. Your health insurance company will inform you of this.

If you are married, in a registered civil partnership or have children who are minors or covered by family insurance and live with them in the same household, the co-payments and income of all family members are added together. Allowances for the members of your household are deducted from the family income so that your family income to be taken into account is reduced.

You must make co-payments for certain medical services that are covered by your statutory health insurance. These include, among other things

  • Medicines
  • Home nursing care
  • Remedies such as massages or physiotherapy
  • Auxiliary aids such as wheelchairs
  • inpatient hospital treatment
  • Inpatient rehabilitation or preventive measures
  • travel costs

Not all costs for medical or medical services are considered co-payments. No co-payments are, for example, your own contribution or additional costs for dentures, medical services without a doctor's prescription or individual health services.


Process flow

To be exempted from the co-payments for statutory health insurance, proceed as follows:

  • Collect the receipts for your statutory co-payments.
  • If you have reached the annual limit, apply to your statutory health insurance fund for exemption from co-payments.
  • You can submit the application for exemption from co-payments by post and - with many statutory health insurance companies - in person at the office or online.
  • Your health insurance company will issue you with a certificate stating that you no longer have to make co-payments. Any excess co-payments already made will be refunded to you.
  • Alternatively, with many health insurance companies you can pay the amount of your annual co-payment limit in advance. Then you do not have to collect any receipts and your health insurance company will issue you with a certificate of exemption from co-payments directly.
  • If you and your family members living in the same household are insured with different health insurance companies, you can submit the application jointly to one of the health insurance companies. The health insurance company will determine the limit for your family, issue you with a certificate of exemption and reimburse you for the excess co-payments on a pro rata basis. You can then use the health insurance company's decision to inform your relatives' health insurance companies, who will also issue the exemption certificates for your relatives and reimburse them for the excess co-payments on a pro rata basis.
Requirements
  • You have already paid at least 2 percent of your gross income for statutory co-payments.
  • If you are seriously chronically ill, a limit of 1 percent applies.
  • You are considered to be seriously chronically ill if you have been treated by a doctor for the illness at least once a quarter for at least one year and at least one of the following characteristics applies to you:
    • You are in need of care and have a care degree of at least 3;
    • You have a degree of disability of at least 60 percent due to the illness or your earning capacity is reduced by at least 60 percent;
    • You require specific medical treatment on a permanent basis because otherwise your state of health would deteriorate to a life-threatening level or your life expectancy would be reduced or your quality of life would be permanently impaired due to your illness.

There are exceptions to the co-payment in these cases, among others:

  • Children under the age of 18 do not have to make any co-payments (exception: travel costs).
  • If you are pregnant, you do not have to make a co-payment for medicines, dressings, remedies and aids if you need them due to your pregnancy; your hospital stay during childbirth or due to normal pregnancy complications is also free of co-payment.
Which documents are required?
  • Proof of income
  • Proof of co-payments already made, e.g. invoices, receipts or a copy of your bank statement
  • Chronically ill persons: proof of a serious chronic illness from your doctor

Further documents may be required in individual cases. Please contact your health insurance company for more information.

What are the fees?

You do not have to pay anything for the application for exemption from co-payment.

What deadlines do I have to pay attention to?

You can apply for exemption from co-payments retroactively for up to 4 years.

Processing duration

Processing normally takes around 4 to 8 working days.

In order to process and decide quickly, your health insurance fund must have the necessary information and any required documents in a complete and meaningful form.
The health insurance company decides on applications promptly, whereby the statutory processing period is adhered to in order to protect patients' rights.
Please note that the processing time stated is an average value for all health insurance companies. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and may be longer. The same applies if documents or records are sent to you or your health insurance company by post.

Legal basis
Appeal
  • Objection
  • Action before the social court
Applications / forms
  • Forms: yes
  • Online procedure possible: Many statutory health insurance companies offer an online procedure.
  • Written form required: no
  • Personal appearance necessary: no
Weiterführende Informationen
Author
Forwarding service: Deep link to the original portal

The text was automatically translated based on the German content.

Teaser

If you have paid more than 2 percent of your gross family income as statutory co-payments in the current calendar year, you can be exempted from this for the rest of the year. For the chronically ill, the so-called burden limit is 1 percent.

Process flow

To be exempted from the co-payments for statutory health insurance, proceed as follows:

  • Collect the receipts for your statutory co-payments.
  • If you have reached the annual limit, apply to your statutory health insurance fund for exemption from co-payments.
  • You can submit the application for exemption from co-payments by post and - with many statutory health insurance companies - in person at the office or online.
  • Your health insurance company will issue you with a certificate stating that you no longer have to make co-payments. Any excess co-payments already made will be refunded to you.
  • Alternatively, with many health insurance companies you can pay the amount of your annual co-payment limit in advance. Then you do not have to collect any receipts and your health insurance company will issue you with a certificate of exemption from co-payments directly.
  • If you and your family members living in the same household are insured with different health insurance companies, you can submit the application jointly to one of the health insurance companies. The health insurance company will determine the limit for your family, issue you with a certificate of exemption and reimburse you for the excess co-payments on a pro rata basis. You can then use the health insurance company's decision to inform your relatives' health insurance companies, who will also issue the exemption certificates for your relatives and reimburse them for the excess co-payments on a pro rata basis.

Requirements

  • You have already paid at least 2 percent of your gross income for statutory co-payments.
  • If you are seriously chronically ill, a limit of 1 percent applies.
  • You are considered to be seriously chronically ill if you have been treated by a doctor for the illness at least once a quarter for at least one year and at least one of the following characteristics applies to you:
    • You are in need of care and have a care degree of at least 3;
    • You have a degree of disability of at least 60 percent due to the illness or your earning capacity is reduced by at least 60 percent;
    • You require specific medical treatment on a permanent basis because otherwise your state of health would deteriorate to a life-threatening level or your life expectancy would be reduced or your quality of life would be permanently impaired due to your illness.

There are exceptions to the co-payment in these cases, among others:

  • Children under the age of 18 do not have to make any co-payments (exception: travel costs).
  • If you are pregnant, you do not have to make a co-payment for medicines, dressings, remedies and aids if you need them due to your pregnancy; your hospital stay during childbirth or due to normal pregnancy complications is also free of co-payment.

Which documents are required?

  • Proof of income
  • Proof of co-payments already made, e.g. invoices, receipts or a copy of your bank statement
  • Chronically ill persons: proof of a serious chronic illness from your doctor

Further documents may be required in individual cases. Please contact your health insurance company for more information.

What are the fees?

You do not have to pay anything for the application for exemption from co-payment.

What deadlines do I have to pay attention to?

You can apply for exemption from co-payments retroactively for up to 4 years.

Processing duration

Processing normally takes around 4 to 8 working days.

In order to process and decide quickly, your health insurance fund must have the necessary information and any required documents in a complete and meaningful form.
The health insurance company decides on applications promptly, whereby the statutory processing period is adhered to in order to protect patients' rights.
Please note that the processing time stated is an average value for all health insurance companies. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and may be longer. The same applies if documents or records are sent to you or your health insurance company by post.

Legal basis

Appeal

  • Objection
  • Action before the social court

Applications / forms

  • Forms: yes
  • Online procedure possible: Many statutory health insurance companies offer an online procedure.
  • Written form required: no
  • Personal appearance necessary: no

Weiterführende Informationen

Author

Forwarding service: Deep link to the original portal

The text was automatically translated based on the German content.

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