Co-payments in the statutory health insurance; application for exemption

If you have paid more than 2 percent of your gross family income as statutory co-payments in the current calendar year (1 percent for the chronically ill), you may be exempt for the rest of the year.

Description

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 pay these co-payments up to the so-called burden limit, after which you can be exempted. To do this, you submit an application to your health insurance company.

The burden limit is 2 percent of your annual gross income for living expenses. If you are seriously chronically ill, the burden limit is 1 percent. You prove your serious chronic illness by means of a medical certificate (sample 55). Further proof may be required. Your health insurance company will inform you about this.

If you are married, live in a registered partnership or have underage children or children with family insurance and live with them in the same household, the co-payments and income of all dependents 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 have to make co-payments for certain medical services that are covered by your statutory health insurance. These include:

  • Medicines
  • Home nursing care
  • Remedies such as massages or physiotherapy
  • Aids such as wheelchairs
  • Inpatient hospital treatment
  • Inpatient rehabilitation or preventive measures
  • Travel costs

Not all costs for medical services are considered co-payments. Co-payments do not include, for example, your own contribution or additional costs for dentures, medical services without a doctor's prescription or individual health services.

Prerequisites

  • You have already paid at least 2 percent of your gross income for living expenses for statutory co-payments.
  • If you are seriously chronically ill, a limit of 1 percent applies.
  • You are considered to have a serious chronic illness if you have been treated by a doctor for the illness at least once every 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 certain medical treatment on a permanent basis because otherwise your health condition would deteriorate in a life-threatening manner or there would be a reduction in life expectancy or a permanent impairment of quality of life due to your illness.

Exceptions to copayment include these cases:

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

Procedure

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

  • Collect the receipts of your statutory co-payments.
  • If you have reached the annual burden limit, submit an application for exemption from co-payments to your statutory health insurance fund.
  • You can submit the application for exemption from co-payments by mail and - for many statutory health insurers - 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, many health insurance companies allow you to pay in the amount of your annual co-payment limit in advance. Then you do not have to collect receipts and your health insurance company will issue you directly with a certificate of co-payment exemption.
  • If you and your dependents living in the same household are insured with different health insurers, you can submit the application jointly to one of the health insurers. The health insurance fund will determine the burden limit for your family, issue you with an exemption certificate and reimburse you for the excess co-payments on a pro rata basis. You can then use the health insurance fund's decision to inform your relatives' health insurance funds, which will also issue the exemption notices for your relatives and also reimburse them proportionately for the excess co-payments.

Deadlines

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

Processing time

Processing usually takes about 4 to 8 working days.

For rapid processing and decision-making, your health insurance fund must be provided with the necessary information as well as any required documents in a complete and meaningful manner.
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 indicated is an average value for all health insurance funds. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and may be longer accordingly. The same applies if documents or records are sent to you or your health insurer by mail.

Required documents

  • Required Documents

    • Einkommensnachweise
    • Nachweise über bereits geleistete Zuzahlungen, zum Beispiel Rechnungen, Quittungen oder Kontoauszug-Kopie
    • Chronisch Kranke: Nachweis über eine schwerwiegende chronische Erkrankung von Ihrer Ärztin oder Ihrem Arzt 

    In Einzelfällen können weitere Unterlagen erforderlich sein. Bitte informieren Sie sich dazu bei Ihrer Krankenkasse.
     

Forms

Fees

  • You do not have to pay anything to apply for a copayment waiver.

Remedy

  • Objection
  • Action before the social court

Status: 20.10.2022

Responsible for editing: Bundesministerium für Gesundheit

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  • Prefillable Form, Bavaria-wide
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