Concept and Fundamentals of Exemption from Co-payment
Die Exemption from Co-payment is a central social law instrument in the German healthcare system. It allows individuals with statutory health insurance to be exempted from personal contributions to the benefits of statutory health insurance (GKV) once an individually determined financial burden limit has been reached within a calendar year. The exemption generally covers co-payments for medications, remedies and medical aids, hospital stays, transportation costs, as well as other GKV services. The legal basis for these regulations is found in Book Five of the Social Code (SGB V), in particular § 61 SGB V and the following provisions.
Legal Framework of Co-payment
Co-payment Obligation for Statutory Insured Persons
According to § 61 SGB V, members of statutory health insurance are required to make financial contributions through co-payments for certain benefits. The aim of these co-payments is to promote cost-effectiveness and personal responsibility in the use of medical services. The type and amount of co-payments are legally defined and concern, for example:
- Medications (§ 31 para. 3 SGB V)
- Remedies (§ 32 para. 2 SGB V)
- Medical aids (§ 33 para. 8 SGB V)
- Hospital treatments (§ 39 para. 4 SGB V)
- Transportation costs (§ 60 para. 1 SGB V)
For adults, a co-payment of 10 %, but at least 5 € and a maximum of 10 € per service, is generally due. For children and adolescents up to the age of 18, there is a general exemption from co-payments with few exceptions.
Burden Limit in Accordance with § 62 SGB V
To prevent unreasonable financial burdens, the law provides for a burden limit. According to § 62 SGB V, the individual burden limit is a maximum of 2 % of the household’s annual gross income. For chronically ill persons, a reduced limit of 1 % applies. After reaching this limit within a calendar year, those affected are exempt from further co-payments for the remainder of the year.
Requirements and Procedure for Exemption from Co-payment
Eligibility Requirements
Exemption from co-payment requires that the relevant burden limit has been reached or exceeded. To determine the individual burden limit, the so-called ‘family income’ of all household members is taken into account. Allowances, for example for children and spouses living in the household, are to be deducted.
Special Regulations for Chronically Ill Persons
For persons with a severe chronic illness, the burden limit is reduced to 1 % of the annual gross income. Proof of chronicity is required for this. This is usually provided by a medical certificate indicating the duration and severity of the illness.
Proof and Application
The exemption is not automatic and must be applied for with the health insurance fund. Insured persons must provide proof that their burden limit has been exceeded by submitting collected receipts, documents, or through the so-called electronic health card. The health insurance fund reviews the submitted documents and, after a positive review, issues an exemption certificate for the remainder of the calendar year.
Scope and Duration of the Exemption
Covered Benefits
The exemption from co-payment extends to all statutory co-payments according to SGB V, such as:
- Medications (excluding individual health services)
- Dressings
- Remedies, medical aids, and their repairs
- Hospital stays (standard co-payment per day)
- Home nursing care and rehabilitation
- Transportation costs (where medically necessary)
Not covered are private medical services, personal contributions for dentures outside the standard subsidy, and co-payments that exceed statutory regulations.
Time Limitation
The exemption always applies to the current calendar year for which it was requested. The application can already be made at the beginning of the year by prepaying the anticipated maximum burden (so-called ‘prepayment’). For each new calendar year, the exemption must be reviewed and, if necessary, applied for again.
Legal Consequences and Special Issues
Refund of Overpayments
If insured persons have made co-payments in total exceeding their burden limit, the excess amounts must be refunded by the health insurance fund. Prerequisites are timely application and proof by receipts.
Effects on Family Members
The burden limit takes into account the total family income and the number of household members. This particularly benefits families with low incomes or several children.
Differences from Exemption in the Area of Social Security
The exemption from co-payment under the GKV is to be distinguished from independent exemption regulations in social assistance or basic security. Persons who receive benefits under SGB II or SGB XII (e.g., unemployment benefit II, social assistance) can be exempted from co-payments according to other, usually more favorable, provisions.
Legal Basis and Literature
- § 61, § 62 and further sections of SGB V
- Case law of the social courts regarding exemption from co-payment
- Guidelines and recommendations of the umbrella associations of statutory health insurance funds
- German Social Code Books SGB V, SGB II, SGB XII
Summary
Exemption from co-payment is an essential element of social protection in healthcare. It provides individuals with statutory health insurance, especially those with low incomes or chronic illnesses, with protection from unreasonable financial burdens caused by co-payments within the framework of medical care. The eligibility requirements, procedure, and specific legal framework are comprehensively regulated by law and are practically implemented by the statutory health insurance funds.
Frequently Asked Questions
How can an application for exemption from co-payment be submitted?
An application for exemption from co-payment must be submitted to the responsible statutory health insurance fund. A written application is generally required, to which evidence of paid co-payments as well as proof of income and, if applicable, documents regarding special personal circumstances (e.g., marital status, number of children) must be attached. The exemption from co-payment usually applies for the current calendar year once the individual burden limit as per § 62 SGB V has been demonstrated. After all necessary documents have been fully submitted, the health insurance fund reviews the information and decides on granting the exemption. It is possible to submit an application retroactively for the current year, but not for previous calendar years.
Which documents must be attached to the application for exemption?
The documents required for the application include in particular all receipts and proof of already paid co-payments during the relevant calendar year. In addition, up-to-date proof of income for all family members living in the household (such as wage or salary slips, pension notices, notices of social benefits) must be attached to determine the level of the burden limit. Furthermore, if applicable, certificates of severe disability, proof of chronic illness, or attested special care situations must be submitted, if these have a legal impact on co-payments or the burden limit.
Who is legally entitled to exemption from co-payment?
A legal entitlement to exemption exists for people with statutory health insurance who have reached their personal burden limit as per § 62 SGB V in a calendar year. The burden limit is generally 2 % of the annual gross income for living expenses, but is reduced to 1 % if a chronic illness is present within the meaning of the legal provisions. Children, adolescents, and certain benefit recipients (e.g., recipients of social assistance, basic security, unemployment benefit II) are taken into account when calculating the burden limit by deducting allowances. The entitlement arises legally only from the point at which all required documents have been submitted and the limit has actually been exceeded.
What happens if the exemption was granted in error?
If an exemption from co-payment is wrongly granted, for instance because income or co-payments have been misreported or documents manipulated, the health insurance fund may revoke the exemption retroactively according to § 48 SGB X and reclaim benefits already granted. This can also occur if the erroneous decision was based on incomplete information. In case of intentionally false information, criminal proceedings or administrative offense proceedings may also be initiated. The insurance fund is obliged to review the situation and, if necessary, issue a recovery notice for the relevant amount.
Does the exemption need to be applied for anew each year?
Yes, the exemption from co-payment always only applies to the respective calendar year and is not valid for multiple years automatically. Insured persons must submit a new application to their health insurance fund every year and provide current proof each time, as both income and other relevant factors may change. The health insurance fund reviews each year anew whether the individual requirements for exemption are met.
What deadlines apply to the application for exemption from co-payment?
In principle, the application for exemption can be submitted until the end of the respective calendar year; a retroactive exemption for years already completed is not possible. When submitting proof for the current year, insured persons should be aware that processing may take time and possible reimbursements or credits can be made with a delay. The legal basis for the deadline and any exceptions arise in particular from the rules of the health insurance funds and the provisions of SGB V.
Which co-payments are counted toward the burden limit?
According to § 62 SGB V, all statutory co-payments that insured persons have made in the respective calendar year for benefits of statutory health insurance are counted, such as co-payments for medications, remedies and aids, transport costs, hospital stays, or home nursing. Expenses for benefits not included in the GKV benefit catalogue or borne privately, as well as personal contributions, practice fees (now abolished), or voluntary additional benefits, are not counted. The exact allocation of which payments are counted results from statutory provisions as well as supplementary administrative regulations of the health insurance funds.
