What health insurance provides: Your comprehensive guide for optimal coverage
17 May 2025
12
Minutes
Katrin Straub
CEO at nextsure
Health insurance is a fundamental pillar of the German healthcare system, but what exactly does it provide in an emergency? Many insured individuals often only know a fraction of the covered services and possible additional options. This article explains clearly what tasks health insurance takes on and how you can optimise your coverage.
The topic in brief and concise terms
Health insurance in Germany is mandatory and ensures basic medical care, with statutory health insurance (GKV) providing approximately 95% standardized services, while private health insurance (PKV) offers more individual options.
Supplementary insurances such as dental, hospital, or travel health insurances can sensibly complement the basic protection of statutory health insurance and close coverage gaps. [1,5]
The costs of statutory health insurance depend on income, whereas private health insurance premiums are determined by risk, age, and plan; it is advisable to regularly compare and adjust the coverage. [1,2]
Understanding the Basics: The Core Tasks of Health Insurance
The primary task of health insurance is to ensure the medical care of its insured individuals. It aims to preserve health, restore it, or improve the state of health. This includes a wide range of services detailed in the Fifth Social Code (SGB V) for statutory health insurance (GKV) and in the respective contract conditions for private health insurance (PKV). In the GKV, all insured individuals generally enjoy the same entitlement to benefits, whereby the services must be adequate, appropriate, and economical. Approximately ninety-five percent of GKV services are legally mandated. Thus, health insurance covers not only acute illness cases but also preventive measures and rehabilitation. This comprehensive protection is a central element of the German social insurance system.
Statutory Health Insurance (GKV): Foundation of Healthcare
The statutory health insurance (GKV) forms the basis of healthcare for around ninety percent of the population in Germany. Its benefits are enshrined in the Social Code Book V and include, among other things, medical and dental treatments, hospital stays, as well as the provision of pharmaceutical, dressing, therapeutic and auxiliary supplies. Many of these services require co-payments, for example ten percent of the costs for medicines (at least five and at most ten euros). Billing usually takes place directly via the electronic health card. It is important to note that about ninety-five percent of GKV benefits are identical across all insurers; differences mainly exist in the additional contributions and voluntary extra benefits. A voluntary health insurance is possible under certain conditions. The GKV ensures that everyone has access to basic medical care.
Private Health Insurance (PKV): Customised Service Design
Private health insurance (PKV) often offers a more comprehensive range of services and more customised tariff options compared to statutory health insurance (GKV). Benefits often include shorter waiting times for specialists, treatment by the chief physician in hospitals, and accommodation in single or double rooms. However, the contributions in PKV are not based on income but on the chosen tariff, age of entry, and health status. A drawback can be the financial risk, as contributions can increase with age. Switching from PKV back to GKV is only possible under certain conditions. For civil servants or self-employed individuals with high income, private health insurance can be an attractive option, as it often offers more favourable tariffs with better coverage. The costs of private health insurance should be calculated carefully.
Detailed service catalog: What is specifically covered?
The range of services provided by the statutory health insurance (GKV) is defined as a framework under the Fifth Social Code (SGB V) and specified by the Federal Joint Committee (G-BA). Core services include:
Medical treatment: Freedom to choose among contracted doctors, treatment by general practitioners and specialists.
Dental treatment: Standard care, fixed subsidies for dental prostheses.
Hospital treatment: Accommodation in a shared room, treatment by the attending doctor.
Medicines: Coverage of costs for prescription drugs, with a co-payment.
Therapeutic treatments: Such as physiotherapy or speech therapy on a doctor's prescription.
Aids: Like walking aids or hearing aids, often with a personal contribution.
Preventive check-ups: For early detection of diseases, such as cancer screening.
Sickness benefit: Wage replacement benefit in case of prolonged inability to work.
Individual health services (IGeL) are usually not covered by the statutory health insurance. The specific details of what the health insurance covers are crucial for the insured. It is important to understand that not all conceivable medical measures are automatically reimbursed; they must comply with the efficiency principle.
Supplementary insurance: A sensible addition to protection
To expand the scope of statutory health insurance (GKV), supplementary insurance can be taken out. These provide coverage in areas that are not or only partially covered by the GKV. Particularly popular are:
Dental supplementary insurance: Covers higher costs for dental prostheses and professional teeth cleaning.
Hospital supplementary insurance: Allows treatment by the chief physician, single or double rooms.
Outpatient supplementary insurance: Can cover costs for glasses, naturopaths or preventive examinations outside the GKV catalog.
Travel health insurance abroad: Essential for travel, as the GKV often provides limited benefits abroad.
Taking out supplementary insurance is voluntary and should be based on individual needs. A supplementary health insurance can fill gaps in provision. It is advisable to compare offers carefully, as benefits and costs can vary greatly. For many, such an addition is an important investment in their own health.
Costs and Contributions: How is health insurance funded?
The financing of statutory health insurance is primarily through income-dependent contributions, which are collected up to the contribution assessment limit (66,150 Euros annually in 2025). The general contribution rate is fourteen point six per cent, plus there is an additional fund-specific contribution (averaging two point five per cent in 2025). Employees and employers share these contributions equally. Self-employed individuals pay the full contribution. In private health insurance, however, contributions are risk-adjusted and depend on the chosen tariff, age, and health condition. The amount of the contribution can therefore vary significantly. It is important to correctly state the health insurance contributions in the tax declaration. The question "Is it mandatory to have health insurance in Germany?" can clearly be answered with yes, and financing is a crucial aspect of this.
Expert tips for your health insurance: Securing optimal care
To receive the best possible health insurance coverage, there are several aspects you should consider. Our expert tip: Regularly review your insurance coverage and adjust it as needed to match your life situation. Compare not only the contribution rates of the health insurance companies, but also their additional benefits and service offerings. When choosing a private health insurance, early health assessment and the accumulation of old-age reserves are important. [1,2-] A thorough examination of the contractual conditions is essential to avoid surprises later on. [1-] Also take advantage of the options for elective tariffs or bonus programs in statutory health insurance. [4-] Consider the insurance coverage for pensioners or the validity of your health insurance abroad. Making an informed decision requires time and information.
Legal framework and current developments
Your next step towards optimal insurance coverage
More useful links
The Federal Statistical Office (Destatis) offers detailed information on health insurance coverage in Germany.
The Federal Statistical Office (Destatis) provides comprehensive data on healthcare spending in Germany.
The Federal Ministry of Health explains the range of services within the German healthcare system.
The Federal Ministry of Health provides information on statutory health insurance (GKV) in Germany.
The National Association of Statutory Health Insurance Funds offers insights into health insurance from the perspective of statutory health insurers.
The Consumer Advice Centre provides comprehensive information to consumers on health insurance.
The Federal Ministry of Health offers information on patient rights.
FAQ
What exactly does health insurance do for me?
Health insurance covers the costs of medically necessary treatments, medications, hospital stays, and preventive measures to maintain or restore your health.
Am I required to have health insurance in Germany?
Yes, in Germany, there is a general health insurance obligation for everyone residing in the country. [2,3]
What costs are covered by my health insurance in the hospital?
The statutory health insurance covers the costs for basic medical care in the hospital, including accommodation in a shared room and treatment by the attending physician. Private health insurance or supplementary insurance may cover treatment by the head physician and accommodation in a single or double room. [1,1]
Does the health insurance also cover alternative healing methods?
The statutory health insurance (GKV) only covers costs for alternative healing methods in exceptional cases and when their benefits are scientifically recognized. Private health insurance or outpatient supplementary insurance often offer more extensive benefits in this area. [2,4]
What happens if I can't pay my health insurance premiums?
In case of payment difficulties, you should promptly contact your health insurance provider. There are options such as deferral or installment payments. If payments are delayed for an extended period, the entitlement to benefits may be restricted, although emergency protection usually remains in place.
How can I change my health insurance?
Switching statutory health insurance providers is generally possible after a binding period of twelve months or in the event of premium increases with a notice period of two months before the end of the month. Switching to private health insurance (PHI) or back to statutory health insurance (SHI) is subject to certain conditions. [1,3-]
