What health insurance provides: your comprehensive guide to optimal protection
17.05.25
7
Minutes
Katrin Straub
Managing Director at nextsure
Health insurance is a fundamental pillar of the German healthcare system, but what exactly does it cover in an emergency? Many policyholders often know only a fraction of the benefits covered and the possible additional options. This article explains in clear terms what tasks health insurance takes on and how you can optimise your cover.
The topic in brief and concise terms
Health insurance in Germany is mandatory and secures basic medical care, with GKV offering standardised benefits for around 95 per cent and PKV enabling more personalised options.
Supplementary insurance such as dental, hospital or travel health insurance can sensibly complement the basic coverage provided by statutory health insurance and close gaps in care. [1,5]
The costs of GKV depend on income, whereas PKV premiums depend on risk, age and tariff; regular comparison and adjustment of cover are recommended. [1,2]
Understanding the basics: The core functions of health insurance
The primary task of health insurance is to ensure the medical care of its insured members. It is intended to maintain health, restore it or improve health status. This includes a broad range of benefits laid down in the Fifth Book of the Social Code (SGB V) for statutory health insurance (GKV) and in the respective policy terms and conditions for private health insurance (PKV). In the GKV, all insured persons generally enjoy the same entitlement to benefits, whereby the benefits must be sufficient, appropriate and economical. Around ninety-five per cent of GKV benefits are prescribed by law. Health insurance therefore covers not only acute illnesses, but also preventive measures and rehabilitation. This comprehensive protection is a key element of the German social insurance system.
Statutory health insurance (SHI): the foundation of healthcare
The GKV forms the basis of healthcare provision for around ninety per cent of the population in Germany. Its benefits are enshrined in SGB V and include, among other things, medical and dental treatment, hospital stays and the supply of medicines, dressings, therapies and aids. Co-payments are предусмотрены for many of these benefits, for example ten per cent of the cost of medicines (a minimum of five and a maximum of ten euros). Billing is generally handled directly via the electronic health card. It is important to note that around ninety-five per cent of GKV benefits are identical across all health insurance funds; differences are mainly 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 benefits
Private health insurance (PKV) often offers a more comprehensive range of benefits and more tailored tariff options than the GKV. Advantages often include shorter waiting times for specialist appointments, treatment by the chief physician in hospital and accommodation in a single or double room. Contributions in the PKV are, however, not based on income, but on the chosen tariff, age at entry and state of health. A disadvantage can be the financial risk, as contributions may rise with age. A switch from the PKV back to the GKV is only possible under certain conditions. For civil servants or self-employed people with a high income, private health insurance can be an attractive option, as it often offers more favourable tariffs with a better range of benefits. The costs of private health insurance should be carefully calculated.
Service catalogue in detail: What is actually covered?
The benefits catalogue of statutory health insurance (GKV) is specified as framework legislation in the Fifth Book of the Social Code (SGB V) and is further defined by the Federal Joint Committee (G-BA). The core benefits include:
Medical treatment: Free choice of doctor among contracted doctors, treatment by general practitioners and specialists.
Dental treatment: Standard care; fixed subsidies are available for dentures.
Hospital treatment: Accommodation in a shared room, treatment by the doctor on duty.
Medicines: Coverage of the costs of prescription-only medicines, with co-payment.
Remedies: For example, physiotherapy or speech therapy on medical prescription.
Aids: Such as walking aids or hearing aids, often with a personal contribution.
Preventive examinations: For the early detection of illnesses, for example cancer screening.
Sickness benefit: Income replacement benefit in the event of prolonged incapacity for work.
Individual health services (IGeL) are usually not covered by statutory health insurance. The exact details of what the health insurance covers are crucial for the insured person. It is important to understand that not all conceivable medical measures are automatically reimbursed; they must comply with the principle of cost-effectiveness.
Supplementary insurance: A sensible addition to cover
To expand the scope of benefits covered by statutory health insurance (GKV), supplementary insurance policies can be taken out. These provide protection in areas that are not covered, or only partially covered, by the GKV. Particularly popular are:
Dental supplementary insurance: covers higher costs for dentures and professional dental cleaning.
Hospital supplementary insurance: enables treatment by the chief physician and a single or double room.
Outpatient supplementary insurance: can cover costs for glasses, alternative practitioners or preventive examinations outside the GKV catalogue.
Travel health insurance: essential for trips, as the GKV often provides only limited benefits abroad.
Taking out supplementary insurance is voluntary and should be tailored to your needs. A supplementary health insurance policy can close gaps in coverage. It is advisable to compare offers carefully, as benefits and costs can vary significantly. For many people, such additional cover is an important investment in their own health.
Costs and contributions: How is health insurance funded?
Funding for statutory health insurance (GKV) is provided mainly through income-dependent contributions, levied up to the contribution assessment ceiling (66,150 euro annually in 2025). The standard contribution rate is 14.6 per cent, plus an insurer-specific supplementary contribution (averaging 2.5 per cent in 2025). Employees and employers each share these contributions equally. Self-employed people pay the full contribution. In private health insurance (PKV), however, contributions are risk-based and depend on the chosen tariff, age and health status. Contribution amounts can therefore differ significantly. It is important to correctly declare the health insurance contributions in the tax return. The question "Do you have to have health insurance in Germany?" can clearly be answered with yes, and funding is an essential aspect of this.
To obtain the best possible health insurance cover, you should consider a few aspects. Our expert tip: review your insurance cover regularly and adjust it to your life situation if necessary. Compare not only the premium levels of health insurers, but also their additional benefits and service offerings. When choosing a private health insurance policy (PKV), an early health check and the build-up of ageing provisions are important. [1,2-] A careful review of the contract terms is essential to avoid later surprises. [1-] Also make use of optional tariffs or bonus programmes in the statutory health insurance scheme (GKV). [4-] Think about insurance cover for pensioners or the validity of your health insurance abroad. A well-informed decision takes time and information.
Legal framework and current developments
Health insurance law is complex and subject to constant change. The Fifth Book of the Social Code (SGB V) forms the main basis for statutory health insurance (GKV). [1,3-] Recent judgments, for example on the medical necessity of treatments or the obligation to pay contributions, can have a direct impact on insured persons. [1] The Federal Court of Justice has thus ruled that, in the unwinding of private health insurance (PKV) contracts, the insurance cover already enjoyed may be taken into account. [1] It is advisable to stay informed about important legislative changes and court rulings, as these can affect the benefits and obligations of insured persons and insurers. Health and long-term care insurance is a dynamic field. These developments show how important it is to monitor the legal position continuously.
Your next step towards optimal insurance cover
Health insurance is an essential part of your personal protection. It covers a wide range of costs in the event of illness and makes a significant contribution to maintaining your health. Whether you are insured through the statutory system or privately – what matters is that your cover suits your individual needs. At nextsure, we see ourselves as your partner for tailored insurance solutions. We help you keep track and find the cover that is right for you. Personal advice can help you identify and close gaps in your cover. Take control of your health care yourself. Request an individual risk analysis now: Have your insurance situation reviewed free of charge and receive concrete suggestions for optimisation.
More useful links
The Federal Statistical Office (Destatis) provides detailed information on health insurance coverage in Germany.
The Federal Statistical Office (Destatis) provides comprehensive data on health expenditure in Germany.
The Federal Ministry of Health explains the benefits catalogue in the German healthcare system.
The Federal Ministry of Health provides information on statutory health insurance (GKV) in Germany.
The GKV-Spitzenverband provides information on health insurance from the perspective of statutory health insurance funds.
The Consumer Advice Centre provides comprehensive information on health insurance.
The Federal Ministry of Health provides information on patients' rights.
FAQ
What exactly does health insurance do for me?
Health insurance covers the costs of medically necessary treatments, medicines, 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 obligation to have health insurance for all people residing in the country. [2,3]
What costs does my health insurance cover in hospital?
The statutory health insurance (GKV) covers the costs of basic medical care in hospital, including accommodation in a shared room and treatment by the doctor on duty. Private health insurance (PKV) or supplementary insurance can cover treatment by the chief physician and single/double rooms. [1,1]
Does health insurance also cover alternative therapies?
Statutory health insurance (GKV) only covers the costs of alternative therapies in exceptional cases and when their benefits are scientifically recognised. Private health insurance or outpatient supplementary insurance often offer more comprehensive benefits here. [2,4]
What happens if I can't pay my health insurance contributions?
If you are having difficulty making payments, you should contact your health insurance provider immediately. There are options such as deferment or instalment payments. If payments remain outstanding for a longer period, entitlement to benefits may be restricted, but emergency cover usually remains in place.
How can I change my health insurance?
Switching statutory health insurance providers is generally possible after a commitment period of twelve months or, in the event of premium increases, with two months’ notice to the end of the month. Switching to private health insurance (PKV) or back to statutory health insurance (GKV) is subject to certain conditions. [1,3-]
