Preamble
Before you submit a prescription to a service provider for the purpose of billing your health insurance, it is absolutely essential that you first clarify with your health insurance provider whether your prescription and the associated costs can actually be billed. Unfortunately, there are different administrative practices among statutory health insurance providers (GKV) that can lead to your disadvantage if you have not involved your health insurance in the supply process beforehand. We can and only want to be contractual partners with health insurance companies that are seriously interested in fulfilling the political mandate of saving costs for the healthcare system and have an interest in the fastest possible supply for their insured members. The procurement model currently practiced by health insurance companies effectively prevents both to the detriment of all other parties involved. We have therefore decided to no longer bill prescriptions with the statutory health insurance providers.
Medical Aids
According to the law, insured persons are entitled to be provided with hearing aids, prosthetic devices, orthopedic aids, and other medical aids to ensure the success of medical treatment, prevent an impending disability, or compensate for a disability, provided that the aids are not to be regarded as general items of daily use or are excluded under Section 34 Para. 4. The claim also includes the necessary modification, repair, and replacement of medical aids, as well as training in their use. The exact definition can be found in Section 33 SGB V.
Co-payments
Co-payments that insured persons must make amount to a minimum of 5 euros and a maximum of 10 euros, but in each case no more than the cost of the medical aid. For medical aids intended for consumption (e.g., incontinence pull-ups), the co-payment is 10% of the retail price, but a maximum of 10 euros per month for all medical aids intended for consumption. The co-payment is calculated based on the fixed price of the medical aid and not the dealer’s retail price, provided a fixed amount has been established for this medical aid. The co-payment must always be paid to the dispensing office, i.e., the service provider, who must issue a receipt to the insured person for the co-payment made.
Fixed Amounts
The central associations of health insurance providers jointly and uniformly determine medical aids for which fixed amounts are set. In this process, aids of the same type and value in terms of their function are to be grouped together. The statements of the various associations and the affected service providers, which they can submit within a reasonable period before the decision, are also taken into account. For example, fixed amounts were agreed upon nationwide for various medical aids, such as for product group 15 “Incontinence Aids,” as of January 1, 2005. Approximately 50% of all expenditures for medical aids are financed via fixed amounts.
Contract Prices
Prices for medical aids are negotiated with associations of approved service providers and/or with individual contractual partners. However, if fixed amounts exist for individual medical aids, the statutory health insurance (GKV) must pay the costs for the medical aid up to the fixed amount agreed upon and published in the Federal Gazette, even if it had negotiated lower prices with various service providers. This case occurs, for example, if a patient cannot cope with the medical aid for which the GKV had agreed on a lower price than the fixed amount; in such cases, the GKV must pay for the other medical aid up to the fixed amount. If the insured person chooses a higher-priced medical aid, they pay the difference between the reimbursement price and the retail price of the dealer or pharmacist themselves.
Out-of-Pocket Limit
Insured persons only have to make co-payments up to the out-of-pocket limit during each calendar year. If the limit is reached within a calendar year, the insured person receives a certificate from the health insurance provider stating that no further co-payments are required for the remainder of the calendar year. The out-of-pocket limit is 2% of the annual gross income for subsistence. For the chronically ill who are in continuous treatment for the same illness, it is 1% of the annual gross income for subsistence. The determination of the out-of-pocket limits is precisely regulated in Section 62 SGB V.
