Outpatient residual cost insurance

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An outpatient residual insurance is a private health insurance that extends the coverage of public insurance people.

Thematic classification & requirements

The outpatient residual cost insurance is one of the private supplementary health insurances and extends the insurance cover for people with statutory health insurance (GKV). The conclusion of the outpatient residual cost insurance is tied to requirements:

  • The insurance can only be taken out for legally compulsorily insured persons or persons with voluntary statutory health insurance, whereby recipients of free medical care are equated with this group of persons and can also take out insurance.
  • The state of health of the insured person must be sufficiently good at the time the contract is concluded.
  • The changeover to the cost reimbursement principle at a health insurance company must be carried out. However, it is strongly recommended to apply for the changeover only after a positive application check by the supplementary health insurer.

Legal requirements: Section 13 of the Social Security Code V

The majority of Germans are compulsory members of statutory health insurance by law. As a result, the path to private health insurance and access to private medical treatment with all its advantages is permanently denied.

With the change in § 13 of the Social Security Code V, however, a possibility was created to enable members of the statutory health insurance to have private patient status with restrictions.

The basic idea of ​​outpatient residual cost insurance

Actual status

Compared to private patients, statutory health insurance patients are subject to a number of regulations and restrictions that make access to medical options significantly more difficult or even completely prevent them.

The main reason for this is the defined service catalog of the statutory health insurances, which is primarily intended to curb the cost explosion in the health care system and thus provides for significant restrictions in the provision of services.

These include, for example:

  • no free choice of medication. As a rule, the GKV determines from which provider the drug must be obtained.
  • Treatments must begin with the family doctor. Further treatments require a referral.
  • no or only partial assumption of costs for remedies and aids
  • Vaccinations and preventive examinations are only included in the catalog of services as voluntary services for some health insurance companies.
  • Limitations on costly treatment methods (MRI, CT)
  • Billing according to the cash register fee schedule ( EBM ) and not according to the private fee schedule for doctors (GOÄ )

In particular, the significantly reduced doctor's fee, which is set as part of the EBM, is one of the decisive points for the colloquial "two-class medicine".

Potential for improvement through cost reimbursement and residual cost insurance

Statutory health insurance patients who take out outpatient residual cost insurance and who choose the cost reimbursement principle with their statutory health insurance are now self-payer at the outpatient doctor. Unlike in the past, the electronic health card is no longer shown or scanned by the outpatient doctor . Services are billed directly between doctor and patient, within the framework of the doctors' fee schedule (GOÄ), without the restrictions that would result from the health insurance bill. The doctor can claim his full fee up to the maximum rates of the fee schedule and apply or use all other recognized and available treatment methods.

The patient himself is now given full, private medical treatment. He enjoys all the advantages of a “real private patient” with only one exception (see restrictions on the provision of services ).

Billing procedure

Way of bills

The private bills are billed jointly by the statutory health insurance and the outpatient residual cost insurance. The following steps take place:

  1. The original invoices are presented to the statutory health insurance. This determines the reimbursement amount, measured against the regular services of the GKV and after deducting a processing fee , and transfers the reimbursement service to the health insurance member .
  2. The reimbursement paid will be noted on the original invoice. The invoice is then returned to the member of the cash register.
  3. Finally, the original invoice must be handed over to the outpatient residual cost insurance, which defines its reimbursement rate taking into account the advance payment of the statutory health insurance and pays it to the customer.
  4. After the invoices have been processed successfully, the customer pays the doctor directly.

Reimbursement amounts for residual cost insurance

The amount of the reimbursement made by the outpatient residual cost insurance depends on the selected insurance tariff. Depending on the provider, deductibles may arise for the customer. But there are also premium tariffs that exempt the insured person from their own contributions and even reimburse the processing fees of the statutory health insurance. In this case, 100% of the doctor's and medication costs are covered.

Regardless of the general reimbursement amount, the insurance contract is usually based on separate service catalogs for remedies and aids . In this way, reimbursements for hearing aids or wheelchairs, for example, are regulated in more detail.

Restrictions on the provision of services

Since the outpatient residual cost insurance is designed as supplementary health insurance, the advance payment of the statutory health insurance is taken into account in the pricing (tariff formation) and is firmly calculated.

If the patient with outpatient residual cost insurance chooses an outpatient doctor without a health insurance license , the statutory health insurance does not have to pay any advance payments, which would mean that the outpatient residual cost insurance would have to reimburse 100% of the services incurred. Since this is not associated with the tariff calculation, the residual cost insurance provides a special clause for this specific case, which, however, varies depending on the insurance company. As a rule, there is a reimbursement of costs of 50%, although there are also providers who do not provide any service.

Contribution calculation of the outpatient residual cost insurance

The contributions to the outpatient residual cost insurance are calculated either according to the type of non-life insurance or the type of life insurance.

Type of damage insurance

With this form, the contribution is not based on the age of entry of the insured person. As a rule, age groups are defined (e.g. starting age from 30 to 45) for which a certain contribution rate is set. As long as the insurance customer is within the contribution group, the corresponding contribution applies to him. If the insured person exceeds an age group, the contribution for the next higher age group automatically applies.

advantages

  • The contributions in the lower age groups are very cheap.

disadvantage

Type of life insurance

The calculations according to the type of life insurance include the exact entry age of the insured person and lead to an age-related contribution. This is not automatically adjusted over the years , but remains at the calculated amount. At the same time, aging provisions are accumulated.

Trustee Procedure

Regardless of the type of calculation, contributions can also be adjusted due to increased health costs. As part of the so-called trustee procedure, an insurance company can or must increase the contributions if the expenditure on insurance benefits exceeds the premium income within certain limits.

Conclusion

Outpatient residual cost insurance in combination with the cost reimbursement principle is a practicable way of making the benefits of a private patient accessible to those with statutory health insurance. In particular, the change to reimbursement of costs, but also back to the principle of benefits in kind, is very easy and unproblematic.

The limitation of reimbursement for outpatient doctors without a health insurance license must be observed.

Individual evidence

  1. ↑ § 13 SGB V reimbursement of costs in the GKV. Retrieved April 25, 2016 .