Base tariff

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The basic tariff is an industry-wide uniform tariff in private health insurance (PKV), which was introduced on January 1, 2009 with Art. 44 of the GKV Competition Strengthening Act (GKV-WSG).

With the GKV-WSG, a comprehensive article law, including the relationship was statutory health insurance (GKV) for PKV redefined and 1 January 2009 a compulsory insurance introduced in the private health insurance ( § 193 para. 3 Insurance Contract Act ). At the time, it was assumed that up to 300,000 people were not covered by statutory or private health insurance in the event of illness. The " Citizens' Insurance " favored by the then Health Minister Ulla Schmidt (SPD) provided insurance cover for all residents with access to all medically necessary services.

The basic tariff is open to all people who were not otherwise insured when it was introduced and for whom the 2007 health reform made compulsory private health insurance mandatory.

Since January 1, 2016, the main statutory regulations on the basic tariff have emerged from Section 152 of the Insurance Supervision Act (VAG). The regulation corresponds to the previous § 12 paragraph 1a to 1c and 4b VAG old version, unchanged in content. In order to increase the readability of the law, the previous § 12 VAG old version has been divided into several regulations. This does not change anything in terms of the content of the regulations, also taking into account the previous case law on the basic tariff.

The contractual services in the basic tariff must be comparable in type, scope and amount with the mandatory services of the statutory health insurance , the contribution may not exceed the maximum contribution of the statutory health insurance and is available to a certain group of beneficiaries without the insurer agreeing a risk surcharge or exclusion of benefits for previous illnesses ( Section 152 (1) VAG, Section 193 (5), Section 203 (1) Insurance Contract Act ).

Access to the base rate

The following persons are eligible for insurance in the basic tariff, i.e. these persons can choose insurance in the basic tariff, but are not obliged to do so. You can also fulfill your compulsory insurance by taking out insurance in a different tariff. Conversely, the insurer must insure these people in the basic tariff if they so wish:

  • People who have been a voluntary member of a statutory health insurance fund since December 31, 2008 (generally within six months of the start of voluntary membership)
  • People residing in Germany who are neither subject to statutory health insurance nor can claim benefits under the Asylum Seekers Benefits Act , or receive assistance with subsistence , basic income support in old age and reduced earning capacity , integration assistance for disabled people or assistance with care , nor are they already adequately private health insurance (otherwise uninsured People)
  • Privately insured persons residing in Germany who concluded their insurance contract after December 31, 2008 (persons who have been subject to compulsory insurance in accordance with Section 193 (3) VVG since January 1, 2009)
  • People who had private health insurance before January 1, 2009 and have reached the age of 55 or have not yet reached the age of 55, but who meet the requirements for entitlement to a statutory pension and have applied for this pension or a civil service pension refer or needs after the SGB II or SGB XII are
  • Persons who were insured under the standard tariff on December 31, 2008
  • Beneficiaries who require additional insurance cover.

The change to the basic tariff, taking into account the rights acquired from the previous contract and the aging provision, is only possible for those with existing insurance if

a) the existing medical expenses insurance was taken out after January 1, 2009 or
b) the policyholder has reached the age of 55 or has not yet reached the age of 55, but has met the requirements for entitlement to a statutory pension and has applied for this pension or receives a civil service pension or needs assistance under SGB ​​II or SGB ​​XII is or
c) the existing medical expenses insurance was taken out before January 1, 2009 and the change to the basic tariff was applied for before July 1, 2009 ( Section 204 (1) No. 1a to 1c VVG).

If insured persons switch from one insurance company to another in the basic tariff, the amount of the contributions will not change due to the transferable aging provision - apart from company-specific surcharges. Due to the industry-standard design of the basic tariff, the benefits also remain the same.

People who had private health insurance before January 1, 2009 and have reached the age of 55 or have not yet reached the age of 55, but who meet the requirements for entitlement to a statutory pension and have applied for this pension or a civil service pension or are in need of help under SGB II or SGB XII, as well as people who were insured in the standard tariff on December 31, 2008, can only request inclusion in the basic tariff from the company with which the insurance has already existed.

The insurance contracts in the standard tariff concluded up to December 31, 2008 by persons without insurance cover were converted to contracts in the basic tariff on January 1, 2009 ( Section 315 (4) SGB V). Only insured persons who had taken out private health insurance at normal rates up to December 31, 2008 enjoy grandfathering and can switch to the standard rate instead of the basic rate in the future. The standard tariff is no longer available to new customers.

Tariff variants

Children and young people

The private health insurance companies must provide variants in the basic tariff for children and young people. With this variant, no provisions for aging are made up to the age of 21 ( Section 152, Paragraph 1, Clause 2, No. 1 VAG).

Deductibles and beneficiaries

The same applies to civil servants and their relatives who are entitled to allowance (limitation of benefits to supplement the allowance (Germany) ). In addition, insured persons must be able to claim and change deductibles (EUR 300, 600, 900 or 1,200 euros, in the case of beneficiaries proportionally for the part not covered by the aid). The insurance companies deduct agreed deductibles from the reimbursement payments. Payments are only made if the agreed deductible is exceeded.

Contribution amount

The amount of the contribution to the basic tariff is limited to the maximum contribution of the GKV in accordance with Section 152 (3) VAG. The individual contribution to the basic tariff can be lower than the maximum contribution. The maximum contribution results from the multiplication of the general contribution rate by the respective applicable contribution assessment limit in the statutory health insurance, plus the average additional contribution according to Section 242a (2) SGB V. Recipients of benefits under SGB II ( unemployment benefit II , social benefits ) or SGB XII ( Social assistance ) can request that the contribution to the basic tariff be halved (Section 152 (4) VAG).

Development of the maximum contribution in the statutory health insurance since the introduction of the basic tariff:

from Maximum contribution halved
01/01/2009 € 569.63 € 284.81
01/01/2010 € 558.75 € 279.38
01/01/2011 € 575.44 € 287.72
01/01/2012 € 592.88 € 296.44
01/01/2013 € 610.31 € 305.16
01/01/2014 € 627.75 € 313.88
01/01/2015 € 602.25 € 301.13
01/01/2016 € 618.68 € 309.34
01/01/2017 € 635.10 € 317.55
01/01/2018 € 646.05 € 323.03
01/01/2019 € 662.48 € 331.24
01/01/2020 € 735.94 € 367.97

Tariff reimbursement services

The contractual services of the basic tariff must be comparable in type, scope and amount to the services according to the third chapter of the fifth book of the Social Security Code to which there is a claim ( Section 152 (1) sentence 1 VAG). That means a broad agreement, but not a complete identity. According to Section 158 (2) VAG, the Association of Private Health Insurance eV is entrusted with the determination of the benefits according to type, scope and amount and their ongoing adjustments to changes in the area of ​​the GKV . For this purpose, it has drawn up the general insurance conditions for the basic tariff (AVB / BT 2009). The Federal Ministry of Finance exercises technical supervision over the private health insurance association with regard to these specifications.

In contrast to those with statutory health insurance, those privately insured in the basic tariff have no legal claim to benefits in kind from statutory health insurance, because private insurers only reimburse their customers for costs after medical treatment. The contract physicians are not legally obliged to provide those insured in the basic tariff (only) the mandatory statutory health insurance benefits that are reimbursable under this tariff.

Those insured with the basic rate are private patients . If medical services are used, a treatment contract under private law is concluded in accordance with § 630a BGB, the subject of which is medical treatment against the granting of the agreed remuneration. The type, scope and amount of the billable services are based in principle on the fee schedule for the GOÄ at the fee rates permitted for private treatment ( Section 1 (1) GOÄ). With regard to the reimbursement benefits, however, a treatment "in accordance with the mandatory benefits of the statutory health insurance" is faked .

In terms of type and scope, only those services are reimbursed that are stipulated for statutory health care in the federal shell contract - doctors / substitute funds, the uniform assessment standard and the guidelines of the Federal Joint Committee . Individual health services , voluntary health insurance benefits through optional tariffs and expenses for medical treatment abroad are not reimbursable . The level of remuneration was agreed by the National Association of Statutory Health Insurance Physicians and the Association of Private Health Insurance eV in agreement with the aid cost bearers with effect from April 1, 2010. As part of the medical treatment of those insured under the basic tariff, the increase factors specified in the agreement are to be used as a basis for the calculation of medical services insured in the basic tariff.

If you wanted to know what remuneration the doctor receives for those with basic rate insurance compared to the remuneration that he would get for the same people, if these were not insured in the basic rate but in the GKV, one would need on the one hand the benefits of the basic rate insured in the private health insurance including quantities and prices and, on the other hand, the services for the same people in the statutory health insurance system, also including prices and quantities in connection with the effect on budgets, control reserve volumes, profitability audits, etc. Since these data are never and are never fully available such a comparison is not legally possible.

A comparability of the benefits in the PKV basic tariff with the care under the regular full insurance tariffs of the private health insurance is expressly not given.

The agreement on the level of benefits was originally valid until December 31, 2012, but is extended by a further year each time unless one of the parties requests negotiations to begin with a lead time of at least 6 months before the respective expiry. In this case, the agreement will continue to apply unchanged until a new agreement is concluded or an arbitration award is made. In addition, the contracting parties have an immediate right of termination if the number of 100,000 insured persons in the basic tariff is exceeded.

Maximum increase factors according to GOÄ Maximum legally determined increase factors for the basic tariff until March 31, 2010 ( Section 75 (3a) sentence 2 SGB V) As of April 1, 2010, agreed maximum increase factors for the basic tariff (Section 75 Paragraph 3b Sentence 1 SGB V)
Chapter A, E, O GOÄ (medical-technical services) 2.5 1.38 1.0
Chapter M and No. 437 GOÄ ( laboratory services ) 1.3 1.16 0.9
all other chapters GOÄ (personal medical services) 3.5 ° 1.8 1.2
Dental services according to GOZ 3.5 ° 2.0 - °°

° Also higher with prior written agreement.
°° For dental services, in the absence of a deviating agreement, the basic tariff remains at the fee rate that is legally limited to 2.0 in Section 75 (3a) sentence 2 of the Social Code Book V.

Of several drugs with the same active ingredients, only one of the three cheapest is reimbursable, i.e. H. only a so-called generic product , but not the original .

According to § 5 No. 1 lit. f of AVB / BT 2009 for an accommodation due to the need for care or custody. Custody conditional accommodation exists if the insured person is accommodated in a hospital on the basis of an official or judicial order without being able to oppose it, which means that they are accommodated there for custody, which may result. a. is to be assumed in the case of accommodation according to the Mentally Ill Act .

Unlike the standard tariff, the basic tariff can be supplemented with supplementary insurance ( Section 152 (1) sentence 6 VAG). However, as long as an insured person is dependent on halving the premium due to need for assistance in accordance with SGB II or SGB XII, the insurer can demand that supplementary insurance taken out at the basic tariff be suspended ( Section 193 (11) VVG).

particularities

Insurance obligation and obligation to contract

After § 193 para. 3 SGA is basically every person commits resident to take out private health insurance, unless they are in SHI or other power system as the aid is hedged. This requirement is met by the basic tariff, for which the insurance company is obliged to contract .

Statutory exceptions to this obligation to contract exist only if the applicant was already insured with the insurance company concerned and the insurance company had contested the insurance contract due to threat or fraudulent misrepresentation or had withdrawn from the insurance contract due to an intentional breach of the pre-contractual notification obligation ( Section 152 (2) sentence 4 No. 1 and No. 2 VAG).

Further exceptions to this obligation exist according to decisions of the Federal Constitutional Court with constitutional interpretation of Section 193 (5) sentence 1 VVG and Section 12 (1b) sentence 1 VAG old version for smaller private mutual insurance associations for non-members. Otherwise, the obligation to contract interferes with the freedom of association ( Article 9, Paragraph 1 of the Basic Law) and therefore only applies to applicants who meet the statutory requirements of the respective association for membership. The two complainants had around 4,200 (1st) and 879 insured persons (2nd). According to the statutes, the circle of members under 1. was limited to Catholic priests and candidates for priesthood in the pastoral course, provided that the policyholders belong to a German diocese or have their residence or their official activities in one of these dioceses. Any priest incardinated in the Diocese of Rottenburg-Stuttgart could become a member of the second , as long as they had not yet passed the age of 50. Alumni and deacons assigned to the diocese could become extraordinary members.

Identification requirement

According to § 9 No. 5 AVB / BT, the insured are obliged to inform service providers such as doctors, pharmacies and hospitals about their insurance cover in the basic tariff by presenting the ID issued by the insurer.

The health insurance companies, on the other hand, provide an electronic health card (eGK) for every legally insured person , which serves as proof of entitlement to use services in the context of contract medical care (proof of insurance) and for billing with the service providers. While the eGK legally secures access to statutory health care ( Section 291 (1) sentence 2 SGB V, Section 13 (1) BMV ), there is no corresponding statutory regulation for those insured in the basic tariff.

The contract doctor is entitled to refuse the treatment of a legally insured person who has reached the age of 18 and does not urgently need treatment, subject to private treatment, if he does not present the electronic health card prior to treatment (Section 13 (7) BMV).

If the insured with the basic tariff violates the obligation to provide identification , the insurer is entitled to deduct an administrative cost deduction of 5 euros per calendar year from each receipt submitted for reimbursement up to an amount of 50 euros (Section 10 No. 2 AVB / BT).

Ensuring medical care

Legal regulation

Those insured in the basic tariff are free to choose among the doctors and dentists who are approved for statutory medical or dental care in the GKV ( contract doctors or contract dentists , § 4 No. 2 of the AVB / BT 2009). The statutory health insurance associations have according to Section 75 (3a) SGB V also ensure the medical care of those insured in the basic tariff with the medical services insured in this tariff. To the security according to According to Section 75, Paragraph 3a, Sentence 1 of the Book V of the Social Code, the requirements to be met are no lower than those of ensuring the statutory health insurance of those insured according to Section 75 (1) and (2) SGB V.

Contract doctors and contract dentists are not directly obliged under the guarantee mandate to treat insured persons under the conditions of the basic tariff, because this mandate is not aimed directly at contract doctors and contract dentists, but rather at the statutory health insurance associations that are independent of their members as corporations under public law.

It is up to the Association of Statutory Health Insurance Physicians and Dental Associations to decide in which way they most appropriately fulfill the statutory mandate. This means that KV or KZV may have to ensure that the person insured with the basic tariff is treated by a doctor or dentist at a reasonable distance under the conditions of the basic tariff.

Insofar as an association of statutory health insurance physicians does not oblige its members to treat insured persons of the basic tariff, the contract doctors are free to decide whether to treat this group of insured persons. Only if the insured person proves to be insured in the basic tariff and the contract doctor then agrees to treatment on his terms will the increase factors agreed on April 1, 2010 apply. Doctors therefore have the choice of either carrying out treatment at these reduced rates or refusing such treatment. With regard to the type and scope of the treatment services, however, the GOÄ and GOZ remain the relevant basis for calculation, because there is no collective-legal written contract between the National Association of Statutory Health Insurance Physicians and the PKV Association within the meaning of Section 72 (2) SGB V.

It is recognized by the highest court that a doctor does not violate the discretion granted to him by the ordinance in § 5 GOÄ in the case of private treatment if he has average medical services with the maximum rate of the standard range, i.e. H. billed at 2.3 times the rate. This means that those insured in the basic tariff who are not provided with the medical services insured in the basic tariff will not be reimbursed for the full expenses that are chargeable under the law on fees. Rather, the insured must bear both the services not included in the mandatory catalog of the statutory health insurance as well as the proportion of fees that exceed the reimbursement rates of the AVB / BT 2009.

The welfare systems of the basic security for jobseekers and the subsistence benefits of the social assistance for privately insured benefit recipients do not provide for a participation in these additional treatment costs.

Legal policy

The coalition agreement of the grand coalition from 2005 provided for a binding anchoring of the reduced fee rates in the medical fee law (GOÄ and GOZ) and a corresponding treatment obligation of the contracted physicians. In this context, the draft of the GKV-WSG contained a § 178 b VVG-E. This should regulate a direct claim of the service providers for payment of their services against the health insurers. The entitlement should be complementary to their new obligation to treat privately insured persons in the basic tariff on an outpatient basis under the same conditions as those insured with statutory health insurance. However, against the resistance of the German Medical Association in particular, a legal regulation was politically unenforceable.

An initiative of the Federal Council in 2011, the obligation to participate in contract medical care according to The federal government did not consider it necessary to extend Section 95 SGB ​​V to those insured in the basic tariff and was therefore not implemented.

Co-payments and load limit

The facts for co-payments are similar to those in the statutory health insurance scheme, but sometimes vary in amount. Even in the basic tariff, additional payments are only to be made up to the individual load limit ( Section 62 SGB ​​V: 2% of gross income or 1% in the case of proven chronic illness). The chronicler guideline of the Federal Joint Committee is to be applied accordingly. The deducted co-payments are recorded every calendar year by the insurance company; the co-payments exceeding the limit will be waived as soon as the insured person has reached this limit.

Billing

As in other private health insurance, the insured will be billed. The cost reimbursement principle applies .

According to Section 6 (3) of the AVB / BT 2009, however, the insurer is entitled to pay directly to the biller (e.g. doctor, therapist, pharmacy) within the scope of the contract if the latter bills him and meets the requirements of the general insurance conditions sent. The policyholder's contractual claim for reimbursement is then fulfilled.

The PKV has done the same as the statutory health insurance and abolished the practice fee on January 1, 2013.

Basic rate in case of need

The humane subsistence level to be granted under social law from Art. 1 Para. 1 GG i. V. m. Article 20.1 of the Basic Law also includes ensuring adequate medical care. For the vast majority of those in need, this entitlement is covered by compulsory health insurance, in particular in accordance with § 5 Paragraph 1 No. 2a or No. 13 SGB V or in accordance with 9 SGB ​​V through voluntary (continued) insurance, for example following an employment subject to compulsory insurance.

Persons with private health insurance who are in need of help according to Book Two or Twelfth of the Social Security Code can switch from their previous optional tariff to the insurer’s basic tariff, which is more cost-effective in terms of contribution amount, taking into account the rights acquired from the contract and the provision for aging ( Section 204 (1) No. 1 b VVG , Section 152 (2) and (3 ) VAG ). The need for help must be reported to the insurance company and, upon request , checked and certified by the respective service provider ( job center , social welfare office ).

Change to the basic tariff

For recipients of benefits under SGB II or XII, the social welfare authorities cannot derive an obligation to change to the basic tariff either from the existing insurance obligation or from the existence of the basic tariff.

However, this does not mean that the authorities accept contributions in other tariffs regardless of the contribution amount. According to Section 32 (4) SGB XII, only contributions up to the amount of the halved monthly fee for the basic tariff according to Section 152 (4) VAG is provided. Also § 26 SGB II limits the contribution subsidy to the amount of to § 152 para. 4 VAG halved contribution to the basic rate in private health insurance, must comply with the need of assistance. If insured persons wish to remain in a different, possibly more extensive tariff, the social welfare authorities can, within the framework of existing obligations to cooperate , ask the insurance company in question to calculate the fictitious individual contribution to the basic tariff. In the context of social benefits, contributions to other tariffs are accepted up to a maximum of this fictitiously determined individual contribution to the basic tariff, as a change to the basic tariff is generally considered reasonable according to current case law. Any existing premium difference to normal tariffs or contractually agreed deductibles to normal tariffs must be borne by the insured themselves.

Even if the social authorities are not allowed to exert direct pressure to switch to the basic tariff, the fundamental reasonableness of a change, together with the limitation of the contribution to the individual halved contribution to the basic tariff, will mean that many people in need of private health insurance from normal tariffs in the Have to change the basic tariff if their previous contribution exceeds the individual halved contribution to the basic tariff.

Temporary need for help due to the COVID-19 pandemic

The legislator assumes that among the estimated one million self-employed and small business owners, the number of those who are dependent on a contribution subsidy for private health insurance according to Book Two of the Social Code or for whom the insurance contribution to health insurance is due to the COVID-19 pandemic in Germany and long-term care insurance is taken into account as a need according to the Twelfth Book of the Social Code, will increase. In order to prevent those with private health insurance from being permanently insured in the basic tariff of private health insurance due to temporary need for help, they have according to § 204 para. 2 VVG a right to return to their previous insurance tariff, taking into account previously acquired rights without a new health examination, if they have overcome the need for assistance within two years after switching to the basic tariff. This is to prevent privately insured persons who are temporarily in need of help from being permanently insured in the basic tariff and - after the need for help has ended - having to pay the full contribution in the basic tariff with a usually lower benefit promise than in the previous tariff.

Contribution amount

Until January 2011, privately insured recipients of unemployment benefit II had to finance part of the contribution for the basic tariff from the standard benefits (so-called private health insurance contribution gap). With the judgment of the Federal Social Court on January 18, 2011, this practice was repealed. Since then, the responsible bodies have taken on private health insurance contributions up to the amount of the individual halved basic tariff.

With the 9th SGB II amendment law , the BSG case law was implemented by a new regulation of § 26 SGB ​​II on January 1, 2017. According to § 26 Paragraph 1 Clause 1 and Paragraph 3 Clause 1 SGB II new version, the contribution to the contributions to health and long-term care insurance is limited to the amount of the contribution for the basic tariff in private health insurance and halved according to § 152 Paragraph 4 VAG half of the maximum contribution to social long-term care insurance .

According to Section 32 (5) SGB XII in the version valid until December 31, 2017, if health insurance is in place with a private insurance company, the expenses for recipients of basic security in old age and in the case of reduced earning capacity and social assistance were taken over, insofar as they are "reasonable" were. When considering the situation, it should be checked whether the beneficiary can get cheaper health insurance and whether the insurance cover provides coverage of their needs within the framework of social assistance law. Since January 1, 2018, according to Section 32 (4) sentence 1 SGB XII in the version of the law for the determination of standard needs and for the amendment of the Second and Twelfth Book of the Social Security Code of December 22, 2016, according to previous administrative practice, only contributions up to the amount of the amount specified in Section 152 (4) VAG recognized half the monthly premium for the basic tariff, provided that the insurance contracts meet the insurance obligation of Section 193 (3) VVG. A higher contribution can only be recognized in exceptional cases and only for a period of up to a maximum of six months (Section 32, Paragraph 4, Clause 3 and 4, SGB XII new version). According to Section 32 (6) SGB XII, since January 1, 2018, contributions for those entitled to benefits according to Section 19 SGB ​​XII up to an amount of the maximum contribution in social long-term care insurance halved according to Section 110 (2) sentence 3 SGB XI must be recognized as an appropriate need .

Payment method

The expenses to be borne by the social service provider are not paid to the beneficiary (insured person) themselves, but to the insurance company with which the beneficiary is insured ( Section 26 (5) SGB II, Section 32a (2) SGB XII).

The beneficiary remains the owner of the contribution claim from the public social law relationship , but in the event of a dispute he can only sue for payment to the insurance company.

Number of people in need in the basic tariff

The group of insured persons is consistently much smaller than the originally assumed 300,000 people. Starting from 13,500 insured persons in 2009, an increase to 32,000 insured persons in the basic tariff was recorded by 2018. Out of a total of 8.75 million fully insured persons in private health insurance, only one hundredth member is insured in the basic tariff, which shows that the use of the basic tariff remains low (as of 2018).

Contract termination

Through the insurer

The insurers cannot terminate contracts in the basic tariff ( Section 206 (1), Section 193 (3) VVG). If there is a certain amount of arrears in payment, the contract is only suspended, unless the insured person is or will need help in accordance with SGB II or XII and provides the insurer with evidence of the receipt of benefits ( Section 193, Paragraph 6 VVG). As long as the contract is suspended, the policyholder is considered to be insured in the emergency tariff according to § 153 VAG (also non-payer tariff) with limited benefits and a reduced premium . If all the arrears in the premium, including the late payment surcharges and the collection costs, have been paid, the contract is continued at the basic rate (Section 193 (9) VVG). The emergency tariff, on the other hand, can be terminated at least extraordinarily if the insurer cannot be expected to continue the contractual relationship, taking into account all the circumstances of the individual case and weighing the interests of both parties, in particular the obligation to insure pursuant to Section 193 (3) VVG (Section 14 AVB / NLT 2013) .

The health insurer's right of withdrawal in the event of grossly negligent breach of pre-contractual notification obligations ( Section 19 (4) VVG) also applies if the policyholder is entitled to insurance cover in the basic tariff. In this case, the policyholder is entitled, in accordance with Section 193 (5) VVG, to be insured at the basic rate with any other insurance company approved for business operations in Germany.

By the insured

The insured person can terminate the contract if he is required to be insured under the statutory health insurance, e.g. B. when taking up dependent employment or when the insurer increases the premium. However, he must prove to the previous insurer that he has concluded a contract with another insurance company that meets the statutory requirements for mandatory insurance under Section 193 (3) VVG ( Section 205 VVG, Section 13 AVB / BT 2009).

The insurance relationship also ends with the death of the insured person or when he gives up his place of residence or habitual abode in Germany.

Membership development and origin

The number of those insured in the basic tariff has developed as follows:

Insured persons 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009
all in all 32,000 31,400 30,300 29,400 28,700 26,700 30,200 23,700 21,000 13,500
from the modified standard tariff 1,700 1,900 2,100 2,700 2,900 3,200 3,700 4,100 4,300 4,600
from non-insurance 12,900 12,800 12,800 11,200 11,200 10,200 9,900 7,700 7,300 5,200
from the GKV 500 500 500 500 500 500 500 400 400 300
Change within a company 15,500 14,700 13,500 13,500 12,600 11,400 15,000 11,400 8,400 3,200
Switching between companies 900 900 900 900 1,000 900 700 500 400 200
other access 500 600 500 600 500 500 400 300 200 0
of which with contribution halving due to need of assistance 18,900 18,300 17,500 16,500 15,400 13,900 11,900 9,600 6,900 4,600

According to this, the number of privately insured persons who remain in the private health insurance system with reduced income and in need of help as defined in SGB II or SGB XII has steadily increased.

Constitutionality

A constitutional complaint from five insurance companies and three people insured privately at normal rates against the basic rate was unsuccessful. The introduction of the basic tariff "to ensure lifelong, comprehensive protection for PKV members" was considered constitutional. The basic tariff represents a "national insurance made up of two pillars of insurance" and "welfare state employment of private health insurance companies for the common good". However, the German health system is still based on the two pillars of statutory health insurance and private health insurance. To make it easier to change insurance and to improve competition in private health insurance, the legislature was allowed to provide for the partial portability of the aging provisions. However, the legislature has an obligation to monitor the consequences of the 2007 health reform for insurance companies and those insured with them. In view of the low number of insured persons, the federal government has not yet been able to identify possible consequences for GKV or PKV (as of February 15, 2011).

Limiting the grant to the increase rates that apply to those insured in the basic private health insurance rate violates the general principle of equality. Civil servants and their dependents who are eligible for consideration and who are insured in the basic tariff in the absence of an alternative are disadvantaged compared to those entitled to benefit under the regular tariff. There is no objective justification for this.

The contractual services of the industry-wide standard basic tariff must be comparable in type, scope and amount to the mandatory services according to the third chapter of the fifth book of the Social Security Code to which there is a claim ( Section 152 (1) sentence 1 VAG). If these services are actually not achievable because the insured person does not have a corresponding right to treatment from doctors and other service providers and the statutory health insurance associations do not meet their statutory security obligations under Section 75 (3a) sentence 1 SGB V, there is sufficient substantiation concrete supply problems, a violation of fundamental rights that can be criticized with the constitutional complaint and a right to further benefits from the social service provider responsible for this.

literature

  • Elisabeth Brörken: Health insurance in the basic tariff with benefits according to SGB XII . info also 2/2016, pp. 55–59

Web links

Individual evidence

  1. ↑ Article 44 GKV-WSG, amendment of the Insurance Supervision Act
  2. ↑ GKV Competition Strengthening Act - GKV-WSG of March 26, 2007 ( Federal Law Gazette I p. 378 )
  3. ↑ Federal Ministry of Health : German Bundestag resolves health reform 2007 Press release and declaration by Health Minister Ulla Schmidt (SPD) "Three decisive good reasons for the reform" in full, February 2, 2007
  4. ↑ a b The PKV basic tariff: Holzklasse der Medizin from March 9, 2011. Doctors' newspaper: Helmut Laschet, accessed on March 25, 2014 .
  5. ↑ Law on the Modernization of Financial Supervision of Insurance from April 1, 2015 ( Federal Law Gazette I p. 434 )
  6. ↑ Draft law of the federal government to modernize the financial supervision of insurance BR-Drucksache 430/14 of September 26, 2014, p. 316
  7. ↑ The new basic tariff in private health insurance - important actuarial principles are suspended AKTUAR aktuell No. 5 04/2007, p. 3
  8. ^ KV Berlin information for practice. Topic PKV - difference between standard tariff and basic tariff , as of February 2010 . Retrieved February 10, 2014
  9. ↑ a b c d e f General insurance conditions for the basic tariff (AVB / BT 2009). Association of Private Health Insurance eV Brochure as PDF file (288.8 kB), accessed on February 6, 2018 .
  10. ↑ The development of the maximum contributions in the statutory health insurance 1970 - 2020 VersicherungsWiki eK, accessed on April 30, 2020.
  11. ↑ Printed matter 17/4782: Answer of the federal government on health care in the basic tariff of February 15, 2011, p. 8. (PDF; 208 kB) German Bundestag, accessed on December 25, 2013 .
  12. ↑ Printed matter 17/4782: Answer of the federal government on health care in the basic tariff of February 15, 2011, p. 8. (PDF; 208 kB) German Bundestag, accessed on December 25, 2013 .
  13. ↑ a b Decision of the Federal Constitutional Court of 5 May 2008, 1 BvR 808/08
  14. ↑ Agreement on the remuneration of outpatient and attending medical services in the PKV basic tariff Annex to the circular of the National Association of Statutory Health Insurance Physicians from February 2, 2010
  15. ↑ Answer of the Federal Government to a small inquiry, burden of pensioners with low incomes in the private health insurance BT-Drs. 18/8590 of May 30, 2016, p. 14
  16. ^ Frank Niehaus: A comparison of the medical remuneration according to GOÄ and EBM . WIP discussion paper 7/09, pp. 20/21 ( Memento of February 28, 2013 in the Internet Archive ). Retrieved March 9, 2019.
  17. ↑ VG Aachen, judgment of October 12, 2018, AZ 7 K 556/18 marginal no. 83
  18. ^ LG Dortmund, judgment of February 19, 2009 - 2 O 265/08 para. 24
  19. ↑ Compulsory insurance, mandatory contracting, basic tariff and more in the PKV (VVG 2009) from April 6, 2009. RiLG Sven Marlow, RiLG Udo Spuhl, accessed on October 12, 2012 .
  20. ↑ Printed matter 17/4782: Answer of the federal government on health care in the basic tariff of February 15, 2011, p. 2. (PDF; 208 kB) German Bundestag, accessed on October 12, 2012 .
  21. ↑ BVerfG, 1 BvR 825/08 of June 10, 2009, paragraph no. (1 - 54). Federal Constitutional Court, accessed on October 12, 2012 .
  22. ↑ Federal Shell Agreement - Doctors from January 1, 2019
  23. ↑ Printed matter 17/4782: Answer of the federal government on health care in the basic tariff of February 15, 2011, p. 8. (PDF; 208 kB) German Bundestag, accessed on October 12, 2012 .
  24. ↑ BR-Drs. 755/06, p. 319; BT-Drs. 17/4782, p. 8
  25. ↑ Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 23; Sodan / Sodan: Handbook of Health Insurance Law, Section 45 No. 33; Ratzel, Luxenburger-Hartmannsgruber: Handbook of Medical Law, § 7 No. 334; Andreas, ArztR 2009, 186, 187; a. A. only Hesral, JurisPK SGB V, § 75 No. 61
  26. ↑ Printed matter 17/4782: Answer of the federal government on health care in the basic tariff of February 15, 2011, p. 8. (PDF; 208 kB) German Bundestag, accessed on October 12, 2012 .
  27. ↑ Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 24; Sodan / Sodan: Handbook of Health Insurance Law, Section 45 No. 34
  28. ↑ Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 24
  29. ↑ BGH, judgment of November 8, 2007 - III ZR 54/07
  30. ^ Position of the German Dental Association on the basic rate, as of June 20, 2014. pdf. Retrieved March 2, 2015.
  31. ↑ BT-Drs. 18/8590 of May 30, 2016. Answer of the Federal Government to a small question / burden of pensioners with low incomes in the private health insurance, p. 14
  32. ↑ Together for Germany. With courage and humanity. Coalition agreement between the CDU, CSU and SPD for the 16th legislative period from 11/11/2005 , p. 104. Accessed on February 12, 2014.
  33. ↑ BT print. 16/3100 of October 24, 2006, p. 206
  34. ^ Coalition agreement - effects on the fee schedule in: Bundesärztekammer : Ärztliche Berufsausbildung , pp. 388–392
  35. ↑ Doctors oppose “Discount-GOÄ”. Hoppe criticizes coalition plans to lower medical remuneration . Saarländisches Ärzteblatt 12/2005, p. 14
  36. ↑ Printed matter 17/7274: Statement by the Federal Council and counter-statement by the Federal Government on the Statutory Health Insurance Supply Structure Act of October 5, 2011, pp. 13-14, 31. (PDF; 456 kB) German Bundestag, accessed on October 12, 2012 .
  37. ↑ Chronicler Guideline (§ 62 SGB V)
  38. ^ BSG, judgment of May 26, 2011 - B 14 AS 146/10 R No. II 2 c aa; BVerfG, judgment of February 9, 2010 - 1 BvL 1/09 - BVerfGE 125, 175 ff, 223 = SozR 4-4200 § 20 No. 12 No. 135; BSG, judgment of April 22, 2008 - B 1 KR 10/07 R - BSGE 100, 221 = SozR 4-2500 § 62 No. 6, RdNr. 31; BSG, judgment of January 18, 2011 - B 4 AS 108/10 R
  39. ↑ Federal Employment Agency : Information sheet on subsidies for health and long-term care insurance contributions to avoid the need for assistance (Section 26 SGB II) as of January 2016
  40. ↑ Federal Employment Agency : Second Book of the Social Code - SGB II. Technical instructions § 26 SGB II: Subsidy for insurance contributions Status: January 1, 2016
  41. ↑ LSG Hessen, December 14, 2009 - L 7 SO 165/09. Regional Social Court of Hesse, accessed on June 2, 2020 .
  42. ↑ LSG Bayern, July 19, 2011 - L 8 SO 26/11. Bavarian State Social Court, accessed on October 12, 2012 .
  43. ↑ BSG, October 16, 2012 - B 14 AS 11/12 R Federal Social Court. Retrieved March 20, 2014.
  44. ↑ Section 204 (2) VVG in the version of Art. Art. 6 of the Second Act for the Protection of the Population in an Epidemic Situation of National Consequences of May 19, 2020, Federal Law Gazette I p. 1018
  45. ^ Draft of a second law for the protection of the population in the event of an epidemic situation of national concern BT-Drs. 19/18967 of May 5, 2020, pp. 2, 4/5.
  46. ↑ B 4 AS 108/10 R
  47. ↑ Federal Law Gazette 2011 I p. 1824
  48. ↑ BSG of January 18, 2011 (B 4 AS 108/10 R); of October 16, 2012 (B 14 AS 11/12 R) and November 15, 2012 (B 8 SO 3/11 R)
  49. ↑ BMAS : Draft of a ninth law to amend the second book of the Social Security Code - legal simplification justification II.4. New version of the regulation on the payment of subsidies for health and long-term care insurance contributions
  50. ↑ § 32 SGB XII old version (old version) in the version valid before January 1, 2018 buzer.de, accessed on February 6, 2018
  51. ↑ BayLSG, judgment of October 21, 2016 - L 8 SO 246/15, UA p. 12
  52. ↑ BGBl. 2016 I p. 3159, 3168 , Article 4: Further changes to Book Twelve of the Social Code on January 1, 2018
  53. ↑ BayLSG November 10, 2016 - L 7 AS 612/16 ER B; Knickrehm / Kreikebohm / Waltermann: Commentary on Social Law , 6th edition 2019, § 26 SGB II, marginal no. 22nd
  54. ↑ The basic rate in private health insurance - an "emergency solution" that is rarely used. Retrieved January 22, 2020
  55. ↑ General insurance conditions for the emergency tariff AVB / NLT 2013, tariff NLT
  56. ↑ BGH, judgment of 27 April 2016 - IV ZR 372/15 paragraph. 23 ff.
  57. ↑ Figures report of the private health insurance 2015 p. 30
  58. ↑ Figures report by private health insurance 2017
  59. ↑ Figures report by private health insurance 2018
  60. ↑ BT-Drs. 18/8590 of May 30, 2016. Answer of the Federal Government to a small question / burden of pensioners with low incomes in the private health insurance, p. 5, p. 12
  61. ↑ BVerfG, judgment of June 10, 2009 - 1 BvR 706/08, margin no. 175, 187
  62. ↑ BVerfG, judgment of June 10, 2009 - 1 BvR 706/08, margin no. 13
  63. ↑ BVerfG, judgment of June 10, 2009 - 1 BvR 706/08 LS
  64. ↑ Printed matter 17/4782: Answer of the federal government on health care in the basic tariff of February 15, 2011, p. 3. (PDF; 208 kB) German Bundestag, accessed on October 12, 2012 .
  65. ↑ BVerwG 5 C 16.13 and BVerwG 5 C 40.13, judgments of April 17, 2014
  66. ↑ BVerfG, decision of August 30, 2017 - 1 BvR 1120/17 para. 9, 12