Contribution rate stability
The principle of stable contribution rates is one of the general principles that apply in statutory health insurance law for the relationships between the health insurance companies and the service providers and which serve to ensure the provision of statutory health insurance . Agreements on the remuneration of contract medical services are to be designed in such a way that the service expenditure does not exceed the premium income.
Legal regulation
The principle was part of the Health Structure Act of December 21, 1992. In § 71 SGB V it says:
"1) The contractual partners on the part of the health insurance companies and the service providers must structure the agreements on the remuneration according to this book in such a way that premium rate increases are excluded, unless the necessary medical care cannot be guaranteed even after exhaustion of economic reserves without premium increases ( Principle of contribution rate stability). Increases in expenditure due to legally prescribed preventive and early detection measures or for additional services that are provided within the framework of approved structured treatment programs (Section 137g) on the basis of the requirements of the statutory ordinance according to Section 266 (7) do not violate the principle of stable contribution rates. "
The regulation primarily affects the overall contracts for the total remuneration of the contract medical and contract dental services, including the dental and dental technical services for dentures as well as the prices for remedies and aids. The agreements on the remuneration "according to this book" also include the remuneration agreements with the providers of the approved preventive or rehabilitation facilities, with the maternal convalescence organization or with outpatient rehabilitation facilities as well as the remuneration agreements on pre- and post-inpatient treatment in the hospital.
The principle of stable contribution rates also applies to the reimbursement of outpatient hospital services and home nursing services.
Practical implementation
The Federal Ministry for Health and Social Security determines the average rates of change in the income subject to contributions of all members of the health insurance funds for the agreements on the remuneration of the following calendar year by September 15 of each year ( change in basic wages ).
The principle allows increases in contribution rates if the necessary medical care cannot be guaranteed even if economic reserves are exhausted. He wants to take into account the medical developments and changes in the morbidity structure of the insured. Increases in expenditure due to legally prescribed preventive measures or approved structured treatment programs ( disease management programs ) do not violate the principle of stable contribution rates. The amount of the total remuneration does not follow the demographic development , changes in morbidity , medical progress or the development of the number of doctors, but is limited by law to an increase in the basic wage . So it does not follow the demand, but a less growing non-relevant parameter.
Since the introduction of the health fund, the health insurers no longer set the contribution rates themselves. Nevertheless, they must also observe the principle of stable contribution rates in the future. Excessive expenditures continue to have an impact on the nationwide contribution rate and the additional contribution for each individual health insurance company.
Dental area
In the dental field, the statutory health insurance supply structure law relaxed the strict requirements for stable contribution rates. In § 85 Abs. 3 SGB V it says:
"In the contractual dental care, the contracting parties to the overall contract agree on changes to the total remuneration , taking into account the number and structure of the insured, the development of morbidity , the cost and supply structure, the working time required for the contractual dental activity and the type and scope of the dental services, insofar they are based on a change in the statutory or statutory scope of services. When agreeing changes to the total remuneration, the principle of stable contribution rates (Section 71) with regard to the volume of expenditure for the entirety of the contract dental services to be remunerated without dentures, in addition to the criteria according to sentence 1, must be taken into account. "
What is essential is the reformulation of the legal text compared to the version valid up to December 31, 2012, according to which the contribution rate stability since January 1, 2013 is no longer to be observed , but to be taken into account , i.e. only in addition to the criteria listed in Section 85 (3) Finding an appropriate fee increase for the annual contract negotiations between health insurance companies and dental associations .
The criterion of the number and structure of the insured enables the number of family insureds to be taken into account. Changes in the structure of insured persons resulting from immigration and / or emigration are also recorded, which was not the case until 2012. The criterion of the development of morbidity represents a decisive parameter for the dental treatment requirement. The criterion of the cost and supply structure allows the cost increases in the dental practices to be taken into account, especially if these have been triggered by legal regulations, for example higher costs due to more complex hygiene measures . The working time as well as the type and scope of the dental services are also used as additional criteria.
The new version also restricts the right of objection by the supervisory authorities , which until 2012 essentially only had to check the contribution rate stability based on the rate of change in the basic wage bill . Since 2013, the right of objection has been limited to non-compliance with the other legal framework conditions of the fifth book of the Social Security Code and a review of the comprehensible and appropriate consideration of the criteria mentioned, whereby the contracting parties, and possibly also the arbitration office , have considerable discretion. However, “reasonable consideration” does not necessarily mean that the additional costs incurred are taken into account in full. In order to do justice to the unchanged principle of stable contribution rates, full consideration can also be dispensed with and only a partial consideration can be made, with the consequence that part of the additional costs are to be borne by the dentists - reducing profit.
hospital
The principle of stable contribution rates also applies in the ordinance regulating hospital care rates ( Bundespflegesatzverordnung - BPflV).
care insurance
For the long-term care insurance funds , the principle of stable contribution rates is laid down in Section 70 of Book XI of the Social Code .
See also
Web link
- Jürgen Lichey, Wolfgang Schilling, Günther Jonitz: Economy and ethos in health care: The myth of the cost explosion Deutsches Ärzteblatt 2017; 114 (24): A-1176 / B-981 / C-959
Individual evidence
- ↑ Klaus Limpinsel: Sommer, SGB V § 71 contribution rate stability / 2.1 Significance and priority of contribution rate stability Haufe.de, accessed on October 8, 2019
- ↑ BSG, judgment of 13 May 2015 - B 6 KA 20/14 R no. 29
- ↑ BSG, judgment of June 23, 2016 - B 3 KR 26/15 R
- ↑ a b P. Axer, contribution rate stability and total remuneration for contract dentists , in Gesundheitsrecht GesR 3/2013 , pp. 135–143
- ↑ Buzer: BPflV § 6 contribution rate stability
