Family insurance

The family insurance , also contributory (family) coinsurance called, recorded in Germany the free co-insurance of family members of the statutory health insured duty members and voluntary members.

history

When it was first introduced, statutory health insurance did not have any general obligation to provide benefits for family members. Only the cost of childbirth (the so-called weekly allowance ) had to be granted to wives and daughters who did not have their own health insurance. However, the health insurance companies could also cover other medical costs for family members on a voluntary basis (so-called family aid , Section 205 RVO). Family assistance was made compulsory for all health insurances by the emergency ordinance of the Brüning I cabinet of July 26, 1930, to compensate for drastic cuts in statutory health insurance in order to secure the consent of the parties in the Reichstag.

Family assistance was designed completely differently from today's family insurance. According to the will of the legislature, it was supposed to relieve the insured of his maintenance obligations towards his relatives and was therefore linked to the existence of a civil law maintenance obligation of the insured towards his spouse and children, which among other things had the consequence that children lost their entitlement to family support upon marriage . Not the individual family members were entitled to claim, only the insured person; the family members had no rights, in particular no right of action against the health insurance company.

Family assistance did not cover the entire spectrum of statutory health insurance benefits, but only three specific benefits: assistance in the event of illness (Section 205 RVO), maternity assistance (Section 205a RVO) and death benefit (Section 205b RVO). The family members even had to pay for medicines themselves; this was not changed until 1975. Until 1975, the individual health insurance companies were able to set the age limit for children themselves; this was standardized to the age limits that are still valid today.

It was only with the introduction of SGB V in 1989 that family insurance was introduced in its current form, in which the claim to benefits was decoupled from the maintenance obligation under civil law and the family members themselves were entitled to benefits. Since then, family members have had access to the full range of statutory health insurance benefits.

Family members

This includes the spouse, registered partner and children . Stepchildren , adopted children and grandchildren are on an equal footing with biological children if their livelihood is predominantly covered by the member. The children of children with family insurance are also covered by family insurance. This is e.g. This is the case, for example, if the child of a family member is still family insured due to attending school or studying, but already has children.

After a divorce , co-insured children continue to be exempt from contributions; On the other hand, a previously co-insured partner must seek his own insurance after the divorce. If the divorced spouse has been a member of the statutory health insurance for a sufficiently long period of time after the final divorce, there is a right to be insured as a voluntary member on request.

Further requirements

By virtue of the law, statutory health insurance according to § 10 SGB V (according to § 25 SGB XI for non-contributory insurance in long-term care insurance ) and a. the following requirements must be met:

A spouse, child and an equivalent person can only be insured with the family if the other spouse, a parent of the child or, in the case of stepchildren and grandchildren, the step-parent or grandparent is a compulsory or voluntary member of the statutory health insurance.

The family member must be domiciled or habitually resident in the Federal Republic of Germany. This is the case with people who are abroad, such as B. Students during their semester abroad, even then - without time limit - still the case if their center of life is still in Germany and the intention is recognizable that they will return to Germany. When staying in EEA countries (including EU countries), in Switzerland, in the successor states of Yugoslavia, in Turkey and in Tunisia, special regulations apply.

The family member may not be a member of the statutory health insurance (e.g. as an employee with a monthly wage of more than EUR 450, as a trainee with a monthly wage of more than EUR 450, pensioner, voluntary social year). The family member may also not be exempt from insurance (e.g. as a higher-paid employee or civil servant). For people who were exempt from insurance during their employment as higher-income employees and who are in the maternity protection period according to Section 3 (1) MuSchG (6 weeks before delivery) and Section 3 (2) MuSchG (eight weeks or twelve weeks in the case of premature and multiple births) or are on parental leave, the exemption from insurance ends when the previous salary ceases to exist. However, you can only be insured with your family during maternity protection or parental leave if you were last (immediately before) voluntarily insured with statutory health insurance in accordance with Section 10 (1) Clause 4 SGB V. On the other hand, it is different for people who were exempt from insurance during their employment as civil servants or equivalent persons within the meaning of Section 6 (1) No. 2 SGB V. During parental leave, if you lose your earnings, your civil servant status and thus your entitlement to benefits remain in place. This means that civil servants are exempt from insurance even during parental leave and cannot be covered by family insurance.

Family members who are self-employed as commercial entrepreneurs or freelancers can only be insured with the family if they do not work full-time as defined by statutory health insurance. This is already assumed if they employ at least one employee who is subject to social insurance (wages higher than EUR 450 per month) or several marginal employees (Section 8 SGB IV) with a total wage of more than EUR 450.00. The employment of an employee who is subject to social security contributions or several marginal employees can be an indication of full-time self-employment, but does not necessarily exclude family insurance. In the course of an examination of the main occupation that meets the practical requirements, the following basic assumptions can be assumed according to the meeting result of the central social insurance associations of March 20, 2019, which is binding for the health insurance companies: a) If the time required for self-employed activity takes more than 30 hours for the self-employed weekly, it can be assumed that the self-employed activity is carried out full-time. This applies if the earned income from self-employment is the main source of livelihood. This can usually be assumed if the earned income exceeds 25% of the monthly reference figure (Section 18 SGB IV 2020 = EUR 3,185.00 / 4 = EUR 796.25 per month). b) If the time required for self-employed activity takes the self-employed person more than 20 hours, but not more than 30 hours per week, it is to be assumed that the self-employed activity is carried out full-time. This applies if the earned income from self-employment is the main source of livelihood. This can usually be assumed if the earned income exceeds 50% of the monthly reference figure (2020 = 1,592.50 euros). c) If the time required for self-employed activity does not exceed 20 hours per week for self-employed persons, it must be assumed that the self-employed activity is not carried out full-time. This does not apply if the earned income exceeds 75% of the monthly reference figure (2020 = 2,388.75 euros) and (in this respect) it can be assumed that it is the main source of livelihood. The work of a day care person who looks after up to five foreign children who are present at the same time in day care was not considered a full-time self-employed activity until December 31, 2018. The health insurance company must, however, assess each of the two cases mentioned in detail on the basis of further established criteria. A legal status review of day care workers by January 1, 2019 is only to be carried out at the request of the person concerned.

The regular total income of the family member must not exceed the amount of one seventh of the reference figure according to Section 18 SGB IV . If you are doing a marginally paid job ( mini job ), the limit is 450 euros per month. It is harmless if the stated limits are exceeded within a maximum of two months within a year. However, in all cases other income, such as B. Income from capital assets (interest, dividends) or income from renting and leasing should be taken into account. Since the relevant total income according to § 16 SGB IV is the sum of income within the meaning of income tax law, the income-related expenses must be deducted from the gross income . If you are not self-employed, this is done by deducting the employee lump sum of 1,000 euros per calendar year or the actual higher income-related expenses. However, income-related expenses may not be deducted if a low-wage activity is taxed at a flat rate. In the case of investment income, only the savings lump sum of EUR 801 per calendar year is deducted - higher income- related expenses cannot be deducted.

Age limits in children

According to Section 10 (2) SGB V, children can only be insured with a family up to certain age limits.

1. Family insurance can generally be taken out up to the age of 18.

2. It is continued until the child reaches the age of 23 if the child is not employed. Employment in this sense is any regular dependent or self-employed activity in which more than 450 euros per month is earned.

3. Family insurance is finally carried out up to the age of 25 if the child is in school or vocational training (e.g. studies) or is doing a voluntary social or ecological year without entitlement to pocket money or benefits in kind. If the school or vocational training is interrupted or delayed due to the fulfillment of a legal service obligation (military service, community service), the family insurance exists for the corresponding period of this service beyond the age of 25. From July 1, 2011, this also applies to an interruption or delay due to voluntary military service, a voluntary service, the Youth Voluntary Service Act or a comparable recognized voluntary service or work as a development worker for a maximum of twelve months.

4. Children are insured with the family without any age limit if they are disabled and unable to support themselves according to Section 2 (1) SGB IX . The disability must have existed at a time when the child was insured with the family. According to a ruling by the Dortmund Social Court, a disabled child is unable to support himself even if he can only do a low-skilled job in the low-wage sector, so that additional basic security benefits are still required.

Costs for non-family insurance in the statutory health insurance

If one of the above criteria is not met, you have to establish your own membership in a health insurance. In statutory health insurance, the contributions are based on gross income. However, if there is no or only little income subject to contributions, a flat-rate income of 1/3 of the reference value is assumed, from which the contribution amount is then calculated. With an average contribution rate of 14.9%, this results in a fictitious gross income of 1,038.33 euros per month for 2019 and thus a contribution for the GKV of 154.71 euros per month (plus long-term care insurance ).

Income limits

In the case of spouses who are not both members of the statutory health insurance (e.g. one spouse is a member, the other spouse is insured as a higher-earning employee, self-employed entrepreneur, civil servant or judge in the private health insurance scheme or e.g. as a contract or professional soldier without health insurance), family insurance for children may be excluded. This is the case if the total income of the privately insured spouse regularly exceeds one twelfth of the general annual income limit (2019: EUR 5,062.50 / month) and at the same time is regularly higher than the total income of the statutorily insured spouse. Special payments such as vacation and Christmas bonuses are to be taken into account proportionally. However, in all cases other income, such as B. Income from capital assets (interest, dividends) or income from renting and leasing should be taken into account. Since the relevant total income according to § 16 SGB IV is the sum of income within the meaning of income tax law, the income-related expenses must be deducted from the gross income . In the case of employment ( employment ), this is done by deducting the employee lump sum of 1,000 euros per calendar year or the proven higher income-related expenses. In the case of investment income, only the savings lump sum of EUR 801 per calendar year is deducted - higher income- related expenses cannot be deducted. According to a judgment of the Federal Social Court B 12 KR 16/02 R , surcharges that are paid with regard to marital status (e.g. the family allowance for civil servants) are also not taken into account when determining the annual wage limit in the family insurance.

Family insurance is also excluded in accordance with Section 10, Paragraph 1, Clause 4 of Book V of the Social Code for spouses and partners who were not insured in statutory health insurance at the start of the maternity protection period (6 weeks before the presumed date of delivery, Section 3 (1) MuSchG). The same applies to the protection period after childbirth (8 weeks or 12 weeks in the case of multiple births, Section 3 (2) MuSchG) and the start of parental leave .

Subordinate family insurance

Family insurance is usually only considered if the person concerned is not compulsorily insured due to statutory provisions.

This applies to

employees subject to compulsory insurance who regularly earn more than 450 euros per month,

Farmers ,

family members working in agriculture, agricultural health insurance ,

Recipients of unemployment benefit I ,

Recipients of unemployment benefit II (Hartz IV) (Until the end of 2015, there is generally still a right to family insurance through the household head of the benefit community (Section 5 (1) No. 2a SGB V). From January 1, 2016, this claim ceases to exist),

Pensioner,

Trainees who receive remuneration,

People who do a voluntary social year or a federal voluntary service and receive remuneration

Despite the - in and of itself - compulsory insurance, family insurance is nevertheless feasible for students and unpaid interns due to a special regulation.

Justification; Criticism and reform efforts

Family insurance is justified in particular on the basis of the principle of performance and solidarity compensation. According to this, the amount of social security contributions (unlike contributions to private health insurance, for example) is not determined by the risk of illness (= the expected costs) of the insured person, but by what he is able to pay. Provided that the assessment ceiling is not exceeded, this principle is guaranteed by the family insurance, since the social contributions then increase proportionally to the income. However, if the income threshold is exceeded, there is an advantage for sole earners. Because spouses pay lower contributions in single-earning rows than in two-earning rows with the same family income, provided it is above the assessment limit, because the contribution assessment limit is based solely on the individual income and therefore z. B. is more likely to be achieved by one full-time employee than by two half-time employees.

The following are examples of how they would apply to a (fictitious) assessment ceiling of 4,000 euros and an insurance contribution of 15%:

Example A, total family income 4,000 euros: If two spouses and their children earn EUR 1,000 per month each, the result would be contributions of (4 × EUR 1,000 × 15%) = EUR 600 contribution burden. If both spouses earn 2,000 euros a month each, they together pay the same amount (2 × 2,000 euros × 15%) = 600 euros contribution burden. If one parent earns 4,000 euros as the sole breadwinner, he pays the same contribution (4,000 euros × 15%) to insure himself and all family members. The total burden on the family in this case is the same.

Example B, total family income 8,000 euros: If two spouses and their children earn 2,000 euros each per month, the result would be contributions of (4 × 2,000 euros × 15%) = 1,200 euros contribution burden. If two spouses earn 4,000 euros each per month, this would result in contributions of (2 × 4,000 euros × 15%) = 1,200 euros contribution burden, i.e. twice the maximum contribution of 15% of the income threshold. If one parent earns 8,000 euros as the sole breadwinner, he only pays the maximum contribution once (4,000 euros × 15%) = 600 euros to insure himself and all family members. In this case, the total burden on the family is twice as high for a two-earner marriage than for a single-earner marriage, despite the same total income.

Reform efforts

The non-contributory family co-insurance has repeatedly been put up for discussion in Germany. Partly it is about the type of burden sharing between single people and couples, partly about the financing of health insurance. In June 2010, for example, the New Social Market Economy initiative proposed that housewives and men should each pay a flat-rate contribution to health insurance.

In order to ensure equal treatment of different employment models as well as a fair distribution of burdens between singles and couples, a model (called "negative spouse splitting") was proposed in which the income of spouses is arithmetically divided between both half and each up to Contribution assessment limit must pay his contribution. In one model variant, the additional amount falling below the income threshold is to be paid by the higher-income or single-income partner.

The proposed changes have not yet found a broad majority.

A call was also made to redesign family co- insurance as part of efforts to reform citizens' insurance.

Situation in other states

In Switzerland , basic insurance is compulsory for all residents, additional insurance is optional, and there is also a deductible to pay for the medical expenses. There is no family co-insurance. There has been a flat rate per capita since 1996; young adults pay a reduced per capita fee, minors a greatly reduced per capita fee. People with low incomes pay a capped head lump sum as a percentage of their income.

In the Netherlands a health system (the zorgverzekering ) was introduced on January 1, 2006 , in which every resident of the Netherlands must have health insurance. Every adult is required to contribute and pays a flat rate per capita as well as an income-related contribution ; Furthermore, there is a mandatory deductible for the treatment costs, the amount of which can be reduced by additional voluntary insurance. For cases of social hardship, only amounts up to a certain unreasonable limit are due. Insured persons up to the age of 18 do not pay a flat rate; their contributions are financed from tax revenues.

In the UK, every resident is covered by the tax-financed National Health Service .

Web links

Individual evidence

^ Louise Schroeder : The emergency ordinance on unemployment insurance and health insurance. In: Arbeiterwohlfahrt, Volume 5, Issue 17, pp. 530f

↑ FamRZ 1985, 982

↑ Health, long-term care and pension insurance. Association of Single Mothers and Fathers, accessed on March 12, 2016 .

↑ Otherwise, there is employment for wages within the meaning of Section 5 Paragraph 1 No. 1 SGB V or Section 20 Paragraph 1 No. 1 SGB XI with the consequence of compulsory insurance.

^ Social Court Dortmund, judgment of June 27, 2013 (Az .: S 39 KR 490/10) Social Court Dortmund: No age limit for free family insurance for disabled people. (No longer available online.) SV-LEX.de, formerly in the original ; Retrieved September 12, 2013 . ( Page no longer available , search in web archives )@1@ 2Template: Dead Link / www.sv-lex.de

↑ Wayback Machine. May 12, 2013, accessed February 18, 2020 .

↑ Art. 1 No. 1 letter a) double letter aa), Art. 17 para. 2 GKV Financial Structure and Quality Further Development Act (GKV-FQWG)

↑ Concise Dictionary of Economics (HdWW), Volume 3, Willi Albers (Ed.), 1981, ISBN 3-525-10258-5 , p. 331

↑ Attack on the free family co-insurance. Focus, June 29, 2011, accessed July 1, 2011 .

↑ Martina Janning: The future of the system is controversial. In: Pharmazeutische Zeitung online, issue 14/201. Retrieved September 3, 2017 .

↑ Financial reform of the statutory health insurance between citizen insurance and flat-rate premium. (PDF; 3.4 MB) Hans Böckler Foundation , June 2006, accessed on July 1, 2011 . P. 5

↑ Speculation about higher contribution limits. Merkur Online, October 26, 2005, accessed July 1, 2011 .

^ Martin Albrecht, Meilin Möllenkamp, Hans-Dieter Nolting and Susanne Hildebrandt: Transformation models of a citizen insurance. Design options from the perspective of the insured and employees of the health insurance companies. In: Study No. 332. Hans Böckler Foundation, October 2016, accessed on September 3, 2017 . P. 44.

↑ Citizens' insurance: Please ask your politician about risks and side effects ... (No longer available online.) In: aerzteblattt.de. 2013, archived from the original on September 3, 2017 ; accessed on September 3, 2017 .

↑ Swiss health system with flat rate per capita. Retrieved February 8, 2013 .

^ Health system in the Netherlands. Retrieved February 8, 2013 .

[1] Louise Schroeder : The emergency ordinance on unemployment insurance and health insurance. In: Arbeiterwohlfahrt, Volume 5, Issue 17, pp. 530f

[2] FamRZ 1985, 982

[3] Health, long-term care and pension insurance. Association of Single Mothers and Fathers, accessed on March 12, 2016 .

[4] Otherwise, there is employment for wages within the meaning of Section 5 Paragraph 1 No. 1 SGB V or Section 20 Paragraph 1 No. 1 SGB XI with the consequence of compulsory insurance.