Statutory Health Insurance Modernization Act
| Basic data | |
|---|---|
| Title: | Law to modernize statutory health insurance |
| Short title: | Statutory Health Insurance Modernization Act |
| Abbreviation: | GMG |
| Type: | Federal law |
| Scope: | Federal Republic of Germany |
| Legal matter: | Social law |
| Issued on: | November 14, 2003 ( BGBl. I p. 2190 ) |
| Entry into force on: | predominantly January 1, 2004 |
| Last change by: |
Art. 1 G of December 15, 2004 ( BGBl. I p. 3445 ) |
| Effective date of the last change: |
December 21, 2004 (Art. 4 Paragraph 1 G of December 15, 2004) |
| Please note the note on the applicable legal version. | |
The law for the modernization of the statutory health insurance , in short: GKV-Modernisierungsgesetz (GMG) , is the legal basis for the attempt to reform the German health system from a cost perspective, which began in 2003 .
With the law, the red-green government coalition under Federal Chancellor Gerhard Schröder pursued the goal of permanently reducing the contributions to the statutory health insurance and thus the ancillary wage costs.
Key points of the GMG
The following is a summary of the key points of the 2003 health reform for the various participants in the health system.
Patient
- The regulations for co-payments for pharmaceuticals will be changed. Instead of the pack size (for standard size N1: € 4.00, N2: € 4.50, N3: € 5.00), the price of the drug decides on the amount of the additional payment (10% of the total costs, but at least € 5 and at most € 10). As before, 100% of the additional payment goes to the health insurance company. If the costs are less than € 5, only the actual amount will be charged. Due to the changes in the Drug Price Ordinance (see below), however, this case cannot occur with prescription drugs, but it can with aids / medical products or reimbursable, non-prescription drugs.
- Over-the-counter drugs (OTC items) are generally no longer reimbursed by statutory health insurances, unless a non-prescription drug is the standard remedy for treating a serious illness. These exceptions are made by the Federal Joint Committee, formerly the Federal Committee of Doctors and Health insurances.
- Additional payments when visiting a doctor: For every doctor called upon in a quarter, a practice fee of € 10 had to be paid once a quarter - by December 31, 2012. Could a transfer , e.g. B. from the house to the specialist , this flat rate was waived (exception: transfers to the organized emergency service were also subject to additional payment).
- Additional payment for inpatient treatment in the hospital: € 10 per day must be paid for a maximum of 28 days.
- Death and childbirth benefits are no longer paid by the health insurance company.
- Vision aids and glasses are also no longer paid for by health insurance.
- For the first 3 attempts, 50% of the costs for artificial insemination are covered by the health insurance company. In addition, the benefit is made dependent on the age of the spouse (cf. § 27 a SGB V). A sterilization will not be refunded.
- When dentures is from 2005 , a diagnosis-related fixed amount introduced. A bonus for regular dental visits (at least once a year) in the last five or ten years is also included.
Load limit In principle, the following applies: The annual co-payments by the insured may not exceed two percent of gross income for living expenses (1 percent for the chronically ill).
doctors
- A family doctor system is to be offered that establishes the family doctor as a guide. This means that he is the first point of contact for the patient and forwards him to the appropriate specialist. Specialists fear that they will lose patients as a result of this measure and that the existing network of specialists will be thinned out through practice closings.
- There is compulsory training for doctors, that is, the KV doctor must attend special training courses in the future. If he does not visit, he faces financial sanctions, in the worst case the withdrawal of his license.
This also applies to specialists in hospitals. Sanctions are not yet clear. The Federal Joint Committee has yet to decide. - An independent institute will be created to evaluate the quality and cost-effectiveness of the treatment of certain diseases ( IQWiG ).
- The existing associations of statutory health insurance physicians (KV) will be partially merged, which should reduce the administrative effort of the KV.
Pharmacies
- A new drug price regulation was introduced, which replaces the previous staggered surcharges on drugs with a flat-rate surcharge (combination model). For each drug, the pharmacist receives € 8.10 plus 3% on the wholesale price; Less a € 2.30 discount for health insurance. This largely removes the incentive for pharmacists to dispense expensive drugs. The pharmacy income is largely decoupled from the price of the drug.
- Introduction of fixed amounts for analog preparations (also "me-too" preparations). This is intended to make sham innovations without additional benefit less attractive for the patient.
- Relaxation of the ban on multiple ownership. Before the statutory health insurance modernization law came into force (January 1, 2004), a pharmacist was only allowed to own one pharmacy. From 2004 a pharmacist can own up to four pharmacies . In addition to his main pharmacy, up to three branch pharmacies, which must meet all the requirements of a full pharmacy (laboratory, prescription, etc.). For each branch pharmacy, the operator must name a (licensed) pharmacist as responsible. (The ban on third-party ownership remains in place. Only licensed pharmacists are allowed to operate pharmacies or act as managers of a branch pharmacy. This is intended to ensure independence in terms of advice and dispensing of medicines.)
- Mail order license for pharmaceuticals. Since January 1st, 2004 it is allowed to send medicines after approval. However, these are subject to the same conditions as the retail pharmacies previously available on the market. The dispatch may only take place under strict conditions, whether the desired cost savings can be achieved is disputed. Foreign competitors in particular run the risk of counterfeit drugs entering the German market.
- The prices in the area of over-the-counter, pharmacy-only drugs (OTC area) are now no longer subject to the drug price ordinance (except when dispensing at the expense of the GKV; then the old drug price regulation applies) and can be freely calculated.
Health insurance
- The health insurance companies have to streamline their administration and should not spend more than 10% per member on their administration costs. Figures on administrative costs and salaries of top fund officials must be published.
According to the GKV Competition Strengthening Act (GKV-WSG) with effect from January 1, 2009, the statutory health insurance companies bear the morbidity risk of the insured. In the past, the expenses for outpatient care for the insured were “capped”: the health insurers transferred a previously fixed amount that could not be increased to the associations of statutory health insurance physicians. The Association of Statutory Health Insurance Physicians was responsible for distributing this money to the individual doctors. The risk of morbidity lay with the statutory health insurance physicians, because if more medical services were provided than in the previous year, the individual services of a doctor were worth less.
The GMG now stipulates that every medical service is assigned a fixed value. If the medical profession as a whole provides more services in the future, the health insurers will have to pay more. The cover, which in the past prevented an increase in the costs of outpatient care, is no longer necessary.
Contributions
Statutory health insurance has to pay the full - and not half as before - contribution rate to health insurance on company pensions and other pension payments. (According to jurisprudence, this does not apply to payments from an insurance that was continued independently after the termination of an employment relationship, see: Company pension scheme # employee's perspective ).
Web links
Individual evidence
- ↑ Health Policy : Supply and Supply Structures , Federal Center for Civic Education , accessed on November 21, 2010.
- ↑ Health policy: The payment of outpatient medical services , Federal Center for Political Education, accessed on November 21, 2010.
- ↑ Hendrik Munsberg: Pensions: Merkel's pension sin. In: www.sueddeutsche.de. October 13, 2019, accessed October 14, 2019 .
