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Treatment during a temporary stay in Germany as if you had private health insurance

It may happen during a temporary stay in Germany that the healthcare provider refuses to accept your European Health Insurance Card (EHIC). It may however also be that you wish to forego using the European Health Insurance Card, pay the invoice privately and submit it to the healthcare insurer of your home country for a cost reimbursement. You will learn below when this procedure makes sense, and what requirements need to be taken into consideration, as well as what you should do if the healthcare provider refuses to accept your EHIC.

Have you forgotten to take along your EHIC and are unable to submit a Provisional Replacement Certificate in time? Have you selected a healthcare provider who only works on a private basis? Would you like to take up a benefit in Germany which is included in the statutory list of benefits in your home country, but not in Germany? The healthcare provider is entitled to issue a private bill for his or her services in these cases. This means that you initially pay the invoice yourself and can submit it to your health insurance fund at home for a cost reimbursement.

You are pregnant and have health insurance in Italy. You visit the child’s father in Germany from the 10th to the 15th week of the pregnancy. In legal terms, you are entitled to use the EHIC to take up all benefits involved with the pregnancy in the same way as if you had statutory health insurance in Germany. You would like to have a prenatal ultrasound nuchal translucency measurement carried out in order to obtain any indications of trisomy 21. The nuchal translucency measurement is included in the statutory list of benefits in Italy. This measurement is however only authoritative between the 11th and 14th weeks of pregnancy. You are therefore not able to wait with the measurement until returning to Italy. This benefit is not (yet) included in the statutory list of benefits in Germany, so that you can only have it carried out privately. This means that you first of all pay the entire cost of the treatment yourself. You can then send the invoice to the Italian healthcare insurer requesting a cost reimbursement at the Italian rates.

What do I need to consider before undergoing private treatment in Germany as a person with statutory health insurance?

If you need or wish to be unexpectedly treated in Germany as a private patient, it may be that the healthcare insurer of your home country is only able to reimburse the costs at its rates if certain preconditions are met under its legislation for this treatment. If you have any doubts in this regard, you should first of all enquire of your healthcare insurer or of the National Contact Point of your home country whether specific preconditions need to be met for treatment in your residence state. For instance, in certain cases you need an advance authorisation or have to submit specific applications (e.g. for in-patient treatment, rehabilitation, prosthetic treatment, etc.). The same conditions also need to be met if the treatment is to be carried out privately in Germany. It must however always be a healthcare provider with a contract (e.g. contract doctor/contract dentist) in such cases.

Should you fall ill and present your EHIC to a healthcare provider with a contract (e.g. a contract doctor/contract dentist) who however fails to accept it, we would advise you to consult a German health insurance fund, where you will receive assistance with regard to this matter. If you would like to undergo treatment as if you had statutory health insurance in Germany, you should by no means sign a treatment contract and pay the treatment costs in advance. If you sign a treatment contract, the healthcare provider is entitled to require you to pay the treatment costs directly on the basis of the respectively applicable Fee Schedule for Privately-Insured Patients (Gebührenordnung für Privatversicherte). These fees can be much higher than those for patients with statutory insurance. If you then pay the invoice and submit it to your health insurer in your home country for a reimbursement, you will receive at most the German health insurance fund rates or those applicable in your home country, and as a rule they will be less than the private rates which you will have paid.

On what basis is treatment provided in Germany?

In the next step, you need to conclude a treatment contract with the healthcare provider whom you have selected, setting out the scope of the benefits and the costs. The costs of private treatment in Germany are in line with fee scales which differ from one professional group to another. Different fee scales for instance apply to doctors than to dentists, so that you should always ask before undergoing any treatment what the costs are likely to be.

What do I need to consider once the treatment has been completed?

Carefully keep all bills issued during treatment by the healthcare providers. They are indispensable for obtaining a cost reimbursement. Make sure that the bill states clearly exactly what was done and what it cost.

How much will my healthcare insurer reimburse me if I undergo treatment in Germany?

If you have not planned to enter Germany in order to undergo treatment and the costs were only incurred for instance during a holiday in Germany because the treatment was not invoiced via the European Health Insurance Card, the healthcare insurer of your home country will reimburse you for at most the amount which it would have had to pay for the same treatment in your own country, unless you insist on being reimbursed the German contract rates. In the latter case, your healthcare insurer would first of all enquire in Germany as to what the contract rates are before making a refund. The refund would be limited to the German contract rates, and these are lower as a matter of principle than the amounts paid by you in accordance with the Fee Schedule for Privately-Insured Patients (Gebührenordnung für Privatversicherte).

Your healthcare insurer or the National Contact Point in your home country will answer any further questions on this matter.

What should I do if my healthcare insurer refuses to approve treatment in Germany?

You can take action if you consider the refund amount paid by your healthcare insurer to be too low once you have submitted the invoice or if you do not agree with a decision taken by your healthcare insurer. Under the Patients’ Rights Directive, your Member State is obliged to provide for the appropriate administrative procedure. Please enquire with your healthcare insurer or with the National Contact Point in your home country as to how this procedure works in detail.

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