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Section 13 of Book V of the Social Code (Sozialgesetzbuch V – SGB V) - Reimbursement of costs in accordance with Directive 2011/24/EU for persons with statutory health insurance in Germany undergoing treatment in other EU States

(1) The health insurance fund may only reimburse costs in place of the benefit-in-kind or service (section 2 subsection (2)) where this is provided for by this Book or by the Ninth Book.

(2) Insured persons may select reimbursement in place of the benefits-in-kind or services. They shall inform their health insurance fund hereof prior to receiving the benefit. The healthcare provider shall inform the insured persons prior to receiving the benefit that costs which are not assumed by the health insurance fund are to be paid by the insured person. A restriction of the selection to medical treatment, to dental care, to the out-patient field or to benefits that have been ordered, shall be possible. Access to healthcare providers not mentioned in the Fourth Chapter may only be had subsequent to the prior authorisation of the health insurance fund. Authorisation can be given if medical or social reasons justify access to this healthcare provider and care is guaranteed that is at least equivalent. Access to healthcare providers in accordance with section 95b subsection (3) sentence 1 via cost reimbursement shall be ruled out. There shall be a right to the reimbursement of a maximum of the payment which the health insurance fund would have to make if the benefit were provided as a benefit-in-kind. The articles of association must regulate the cost reimbursement procedure. In doing so, they may deduct for administrative costs a maximum of five (5) percent from the amount reimbursed. In the event of a cost reimbursement in accordance with section 129 subsection (1) sentence 5, the discounts foregone by the health insurance fund in accordance with section 130a subsection (8), as well as the additional costs in comparison to dispensing a medicinal product in accordance with section 129 subsection (1) sentences 3 and 4, shall be taken into account; the deductions are to be calculated on a lump-sum basis. The insured persons shall be bound by their selection of the reimbursement of costs for at least a calendar quarter.

(3) If the health insurance fund has been unable to provide in good time a benefit that cannot be postponed, or if it has wrongly rejected a benefit, and insured persons have thereby incurred costs for the privately-obtained benefit, these shall be reimbursed by the health insurance fund in the amount incurred where the benefit was necessary. The costs for privately-obtained benefits for medical rehabilitation in accordance with the Ninth Book shall be reimbursed in accordance with section 15 of the Ninth Book.

(3a) The health insurance fund shall decide rapidly on an application for benefits, at the latest by three weeks after receiving the application, or in cases in which an expert opinion, in particular from the Health Insurance Medical Service (Medical Service, MDK), is commissioned, within five weeks after receiving the application. If the health insurance fund considers an expert opinion to be necessary, it must commission it promptly and inform the entitled individuals thereof. The Medical Service shall deliver an expert opinion within three weeks. If an evaluation procedure is carried out that is provided for in the Federal Skeleton Agreement for Dentists (Bundesmantelvertrag für Zahnärzte), the health insurance fund shall decide within six weeks after receiving the application; the expert shall make a statement within four weeks. If the health insurance fund is unable to meet the deadlines in accordance with sentence 1 or sentence 4, it shall inform the entitled individuals accordingly in writing in good time, explaining the reasons. If no adequate reason is notified, the benefit shall be deemed to have been approved on expiry of the deadline. If entitled individuals obtain a necessary benefit themselves on expiry of the deadline, the health insurance fund shall be obliged to effect a reimbursement of the costs incurred thereby. The health insurance fund shall report annually to the National Association of Statutory Health Insurance Funds as to the number of cases in which deadlines were not met or reimbursements were carried out. Sections 14 and 15 of the Ninth Book shall apply to benefits for medical rehabilitation with regard to the declaration of competence and reimbursement of privately-obtained benefits.

(4) Insured persons shall be entitled to also access healthcare providers in another Member State of the European Union, another Contracting Party of the Agreement on the European Economic Area or Switzerland by way of cost reimbursement, instead of the benefits-in-kind or service, unless treatment for this group of individuals in the other state is to be reimbursed on the basis of a lump sum or is not subject to reimbursement because of an agreed waiver of reimbursement. Only those healthcare providers may be accessed with regard to which the conditions of access to and exercise of the occupation are the subject-matter of a directive of the European Community or which are entitled in the respective national health insurance system of the state of residence to provide care to the insured persons. The right to reimbursement shall exist up to a maximum of the payment which the health insurance fund would have to make in the case of provision as benefits-in-kind at home. The articles of association shall regulate the procedure for cost reimbursement. They shall provide for sufficient deductions from the reimbursement amount for administrative costs and the lack of a value-for-money audit, and shall deduct co-payments that are provided for. If a disease can only be treated according to the generally-recognised state of medical knowledge in another Member State of the European Union or in another Contracting Party of the Agreement on the European Economic Area, the health insurance fund may also assume the entire costs of the necessary treatment.

(5) In derogation from subsection (4), hospital services can only be received in another Member State of the European Union, in another Contracting Party of the Agreement on the European Economic Area or in Switzerland in accordance with section 39 after prior authorisation by the health insurance funds. Authorisation may only be refused if the same treatment of a disease, or treatment which is equally effective for the insured person, corresponding to the generally-recognised state of medical knowledge, can be obtained in good time from a contracting partner of the health insurance fund at home.

(6) Section 18 subsection (1) sentence 2 and subsection (2) shall apply mutatis mutandis in cases falling under subsections (4) and (5).

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