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Hello lovely Germany-based OMSers

I am considering a job in Germany (I have EU passport) and I am wondering about the health insurance there. I know it's "one of the best" but wondering what it means for us with MS. So far my (MS) experience has been under a private insurer in Dubai so I never had any issues seeing a neurologist (on a short notice), switching medication, doing the necessary tests etc.

Any insight/English link would be much appreciated.

Thank you in advance!
MS = April 2017
OMS = April 2017
Hello MM123!
Yes, health insurance is almost universal and generally not bad in Germany. But you should know that healthcare in Germany divides Germans into two classes: those who are insured by a private health insurance (private Krankenversicherung = PKV), about 11% of all inhabitants of Germany, and the majority of people, who are insured by statutory/social health insurance (gesetzliche Krankenversicherung = GKV). As the private health insurers pay a doctor or any other health care provider about 2.5 fold the amount for the same service, all health care providers are extremely keen on serving the privately insured patients and, therefore, prone to neglecting their only statutorily insured patients. For the majority of people it can be hard to obtain a doctor’s appointment without much waiting time, to get an MRI, to get an expensive drug or a prescription for physiotherapy. Generally, this lesser service for the majority of people is not really a problem, since healthcare is still better than in many, many other countries, but as a statutorily insured patient (gesetzlich versicherter Patient or simply “Kassenpatient”) one should be prepared to face longer waiting times for appointments or to face doctors’ resistance to prescribe something (or more time and effort for switching doctors, telephoning for sooner appointments etc.).
As to who qualifies for which kind of health insurance (PKV or GKV): All employees /salaried people whose salary is below 59,400 € per annum (gross; number for 2018) are automatically insured in the statutory/social health insurance – without choice. The premium for the insurance is being automatically deducted from the salary and transferred from the employer to the insurer directly.
All employees who earn more than those 59,400 € per annum (gross) can choose between the statutory/social health insurance and the private health insurance. All self-employed people can likewise select between statutory/social health insurance (they are then “freiwillig gesetzlich Krankenversicherte”) and the private health insurance (and in most cases opt for the private health insurance).
To the cost: The statutory health insurance costs a fixed percentage of the salary (around 15% of the salary), but if you are self-employed roughly twice as much. The private health insurance takes your age, risk factors, preexisting conditions into account and, therefore, can be less expensive than statutory health insurance, while one is young and healthy, but becomes more and more expensive with age and ill-health (and can be forbiddingly costly). Therefore, many people would love to switch to statutory health insurance when they are older and they face ever rising health insurance costs. But the law blocks them from doing this above the age of 53 (? not sure! Would need to look that up), because it wants to protect the statutory health insurance from being exploited. As you won’t be able to hide your MS diagnosis I would expect the premium in a private health insurance to be really high.
Therefore, the most important questions might be:
Will you work an Germany as an employee / salaried person? Or will you be self-employed?
if salaried, will you earn below or above the amount of 59.400 € per annum (gross).
If you earn below that limit, will you be prepared to face the less comfortable health care service that the vast majority of Germans have to put up with? (Even in the statutory health insurance you will have the pick between different providers, and there are better ones and stingier ones: A good pick would be “Techniker Krankenkasse = TK”. If you think you would fall into this category, it might be a good idea to contact this insurer and ask, whether they would pay for your MS drug or what else it is that you need!).
If you will be self-employed, it might be a good idea to contact the private health insurers and ask them, which premium they would demand from you and which service they would offer you. The ten largest health insurers in Germany are Debeka, Deutsche Krankenversicherung (DKV), Axa, Allianz Private Krankenversicherung, Signal Idun, HUK-Coburg-Krankenversicherung, Bayerische Beamtenkrankenkasse, Continentale Krankenkasse, Central Krankenversicherung, and Barmenia. I am sure they can provide information in English.
Hope this helps! (I am no expert! Personally I am statutorily insured, at the “Barmer Krankenkasse” and receive the less comfortable service. I sometimes find it cumbersome to “fight” e. g. for a prescription of physio, but otherwise have suffered no ill effect from this “second class” service yet, I believe.).
Best wishes
Zoë
Wikipedia has information, too:
See https://en.wikipedia.org/wiki/Healthcare_in_Germany
Dear Zoe,

Thank you so much for such a detailed reply. I think I wasn't clear in my first post - I am considering moving to Germany as a salaried employee :)
For salaries above 59.4k would you advise to go for the private insurance? Would the premium for pre-existing condition not be prohibitively expensive?

I checked the Wikipedia article before but had trouble finding info (in English) for MS care in particular. My main concern is regarding prescribing guidelines, co-payments (if any), and access to neurologists.

Would you know if I have to disclose my condition to the employer?

Thanks a lot!
MS = April 2017
OMS = April 2017
Dear MM123,
I am not finding the time to respond today (or tomorrow). I will try to write next weekend.
Best wishes
Zoë
Dear MM123,
you can be assured: All statutorily insured patients in Germany have access to a neurologist! Some neurologists (like other doctors) may decline to treat statutorily insured patients (When calling a doctor you will often hear the question “What is your insurance?” [“Wie sind Sie versichert?”]. If your answer is “statutorily insured” [“gesetzlich versichert” / “Kassenpatient”], some doctor’s offices might decline and say “Sorry, we treat only privately insured patients!” [“Tut uns leid; wir behandeln nur Privatpatienten!” / “Tut uns leid, wir sind eine Privatpraxis!”], and others may give you an appointment with more waiting time than you find acceptable because they want to reserve a number of time slots for the much more lucrative and desirable privately insured patients), but investing some time and effort for telephoning several doctor’s offices you will get an appointment! A reliable way to get a first appointment at a neurologist’s might be to go to a GP first and ask her/him for a medical referral to a neurologist and for the GP’s staff organizing this appointment (them calling the neurologist and asking for the appointment). If symptoms are acute (e.g. in a relapse) you will probably get an appointment with a neurologist within three days if not immediately. If symptoms are not acute, you may have to wait some weeks or even months.
In my opinion the “second class” treatment of statutorily insured patients in Germany (in contrast to the better treatment of privately insured patients) in most cases is more annoying (Who wants to be treated as “second class”?) than really harmful, at least as long a you are able to invest more time and effort in getting the appointments that you may need.
Besides the medical practices of individual resident doctors who may differ widely in what they view as the best treatment or in what they are willing to prescribe, there are MS centers (“MS-Zentren”), where you can go to (independent of whether you are statutorily or privately insured). The certification of these MS centers is a responsibility of the German Society for MS (Deutsche Multiple-Sklerose Gesellschaft [DMSG], see www.dmsg.de ). These MS centers will treat you exactly according to the official guidelines for the treatment for MS, so that these guidelines set the standard, which you can rely on. You do not need to fear that you may not be able to obtain the treatment that these guidelines stipulate!
The German Neurological Society (Deutsche Gesellschaft für Neurologie [DGN], www.dgn.org ) is the body which issues the official guidelines for the treatment of MS (Leitlinien zur Behandlung der Multiplen Sklerose, see http://www.dgn.org/images/red_leitlinie ... engert.pdf .) The current guidelines are outdated and are being prolonged provisionally for a couple of months from time to time while a general revision is currently under way. As you can see in figure 1 (Abbildung 1) on page 2 of the PDF the currently available DMTs for RRMS are dimethylfumarat (Tecfidera), glatirameracetat (Copaxone), several interferons, Teriflunomid (Aubagio), and (only!) for aggressive forms of RRMS Alemtuzumab (Lemtrada), Fingolimod (Gilenya) and Natalizumab (Tysabri). So, this is what you can get as a statutorily insured patient in Germany.
The availability of new medications for statutorily insured patients depends a) on the approval by the European Union’s EMA (European Medicines Agency) and b) on the inclusion into the DGN’s guidelines. For privately insured patients: only on the EMA’s approval and the “green light” given by the individual private insurance. E. g. ocrelizumab has not yet been approved by the EMA and can, therefore, not be prescribed within the EU. (A decision of the EMA on ocrelizumab is expected within the first months of 2018.) After that approval a neurologist in Germany will be allowed to prescribe ocrelizumab, but the big question will be whether the health insurance may be willing to cover the cost of the drug. Statutorily insured patients will probably only get it, after the drug has made it into the DGN’s official guidelines.
A treatment such as HSCT will probably not be covered by the statutory health insurance.
Please, take into account, that I am no expert and only describe how I myself – perhaps erroneously – understand the MS health care in my country. I refuse any liability for what I have written here!
It is impossible for me to offer advice for the case, that you may have the free choice between private health insurance and voluntary statutory health insurance. The cost of private health insurance is impossible to know, before you ask the different private health insurances and state all your risk factors and preexisting conditions (They will subject you to a detailed medical examination [going back 10 years or more into the past], ask you to release all your doctors from confidentiality, so that they can obtain all your past medical records ... Any voluntary or even involuntary [!] failure to disclose a risk will result in their rescission of the contract!).
Whether you are considering living in Germany for only a couple of years or for many years to come (and into your fifties, when it will become impossbile to switch health insurance to the then more affordable statutory health insurance.) may also play a role. Generally, the older and more vulnerable one is, the safer the statutory health insurance is, I would say.
If you have the free choice and opt for the statutory health insurance you will be bound to remain with the chosen health insurer for a minimum of 18 months, but are allowed to switch after these 18 months to another (statutory or private) health insurer, provided you give notice to leave 2 months before. Thus, you could for your first 18 months in Germany try out, whether you can live with the “second class” health service which the statutory health insurance provides.
Another thought: If you are considering a job offer in Germany, don’t let yourself be blinded by a very good looking gross salary! There are so many compulsory insurances (health + nursing care insurance, old age insurance, unemployment insurance) and deductions/taxes, that your net salary will be much lower. (E. g. my personal monthly net salary amounts to only about 57% of my gross salary.) Always ask what to expect as your net salary!
To your final question: The German law requires you to answer truthfully, if you are asked during a job interview whether you have a chronic disease or not (Personally, I was never asked this question in a job interview, while I was younger, and I would be confident that you will not be asked this question likewise). As you know you have MS, you are, therefore, bound to answer “Yes”. You are not required to disclose, what you have, and nobody should ask you that (If they do, you may decline to give specific information.) You may disclose your diagnosis, if you want to, but as the general perception of MS still is that of inevitable “fast decline”, I would rather dissuade you from disclosing more than is required by the law.
If you have a disabled person pass (“Schwerbehindertenausweis”) which states a degree of disability (“Grad der Behinderung”) of 50 or more (comparatively recently diagnosed as you are, you probably don’t have such a card), the German law requires you to state that fact as early as in your job application. The job interview will then be attended by the company’s disabled persons’ representative (“Vertrauensperson der Schwerbehinderten”), too, and you will be asked, whether you need any special devices, or you may be asked, whether you are able to perform e. g. a specific physical task that is required in the job (But again: Nobody is allowed to ask you, what you have.). Depending on whether the company already complies with the German legal requirement to give 5% of their jobs to disabled persons (or to pay financial compensation for their failure to do so), it may even be desirable for the company to hire someone with a disability pass, in order to evade the fine. But of course, the companies try to comply with this legal requirement by hiring the least disabled persons who have such a disability pass – and for the lowliest payed jobs within their company (There is no such requirement that they need to fill 5% of every level with disabled people.) Personally, I have experienced in my life three job interviews, after I had received a disabled person pass (stating a degree of disability of 50 [I am mildly impaired in my walking – mostly speed and distance – , but not visibly so, I believe, and otherwise almost unimpaired]), that is: stating the fact of a disability pass (but not the diagnosis) in my application. None of these applications has been successful. In one of these three cases the person with the most decisive say positively knew (by chance), that I have MS. With hindsight I believe, that his fear I might sooner or later become a liability for the team because of my MS, persuaded him to give the job to someone else – a decision which had really unwelcome consequences for me (loss of responsibility, much less attractive tasks and a loss of income of 1/3). My personal experiences, therefore, would incline me to advise: Discrimination against disabled people is real. Don’t apply for a disabled person pass, before you have secured the indefinite work contract you will stay on until retirement! Don’t disclose anything to your employer unless you must! But other people will – hopefully! – look back on much better experiences!
Hope, you find this information helpful!
Best wishes!
Zoë
Dear Zoe,

I somehow missed your reply! Thank you so much for taking the time to explain everything to me. This is exactly what I needed. Having MS in Dubai is a very different experience with no MS centers, support, regulation but also very generous private health insurance through an employer (the only way to be insured as a non-national). I will make sure I do my homework regarding the gross/net salary for sure. I agree with you completely and will not (voluntarily) disclose my "disability" unless asked.

Just to confirm, there is no co-payment on medication/visits/and such as long as I am insured regardless of being a non-citizen?

Again, thanks a lot!
MS = April 2017
OMS = April 2017
Dear MM123,
please, excuse the delay! First I had a cold and then so much to do prior to the holidays, that I have not yet found the time to write.
In the statutory health insurance in Germany, there are always co-payments! But they are generally minor, and as long as you are not struggling economicly or need a multitude of drugs, aids and hospitalizations, tolerable (in my opinion)!
E. g. on each single drug prescription every statutorily insured patient in Germany has to pay a fee or co-payment (“Zuzahlung”) of 5–10 € (5 € for the less expensive drugs, 10 € for the more expensive drugs) at the pharmacist’s counter. Or for every day in the hospital or in rehabilitation 10 € (per day), for every physiotherapy 10% (e. g. for a prescription of 6 x 20 minutes of physio a total of 19,50 €), and so on.
In order to avoid economic hardship for patients these co-payments are capped. E. g. the co-payments to a hospital stay are capped at a maximum of 28 days, that is 280 €. The 29th and all following days are exempt from any co-payment / fully covered by the statutory insurance. Same with rehabilitation.
All co-payments of this kind (“alle Zuzahlungen”) are capped at a maximum of 2% of the gross income of the household, in the case of a chronically ill person at a maximum of 1% of the gross income of the household (i. e. including the gross income of a spouse or a partner living in the same household). If you think, that every person with a chronic condition would be considered chronically ill, you probably err: the health insurance’s definition of a chronically ill patient is one who receives permanent medical treatment or needs permanent assistance. I do not know whether every person with MS would automatically fall under the 1% cap. I don’t think so. My personal guess is, that pwMS who do not take permanent medication and, therefore, don’t show up regularly at a doctor’s office, would not fit the definition and would be given only the 2% cap.
Personally, in the past, I may in some years have made co-payments which exceeded 1 % of my gross income (?) or even 2 % (??), but I have not yet bothered to collect all receipts and to apply for exemption of any further co-payment of this kind (which would involve some bureaucratic effort on my side!), — no doubt, because I have until today not felt unduly burdened by these co-payments.
A completely different thing are fields of health care, in which you may find the standard care which is provided by the statutory health insurance insufficient. This is clearly the case in dental health care: The standard which is paid for by the statutory health insurance is almost never, what you would like to have in your mouth! Be prepared to receive only a small portion of the cost towards what you want from the statutory health insurance, but to pay the by far larger portion (perhaps 75%–90%?) out of your own pocket (e. g. for dental crowns, dental bridges or dental implants).
I have no first-hand experience of how satisfactory the standard care covered by the statutory insurance is regarding incontinence care or regarding such aids as a wheelchair. But I have heard that the standard is unsatisfactory, which means that you would have to make up for the difference to a satisfactory solution out of your own pocket.
If you wear eyeglasses don’t expect even the tiniest contribution from the statutory health insurance! You will have to pay for them in full out of your own pocket. The statutory health insurance defines glasses as common items of use (“allgemeine Gebrauchsgegenstände”) instead of medical aids (“Hilfsmittel”). (They stopped short of defining glasses [or eyewear?] as items of fashion!) The difference between common items (such as glasses) and medical aids is not always clear, and there are many lawsuits being fought over these questions. Good glasses can cost a lot. If one needs varifocal lenses e. g., 1,000 € for new glasses is not an outrageous amount, but rather medium price range, I would say.
For other things statutorily insured patients have to make a co-payment (= a deductible?) called “Eigenanteil”, e. g. if the doctor prescribes specific orthopedic shoes or a special bra with an epithesis to aesthetically correct loss of breast tissue after breast surgery. In these cases the reckoning is, that the patient would otherwise have had to pay for normal shoes her-/himself or for a normal bra herself and can as well pay the amount equivalent to the normal cost that he/she would have incurred otherwise towards his/her special needs out of his/her own pocket.
Visits to doctors (regardless whether to a GP or a specialist) and diagnostic tests (like MRIs) which a doctor (and the insurance) considers necessary, are exempt from co-payments. There are some tests (not MS specific) that doctors offer at medical check-ups, but which the statutory health insurance doesn’t consider necessary. These are called IGEL (“individuelle Gesundheitsleistungen” = individuel health services) and the patient has to pay them out of his/her own pocket (in full). However, they are rarely really necessary!
As you can gather from these again far too long remarks, this is really a complicated topic with many paragraphs, details, ifs and qualifications.
My personal short summary would be: As long as you have a good salary and do not belong to the lowest income tertile, the co-payments in the statutory health insurance should be tolerable.
On the co-payments in the private health insurance I really can’t say anything, because the insurers offer so many different plans. They offer plans with low premiums, but various and/or high co-payments, plans with high premiums and zero co-payments, – and anything in between. Some will offer plans which reward healthy behaviour ... Only the insurers will be able to give reliable information on what sort of co-payment this or that plan includes! .....
As far as I know, neither in the statutory health insurance, nor in private health insurance any difference is made between German citizens and non-citizen legal residents. (In case you are a UK citizen I do not know whether Brexit would have consequences for your state of legal residence in Germany.)
I hope, my English is not too unintelligible and you got an impression!
I wish other OMSers living in Germany chimed in and gave their information and opinion!
Best wishes
Zoë

PS: On all questions more general (i. e. not specific to MS health care), the German embassy in Dubai should be able to provide information. Have you tried to get an appointment there? The German staff will most likely be German civil servants (and, therefore, privately health insured), so that they will be much more knowledgeable on conditions, plans and service of private health insurance than I am.
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