Medical aids – cost coverage and co-payment

Medical aids are movable items that support the treatment of people with health conditions or disabilities, assist in their recovery, compensate for a disability, or make daily life easier to manage. They include, for example, hearing aids, prosthetics, wheeled walkers and orthopedic aids. Incontinence aids, inhalation devices and compression stockings are also considered to be medical aids.

For those with statutory health insurance, the health insurance fund will cover part or all of the cost, provided that the aid is medically necessary. The entitlement to medical aids also includes everything that may be necessary for their use, such as adjustments, maintenance and repair.

People who have private health insurance and are paying the agreed rate for the relevant level of cover can submit a claim to have the costs of medical aids reimbursed by their private health insurance provider.

It is important to note that medical aids (“Hilfsmittel” in German) are not to be confused with therapeutic services (“Heilmittel”). These are treatments provided by specially trained therapists rather than family doctors – for example, physiotherapy or speech therapy.

If you want to have the cost of a medical aid covered by your health insurance provider, it is essential that the aid be prescribed by a doctor. In other words, you need a prescription. You then need to send the prescription, together with your claim, in written form, to your statutory health insurance fund, asking for the cost to be covered. The insurance provider will check your claim and tell you what the next steps are. The health insurance fund may have contracts in place with certain providers of medical aids. In this case, they will purchase the aid from their contractual supplier. It may be possible to hire medical aids that are only needed on a temporary basis and can be used again by another person. This is the case, for example, if a wheelchair is required for a certain time only.

Prerequisites for cost coverage

Certain prerequisites must be met in order for a statutory health insurance fund to cover the cost of a medical aid. For example, the aid must be required in order to ensure successful treatment, prevent further progression of a health condition or compensate for a disability on a daily basis. If the health insurance fund determines that the prerequisites are not met, they will send you confirmation of their decision.

The health insurance fund may not require you to submit a claim for prior approval for certain medical aids. This may be the case, for example, with medical aids that fall below a certain price threshold. If in doubt, find out from your health insurance fund in advance whether a written claim is required. It is not possible to claim for the approval of medical aids in retrospect.

Medical aids for care and other life situations

Medical aids that facilitate home care, help relieve symptoms suffered by care recipients or enable them to lead a more independent life (for example, care beds or a home emergency call system) may be covered by long-term care insurance for those assigned care grade 1 or higher – subject to certain conditions. These aids are sometimes referred to as care aids. As well as technical care aids, there are also some consumable aids that are covered by long-term care insurance. Seek advice if necessary from your long-term care insurance fund or the private insurance provider with which you have a long-term care insurance policy.

If a medical aid is required for work or education, the costs are covered by pension insurance, statutory accident insurance, the Integration Office or the Federal Employment Agency, depending on the individual circumstances.

Answers to the most important questions concerning the claims process and cost coverage for medical aids are provided on the website of the Independent Patient Advice Service for Germany (UPD).

Health insurance providers pay fixed amounts for certain medical aids. In other words, only a certain portion of the costs of these medical aids is covered by the health insurance provider. If the purchase price exceeds the fixed amount, you are required to cover the difference in price yourself. This is the case for glasses, hearing aids and orthopedic insoles, for example.

An overview of medical aids for which a fixed amount is covered is provided on the website of the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband).

For most other medical aids, the health insurance fund will cover the full cost. However, the co-payment rule applies, i.e., you must pay 10 percent of the cost yourself, although this is limited to a minimum of 5 euros and a maximum of 10 euros. Your own contribution to the cost may exceed this maximum in exceptional cases. Co-payment does not apply to aids for children and adolescents.

Most medical aids are available in various versions. Health insurance funds generally cover the costs of standard models of medical aids. They cover the medical requirement. If you would like a model that goes beyond what is medically necessary, you will have to cover the excess cost yourself.

If you have private health insurance, costs are reimbursed on the basis of your agreed rate of cover and the corresponding catalog or index of reimbursable costs.

A specific directory or register of products approved for cover by the statutory health insurance funds has been compiled by the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband).

For an overview of products covered by health insurance funds, refer to the online list of approved aids maintained by the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband).

In some cases, however, products that are not listed there may still be covered by your statutory health insurance fund. It is necessary to supply a documented reason why the medical aid is required in your individual case.

Private health insurance providers also have lists or catalogs of medical aids for which costs may be reimbursed, depending on the policyholder’s level of cover. These specify both the products approved and the maximum amounts that can be reimbursed. Note that private health insurance providers offer certain levels of cover at which the costs of medical aids are reimbursed in full.

Which medical aids are not covered by health insurance funds?

The following aids are excluded from the list of aids approved for cover by the statutory health insurance funds:

• Items with little or no documented therapeutic benefits, such as hot-water bottles
• low-price items such as alcohol swabs
• items for general use in daily life, such as cushions or phones. People with a visual impairment can pay for specially adapted items for everyday use from their monthly disability benefits.

For information about accessible living, see the article “Accessible living: information on renovations and aids”.

Your health insurance fund may reject your claim. You then have one month in which to lodge an appeal if you wish to do so. While it is not mandatory to specify a reason, it increases the chance of success. The reason should explain why the medical aid is medically necessary in your individual case. It is also beneficial to ask your doctor to write a report and attach this to your appeal.

The article Appealing a decision by a health insurance provider explains how to lodge an appeal against a decision by your health insurance provider and important points to note during the process.

The Independent Patient Advice Service for Germany (UPD) offers free advice on issues relating to healthcare and healthcare legislation, including questions about medical aids. All relevant contact details are available on the UPD information portal.

Advice and support relating to medical aids is also provided by social associations, self-help organizations and welfare associations.

People with disabilities will find the contact details of information and advice centers dealing with the topic of medical aids on the following web portals:

“REHADAT Assistive Products & Technical Work Aids”: https://www.rehadat-hilfsmittel.de/de/

EUTB Ergänzende unabhängige Teilhabeberatung (Complementary independent participation counseling®): https://www.teilhabeberatung.de/beratung/beratungsangebote-der-eutb