As is known, some health services provided by the Social Security Institution (SGK) require a co-payment, while treatments for certain illnesses do not require any contribution. Additionally, the state offers many healthcare services to citizens at reduced or no cost. The SGK has defined which illnesses and treatments are exempt from co-payments.
People often wonder which diseases require a co-payment and which treatments are free. A co-payment, also called a participation fee, is the amount that beneficiaries must pay for health services covered by the Social Security Institution. These fees are determined by the state, and the scope, conditions and implementation of SGK-covered health services are explained in the SGK Health Implementation Communiqué.
There are several reasons why co-payments are collected from citizens. Co-payments help insured individuals contribute to the social security budget and deter unnecessary use of health services.
The Social Security Institution does not charge a co-payment for every service. The services that are subject to co-payments have been specified; those using services outside this list are not required to pay. Services for which SGK collects co-payments include the following:
- Co-payments are charged for outpatient physician and dentist examinations, except for family physicians who are contracted, assigned or authorized by the Ministry of Health.
- Co-payments apply to medications provided in outpatient treatment.
- Co-payments are charged for external prostheses and orthoses.
- Co-payments apply to assisted reproductive treatment procedures.
According to the Social Security Institution, co-payments are applied to outpatient medications. For drugs covered by SGK, beneficiaries who receive income from SGK and their dependents pay a 10% co-payment, while other citizens pay 20%.
There are also health services for which the Social Security Institution does not charge co-payments. Examples of services exempt from co-payments include:
- No co-payment is required for health services provided in emergency departments.
- No co-payment is charged for outpatient physician and dentist examinations when the cost is not covered by the Institution.
- No co-payment is required for family physician examinations that are contracted, assigned or authorized by the Ministry of Health.
There are situations where medication co-payments are not applied. No co-payment is charged for medications used for tests or diagnostics, drugs used during inpatient treatment, or certain medicines documented by a medical report.
Insured persons who suffer a work accident or contract an occupational disease are not charged co-payments for examinations, outpatient medications or medical supplies. In addition, health services provided during military exercises are exempt from co-payments.
How Are Co-Payments Collected?
It is important to understand not only when co-payments apply, but also how they are collected. The collection method varies based on the citizen’s insurance status. For those receiving income from the Social Security Institution and their dependents, co-payments are deducted from their income and pensions. For other citizens, payments are collected through pharmacies contracted with the Social Security Institution. If medications are obtained from abroad, co-payments are collected by the institution or the entity that supplies the medicines.