Basic principles of statutory health insurance
The system of statutory health insurance (SHI) is based on several essential basic and structural principles.
Self-government
The statutory health insurance funds are carriers of the statutory health insurance and have a right to self-government as corporations under public law. Certain framework conditions and the tasks are specified by the state. The health insurance funds assume responsibility for this, i.e. they are organizationally and financially independent, under the legal supervision of the state.
Self-governance in the statutory health insurance funds is exercised by the administrative board, which consists of honorary representatives who are elected in social elections every six years by insured persons and employers. The administrative board makes fundamental decisions and, for example, adopts the statutes and the budget.
Solidarity principle
The solidarity principle is of key importance for the payment of contributions and provision in the statutory health insurance system:
Contributions to the GKV are based on the personal economic capacity of each individual insured person. The basis of assessment is the income of the insured. Consequently, the healthy pay for the sick, the high-income for the low-income and the young for the old. In this way, risks are to be borne jointly, i.e. on a basis of solidarity.
Regardless of the amount of contribution paid, everyone with statutory insurance has the same right to medical care, depending on their level of need.
This contrasts with the equivalence principle in private health insurance (PKV), where health insurance premiums are based on the individual risk factors of each insured person. The amount of the contribution is therefore determined by age, gender and previous illnesses, for example.
Principle of benefits in kind
Within the framework of statutory health insurance, health insurers are obliged to provide their insureds with all benefits in kind or in the form of services (§ 2 para. 2 S. 1 SGB V). Thus in the GKV the benefit-in-kind principle, also called benefit-in-kind principle, applies.
Insured persons therefore receive the required treatment or prescription from their doctor or therapist in kind against proof of their insurance through the health card, without having to pay in advance themselves. The financial settlement of the service is made solely between the doctor and the health insurance company or. Association of Statutory Health Insurance Physicians.
This only covers those benefits that the health insurance company is obliged to provide in accordance with the principle of economic efficiency. For other additional services, the patient himself must pay the costs to the service provider.
Opposed to the benefit-in-kind principle is the reimbursement principle, which applies fundamentally in private health insurance. Insured persons receive a bill from their doctor in this case, which they must first pay themselves and then submit to the insurance company to have the costs reimbursed.
Cost-effectiveness requirement
The statutory efficiency requirement both defines and limits the insured person's entitlement to benefits from their health insurer. Accordingly, the statutory health insurance funds only have to cover the costs of a service if it is sufficient, appropriate and economical and does not exceed what is necessary (cf. § 12 para. 1 SGB V). This principle applies to all contractual medical care, d.h. for preventive medical checkups just as for drug prescriptions or diagnostic examinations.
If a service does not meet these requirements, the insured does not have a claim against the health insurance company to have it cover the costs.
The aim of the efficiency principle is to provide high-quality care, while at the same time ensuring the financial stability as well as the functionality and performance of the SHI system.