Why the chronically ill pay less
People who are ill in the long term often need medicines, medical aids or therapies for years. Co-payments then add up especially quickly. That is why § 62(1) SGB V halves the burden limit for chronically ill people in long-term treatment for the same serious illness: instead of 2%, 1% of annual gross income for living expenses applies.
For a single person with €30,000 income that means €300 instead of €600 per year. For a married couple with two children and €60,000 income, the limit falls from €667.38 to €333.69. It is enough for one household member to meet the conditions — the 1% limit then applies to the joint calculation.
When is an illness seriously chronic?
The exact definition is set out in the chronic illness guideline of the Federal Joint Committee. An illness is seriously chronic if it has been treated by a doctor at least once a quarter for at least one year (long-term treatment) and one of the following criteria is also met:
- need for care at care level 3, 4 or 5
- a degree of disability or degree of damage of at least 60, or a reduction in earning capacity of at least 60%, each at least partly due to the illness being treated
- continuous medical care (for example medical treatment, drug therapy, therapeutic remedies or medical aids) without which, in the doctor's assessment, a life-threatening deterioration, reduced life expectancy or a lasting loss of quality of life would be expected
Typical examples include diabetes, heart disease, chronic lung disease, rheumatism or severe mental illness — but what counts is always the individual case, not the diagnosis alone.
The check-up rule for people born after 1 April 1972
One restriction affects younger insured people. Anyone born after 1 April 1972 who did not regularly attend the health check-ups provided for in § 25(1) SGB V before falling ill only gets the 2% limit. Under the chronic illness guideline this concerns a medical consultation on cancer screening — for women born after 1 April 1987 and men born after 1 April 1962. People who already have the illness being screened for, or who are severely mentally ill, are exempt.
The good news: anyone taking part in a structured treatment programme (disease management programme) for their illness still gets the 1% limit. Ask your doctor whether such a programme exists for your illness.
How to prove chronic illness
Your health insurer makes the decision. You usually need:
- a medical certificate of long-term treatment stating the illness — many insurers have their own form for this
- for care level, disability degree or reduced earning capacity, a copy of the final official decision naming the illness being treated as the reason
- for continuous care needs, a medical certificate confirming this
With care level 3 to 5, long-term treatment is assumed after one year at that level. You generally have to prove continued treatment to the insurer after the end of each calendar year. The insurer can waive this if the necessary findings have already been made and nothing suggests the illness has ended.
Is it worth the effort?
Almost always. Even on an average income, the chronic illness rule saves several hundred euros a year. In the co-payment exemption calculator you can switch the “chronically ill” option on and off and immediately see how much your limit drops. If you are ill for a longer period, also check which benefits you are entitled to while unable to work — the sick pay calculator helps.