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Statutory health insurance has been funded since 1 January 2009 via the Health Fund, which is operated at the Federal Insurance Office as a special fund of the Federation. The Health Fund is financed from premium income coming from the health insurance funds, based on a contribution rate that is identical for all health insurance funds, as well as from a federal subsidy provided from taxes. The federal contribution has been provided since 1 January 2004 as a flat-rate sum to compensate for the many non-insurance benefits provided by statutory health insurance, for instance for non-contributory insurance periods of women on maternity leave or for the much reduced health insurance contributions made by “Hartz IV” benefit recipients.

With effect as from 1 January 2015, the uniform contribution rate has been set by law at 14.6 percent. The employers’ share has been fixed at 7.3 percent, so that health insurance fund members will have to fund future expenditure increases in the healthcare sector, and the concomitant income that is needed, solely via their supplementary premiums. Health insurance funds that can not cover their financial needs with the allocations from the health fund can raise a percentage supplementary premium from their members in addition to the uniform contribution rate of 14.6 percent (§ 242, § 242a SGB V). Co-insured children or partners (family insured) do not pay an additional contribution rate.

The statutory health insurance “Schätzerkreis” group of assessors, consisting of the Federal Insurance Office, the Federal Ministry of Health and the National Association of Statutory Health Insurance Funds, plays a central role in establishing the average supplementary premium. The experts meet at regular times of the year in order to assess the financial situation of the Health Fund (income/expenditure situation). At their autumn meeting, they submit a recommendation for the average supplementary premium for the coming year, which is then established by the Federal Government.

Morbidity-orientated RSE (Morbi RSE)

Since the beginning of 2009, the risk structure equalisation (RSE) effected between the statutory health insurance funds has also been orientated towards the disease levels of the insured – known as morbidity. This “Morbi RSE” places the financial equalisation, which was introduced in 1994, on a new footing.

At the same time as the Morbi RSE, the Health Fund was launched on 1 January 2009. The two instruments – that is the Morbi RSE and the Health Fund – do not depend on one another, and they could in fact operate independently of one another.

Criteria for the Morbi RSE:

  • Morbidity risks are examined directly, using 80 selected disease groups via pseudonymised in-patient and out-patient diagnoses
  • Data on pharmaceuticals are used in order to reliably secure out-patient diagnoses
  • Consideration of the indirect morbidity criteria of age, gender and right to reduced earning capacity which were used in the previous financial equalisation
  • Insured persons registered in structured treatment programmes (disease management programmes = DMPs) are no longer separately included.
  • Risk pool abolished

The health insurance funds receive from the Health Fund a basic flat-rate amount for each insured person, plus a risk-adjusted supplement or reduction. This means that health insurance funds with insured persons who are more ill receive more money than those with members who are healthy.

It is necessary to distinguish between allocations to cover mandatory benefits, for statutory benefits and extras, for expenditure to develop and implement structured treatment programmes (DMP), as well as to cover administrative costs. The Federal Insurance Office (BVA), which operates the Health Fund, informs the health insurance funds in two types of notice of the amount of the allocations from the Health Fund: basic assessment notice (values per insured person for each individual fund) and allocation notice (determination of the monthly allocation amount).

The information from the basic assessment notice helps the health insurance funds when carrying out their budget planning and has a major effect in determining whether health insurance funds are able to pay out dividends or have to levy a supplementary premium.