The health insurance card grants asylum seekers access to health services according to the Asylum Seekers Benefits Law (AsylbLG), provided their federal state of residence has adopted the card.
The electronic health insurance card offers one way of providing low-threshold access to health care by the municipalities or federal states. People concerned are asylum seekers after they have been allocated to a municipality until the end of the first 15 months of their stay in Germany.
After registering, asylum seekers usually receive a provisional certificate of health insurance and afterwards the health insurance card is sent to them. With the provisional certificate they can already go to a doctor of their choice. With the health card they can make use of regular health services. Billing is taking care of by the health insurance – as with statutory insured persons. However, the social welfare office remains being the cost-bearer.
The legal basis of medical treatment are §§ 4 and 6 of the AsylbLG. Some federal states are able to provide a treatment and billing that almost compares to the regular one, through a link to § 264 para. 1 of the SGB V (the legal basis of regular health care).
All three city states have introduced the health card statewide, some for many years. The non-city states, such as North Rhine-Westphalia, have agreed on framework contracts with some statutory health insurances. Depending on the framework agreement, the municipalities decide individually, whether they want to join the agreement and, thus, replace the practice of treatment certificates with the electronic health card. The implementation status in the individual federal states varies and is shown below.
After 15 months of asylum procedure, all asylum seekers have access to the same benefits as statutory insured persons (legal basis here is the SGB XII ) and, thus, the payment of benefits after the benefits catalog of services by the statutory health insurance (GKV).
Solo effort in Bremen, 2005
In 2005, through the political will of the coalition of Bremen’s SPD/CDU government at the time, Bremen introduced the Health Card for refugees in a nationwide unique move. The idea was to have healthcare for refugees essentially correspond to the standard medical care and, thus, simplified and improved, non-stigmatizing treatment. For this purpose, the councils of Bremerhaven and Bremen entered into a contract with AOK health insurance. The Asylum Seekers Benefits Law (AsylbLG) §§ 4 and 6 remains the legal basis, however, in conjunction with § 264 para. 1 SGB V (Social Code Statutory Health Insurance) it enabled medical treatment covered by health insurance and resulted in extensive care according to regular provision.
The amendment of the Asylum Seeker Benefits Law
In the course of the public discussion about the AsylbLG 2014 following the Federal Constitutional Court Decision of 18th July 2012 (the Federal Constitutional Court ruled that some of the law that regulated the benefits to secure subsistence was unconstitutional and stipulated guidelines for services in general), healthcare also became a part of the social debate. As the German government could not be convinced to cancel the AsylbLG – mainly for political reasons – and despite virtually all NGOs recommending exactly that, the prospect of an improvement – if not legal, at least practical – to healthcare was held out. The Health Card according to the Bremen Model, which in all previous years had been dismissed by other federal states as unfeasible, was now discussed in Berlin as a compromise, and solutions for the territorial states were sought.
The problem of the territorial states with the Health Card
In contrast to the city states Bremen, Hamburg and Berlin, territorial states face several bureaucratic obstacles.
- The national government is responsible for the organization and funding of refugee healthcare in the initial registration centers. However, after distribution to the asylum camps, the municipality is the responsible entity. The payments they receive vary greatly depending on the federal state.
- In order to introduce a Health Card every municipality/ district has to enter into a contract with a health insurance provider. In the territorial states, until recently, this meant numerous individual contracts and specific conditions in accordance with the particular negotiations. Since the new legislation from October 2015, standardized framework contracts for the individual states are also an option (see below).
- The administration fee, that monthly pays up to 5% blanket expenditure on benefits to health insurers for similar groups of people according to the law on social assistance, is higher in the previous contracts (minimum 10 euros, up to maximum 8%). The health insurance providers justify this with their certain additional effort. Some municipalities regard this amount as too high.
- The municipalities are arguing with the state and federal governments about the funding of healthcare for asylum seekers and they hope to receive more support.
- Also, in the past, the municipalities had entirely different practices in regards to dealing with the legal situation. These range from non-bureaucratic quarterly distribution of healthcare vouchers without the label “restricted care” to the most restrictive issuing of individual vouchers limited to acute/painful illnesses. In some municipalities with well working non-bureaucratic systems, medical care would worsen, if a card labelled with a person’s status would be introduced.
Asylum package I and framework contracts for the Health Card
Through the changes of § 264 Abs. 1 SBG V (legal status since 29 December 2015), the federal states can conclude framework contracts for their municipalities and oblige health insurers to sign the contracts with the municipalities. This is supposed to lead to uniform contract agreements in the territorial states.
Labelling of cards with §§ 4 and 6 AsylbLG
While care through statutory health insurance in general will simplify matters, the simultaneous provision to label cards with §§ 4 and 6 AsylbLG is counterproductive. The labelling leads to a negation of the recent and hard-won simplification of the treatment process, because once again the ambiguity of what is included in the scope of provision (especially with attending physicians) and the stigmatization of these individuals in medical centers will continue. Medically, it is impossible to clearly differentiate between acute and other diseases, or the degree of pain, therefore, this labelling makes no sense for billing purposes. According to the legal wording, the card has to be labelled if health insurers are obliged to provide treatment; this probably (it is legally not clear) is not the case, if health insurers voluntary assume responsibility.
Municipalities are decision makers for or against the Health Card
With or without framework contracts from the federal states, it is up to the municipalities/districts to decide if they want to enter into a contract with a health insurance provider in order to introduce the Health Card. A health insurance provider can be obliged to join, a municipality cannot. Municipalities have the following options:
A) A state that has decided against a framework contract or has not implemented it yet:
- The drafting of a separate contract and selection of a health insurer (throughout Germany) with which they want to sign the contract to introduce a Health Card. This is what Bremen and Bremerhaven have done and is still an option for other states.
- Continuation of healthcare as before with the healthcare voucher.
B) A state with a framework contract
- Accession to the state’s framework contract with a health insurer that has been obliged through the state.
- Continuation of healthcare as before, with the healthcare voucher.
- It is not clear if it is possible to conclude a separate contract on a voluntary basis with a health insurer when a framework contract already exists.
Literature and further information
- Asylum seekers receive improved access to health benefits. The process is less tiresome as they do not need to go (while sick) to the social welfare office beforehand to obtain a healthcare voucher. It is also less prone to discrimination, because the card puts them on par with statutory insured persons in the medical practice.
- Social welfare authorities will be relieved of the burden of assessment and decision. The statutory health insurers that deal on a daily basis with these matters are responsible for administration and management. Their experienced staff can utilize their knowledge for this purpose.
- No additional administrative burdens occur anymore for the benefit providers.
- The framework contracts between the health insurers and the federal states usually state clearly that physicians and not – as sometimes previously occurred – administrative staff of the social welfare offices decide whether a treatment is necessary.
- The labelling of Health Cards now stipulated by federal law can lead to stigmatizing and to arbitrary restriction of health services, if the physician is not well informed.
- Interpreting persons have to be requested separately at the welfare office. This leads to a duplication of the administrative work.
- The scope of provision is also laid out in the framework contract between the federal states and the local health insurers. Attention needs to be paid this.
- Depending on the federal state, the municipalities now sometimes have to decide individually if they want to join the framework contracts and introduce the electronic healthcare voucher.
Interestingly, based on all findings so far, restricted medical care according to §§4 and 6 AsylbLG with the distribution of healthcare vouchers by the social welfare office is not cheaper but probably more expensive than standard healthcare. The following facts are relevant here:
- Standard care is more cost-effective
Comparisons of per-capita expenses when implementing §§ 4 and 6 AsylbLG have almost always been higher than treatment according to standard care, despite the latter including more services (s. Classen 2014 & Bozoghmehr 2015).
It can be assumed that aggravation, chronification of diseases and provocation of emergency situations through restricted medical care would also have a negative financial impact.
- Abolition of redundant and expensive bureaucratic structures
Staff with hands-on experience of the AOK Bremen/Bremerhaven and of the authorities in Hamburg and Bremen continue to point out the financial advantages of the so called “Bremen Model”. As invoicing happens here via the regular health insurance providers, additional administrative costs for the social welfare and health offices are eliminated. This means less expenditure on personnel, staff training, software and premises, than required by individual healthcare voucher distribution and high assessment effort.
References and further reading
Statutory health insurers are financially and organizationally independent public bodies. They have been commissioned by the government to fulfil statutory tasks of healthcare (see Volume V of the German Social Insurance Code – Statutory Health Insurance (SGB V)). According to § 1 SGB V, it is the task of “health insurance as a mutually supportive group […] to preserve, restore or improve the health of its insured members.”
In the context of healthcare for refugees by means of health insurance, many ambiguities and myths have arisen. Some of these will be clarified below:
Can the insurance premium go up, when healthcare for refugees will be covered by health insurers?
The currently planned uptake healthcare of people in need and beneficiaries according to SGB XII through health insurers is nothing new. For refugees that have been in the country for more than 15 months this is already legally defined; they receive a Health Card with benefits according to the standard benefits catalogue of the statutory health insurers, the costs however are paid for by the local social welfare offices. The health insurer organizes medical treatment in these cases and issues the Health Card, but this does not stipulate an insurance contract. The same applies to persons that have been in the country for less than 15 months and have been assigned to a municipality. If a state has introduced the electronic Health Card, the health insurer receives the “full expenditures for the individual case as well as an appropriate share of the administrative costs” (§264 para. 1 sentence 2 SGB V), that means the costs of the medical treatment are paid for in full by the respective Office for Social Affairs, and have no overlap with general insurance premiums for the health insurance members. An increase in the insurance premium of the statutory health insurers for reasons of them taking on the administrative responsibility for healthcare of refugees is not possible.
Do health insurers make money through the provision of Health Cards for refugees?
The payment of administration costs to the health insurance providers for taking on medical care of non-insured persons has been the standard approach for many years now. According to § 264 para. 1 SGB V, health insurers are supposed to receive an “appropriate share of their administrative costs” for their expenditures when organizing healthcare. For non-insured social welfare recipients a lump sum up to 5 % of the invoiced expenditures on benefits has been specified (see § 264 para. 7 SGB V). Many federal states have determined an administrative fee of 10 euros per month per person (see Bremen, Hamburg, Berlin, Schleswig-Holstein), others 8% (for instance North Rhine Westphalia). Ten euros correspond to a percentage of 6.5%-8% of the actual expenditures. Through the restriction of benefits according to AsylbLG, these mean extra burdens for the health insurers. Additionally, this condition only lasts up to 15 months (according to § 2 AsylbLG), after which medical treatment is subject to the legal basis of SGB XII – Social Assistance Act. This also means additional administrative cost for the health insurers. Health insurers cannot be expected to profit from 10 euros per month.
Why should health insurers assume responsibility for the medical treatment of refugees?
In Germany, the health insurers are commissioned by the government to be responsible for medical treatment of insured persons, but – if possible – also for non-insured persons. This means, for instance, non-insured beneficiaries according to SGB XII have been treated since 2004 via health insurers, which means that, as statutory insured persons, they can make use of medical treatment with the Health Card. For refugees also, medical treatment takes place mostly within the standard healthcare system. The health insurers are supposed to be responsible for medical care and from the formal health system perspective are the responsible entities.