🩺 Health on a low income
In brief
Poverty and illness are often linked: if you have little money, co-payments for medicines, remedies and aids or travel costs can be harder to afford, and conversely health problems can lead to loss of income. The law therefore limits how much people with statutory health insurance have to pay in total in co-payments in a calendar year: the so-called co-payment ceiling (Belastungsgrenze). Once it is reached, the health insurance fund issues an exemption for the rest of the year on application.
Step by step
- Collect co-payment receiptsKeep all receipts for co-payments for medicines, remedies and aids, hospital stays and travel costs during the year.
- Work out (or have worked out) your ceilingThe ceiling depends on the household's annual gross income; the health insurance fund or an advice centre can help with the calculation.
- Apply for exemption at your health insurance fundAs soon as your receipts reach your individual ceiling, you can apply to your health insurance fund for exemption from further co-payments for the rest of the calendar year.
- If chronically ill, have the reduced ceiling checkedFor seriously chronically ill people, a reduced ceiling applies under certain conditions; the health insurance fund checks this on application.
Deadlines
- For people receiving benefits under SGB II or SGB XII, a special reference amount, often lower than actual income, generally applies when calculating the ceiling – have the health insurance fund explain the calculation in your individual case instead of estimating yourself.
- The exemption applies only to co-payments still incurred in the current calendar year; co-payments already made beyond the ceiling can be refunded on application, but are not repaid automatically.
- The reduced ceiling for the chronically ill applies only under certain statutory conditions (including continuous treatment); the health insurance fund checks whether they are met in an individual case on the basis of medical documents.
In depth · legal basis, figures and practice – for advisers and professionals
Co-payment ceiling under § 62 SGB V
§ 62 SGB V limits the annual co-payment burden to 2 % of the household's annual gross income for living expenses, and to 1 % for seriously chronically ill people in continuous treatment for the same illness. For recipients of SGB II or SGB XII benefits, gross income for living expenses under § 62 Abs. 2 in conjunction with § 2 Abs. 2 of the relevant provisions is regularly standardised reference amounts instead of the individually calculated household income; the exact minimum amounts and allowances should be asked about at the health insurance fund in each case, as they can change annually.
Relationship to basic income support
People receiving basic income support under SGB II or SGB XII are particularly affected by the ceiling because even small co-payments can make up a noticeable share of the standard rate. The possibility of exemption exists regardless of employment status for everyone with statutory health insurance whose co-payments reach the individual ceiling.
A question about your situation that this page does not answer? Write to us or use the contact form – we will tell you which office is responsible and what to bring. Free of charge, without individual legal advice.