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If you would like to be treated in Germany as a private patient, you should first of all enquire of your healthcare insurer or of the National Contact Point of your home country whether specific preconditions need to be met for treatment under the legislation of your home country. For instance, in certain cases you need an advance authorisation (advance approval system) or have to submit specific applications (e.g. for in-patient treatment, rehabilitation, prosthetic treatment, etc.). The same conditions also need to be met if the treatment is to be carried out in Germany.
You have statutory health insurance in Austria with the Tiroler Gebietskrankenkasse (TGKK) and are seeking approval to have an artificial knee joint implanted in Germany. Under Austrian law, the cost is only met if certain indications apply and subject to the prior authorisation of the statutory health insurance fund. You also need one of these indications to apply, and you must obtain prior authorisation, as a minimum in order to have the operation carried out in Germany.
If you do not meet the requirements under the law of your state of residence, but nonetheless undergo medical treatment in Germany, your healthcare insurer is not obliged to refund all or any of the costs.
The healthcare insurer can refuse to give advance authorisation for the treatment under the European Patient Mobility Directive if the treatment can take place in the state of residence within a period which is medically justifiable. It is necessary to clarify in individual cases what constitutes a medically-justifiable period. In other cases, the decision as to whether authorisation is granted is at the “discretion” of your health insurance fund.This means that it can grant authorisation, but is not obliged to do so.
We recommend you to contact your healthcare insurer and where appropriate your country’s National Contact Point prior to undergoing treatment should you have any doubts. You will find the contact details of the respective National Contact Point by following the appropriate link in the document and link box below.
If the conditions are met for treatment in Germany, you can select a healthcare provider in Germany who is to carry out the treatment. The provider must be
or belong to one of the following professional groups, amongst others:
If neither of these cases applies, your healthcare insurer is not obliged to reimburse you for the cost of the treatment.
In the next step, you need to conclude a treatment contract with the healthcare provider whom you have selected, setting out the scope of the benefits and the costs. The costs of private treatment in Germany are in line with fee scales which differ from one professional group to another. Different fee scales for instance apply to doctors than to dentists, so that you should always ask before undergoing any treatment what the costs are likely to be.
Carefully keep all bills issued during treatment by the healthcare providers. They are indispensable for obtaining a cost reimbursement. Make sure that the bill states clearly exactly what was done and what it cost.
If you opt for treatment in Germany under the European Patient Mobility Directive, you are entitled to have the costs reimbursed by your healthcare insurer in the state of residence, subject to the preconditions detailed above. However, the maximum amount that will be reimbursed to you is what your healthcare insurer would have paid for the same treatment in your state of residence. The reimbursement may not be more than the costs which you have actually incurred.
Your healthcare insurer or the National Contact Point of your state of residence will be glad to answer any questions you may have on reimbursing overnight stays, travel or additional costs in connection with cross-border healthcare.
Should your healthcare insurer refuse to authorise planned treatment in Germany, or if you consider the refund payment made by your healthcare insurer once you have submitted the invoice to be too low, you can take action against this. Under the Patients’ Rights Directive, your Member State is obliged to provide for the appropriate administrative procedure. Please enquire with your healthcare insurer or with the National Contact Point in your home country as to how this procedure works in detail.
Treatment in the context of the European Patient Mobility Directive generally provides for greater choice with regard to the range of benefits provided. It may however cost more than being treated under the conditions applying to persons with statutory insurance in the treatment State. You will also definitely have to first of all advance the costs incurred. Please therefore seek detailed advice from your health insurance fund in Germany before undergoing treatment in the other State.