Co-payment exemption

The co-payment limit is always calculated for all family members within the entire household. The household includes:

• Your spouse or civil partner
• Children under 18 years of age
• Children who are 18 and still covered by statutory family insurance

The co-payment limit is always calculated for all family members within the entire household. If you have reached the 2% limit, you and all of the aforementioned family members in the household are exempt from further co-payments for the rest of the calendar year. 

Co-payment exemption always applies to one calendar year, e.g. from 01/01/2017 to 31/12/2017. The co-payment limit must therefore be recalculated every year, even if your income has not changed. 

In calculating the co-payment limit, all personal income received by you and your family members within the household for covering your cost of living is taken into account, regardless of whether it is taxable or not. This includes, among other things:

• Salary or wages 
• Pension (including workplace pension) 
• Returns from interest 
• Rental income 
• Unemployment benefits (ALG I)

Provide suitable evidence of all sources of income with your request for exemption. This includes:

• Pension statements 
• Pay slips 
• Tax statements 
• Official notifications of approval

There are certain types of income that are not taken into account when calculating your co-payment limit. These are generally sources of income that are intended to compensate for additional expenditure – such as disability benefits, sick pay or nursing care allowances. This includes:

• Child benefits 
• Nursing care allowances 
• Vision impairment allowances 
• Federal financial aid for education 
• Student loans

Despite this, please include all sources of income with your request for exemption from co-payments, in order to avoid unnecessary delays and confusion.

For some individuals, individual sources of income are not counted together; instead a legally defined level of income is used as a basis for the calculation. This income is defined as €4,906.00 for 2017. This special rule applies to individuals who meet one of the following conditions for the year for which they are requesting exemption:

• They receive ongoing aid for covering their cost of living or receive basic income support in old age and where they have a reduced earning capacity.
• They are living in a home at the cost of a social welfare provider.
• They receive unemployment benefits (ALG II).

Please include your official notification of approval for the service in question with your request for exemption from co-payments in this case.

Your co-payment limit is reduced to 1% if a family member in your household has a serious chronic illness. An illness is considered serious and chronic if it has been medically treated for at least one year, at least once per quarter. This is called sustained treatment.

In addition, at least one of the following points must apply:

• A doctor has determined that foregoing treatment would lead to life-threatening deterioration of the patient’s condition, a reduced life expectancy or a permanent adverse effect on the patient’s quality of life.
• The patient requires care level 3.
• A degree of disability or reduction of earning capacity of at least 60% has been established.

Mr Smith requests exemption from co-payments with SBK. He receives a pension of €800.00 per month before social security and taxes are deducted (gross pension). In addition he receives rental income of €150.00 per month.

Mr Smith has a gross annual income of €11,400.00. This means that he has to pay up to €228.00 in co-payments per year. Co-payments that exceed this amount will be reimbursed by SBK. 

This year he has already made multiple payments towards his treatment costs, like when he was in hospital for an extended period:

So this year, he has already paid €240.00 in co-payments. Since his individual co-payment limit is €228.00, SBK has reimbursed him €12.00. He has also received an exemption pass so that he does not have to make any more co-payments this year. 

If Mr Smith were chronically ill, his individual co-payment limit would be €114.00. Then, he would have been reimbursed €126.00.

Save yourself the hassle of collecting up receipts: if you already know that you will spend 2% or 1% of your income on co-payments in the coming year, you can transfer us that amount in advance. You will then receive your exemption pass right at the start of the year and will not have to pay any additional co-payments throughout the year. Simple contact your personal consultant.

Important: if contrary to expectations you do not end up incurring co-payments up to the limit, you will not receive any prepaid co-payment amounts back. For this reason, paying co-payments in advance is primarily suited to individuals who have a chronic illness that spans years and therefore have a good idea of what co-payments they will have to pay each year.

There are two ways to get exemption:

1. Have you already paid co-payments this year? Your personal consultant will be happy to send you the request form.

Want to know in advance how high your co-payment limit is? Simply call your personal consultant directly – they will be happy to send you a request form and check for you.

2.  Want to get exemption from co-payments in advance, in order to avoid the hassle of having to collect up the receipts? Simply contact your personal consultant for this. They will then send you the request form. Then you transfer the amount of the co-payments you will have to pay. You will then receive your personal exemption pass, which you can present to the pharmacy or other service provider later.