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Social Code (SGB) Book Five (V) - Statutory Health Insurance - (Article 1 of the law of December 20, 1988, Federal Law Gazette I, p. 2477)
§ 13 Reimbursement of costs
Unofficial table of contents
(1) The health insurance company may only reimburse costs in lieu of material or services (Section 2 (2)) insofar as this or the ninth book provides for it.
(2) Insured persons can choose reimbursement of costs instead of goods or services. You have to inform your health insurance company about this before using the service. The service provider must inform the insured before using the service that costs that are not covered by the health insurance are to be borne by the insured. A restriction of the choice to the area of medical care, dental care, the inpatient area or to arranged services is possible. Service providers not mentioned in the fourth chapter may only be used with the prior consent of the health insurance company. Approval can be given if medical or social reasons justify the use of these service providers and at least equivalent care is guaranteed. The use of service providers according to § 95b paragraph 3 sentence 1 by way of reimbursement is excluded. Entitlement to reimbursement exists at most in the amount that the health insurance company would have to bear if the provision was made as a benefit in kind. The statutes regulate the reimbursement procedure. It can deduct deductions from the reimbursement amount for administrative costs up to a maximum of 5 percent. In the case of reimbursement according to Section 129 (1), sentence 5, the rebates lost to the health insurance company according to Section 130a (8) as well as the additional costs compared to the dispensing of a drug according to Section 129 (1) sentences 3 and 4 must be taken into account; the discounts should be applied as a flat rate. The insured are bound by their choice of reimbursement for at least one calendar quarter.
(3) If the health insurance company was unable to provide a service that cannot be postponed on time or if it has wrongly refused a service and the insured person incurred costs for the self-procured service, the health insurance company must reimburse them in the amount incurred, insofar as the service was necessary. The costs for self-procured services for medical rehabilitation according to the ninth book are reimbursed according to § 18 of the ninth book. The costs for self-procured services that are provided by a psychotherapist are reimbursable, provided that the psychotherapist meets the requirements of Section 95c.
(3a) The health insurance company must decide on an application for benefits quickly, at the latest within three weeks after receipt of the application or, in cases where an expert opinion, in particular from the medical service, is obtained, within five weeks after receipt of the application. If the health insurance company considers an expert opinion to be necessary, it must obtain it immediately and inform the beneficiaries of this. The medical service provides an expert opinion within three weeks. If an expert opinion procedure for dentists in accordance with Section 87 (1c) provided for in the federal contract is carried out, the health insurance company must make a decision within six weeks of receipt of the application; the reviewer responds within four weeks. If the health insurance company cannot meet the deadlines according to sentence 1 or sentence 4, it will inform the beneficiaries of this in good time in writing or electronically, stating the reasons; § 37 Paragraph 2b of Book 10 applies accordingly to electronic communication. If no sufficient reason is given, the service is deemed to have been approved after the deadline has expired. If those entitled to benefits procure the required service themselves after the deadline, the health insurance company is obliged to reimburse the costs incurred as a result. The health insurance company reports annually to the National Association of Health Insurance Funds on the number of cases in which deadlines were not met or reimbursements were made. For medical rehabilitation services, Sections 14 to 24 of the Ninth Book apply to the coordination of services and the reimbursement of self-procured services.
(4) Insured persons are entitled to use service providers in another member state of the European Union, another signatory to the Agreement on the European Economic Area or Switzerland instead of the material or service by way of reimbursement, unless treatment for this group of people in the other country are to be reimbursed on the basis of a lump sum or are not subject to reimbursement due to an agreed reimbursement waiver. Only those service providers may be used for whom the conditions of access and exercise of the profession are the subject of a European Community directive or who are entitled to care for the insured in the respective national system of health insurance in the country of residence. The right to reimbursement is limited to the amount that the health insurance company would have to pay if the service was provided in kind in Germany. The statutes regulate the reimbursement procedure. In doing so, it must provide sufficient deductions from the reimbursement amount for administrative costs in the amount of a maximum of 5 percent and deduct any planned additional payments. If treatment of an illness in accordance with the generally recognized state of medical knowledge is only possible in another member state of the European Union or another signatory to the Agreement on the European Economic Area, the health insurance company can also cover the costs of the necessary treatment in full.
(5) Notwithstanding paragraph 4, hospital services in accordance with Section 39 can only be used in another member state of the European Union, another signatory to the Agreement on the European Economic Area or Switzerland with the prior consent of the health insurance companies. Approval may only be refused if the same treatment or treatment for an illness that is equally effective for the insured and which corresponds to the generally recognized state of medical knowledge can be obtained in good time from a contract partner of the health insurance company in Germany.
(6) Section 18, Paragraph 1, Clause 2 and Paragraph 2 shall apply accordingly in the cases of Paragraphs 4 and 5.
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