This article was translated from the original human-written German version. While we strive for accuracy, we cannot guarantee it is error-free. We recommend consulting the German original for the most precise information. This content is for informational purposes only and does not constitute financial or legal advice. Always consult with a qualified professional before making insurance or financial decisions.

Health Insurance for the Self-Employed: A System Comparison of GKV and PKV

For the self-employed, choosing the right health insurance is one of the most important entrepreneurial and financial decisions. In the German healthcare system, there are fundamentally two systems to choose from: Statutory Health Insurance (GKV) and Private Health Insurance (PKV). Both are based on different principles that affect benefits and contributions, and which should be objectively examined.

1. Overview of Fundamental System Differences

GKV is based on the solidarity principle. This means that benefits are based on medical need, and contributions are collected income-dependently. Financing is done through a pay-as-you-go system. Benefits are uniformly defined by the legislator in SGB V.
PKV follows the equivalence principle. Here, contributions depend on the chosen tariff, the age of entry, and the state of health. Insured individuals provide for the future through provisions for old age (funded system). Benefits are individually agreed upon by contract.

2. Benefit Design and Medical Care

In the GKV system:

The catalog of benefits is defined by SGB V, is uniform for everyone, and subject to the economic efficiency mandate.
New medical procedures must first be approved by the Joint Federal Committee (G-BA).
The catalog of benefits can be adjusted through healthcare reforms.
Doctors are compensated through budgets, which can influence appointment scheduling.
Statutory co-payments must be made for many services.
Coverage abroad is usually limited to Europe.

In the PKV system:

The scope of benefits is determined by the individual tariff choice.
The agreed-upon benefits are contractually defined.
Free choice among doctors and hospitals, including private clinics.
Billing is done independently of budgets according to the Scale of Fees for Doctors (GOÄ), which can contribute to different waiting times.
Instead of co-payments, annual deductibles may be agreed upon.
Many tariffs offer worldwide insurance coverage.
The reimbursement principle applies: The insured person pays the bill and submits it for reimbursement.

3. Contribution Design and Pension Provision

Contributions in GKV:

Contributions are income-dependent up to the contribution assessment ceiling (BBG). For the self-employed, all income is considered.
The GKV maximum contribution is steadily increasing (forecast for 2025: > €1,100/month for those without children).
The system is co-financed by federal subsidies.
Demographic change presents challenges for the pay-as-you-go financed system.

Contributions in PKV:

Contributions are income-independent and depend on the tariff, age of entry, and health status.
A significant portion goes into provisions for old age to stabilize contributions in old age.
Contribution adjustments are based on legally defined triggers.
Mechanisms such as the elimination of the statutory surcharge (at age 60) or tariff changes help in contribution management.
Contributions for basic coverage are tax-deductible.

4. Family Situation

In GKV:

A key advantage is the possibility of contribution-free family insurance for spouses and children under certain conditions.
This option may cease if the other parent is privately insured and earns above the JAEG (annual income threshold).

In PKV:

Each family member requires their own contract and pays a contribution.
There are more affordable tariffs for children and students.
Newborns can be insured without a new health check (infant follow-on insurance).

5. System Change and Flexibility

Return to GKV:

A return is possible if statutory insurance obligation arises (e.g., through employment below the JAEG).
This option is generally limited to individuals under 55 years of age.
Upon returning, the majority of the provisions for old age are lost.

Flexibility in PKV:

Insured individuals have a legal right (§ 204 VVG) to switch to other tariffs within their company and take their provisions for old age with them.

6. Specifics for Start-ups

In GKV, contributions are initially calculated provisionally based on estimated income and later definitively calculated after submission of the tax assessment.
In PKV, start-ups can get insured from the beginning; the contribution is independent of income.

Important Aspects for the Decision

The choice of health insurance is an individual decision. Self-employed individuals should consider the following factors:

Income situation: How high and stable is my income and its expected development?
Benefit needs: What level of medical care is personally important to me?
Health status: Are there pre-existing conditions that could lead to risk surcharges in PKV?
Long-term perspective: Which financing model (pay-as-you-go vs. funded) do I prefer?
Family situation: What are my current and future family plans?

Summary

The decision between GKV and PKV for the self-employed depends on a variety of individual factors. GKV offers a solidarity-based system with income-dependent contributions and the option of family insurance. PKV allows for individual tariff design with contractually guaranteed benefits and uses provisions for old age to finance costs in retirement. A well-informed decision requires careful consideration of personal needs, financial situation, and long-term life planning.

Read this article in...