Reimbursement Rate

The reimbursement rate indicates what percentage of a submitted invoice is covered by the plan. Along with the budget and any sublimits, it is the third factor that determines how much is ultimately reimbursed—and it is the one most often overlooked.

Where Reimbursement Rates Apply

At the core of the healthcare budget, the reimbursement rate is often 100 percent: whatever is submitted is fully reimbursed up to the budget limit. In two areas, however, this is regularly different:

• Dental prosthetics: Common reimbursement rates are 70, 90, or 100 percent
• Vision aids: Common rates are 75 or 100 percent

In many plans, these components are listed as separate modules and can be selected when taking out the policy—the premium increases with the reimbursement rate.

What a lower rate means in practice

For a dental prosthesis bill exceeding 2,000 euros:

• 70 percent: 1,400 euros reimbursable, 600 euros out-of-pocket
• 90 percent: 1,800 euros reimbursable, 200 euros out-of-pocket

Whether this amount is actually paid out depends additionally on the available budget, any applicable sublimit, and a possible sliding scale. The reimbursement rate is therefore not the final step in the calculation, but rather the first.

The Interplay of the Three Variables

The reimbursement rate, sublimit, and budget apply in that order:

• The reimbursement rate reduces the invoice amount to the reimbursable portion.
• A sublimit caps this portion on a per-area basis.
• The budget sets a limit on the total amount of all reimbursements for the year.

If you consider only one of the three factors, you will often arrive at a result that is too optimistic.

The Special Case of Advance Payments Under Statutory Health Insurance

If a plan requires that statutory health insurance pay first, the reimbursement rate applies to the remaining balance—not to the total bill. If a plan does not require advance payment, some insurers apply a flat-rate deduction instead. Both options are common and can significantly affect the final amount.

What to Look for When Comparing Options

• To which amount does the rate refer —to the total bill or to the balance remaining after GKV coverage?
• Does the same rate apply permanently, or does it increase over the course of the contract years?
• Are higher rates available as an add-on, and how much does the surcharge cost relative to the expected demand?
• Does this rule apply to add-on modules as well, or only to services covered by the budget?

Conclusion

The reimbursement rate is the least noticeable of the three limits and affects precisely the types of bills that matter most to employees—dental work and vision care. When comparing plans, it’s worth running a realistic sample calculation that includes the reimbursement rate, sublimit, and budget, rather than looking at the three values individually.