Advance Payment by Statutory Health Insurance

Some supplementary health insurance plans require that statutory health insurance first cover its share before the supplementary health insurance provides reimbursement. This requirement is called “GKV advance payment”—and it affects the bill more significantly than the term might suggest.

How Billing for Advance Payments Works

For dental prosthesis treatment, statutory health insurance pays a fixed subsidy. If the bKV plan requires upfront payment, this subsidy is applied first, and the bKV reimburses the remaining balance—in accordance with its reimbursement rate.

In practical terms, this means that employees must first submit their claims to their statutory health insurance provider, wait for reimbursement, and then submit the reimbursement document along with the invoice to the bKV. This is an additional step that takes time.

Rates with No Wholesale Obligation

If a health insurance plan does not require advance payment, claims can be submitted directly to the supplementary health insurance provider (bKV). In such cases, insurers often apply a flat-rate deduction that corresponds to the typical statutory health insurance (GKV) copayment.

This is the more important practical consideration when it comes to the utilization rate: One fewer step in the reimbursement process makes a bigger difference in people’s perception than a few percentage points in the reimbursement rate. Anyone introducing a supplementary health insurance plan to provide tangible relief should not overlook this point.

The Special Case of Privately Insured Employees

For employees with private health insurance, there is no statutory health insurance (GKV) portion. How the plan handles this varies:

• Some plans calculate premiums the same way as they do for those with public health insurance and deduct a flat fee.
• Others focus on the actual benefits provided by private health insurance.
• Still others exclude certain benefits for privately insured individuals.

In the case of a mixed workforce, this issue must be clarified before a decision on the rate is made—otherwise, discrepancies in reimbursement will arise that are difficult to explain internally.

When Advance Payment Typically Applies

• Dental prosthetics: the most common case, because the public health insurance provider provides a fixed subsidy for this
• Dental Treatment Depending on the Plan
• Medical devices, provided that the statutory health insurance plan covers part of the cost

For services that statutory health insurance does not cover anyway—such as alternative practitioners, many preventive medical checkups, or vision aids for adults—upfront payment is not an issue.

What to Look for When Comparing Options

• Does the collective bargaining agreement require advance payment, and if so, for which service areas?
• What is the flat-rate deduction for plans without a wholesale service requirement?
• What are the rules for dealing with privately insured individuals?
• How many steps does the reimbursement process actually involve—and can it be mapped out using an app?

Conclusion

The GKV advance payment is not a matter of the benefit amount, but rather a question of the reimbursement process. It determines how many steps there are between the invoice and reimbursement—and thus how many employees actually see the process through to the end.