Sublimit

Two bKV plans with identical annual budgets can differ significantly in terms of the actual scope of coverage. The most common reason for this is sublimits: spending limits that apply within the budget to individual coverage areas and take effect even when the total budget is far from being exhausted.

How a sublimit works

At first glance, a budget plan seems to offer unlimited use. A sublimit restricts this freedom in certain areas. Two plans, each with an annual budget of 900 euros:

• Plan A without sublimits: The full 900 euros is available for each reimbursable service—including the full amount for dental prosthetics.
• Plan B, with a sublimit of 300 euros for vision aids and 150 euros for alternative practitioners: If you submit a claim for glasses costing 600 euros, you’ll receive 300 euros—the remaining 600 euros of your budget will still be available, but cannot be used toward this claim.

The difference doesn't become apparent until the first large claim is filed. That is precisely why sublimits are among the factors that should be reviewed before deciding on a plan—and not during the first round of reimbursements.

Typical areas with sublimits

• Vision aids: often covered as a fixed amount per period, such as every two years
• Alternative Practitioners and Natural Remedies: Annual Maximum Amount or Limit on the Number of Sessions
• Dental prosthetics: often combined with a tiered pricing structure during the first few years of the contract
• Medical devices: some come with their own list of reimbursable items
• Digital health applications: often a separate annual amount
• Preventive Screenings: Limiting Them to Specific Intervals

Why Insurers Set Sublimits

Sublimits are not a gimmick, but a tool for calculating costs. Without them, coverage would be heavily concentrated in a few expensive areas—especially dental prosthetics and vision aids, where demand is predictable. A plan with no limits whatsoever would therefore have to charge a higher premium.

This leads to a practical rule: A policy with sublimits isn’t necessarily the worse option. It’s the more affordable one—and the question is whether those limits align with your workforce’s actual needs.

Sublimit, Reimbursement Rate, and Budget: A Combined Overview

Three factors come into play one after another and can have a cumulative effect:

• The total budget limits the total amount of all reimbursements for the year.
• The sublimit caps the proportion that may be allocated to a specific area.
• The reimbursement rate limits the portion of each invoice.

Example: Glasses for 500 euros, reimbursement rate 75 percent, sublimit for vision aids 300 euros. The reimbursable amount would be 375 euros, but the sublimit caps it at 300 euros. Someone who only looks at the 900-euro budget would expect 500 euros and receive 300.

What to Look for When Comparing Rates

• Does the sublimit apply per year or per period? A sublimit for vision aids every two years has a different effect than one per calendar year.
• Are sublimits counted against the budget, or are they in addition to it? Both situations occur.
• Will the limits increase over the term of the contract? This is especially common with dental coverage.
• Do the coverage limits align with the workforce? A low sublimit for alternative medicine providers isn't a problem at all for a workforce that rarely uses these services.

Conclusion

Sublimits are the main reason why the budget tier alone does not indicate the quality of a plan. When comparing plans, they should be considered alongside the reimbursement rate and budget—and evaluated based on where your workforce actually has needs. A more affordable plan with limits in non-essential areas is a better choice than a more expensive one without them.