Defining benefit catalogues and entitlements to health care in Germany - decision makers, decision criteria and taxonomy of catalogues
Stargardt T, Schreyögg J, Simon C, Martin
2005/5, Technische Universität Berlin, Fakultät Wirtschaft und
While the general framework for the German health care system is laid down by the government, the definition of benefits is delegated to self-regulated organizations of payers and providers that are actually involved in financing and delivering health care covered by social insurance schemes. However, the explicitness of defined benefits varies largely by sector and among the different schemes. While some schemes rather have an implicitly defined benefit basket, benefits provided by other schemes are laid down explicitly in one or several catalogues. Most schemes determine their benefits following the Statutory Health Insurance Scheme which covers 88% of the population and accounts for 56.9% of Germany’s total health expenditure. Under the Statutory Health Insurance Scheme entitlements of the insured are defined in different benefit catalogues and the directives of the Federal Joint Committee. The entitlements of the insured, the taxonomy of benefit catalogues, the actors involved in the decision making process and the decision criteria for the inclusion of new benefits are described and analyzed in this paper.