Legal Basis: Where Does the Co-Payment Obligation Come From?
The obligation to pay a co-payment for therapeutic services is set out in § 32 SGB V (the German Social Code, Book V) in conjunction with § 61 SGB V. These provisions apply to all remedial treatments (Heilmittel) covered by statutory health insurance, including physiotherapy, occupational therapy, speech therapy and podiatry. The calculation is not discretionary – it is fixed by law.
In practice, the monetary basis for the calculation is the contractually agreed reimbursement rate per treatment unit. These rates are negotiated between the statutory health insurers (Krankenkassen) and the relevant professional associations at Länder level. They form the foundation for any co-payment calculation and should be maintained accurately in your practice management system.
Importantly, the co-payment obligation applies regardless of whether the prescription was issued as a standard prescription or as a blank prescription (Blankoverordnung) giving the therapist clinical discretion over the exact treatment. What matters is the patient's GKV status and whether a valid exemption certificate is on file.
- ✓Statutory basis: § 32 SGB V (therapeutic services) read with § 61 SGB V (co-payments)
- ✓Applies to GKV patients only – private patients (PKV) have separate contractual arrangements
- ✓Calculation base: contractually agreed reimbursement rates, not in-house list prices
- ✓Covers all Heilmittel: physiotherapy, occupational therapy, speech therapy, podiatry
The Formula: Step-by-Step Calculation
The co-payment consists of two elements that are simply added together: a percentage component and a fixed prescription fee. The formula is: Co-payment = (total prescription value × 10 %) + €10 prescription fee. Both elements are charged per prescription – not per individual treatment session.
The percentage component is based on the total reimbursement value of the prescription, calculated as the contractually agreed rate per treatment unit multiplied by the number of units prescribed. If a prescription is only partially used – for instance because the patient recovers early or the prescription expires – the calculation is adjusted to reflect only the sessions actually provided.
The €10 prescription fee is a flat charge levied once per prescription, regardless of how many units it covers. If a doctor issues two separate prescriptions at the same appointment, two separate prescription fees are payable. Practices should communicate this clearly during the initial consultation to avoid surprises.
- ✓Formula: (prescription value × 10 %) + €10 prescription fee
- ✓Both elements apply per prescription, not per session
- ✓Calculation base: contractually agreed rates (not private fee schedules)
- ✓Two prescriptions at one appointment = two prescription fees
Three Worked Examples from Real Practice
Example 1 – Standard physiotherapy prescription: A patient receives a prescription for 6 units of Krankengymnastik (KG) at a contractually agreed rate of €20.00 per unit. Total prescription value: €120.00. Co-payment: 10 % of €120 = €12.00, plus the €10 prescription fee = €22.00 total, payable at or before the first session.
Example 2 – Larger prescription: A patient has a prescription for 10 units of KG at €22.00 per unit. Total value: €220.00. Co-payment: €22.00 (10 %) + €10.00 = €32.00. If the patient attends only 8 of the 10 sessions before the prescription expires, the final co-payment is recalculated on 8 sessions (8 × €22 = €176, 10 % = €17.60, plus €10 = €27.60), and any overpayment must be refunded.
Example 3 – Two prescriptions from one appointment: A patient brings two prescriptions issued during the same GP visit: one for 6 sessions of KG (€20 each) and one for 6 sessions of KMT (classical massage, €16 each). KG co-payment: €12 + €10 = €22.00. KMT co-payment: €9.60 + €10 = €19.60. Total patient liability: €41.60. Alerting patients to this before treatment begins prevents misunderstandings.
Who Is Exempt from Co-Payments?
The most straightforward exemption applies to children and young people under 18. They are fully exempt from all GKV co-payments – both the percentage component and the prescription fee – without any need to present a certificate. The date of birth on the health insurance card is sufficient confirmation.
Adult GKV patients can obtain an exemption certificate from their health insurer once their annual out-of-pocket burden exceeds the statutory ceiling. The general threshold is 2 % of annual gross household income. For patients with chronic conditions as defined by the Federal Joint Committee (G-BA), the threshold is reduced to 1 %. All GKV co-payments count towards this limit – including those for medicines and hospital stays. Once the ceiling is reached, the insurer issues an exemption certificate valid for the remainder of the calendar year.
Further exemptions apply to recipients of benefits under SGB II (Bürgergeld), SGB XII (social assistance) and certain war victims' benefits. In each case, the patient must present documentary evidence. Practices should verify and copy the exemption certificate for every new prescription – a certificate valid in a previous quarter may well have lapsed.
- ✓Under-18s: fully exempt – insurance card date of birth suffices, no certificate needed
- ✓General ceiling: 2 % of annual gross household income (1 % for chronically ill patients)
- ✓SGB II / SGB XII recipients: exempt with supporting documentation
- ✓Certificates expire on 31 December – check annually and archive copies
Blank Prescriptions and Long-Term Approvals
The Blankoverordnung – applicable across most therapeutic areas from 2024/2025 – gives therapists greater clinical autonomy over treatment selection. However, the co-payment rules are unchanged: 10 % of the final prescription value plus the €10 fee. With a blank prescription, the exact value is confirmed only once treatment is complete, since the therapist may adjust the plan within the approved framework. Practices should therefore give patients a realistic estimate of the likely co-payment range at the outset.
Patients with a long-term approval (Langfristgenehmigung under § 32 Abs. 1a SGB V) still receive individual prescriptions for each treatment period, each triggering its own €10 fee. Patients receiving continuous physiotherapy should be proactively informed that their cumulative annual co-payments may approach the statutory ceiling and that an exemption application may be worthwhile.
A common misconception is that a long-term approval exempts patients from co-payments. It does not. The approval streamlines the administrative authorisation process only; co-payments remain fully payable unless an exemption certificate is in place.
Day-to-Day Practice: Collection, Documentation and Compliance
Legally, co-payments fall due at or before the first session on each prescription. Collecting the full amount at the first appointment is strongly recommended to minimise the risk of non-payment. If a patient presents an exemption certificate part-way through a series of sessions, the exemption applies only to prescriptions begun after the certificate was issued; earlier sessions remain subject to the original co-payment.
From a compliance perspective, every co-payment collected must be recorded individually, with a date stamp and a corresponding receipt. Grouping together several days' cash receipts without individual records is not permitted under the GoBD principles governing digital bookkeeping in Germany. Practices that still rely on paper records should be aware that GoBD audits can result in significant liability if documentation is incomplete.
Practice management software eliminates most of this burden: co-payments are calculated automatically from stored reimbursement rates, exemption status is flagged in the patient record, and receipts are generated and linked to the billing module. TheraNext integrates co-payment calculation directly into the §-302 direct billing workflow, ensuring GoBD-compliant documentation without additional manual steps.
- ✓Collect co-payments at or before the first session on each prescription
- ✓Check and copy exemption certificates for every new prescription
- ✓GoBD: record every cash payment individually, with a date and receipt
- ✓Software integration eliminates manual calculation errors and speeds up collection
Common Mistakes – and How to Avoid Them
The most frequent calculation error is using a private fee list price rather than the contractually agreed GKV reimbursement rate. The co-payment must always be based on the latter. If your practice maintains separate fee schedules for different patient groups, the billing system must clearly distinguish between them and apply the correct rate automatically.
Collecting a co-payment from an exempt patient is another common mistake. If a valid exemption certificate is presented, neither the percentage component nor the prescription fee may be charged, even in part. Any amount incorrectly collected must be refunded promptly. Exemption status should be stored in the patient record and checked automatically at the point of billing.
Many patients – and occasionally practice staff – underestimate how quickly multiple prescriptions accumulate. A patient receiving treatment for a chronic condition may generate six or more prescriptions per year, each with its own €10 fee. Proactively mentioning that a ceiling exemption application might be worthwhile is good patient care, even though there is no strict legal obligation to do so.
Electronic Prescriptions (eVO) and the Future of Co-Payment Billing
The electronic prescription for therapeutic services (eVO), mandated under § 360 SGB V with a phased rollout from 2025 onwards, changes the administrative workflow but not the co-payment calculation. The formula – 10 % of the prescription value plus €10 – remains exactly as it is. What changes is how the prescription reaches the practice and how it is submitted for reimbursement.
Practices that have already moved to direct billing under § 302 SGB V (Selbstabrechnung) are well placed for this transition. With reimbursement rates stored in the system, co-payments are calculated instantly, exemption status can be queried and the entire billing cycle is handled within a single platform. TheraNext supports §-302 direct billing natively and is prepared for eVO integration, enabling practices to adopt the new workflow without changing their software.
In the longer term, the digitalisation of the prescribing process should reduce patient confusion: when prescription value and co-payment are visible at the point of prescribing, many of the questions that currently arrive at the reception desk will be answered before the patient steps through the door. Until then, a clear explanation at the first appointment remains the most effective tool for building trust and avoiding payment disputes.
Written & reviewed by
TheraNext Fachredaktion
Practice Management & Billing Expertise