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Type of SystemGesetzliche Krankenversicherung: statutory insurance provided by 109 nonprofit “sickness funds," covering 88% of population. High-income individuals & civil servants can opt out for fully substitutive private insurance, which covers 11% of population.Financing
Sickness funds: compulsory wage contributions shared equally between employers and employees and distributed to lớn sickness funds using risk-adjusted capitation; additional income-dependent contributions paid directly to lớn sickness funds; general tax revenue. Private insurance: individual premiums.
Secondary Health InsuranceSickness fund enrollees purchase supplementary or complementary policies covering minor benefits not covered by SHI, including some copayments and private hospital rooms.
Patient Cost-Sharing
Physician Visits
None
Hospital Inpatient CareEUR10.00 (USD12.84) per day.
Prescription DrugsCovered drugs: 10%, with EUR 5.00 (USD 56.60) minimum và EUR 10.00 (USD 112.21) maximum (or price of drug), plus difference between price and reference price.
No copay if price is 30% lower than reference price.
Caps on Cost-SharingHospital inpatient costs capped at 28 days per year. Overall medical costs capped at 2% of household income; 1% of income for people with chronic illness.
Safety NetsChildren under 18 exempt from cost-sharing.
Providers
Primary Care
Private providers paid through regionally negotiated FFS payments up khổng lồ maximum number of services per quarter. Generally no gatekeeping & patient registration not required, but sickness funds are required khổng lồ offer option to enroll in a family physician mã sản phẩm with gatekeeping.
HospitalsMix of public và private nonprofit, some for-profit. Paid through case-based DRG payments, with supplementary fees for highly specialized và expensive services and technologies (e.g., chemotherapy).
Medical Schools
Ownership
35 public, five private
Tuition FeesPublic: No tuition.
Private: Some require EUR6,000 (USD6,700) & EUR11,500 (USD12,900) per semester.
By Miriam Blümel and Reinhard Busse, Department of Health Care Management, Technische Universität Berlin
Health insurance is mandatory in Germany. Approximately 86 percent of the population is en-rolled in statutory health insurance, which provides inpatient, outpatient, mental health, và prescription drug coverage. Administration is handled by nongovernmental insurers known as sickness funds. Government has virtually no role in the direct delivery of health care. Sickness funds are financed through general wage contributions (14.6%) và a dedicated, supplementary contribution (1% of wages, on average), both shared by employers và workers. Copayments apply lớn inpatient services & drugs, & sickness funds offer a range of deductibles. Germans earning more than $68,000 can opt out of SHI & choose private health insurance instead. There are no government subsidies for private insurance.
Sections
How does universal health coverage work?
Chancellor Otto von Bismarck"s Health Insurance Act of 1883 established the first social health insurance system in the world. At the beginning, health insurance coverage was restricted khổng lồ blue-collar workers. In 1885, 10 percent of the population was insured & entitled to cash benefits in case of illness (50% of wages for a maximum of 13 weeks), death, or childbirth. While initially limited, coverage gradually expanded. The final step toward universal health coverage occurred in 2007, when health insurance, either statutory or private, was mandated for all citizens and permanent residents. Today’s system provides coverage for the entire population, along with a generous benefit package.
Health insurance is provided by two subsystems: statutory health insurance (SHI), consisting of competing, not-for-profit, nongovernmental health insurance plans known as sickness funds; and private health insurance.
Long-term care services are covered separately under Germany’s mandatory, statutory long-term care insurance (LTCI).
Unlike those in many other countries, sickness funds and private health insurers, as well as long-term care insurers, use the same providers. In other words, hospitals & physicians treat all patients regardless of whether they have SHI or private insurance.
Role of government: The German health care system is notable for the sharing of decision-making powers among the federal and state governments and self-regulated organizations of payers and providers (see exhibit).
Within Germany’s legal framework, the federal government has wide-ranging regulatory power over health care but is not directly involved in care delivery. The Federal Joint Committee, which is supervised by the Federal Ministry of Health, determines the services to be covered by sickness funds. Khổng lồ the extent possible, coverage decisions are based on evidence from comparative-effectiveness đánh giá and health giải pháp công nghệ (benefit-risk) assessments.
The Federal Joint Committee also sets quality measures for providers and regulates ambulatory care capacity (the number of SHI-contracted physicians practicing), using needs-based population–physician ratios.
The Federal Joint Committee has 13 voting members: five representatives from associations of sickness funds, five from associations of providers, and three unaffiliated members. Five patient representatives have an advisory role but no vote. However, representatives of patient organizations have the right to participate in other decision-making bodies, including subcommittees of the Federal Joint Committee.
The Federal Association of Sickness Funds works with the Federal Association of Statutory Health Insurance Physicians and the German Hospital Federation to lớn develop the ambulatory care fee schedule for sickness funds và the diagnosis-related group (DRG) catalog, which are then adopted by bilateral joint committees. Germany’s state governments also play an important administrative role. The 16 state governments determine hospital capacity và finance hospital investments. States also supervise public health services.
Regional associations of SHI-contracted physicians are required by law to lớn guarantee the local availability of ambulatory services for all specialties in urban và rural areas. These regional associations also negotiate ambulatory physicians’ fee schedules with sickness funds.
Role of public health insurance: In 2017, total health expenditures made up 11.5 percent of the gross domestic sản phẩm (GDP). Of this health spending, 74 percent was publicly funded, and most of that spending (57% of total) went toward SHI.
About 88 percent of the population receives primary coverage through sickness funds, và 11 percent through private insurance. There were 109 sickness funds in January 2019.1
As of 2019, all employed citizens (and other groups such as pensioners) earning less than EUR 60,750 (USD77,985) per year are mandatorily covered by SHI.2 Individuals whose gross wages exceed the threshold, as well as the self-employed who were previously covered by SHI, can elect khổng lồ remain in the publicly financed scheme (as 75% do) or lớn purchase substitutive private health insurance. Civil servants are exempt from SHI; their private insurance costs are partly refunded by their employer. Military members, police, và other public-sector employees are covered under small programs that are separate from SHI. Visitors are not covered through German SHI. Refugees and undocumented immigrants are covered by social security in cases of acute illness & pain, as well as pregnancy và childbirth.
Sickness funds are financed through compulsory wage contributions levied as a percentage of gross wages up khổng lồ a ceiling. Dependents (nonearning spouses and children) are covered không lấy phí of charge. Since 2016, the legally phối uniform contribution rate has been 14.6 percent of gross wages, shared equally by the employer and employees. As of 2019, earnings above EUR 54,450 (USD 69,897) per year are exempt from contribution.
The wage contributions are centrally pooled in a health fund (Gesundheitsfonds) and reallocated to individual sickness funds. A risk-adjusted capitation formula is used, accounting for age, sex, and morbidity from 80 chronic và serious illnesses.
In addition khổng lồ compulsory wage contributions, a supplementary, income-dependent contribution is paid directly lớn the sickness funds, the rate of which is determined by the fund.3 For 2019, the average supplementary contribution rate is estimated at 1.0 percent.4
Role of private health insurance: In 2017, private health insurance accounted for 8.4 percent of total health expenditures.5 This includes substitutive coverage purchased by individuals who are exempt from or can opt out of SHI (such as higher-income individuals) as well as supplementary policies bought by sickness fund enrollees.
In 2017, 8.75 million people were covered through substitutive private health insurance.6 In June 2018, there were 41 substitutive private health insurance companies in Germany, of which 25 were for profit.7
The privately insured pay a risk-related premium, with separate premiums for dependents; risk is assessed only on entry, và contracts are based on lifetime underwriting. Private health insurance is especially attractive for young people with good incomes, as insurers may offer them contracts with a more extensive range of services and lower premiums.
For sickness fund enrollees, private insurance plays a mixed complementary và supplementary role, covering minor benefits not covered by SHI, including some copayments (like for dental care) và private hospital rooms.
Private health insurance is regulated by the Ministry of Health và the Federal Financial Supervisory Authority to lớn ensure that the insured vì chưng not face large premium increases as they age và are not overburdened by premiums if their income decreases. The federal government determines provider fees under substitutive, complementary, and supplementary private insurance through a fee schedule. These fees tend khổng lồ be higher than SHI fees. There are no government subsidies for private insurance.
Services covered: SHI covers the following:
Preventive services, including regular dental checkups, child checkups, basic immunizations, chronic disease checkups, and cancer screenings at certain agesInpatient and outpatient hospital care
Physician services
Mental health care
Dental care
Optometry
Physical therapy
Prescription drugs, except for those explicitly excluded by law (mainly so-called lifestyle drugs like appetite suppressants) và those excluded following an unfavorable benefit-risk assessment
Medical aids
Rehabilitation
Hospice và palliative care
Maternity care
Sick leave compensation.
(See also the “ Long-term care & social supports” section for long-term care benefits.)
This broad framework for SHI benefits is defined by law; however, specifics are determined by the Federal Joint Committee.
Private benefit packages purchased by higher-income earners who opt out of SHI may be more extensive.
Cost-sharing & out-of-pocket spending: Out-of-pocket spending accounted for 13.5 percent of total health spending in 2017, and most individual spending went lớn nursing homes, pharmaceuticals, and medical aids.8
Copayments are determined by federal legislation và apply at the national màn chơi (see table below).
To compete for patients, sickness funds offer a range of deductibles & no-claims bonuses. Preventive services vì chưng not count toward the deductible, và there are no copayments for recommended preventive services (such as cancer screenings at certain ages).
Physicians who contract with sickness funds are not allowed to charge above the fee schedule for services in the SHI benefit catalogue. However, a danh mục of individual health services outside the comprehensive range of coverage may be offered for a fee lớn patients paying out of pocket.
Safety nets: The unemployed contribute lớn SHI in proportion to lớn their unemployment entitlements. For the long-term unemployed, the government contributes on their behalf. In addition, copayment caps và exemptions (see table above) help reduce the out-of-pocket burden on Germans.
How is the delivery system organized & how are providers paid?
Physician education và workforce: About 35 public universities & five private ones offer degrees in medicine. Studying at public universities is free, while private institutions sometimes require tuition fees ranging from EUR 6,000 (USD 7,702) khổng lồ EUR 11,500 (USD 14,763) per semester. The minimum qualifications for a medical degree are determined at the federal cấp độ by the Licensing Regulations for Physicians, state laws, & individual university requirements. Specialization requirements are regulated và enforced by the medical chambers within each state.
Primary & outpatient specialist care: General practitioners (GPs) & specialists in ambulatory care typically work in their own private practices—around 56 percent in solo practice and 33 percent in dual practices. In 2017, there were about 2,500 multispecialty clinics, where some 18,000 of Germany’s ambulatory care physicians (11%) work. Most physicians working in multispecialty clinics are salaried employees. Some specialized outpatient care is provided by hospital specialists, including treatment of rare, severe, or progressive diseases as well as highly specialized procedures.
The total number of ambulatory care physicians & psychotherapists is more than 170,000.9 In 2017, family physicians, including GPs, internists, & pediatricians, accounted for 45 percent of self-employed, SHI-contracted ambulatory care physicians (57,600 of roughly 129,000), while 55 percent (71,400) were specialists.
Most physicians employ medical assistants, while other nonphysicians (such as physiotherapists) have their own premises. Advanced practice nurses have not yet prevailed in primary care; however, there are an increasing number of medical assistants who complete further training as care managers.
Individuals have không tính phí choice among GPs and specialists. Registration with a family physician is not required, và GPs have no formal gatekeeping function. However, sickness funds are required lớn offer members the option of enrolling in a family physician care model, which has been shown khổng lồ provide better services than traditional care approaches và often provides incentives for complying with gatekeeping rules.
Under SHI, GPs & specialists are generally reimbursed on a fee-for-service (FFS) basis according to a uniform fee schedule that is negotiated between sickness funds và regional associations of physicians. The law requires SHI-contracted ambulatory physicians khổng lồ be members of these regional associations, which act as financial intermediaries between physicians & sickness funds và are responsible for coordinating care requirements within their region.
The associations receive monies from sickness funds in the size of annual capitations. The physicians then bill the associations according to the SHI fee schedule. However, physician payments are limited lớn a predefined quarterly maximum number of patients per practice and reimbursement points per patient, setting quarterly thresholds for the number of patients & of treatments per patient for which a physician can be reimbursed. If physicians exceed the quarterly thresholds, they are paid considerably less for any additional services provided. This can lead physicians khổng lồ postpone nonurgent patient visits once they reach the thresholds, which means patients may have longer appointments wait times at the over of each quarter.
For private patients, GPs và specialists are also paid on a fee-for-service basis, but private tariffs are usually higher than the tariffs in the SHI fee schedule.
The average SHI reimbursement for a family physician is more than EUR 200,000 (USD 256,739) per year. This must cover the costs of operating a practice, including personnel, etc. Physicians may also earn income from privately insured patients.
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The average SHI reimbursement for ambulatory care specialists is about the same as for GPs. But reimbursement varies widely across specialties, depending on the specialty, from EUR 77,000 (USD 98,845) for a psychotherapist to lớn EUR 367,000 (USD 471,117) for a radiologist, not including private health insurance reimbursements and direct patient payments.10
Pay-for-performance has not yet been established. Financial incentives for care coordination can be part of integrated-care contracts, but are not routinely implemented. The only regular financial incentive that GPs receive is a fixed annual bonus (EUR120, or USD154, in 2016) for patients enrolled in a disease management program, in which physicians provide patient training and document patient data. Bundled payments are not common in primary care. But a regional shared-savings initiative, called Healthy Kinzigtal (named for a valley in southwest Germany), offers primary care physicians và other providers financial incentives for integrating care across providers và services.
Administrative mechanisms for direct patient payments khổng lồ providers: Copayments or payments for services not included in the SHI benefit package are paid directly khổng lồ the provider. In cases of private health insurance, patients pay up front and submit claims khổng lồ the insurance company for reimbursement.
After-hours care: After-hours care is organized by the regional associations to ensure access khổng lồ ambulatory care around the clock. After-hours care assistance is available mainly through a nationwide telephone hotline. However, physicians are obliged to provide after-hours care in their practices, with differing regional regulations. In some areas, such as Berlin), after-hours care has been delegated lớn hospitals. The patient is given a report of the visit afterwards to lớn hand khổng lồ his or her GP.
There is also a tight network of emergency care providers (under the responsibility of the municipalities). Payment for ambulatory after-hours care is based on fee schedules, with differences in the amount of reimbursement by SHI and private health insurance.
Hospitals: Public hospitals trang điểm about half of all beds, while private not-for-profits account for about a third. The number of private, for-profit hospitals has been growing in recent years (now accounting for about one-sixth of all beds). All hospitals are staffed principally by salaried physicians. Physicians in hospitals (similar to lớn U.S. Hospitalists) are typically not allowed khổng lồ treat outpatients, but exceptions are made if necessary care cannot be provided by office-based specialists. Senior doctors can treat privately insured patients on an FFS basis. Hospitals can also provide certain highly specialized services on an outpatient basis.
Inpatient care is paid per admission through a system of DRGs, which are revised annually. Currently, there are around 1,300 DRG categories. DRGs cover all services & all physician costs. Highly specialized & expensive services like chemotherapy, as well as new technologies, can be reimbursed through supplementary fees. Other payment systems like pay-for-performance or bundled payments have yet lớn be implemented in hospitals.
Mental health care: Acute psychiatric inpatient care is provided largely by psychiatric wards in general (acute) hospitals. The number of hospitals providing care only for patients with psychiatric and/or neurological illnesses is low.
In the ambulatory care sector, there were about 38,000 office-based psychiatrists, neurologists, & psychotherapists in 2017.11 Qualified GPs can provide basic psychosomatic services. Ambulatory psychiatrists also coordinate a phối of SHI-financed benefits called sociotherapeutic care (which requires referral by a GP), intended to encourage the chronically mentally ill lớn access needed care và to avoid unnecessary hospitalizations. To lớn further promote outpatient care for psychiatric patients (particularly in rural areas with a low mật độ trùng lặp từ khóa of ambulatory psychiatrists), hospitals can be authorized lớn offer treatment in outpatient psychiatric departments.
Long-term care và social supports: Statutory LTCI is mandatory. People typically get statutory LTCI from the same insurers that provide SHI. Employees giới thiệu the contribution rate of 3.05 percent of gross salary with their employers; people without children pay an additional 0.25 percent.
Everybody with a physical or mental illness or disability (who has contributed for at least two years) can apply for LTCI benefits, which are:
Dependent on an evaluation of individual care needs by the SHI Medical đánh giá Board, which leads either to a denial of benefits or to lớn an assignment to one of five levels of careLimited to certain maximum amounts, depending on the màn chơi of care.
Beneficiaries can choose between miễn phí or discounted long-term care services & cash payments. Around a quarter of LTCI expenditures go toward cash payments. Both home and institutional care are provided almost exclusively by private not-for-profit and for-profit providers.
As benefits usually cover approximately only 50 percent of institutional care costs, people are advised to lớn buy supplementary private LTCI. In 2016, around 3.4 million Germans with SHI và private health insurance also had supplementary private LTCI.
As a separate public benefit, family caregivers get financial support through continuing payment of up khổng lồ 50 percent of care costs.
Of the approximately 2.9 million recipients of long-term care in 2015, 48 percent were cared for at trang chủ by relatives, 24 percent received home care supplied by ambulatory care service providers, & 27 percent were treated as inpatients in nursing homes.
Hospice care is partly covered by LTCI if the SHI Medical reviews Board has determined a care level. Medical services or palliative care in a hospice are covered by SHI. The number of inpatient facilities in hospice care has grown significantly over the past 15 years, lớn 235 hospices & 304 palliative care wards nationwide in spring 2016.12
What are the major strategies to ensure quality of care?
Quality of care is addressed through a range of measures broadly defined by law & in more detail by the Federal Joint Committee. The Institute for chất lượng Assurance & Transparency (IQTi
G) is responsible for measuring and reporting on chất lượng of care và provider performance on behalf of the Federal Joint Committee. In addition, the institute develops criteria for evaluating certificates and chất lượng targets & ensures that the published results are comprehensible khổng lồ the public. All hospitals are required to lớn publish findings on selected indicators, as defined by the IQTi
G, to enable hospital comparisons. There is a mandatory quality reporting system for the roughly 1,600 acute-care hospitals, in which data of 290 publicized process và outcome indicators across 30 treatment areas are collected. Based on these data, sickness funds & the White danh sách (Weisse Liste), a nonpartisan online tool, report outcomes lớn help patients choose hospitals. Indicators for quality-related hospital accreditation và payment are currently being developed.
Nursing homes and trang chủ care agencies are assessed by the regional SHI Medical đánh giá Boards for, among other things, care deficits. The results of these unique checks are published in transparency reports. In addition, scores in nursing care are created based on these checks và surveys of nursing home residents and employees.
Structural chất lượng is further assured by the requirement that providers have a quality management system, by the stipulation that all physicians continue their medical education, và by health công nghệ assessments for drugs và procedures. For instance, all new diagnostic và therapeutic procedures applied in ambulatory care must receive a positive evaluation for benefit và efficiency before they can be reimbursed by sickness funds. In addition, the Institute for quality and Efficiency in Health Care (IQWi
G), an independent scientific institute, is legally charged with evaluating the cost-effectiveness of drugs with added therapeutic benefits.
Although there is no revalidation requirement for physicians, many institutions and health service providers include complaint management systems as part of their quality management programs. This system became obligatory for hospitals in 2013. At the state level, professional providers’ organizations are urged to establish complaint systems and arbitration boards for the extrajudicial resolution of medical malpractice claims.
The Robert Koch Institute, a governmental agency subordinate to the Federal Ministry of Health và responsible for the control of infectious diseases & for health reporting, has conducted national patient surveys and published epidemiological, public health, and health care data. Disease registries for specific diseases, such as certain cancers, are usually organized regionally. As part of the National Cancer Plan, the federal government passed a bill that mandated implementation of standardized cancer registries in all states by 2018 lớn improve the chất lượng of cancer care. Full implementation, however, has yet lớn occur.
Disease management programs ensure chất lượng of care for people with chronic illness. These programs are modeled on evidence-based treatment recommendations, with mandatory documentation and quality assurance.
Nonbinding clinical guidelines are produced by the Physicians’ Agency for quality in Medicine và other professional societies.
What is being done khổng lồ reduce disparities?
Compared to percentages in other European countries, the nội dung of population reporting an unmet need for medical care is very low (0.3%), ranging between 0.8 percent in the lowest income quintile and 0.1 percent in the highest income quintile in 2017.13 This suggests good access with few disparities.
The Health Monitor (Gesundheitsmonitor) was a national initiative of not-for-profit organizations & sickness funds. To lớn assess the performance of the health care system, it regularly conducted studies from the patient perspective—for example, on the availability of information, experiences with health care, và the progress of health system reforms. The Health Monitor, which last conducted a study in 2016, ceased to exist after 15 years. A comparable survey on health access has not been provided.
Strategies khổng lồ reduce health disparities are delegated mainly to public health services, and the levels at which they are carried out differ among states. Health disparities are implicitly mentioned in the national health targets. A network of more than 120 health-related institutions, including sickness funds & their associations, promotes the health of the socially deprived.14 Primary preventive care is mandatory by law for sickness funds; detailed regulations are delegated khổng lồ the Federal Association of Sickness Funds, which has developed guidelines regarding need, target groups, and access, as well as procedure and methods. Sickness funds tư vấn 22,000 health-related programs in nurseries, schools, và other setting.15
What is being done lớn promote delivery system integration & care coordination?
Many efforts to lớn improve care coordination have been implemented; for example, sickness funds offer integrated care contracts & disease management programs for chronic illnesses khổng lồ improve care for chronically ill patients & to improve coordination among providers in the ambulatory sector. In December 2017, 9,173 registered disease management programs for six indications had enrolled about 6.8 million patients (more than 9% of all the SHI-insured).16 There is no pooling of funding streams by the health và social care sectors.
Since 2016, the Innovation Fund has been promoting new forms of cross-sectoral and integrated care (also for vulnerable groups) with an annual funding of EUR300 million, or USD382 million (including EUR75 million, or USD95 million, for evaluation and health services research). Funds are awarded through an application process overseen by the Federal Joint Committee.17 So far, the fund has sponsored care models in structurally weak và rural regions & care models using telehealth.
What is the status of electronic health records?
Since 2015, electronic medical chip cards have been used nationwide by all the SHI-insured; they encode information including the person’s name, address, date of birth, and sickness fund, along with details of insurance coverage & the person’s status regarding supplementary charges.18 Patients can decide whether they want clinical data, such as on medications, lớn be stored và whether these are lớn be passed on lớn their physician.
In 2015, Parliament passed a law for secure digital communications và health care applications; the E-Health Act provides concrete deadlines for implementing infrastructure và electronic applications (such as documentation of willingness to donate organs) và introduces incentives & sanctions if schedules are not adhered to.
SHI physicians receive additional fees for sharing electronic medical reports with other providers (since 2016–2017), collecting và documenting emergency records (since 2018), & managing and reviewing basic insurance claims data online. In the future, SHI physicians who do not participate in online reviews of the basic insurance claims data will receive reduced remuneration.
Furthermore, to lớn ensure greater safety in drug therapy, patients who use at least three prescribed drugs simultaneously will receive an individualized medication plan. In the medium term, this medication plan will be included in the electronic medical record.19
How are costs contained?
Recently, there has been a shift away from reliance on overall budgets for ambulatory physicians và hospitals & collective regional prescription caps for physicians, toward an emphasis on chất lượng and efficiency. The Hospital Care Structure Reform Act of năm nhâm thìn aims not only to link hospital payments khổng lồ good service quality but also to reduce payments for low-value services. Currently, the IQTi
G works on preparing appropriate concepts và recommendations for the Federal Joint Committee.
To enhance competition, some purchasing nguồn has been handed over khổng lồ the individual sickness funds instead of relying on collective contracts with regional associations. For example, the funds can now selectively negotiate integrated-care contracts with providers và negotiate rebates with pharmaceutical companies.
All drugs, both patented and generic, are placed into groups with a reference price serving as a maximum cấp độ for reimbursement, unless an added medical benefit can be demonstrated. For new drugs with added benefit (as evaluated by IQWi
G and decided on by the Federal Joint Committee), the Federal Association of Sickness Funds negotiates a reimbursement price, based on the manufacturer’s price, that is applied khổng lồ all patients. In addition, rebates are negotiated between individual sickness funds and pharmaceutical manufacturers khổng lồ lower prices below the reference price.
What major innovations và reforms have recently been introduced?
After a period of active health reform in several areas between 2012 and 2016, new reform debates and proposals stagnated until spring 2018. One of the reasons is that after the federal elections in September 2017, it took six months of difficult talks và political insecurity to again size a grand coalition between political parties (Christian Democrats and Social Democrats). The first new bill introduced in 2018 (the SHI-Contribution Relief Law, or GKV-Versichertenentlastungsgesetz) aims khổng lồ reduce the mandatory contributions that individuals in SHI pay every month.20 While the general contribution of 14.6 percent has been equally shared between employers và employees since 2015, the supplementary contribution is paid by employees only. The law plans khổng lồ reinstate the equal split of general và supplementary contributions between employers & employees. Furthermore, the law stipulates halving the reference amount used lớn calculate the minimum contribution for the self-employed insured. Until now, independent of their actual income, the self-employed have paid a contribution based on expected minimum income of EUR 221 (USD 284) per month. This is unmanageable for a large proportion of small-business owners & increases their risk of having no health insurance.21
Furthermore, the Ministry of Health has recently issued a decree on minimum staffing requirements for nurses in hospitals. The maximum number of patients per nurse has been defined for hospital units where nursing staff is particularly needed — intensive care, geriatric, cardiology, & trauma surgery — khổng lồ guarantee patient safety. The regulation went into effect January 2019. Khổng lồ further expand the capacities of nurses in hospitals and in long-term care and to reform salaries và working conditions for nurses, the Nursing Staff Strengthening Act was enacted in September 2018.22
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Smith-Hutson Scholarships
Dedicated khổng lồ providing opportunities to students who otherwise may not have a chance lớn earn a baccalaureate degree, the Smith-Hutson Scholarship Program is targeted toward individuals with demonstrated financial need and academic potential. The Smith-Hutson Scholarship Program provides educational opportunities for Texas high school graduates pursuing a baccalaureate degree from Sam Houston State University. Additionally, the Smith-Hutson Scholarship program is available khổng lồ transfer students from a Texas community college who are pursuing a baccalaureate degree at Sam Houston State University. The number of Smith-Hutson scholarships varies year-to-year depending on the number of qualified applicants.
For more information visit the Smith-Hutson Scholarship page.
Honors ScholarshipThe Honors Scholarship is distributed over an mailinhschool.edu.vn undergraduate college career no longer than four years at a maximum of $40,000.
For more information visit the Honors Scholarship page.
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Frequently Asked Questions
Need help logging into Scholarships4kats?
Are you a current student? – Only mailinhschool.edu.vn students can access Scholarships4Kats Be sure that you are accessing Scholarships4Kats through the mailinhschool.edu.vn portal, not through Google or anyother tìm kiếm engine. Go lớn your My
Sam account, select the Student tab, then click on the
Scholarships4Kats link. Students should never have to lớn ‘’login” thanks lớn the single sign on feature (SSO).
The Letters of Recommendation are the only documents/entries that can be edited in regards to the
Scholarships4Kats Application. No other changes can be made khổng lồ your application after submitting
Review opportunities on the Scholarships4Kats trang chủ page. All of the requirements are listed under each scholarship opportunity.
You have excelled at meeting the priority deadline, however, many departments award at later dates.At this time, we cannot provide a definite date of notification. If you are selected as a recipient, you willbe notified through your mailinhschool.edu.vn email account. Scholarship committees are urged khổng lồ notify recipients by May 1st. Keep in mind that just because you qualify for a scholarship does not guarantee that you will beselected. Our scholarship process is very competitive.
No. Preference is given to lớn students who meet the priority deadline. We have established this deadlineto allow students the best opportunity for awards by meeting the deadline closest khổng lồ the majority of thescholarships offered at mailinhschool.edu.vn.
Summer awards depend on the funds available. Scholarship applications will be posted on the Financial Aid và Scholarships website.
In regards to lớn majors, we pull student’s majors through University data. Be sure that when you “change yourmajor” that you did so with an advisor so that it was changed in the system.
The application for the next academic year opens the September prior to the priority deadline for thatyear
Be sure that the organization knows to include your name & SAM ID on the check as well as indicatehow the funds are to be disbursed (½ in Fall and ½ in Spring or all in one term).
Scholarships awarded khổng lồ students at Sam Houston State University are applied lớn the student’s accountthrough their Banner Self Service. The scholarship funds will apply to the student’s balance due. Anyresidual funds will then be issued khổng lồ the student as a refund. Refund preferences can be thiết lập through the student’s Bearkat One account. The contact information islisted on the back of the Bearkat One Card.
You will need to complete your Scholarships4Kats Application by the November 1st priority deadline inorder khổng lồ qualify for scholarships offered at Sam Houston State University. Meeting the November 1st priority deadline for Early Freshmen Awards will include you in early awardssuch as Annual Fund & University Scholars. The criteria for University Scholars are: Be in the upper 10% of class Minimum SAT score of 1300 (reading and math) or minimum of 30 on the ACT The criteria for Annual Fund are: Be in the đứng đầu 20% of class Minimum SAT score of 1200 (reading và math) or minimum 27 on the ACT Also, remember to check with your high school counselor on additional scholarship opportunities.
There are essays within the application. Use a program lượt thích Microsoft Word khổng lồ spell check your essays. Submit your application well in advance of the deadline to lớn avoid any technical errors.
